Pocket Prep 0 Flashcards
mnemonics
- OPQRST
- SOAP
- DCAP-BTLS
OPQRST: Onset > Provocation > Quality > Radiation / Region > Severity > Timing
SOAP: Subjective > Objective > Assessment > Patient care
Subjective: only be identified by the person giving that statement → ie chief complaint and past medical history
Objective: finding that can be seen, heard, felt, smelled, or measured
DCAP-BTLS: Deformities Contusions Abrasions Punctures Burns Tenderness Lacerations Swelling
define the following:
- symptom
- sign
- tachycardia
- bradycardia
Symptom: subjective finding that the patient feels and that can be identified only by the patient
Sign: objective finding that can be seen, heard, felt, smelled, or measured
Tachycardia: abnormally high heart rate
Bradycardia: abnormally low heart rate
what is in the upper airway vs lower
Upper airway: vocal cords, nose, mouth, jaw, oral cavity, pharynx (incl naso, oro, and laryngo)
Lower: trachea, and more
RESUSCITATION / CPR STANDARDS
for a one person CPR on adults
Compressions: rate of 100 to 120 per minute
Sternum should be depressed 2 to 2.5 inches (5 - 6 cm)
After 30 chest compressions (approx 17 s), two ventilations of 1 sec each are given
Repeat until AED is available, and the rhythm is being analyzed
what is gastric distension and how do you address it
condition in which air is forced into the stomach secondary to artificial ventilations.
Prevent this by ensuring the airway is appropriately positioned and ventilate at an appropriate rate and volume.
Alleviate by repositioning head and watching for rise / fall of chest wall with ventilations.
3 methods of providing oxygen to a patient
- what are they
- rate
- percentage
Bag valve mask: should be used on a patient in severe respiratory distress / failure
- 15 liters / minute
- 100% oxygen
Nonrebreather: should be used on a patient with adequate breathing but has suspected / obvious signs of hypoxia (ie <94%)
- 10 to 15 liters / minute
- 95% oxygen
Nasal Cannula: used in patients that are intolerant of a mask
- 1 to 6 liters / minute
- 24% to 44% oxygen
what is the appropriate tidal volume of an adult
should be enough to cause a noticeable rise of the patient’s chest over one second
Adult: about 600 mL
treatment of bleeding
- Direct pressure
- Pressure dressing
- Tourniquet: placed in groin for lower extremities; armpit (aka axillary) for upper
Open pneumothorax
aka “sucking chest wound” requires emergent care and transport
After ensuring a patent airway and oxygenation, SEAL WOULD W OCCLUSIVE DRESSING to prevent air from being sucked into it; three sides to simulate flutter valve, thus allowing air to escape but not re-enter the chest cavity.
Pneumothorax
- spontaneous
- tension
partial or complete accumulation of air in the pleural space
Spontaneous: no identifiable cause but is associated w certain conditions (ie patients w ephysema / asthma or that are tall / thin men) → symptoms: dyspnea, pleuritic chest pain, absent / decreased breath sounds on the affected side are common ⇒ can progress into a life threatening condition
Tension: more likely caused by blunt trauma to the best; can also be spontaneous but very rare → symptoms: chest pain, respiratory distress, decreased lung sounds, tachycardia, signs of shock
More on Occlusive Dressing (6)
Serves to prevent air and liquids from entering / exiting a wound
Used in chest wounds to prevent tension pneumothorax from developing
Used in abdominal eviscerations to prevent mesenteric necrosis and hypothermia
Used in penetrating back wounds to prevent peritonitis
Used in neck injuries to prevent mediastinitis
Can be used together w sterile gauze that is moistened with sterile saline solution in situations with an open abdomen → open abdomen can lose body heat and fluid rapidly, thus must keep the organs warm and moist
coronary arteries
Coronary arteries provide oxygenated blood from the heart to the rest of the body, and are branches from the aorta.
Carotid goes to the head, located in neck
Cerebral goes to the brain, located in skull
Femoral goes to lower extremities, located in thigh
Oral glucose
medication for diabetic emergencies; contraindication is the inability to swallow and/or unconsciousness (due to aspiration)
Conscious patient who does not really need glucose will not be harmed by it
signs of a mild / partial airway obstruction
- how to treat
Wheezing, stridor, and coughing
Monitor for adequate oxygenation and progression of obstruction; patient may present w ineffective cough / stridor / increased difficulty breathing / cyanosis.
If obstruction is visible, do a (gloved) index finger sweep. Suction may be used to assist w this procedure as well as to maintain a clear airway.
If not visible and are exchange is adequate, administer oxygen and rapidly transport.
lung sounds to know (4)
Stridor: brassy, crowing sound that is most prominent on inspiration;; most often heard before auscultating and is likely indicative of an airway obstruction
Rhonchi: low pitched sound that is prominent on expiration; indicative of mucus in the lungs and is often accompanied by a productive cough
Wheezing: high pitched whistling sound, louder on expiration; obstruction or narrowing of the lower airway will commonly cause wheezing
Crackles: wet, crackling breath sounds heard on inspiration and expiration that may be the result of fluid within the lungs
ventilation rates for adults vs children
Ventilations should be given to adult patients every 5-6 seconds; child patients every 3 seconds.
Provide ventilations just enough to see chest rise and fall + avoid gastric distension (result of rapid ventilation; may lead to vomitus and subsequent aspirate)
how to transport heavy patients
Any patient who weighs >250 lbs should be lifted w no fewer than four providers.
Stair chair can be used BUT still needs additional personnel.
Alternatively, can use a backboard BUT never a stretcher.
Gastroenteritis
typically involve infection combined w gastrointestinal complaints
Common signs: abdominal pain, nausea, vomiting, diarrhea, anorexia, fever
Dehydration can occur if diarrhea or vomiting persists. Shock is also possible.
Gastrointestinal hemorrhage
Melenda (dark, tarry stools) commonly occur due to a bleed in the upper gastrointestinal tract
Common pneumonia symptoms
dyspnea, wheezing, coughing, fever, cyanosis, dry skin, chest pain, musculoskeletal pain, tachycardia, hypotension
normal glucose levels
+ hypoglycemia
+ hyperglycemia
Normal blood glucose level is btwn 80 and 120 mg / dL
Hypoglycemia: aka low blood glucose levels
- Rapid onset: pale / cool / clammy skin, shallow breathing, hypotension, rapid / weak pulse, altered mental state, diaphoresis (moist skin or sweating, esp to an unusual degree)
- Treatment: oral glucose (remember contraindications)
Hyperglycemia: aka high blood glucose levels:
– Gradual onset: intense thirst / hunger, increased urination (aka polyuria), abdominal pain, vomiting, rapid / weak/ thready pulse; restlessness w progression to coma, slurred speech, unsteady gait
Diabetic ketoacidosis symptoms
- symptoms
ketoacidosis and hyperglycemia; can present in less than 24 hours
Signals: sweet / fruity breath due to exhaled acetone, deep / Kussmaul respirations; incl symptoms of hyperglycemia
– Kussmaul respirations / hyperventilation occurs as an attempt by the body to reduce the acidity by releasing more carbon dioxide (which is an acid, thus heavy breathing will decrease carbon dioxide levels within the body)
Can progress to coma and death
Hyperosmolar hyperglycemic state
severe hyperglycemia; evolves over several days to weeks
Found in patients with type 2 diabetes mellitus when hyperglycemia is uncontrolled
Type 1 Diabetes Mellitus
autoimmune disorder where antibodies are created against pancreatic beta cells ;; Insulin subsequently inadequate / absent
Common signs and symptoms for NEW ONSET: polyuria (increased urination), polydipsia (increased fluid intake due to thirst); polyphagia (increased food intake due to hunger); fatigue; weight loss
Injectable insulin or other means of external insulin use is REQUIRED for survival in patients who have autoimmune diabetes mellitus
Acute coronary syndrome (ACS)
caused by myocardial ischemia; hallmark symptom is chest pain that it described as pressure or heaviness (but not all patients have chest pain during ACS or an AMI).
ANY PATIENT COMPLAINING OF NON TRAUMATIC CHEST PAIN SHOULD BE ASSUMED TO HAVE AN AMI UNTIL IT IS RULED OUT BY A PHYSICIAN.
signs and symptoms of ACS / AMI
weakness, dyspnea, nausea / vomiting, lower jaw / arm / back / abdominal / neck pain, sweating without an obvious cause, pink frothy sputum (indicating possible pulmonary edema), irregular cardiac rhythm, syncope, sudden death
define the following:
- stable angina pectoris
- unstable
- acute myocardial infarction
Stable angina pectoris: cardiac chest pain alleviated by rest
Unstable angina pectoris: cardiac chest pain NOT alleviated by rest
Acute myocardial infarction; aka AMI; death of myocardial tissue
Prehospital care of electrical injuries
- steps
- other concerns
- Remove the patient from the contact with the source, using rubber or wood; do not touch patient directly
- Assess need for CPR, as ventricular defibrillation is the most common arrhythmia
- Transport
Electrical currents can cross the chest and cause cardiac arrest or dysthymia; however, cardiac arrest is unlikely to develop if not seen on initial assessment.
- Check for entrance and exit wounds when dealing with electrical burns.
- Internal bleeding can occur, either immediately or delayed; however, thrombosis is more common and can result in organ damage.
- Cardiac arrhythmia is a greater concern in the pre-hospital setting but Respiratory arrest is also possible.
PRIMARY ASSESSMENT
after scene size up
- General impression of patient
- Assess LOC
- Assess airway / breathing / circulation / any life threats via
Every patient needs to be assessed and examined prior to any treatment.
Nitroglycerin
+ common side effects
Nitroglycerin should be given to a patient that is having chest pain, especially one w a history of angina. This medication dilates the coronary arteries and improves blood flow thru them, in the efforts of decreasing pain.
Common side effects of taking nitroglycerin:
- Hypotension
- Headache
- Changes in heart rate (tachycardia or bradycardia)
contraindications to nitroglycerin (7)
Systolic blood pressure of less than 100 mmHg
Heart rate less than 60
Have not been prescribe this medication (6 rights)
Are pediatric (under 13 years of age)
Have taken medication for pulmonary artery hypertension within the previous 48 hours (ie Adcirca, Revatio)
Have taken medications for erectile dysfunction within the previous 48 hours (ie Viagra / sildenafil, Levitra / vardenafil, Cialis / tadalafil)
Have already taken their maximum doses (typically 3)
Four person log roll
effective method for moving a patient from the ground to the long backboard; Rescuer at head should direct all movements
- Maintain inline stabilization and assess neurovascular status of extremities
- Apply a cervical collar
- Logroll patient onto backboard
- Secure patient with belts / etc
- Reassess neurovascular status of extremities
Epinephrine symptoms (when delivered via metered-dose inhaler)
+ alternatives
Tachycardia: abnormally rapid heart rate
Hypertension
Restlessness
Albuterol and metaproteronol are alternatives to epinephrine inhalers w fewer side effects, and thus are more commonly used.
Albuterol
beta-agonist medication that dilates bronchioles; often used in setting of dyspnea ;; commonly found with patients who have asthma, bronchitis, and chronic obstructive pulmonary disease
Side effects: tachycardia, nervousness, muscle tremors, slight coughing after inhalation
Obstructive shock
+ causes
mechanical obstruction of cardiac muscle, yielding a decrease in cardiac output
Common causes: tension pneumothorax, cardiac tamponade, pulmonary embolism → beck’s triad, seen in cardiac tamponade: jugular vein distension + narrowing pulse pressures + muffled heart sounds
Chronic obstructive pulmonary disease
+ symptoms
haracterized by persistent, progressive airflow limitation, which arises from structural lung changes due to chronic inflammation as a result of inhaling noxious particles or gases
Categorized based on the degree of irreversible airway obstruction (emphysema) and the presence of significant inflammation (chronic bronchitis), with or without reversible airway disease (asthma)
Symptoms: dyspnea, poor exercise tolerance, chronic cough with/out sputum production, wheezing, respiratory failure or cor pulmonale
STROKES
+ common signs / symptoms
cerebral vascular accident (CVA) or stroke, should be considered in any patient presenting w acute neurologic deficit or altered mental status
Common signs / symptoms: sudden onset loss of motor or sensory control in the body, affecting primarily one side ;; loss of vision / double vision / deficits of the visual field / nystagmus ;; difficulty swallowing or speaking ;; facial droop ;; sudden difficulty walking or standing ;; sudden alteration of mental status, or decrease in level of consciousness
ischemic strokes
- definition only
ESTABLISH A TIMELINE !!! characterized by the sudden loss of blood circulation to an area of the brain, resulting in the corresponding loss of neurologic function ;; treatment within 3 hours of onset in a hospital setting is effective (but there are some treatments that are effective within 6)
hemorrhagic stroke
bleeding occurs directly into the brain tissue; one common mechanism is thought to be from damage due to chronic hypertension
More common symptoms of Hem vs Isch: severe headache, altered mental status, seizures, nausea and vomiting, and / or marked hypertension
ischemic strokes
- acute
- transient
Acute: caused by thrombotic or embolic occlusion of a cerebral artery ;; super common (approximately 85% of CVA patients)
Transient: brief episode of neurologic dysfunction caused by focal brain, spinal cord or retinal ischemia without acute infarction ;; often labeled as “mini stokes” due to relatively benign immediate consequences BUT can also indicate the likelihood of a coming stroke → approx 33% of people who have a transient ischemic stroke have a more severe stroke within the following year
migraine
+ symptoms
complex disorder characterized by recurrent episodes of headache, most often unilateral and in some cases associated w visual or sensory symptoms, aka an AURA
Symptoms: throbbing / pulsating headache that intensifies w movement or physical acticity, nausea (80% of patients) and vomiting (50%), incl anorexia and food intolerance, lightheadedness, and sensitivity to light and sound (aka photophobia)
Ventricular tachycardia
rapid heart rhythm, usually btwn 150 to 200 bpm ;; electrical activity begins in the ventricle instead of the atrium, thus there is not sufficient time for the ventricle to fill w blood, leading to a subsequent drop in blood pressure
Patients may complain of weakness or lightheadedness, or may be unresponsive
Some cases may deteriorate into ventricular fibrillatio
SWIMMING POOL SITUATIONS
Patients in diving accidents will likely have head and / or spinal injuries. These patients should be immobilized WHILE IN THE WATER prior to removal.
DROWNING PATIENTS
Inhaling small amounts of water irritates the larynx and can initiate a muscular spasm (laryngospasm) as a mechanism to prevent further entry of fluid; laryngospasm can prevent assisted ventilation
When drowning person loses consciousness, the spasm relaxes, allowing further entry of water into the lungs → after rescue, this can also obstruct assisted ventilation due to water
PROFESSIONS OF EMERGENCY HEALTHCARE:
EMR aka emergency medical responder: first trained professionals (ie police, firefighters, lifeguards) to arrive at the incident to provide initial medical assistance
EMT aka emergency medical technician: training in BLS (ie AED), use of definitive airway adjuncts, and the assistance of patients w certain meds
AEMT aka advanced EMT: training in specific aspects of ALS (ie intravenous therapy and administration of certain emergency meds)
Paramedic: extensive training in ALS (ie endotracheal intubation, emergency pharmacology, and cardiac monitoring)
PREGNANCY SITUATIONS
- when should you deliver at scene
- multigravida vs primigravida
- patient without urge to push
Delivery at the scene should be considered when delivery is imminent (ie crowning is present) or if transport is delayed by external factors (ie natural disaster, inclement weather)
Multigravida (previous pregnancy / ies) patients are more likely to have a short labor than those who are primigravida (first pregnancy)
A patient without an urge to push or who had a recent water breaking or bloody show is unlikely to have an imminent delivery; they are more likely in the first stage of labor (before full dilation of the cervix)
PREGNANCY SITUATIONS
- limb presentation
- prolapsed cord
- meconium
Limb presentation cannot be delivered in the field and requires surgical intervention ;; prolapsed cord (umbilical cord is the first presenting part) also requires hospital intervention
Meconium is the amniotic fluid that may lead to aspiration by the baby during delivery ;; indicated by the amniotic fluid being greenish ;; receiving hospital should be informed of the presence of meconium in the amniotic fluid
STAGES OF LABOR
First: uterine contractions and dilation of cervix; ends when cervix is fully dilated
Second: delivery of baby
Third: delivery of placenta
TYPES OF PREGNANCIES, or issues w pregnancies
- ectopic
- placenta previa
pregnancies usually last about forty weeks or nine months (normal gestation period)
Ectopic: pregnancy that occurs outside the uterus (most commonly in the fallopian tubes); medical emergency and should be evacuated in a hospital setting
- Risk factors: history of pelvic inflammatory disease, tubal ligation, previous ectopic pregnancy
- Symptoms: internal bleeding, sudden / severe unilateral lower abdominal pain
Placenta previa: development of the placenta over the cervical → heavy vaginal bleeding is common BUT abdominal pain is rare
TYPES OF PREGNANCIES, or issues w pregnancies
- preeclampsia
- nuchal cord
Preeclampsia: possible complication during pregnancy, typically found in primigravida patients; can develop after the twentieth week of gestation and is characterized by severe hypertension, headaches, visual abnormalities, edema, and anxiety → can progress into eclampsia, which is defined by the onset of seizures due to hypertension
Nuchal cord: umbilical cord wrapped around a baby’s neck on delivery; typically can be gently slipped over the baby’s head BUT if the cord is wrapped too tightly, the baby could be strangled, thus cord should be clamped in two places about two inches apart and cut btwn the clamps → delivery must be expedited as the baby will be no longer be receiving oxygen from the delivering mother
TYPES OF PREGNANCIES, or issues w pregnancies
- prolapse of umbilical cord
Prolapse of the umbilical cord: when the umbilical cord presents out of the vagina PRIOR to the fetus, thus creating a medical emergency bc the fetus’ head may compress the cord during birth and stop oxygen flow btwn the mother and fetus ;; commonly occurs early in labor after the amniotic sac ruptures
Patient should be in either a supine position w the foot of the cot raised 6-12 inches (15-30cm) higher than the head and the hips elevated on a pillow or folded sheet OR in the knee-chest position (kneeling and bent forward, face down) → these positions help keep weight of the fetus off the prolapsed cord
A sterile-gloved hand should be used to gently push the fetus’ head away from the umbilical cord; this position should be maintained until arrival at the hospital
Cord should be wrapped in a sterile towel that has been moistened w saline
High flow oxygen and rapid transport are appropriate
TYPES OF PREGNANCIES, or issues w pregnancies
- sudden infant death syndrome
Sudden infant death syndrome: death of an infant or young child that remains unexplained after the autopsy
Maternal factors: young maternal age (<20 years) ** , maternal smoking during pregnancy **, late or no prenatal care
Infant / environmental factors: preterm birth and / or low birth weight, prone sleeping position (lying flat on stomach), sleeping on a soft surface and / or with bedding accessories such as loose blankets and pillows ; bed sharing (sleeping in parent’s bed) ; overheating
HALLUCINOGENS (2)
Classic: typically produce visual and auditory hallucinations; may result in an altered sense of time and heightened sensory experiences ;; ie LSD, shrooms, peyote, DMT
Dissociative: produce feelings of detachment, such as derealization (where one is detached from reality or that things are not real) or depersonalization (the feeling that one is detached from one’s own physical body) ;; ie PCP, ketamine
SIX RIGHTS FOR ADMINISTRATION OF MEDICATION
Right client Right route Right drug Right dose Right time Right documentation
** Medical direction must be obtained for any intervention that is not allowed under standing local protocols.
Contraindications to (assisted) use of a metered dose inhaler
Inability of patient to help coordinate inhalation w depression of trigger
One of 6 rights not being “right”
Patient has already met max number of prescribed doses (as listed on medication or within local protocol)
HYPOTHERMIA
extreme loss of body heat
Early symptoms: shivering, tachypnea, may be withdrawn ;; skin may be flushed and cool
Later / more severe: bradycardia and bradypnea, more altered mental status or unresponsive; skin may be cyanotic
CPR on CHILDREN
CPR should be initiated on an infant without a palpable pulse or a pulse less than 60 bpm.
If they have a palpable pulse but are unable to breathe adequately, then the patient should be given assisted ventilations. For a child, that should be a breath every 3 to 5 seconds.
Children should be placed in a position that allows for the management of the airway.
CORE BODY TEMPERATURES
To estimate a patient’s core body temperature, one can place the back of a non-gloved hand against the skin of the patient’s abdomen.
– average about 97.7 to 99.5 degrees F
Btwn 93 and 95 degrees F: patient may present with shivering, rapid breathing, and constricted blood vessels ; may be withdrawn.
89 to 92: loss of coordination, muscle stiffness, and slowing respirations / pulse ;; confused, lethargic, sleepy
80 to 88: unresponsive in a coma-like state with a weak pulse and very slow respirations
Less than 80: severe hypothermia; may show signs / symptoms of apparent death, incl unresponsiveness and a cessation of cardiorespiratory activity (apnea and nonpalpable pulse due to cardiac dysthymia)
primary vs secondary assessment
PRIMARY ASSESSMENT: aka rapid exam; focused assessment of specific life threatening injuries which must be addressed prior to transport; should take no more than 60-90 seconds
- Head, neck, chest, abdomen, pelvis, extremities, and back
- DCAP-BTLS
SECONDARY ASSESSMENT: more detailed than rapid but takes longer
Neurological function
Pupillary response
GLASCOW COMA SCALE
evaluation tool used to determine the level of consciousness; evaluates eye opening, verbal response, and motor response ;; lower score suggests a more severe extent of brain injury
Eye opening: -- Spontaneous eye opening = 4 points Eye opening in response to speech = 3 -- In response to pain = 2 -- No response / no eye opening = 1
Verbal response:
- Responding w oriented conversation = 5
- Confused conversation 4
- Inappropriate words = 3
- Incomprehensible sounds = 2
- Not responding verbally = 1
Motor response
- Following basic commands = 6
- Responding locally to pain = 5
- Withdrawing from painful stimuli = 4
- Abnormal flexion (decorticate posturing) = 3
- Abnormal extension (decerebrate posturing) = 2
- No motor response = 1
WHAT’S ON A PATIENT CARE REPORT? (7)
Patient information and demographics
Chief complaint
Level of consciousness
At least two sets of vital signs
Objective and subjective findings on assessments
Treatment provided + patient response to it
Times of incident reporting / EMS notification / EMS arrival on scene / EMS departure from scene / EMS arrival at receiving facility / transfer of patient care
HEART VESSELS
Superior and inferior vena cava: take in deoxygenated blood from the body to the right atrium
Pulmonary artery: flow of deoxygenated blood from right ventricle to lungs
Pulmonary veins: flow of oxygenated blood from lungs to left atrium
Aorta: flow go oxygenated blood from left ventricle to body
HEART VALVES
Tricuspid valve: deoxygenated blood (from body via superior / inferior vena cavae) flows from right atrium to right ventricle
Pulmonic valve: deoxygenated blood flows from right ventricle to lungs, via pulmonary artery
Mitral valve: oxygenated blood (from lungs via pulmonary vein) flows from left atrium to left ventricle
Aortic valve: oxygenated blood flows from left ventricle to body, via aorta
TIMING OF THE HEART
Diastole: relaxation period of the cardiac cycle; ventricles are relaxed and fill w blood in preparation
Systole: contraction period; after the ventricles are filled, they contract and force the blood to the body or lungs (left and right ventricles, respectively)
define the following:
- perfusion
- systemic vascular resistance
Perfusion: circulation of blood in an organ or tissue in an adequate amount
Systemic vascular resistance: resistance to blood flow within all of the blood vessels except the pulmonary vessels
define the following:
- pericardium
- myocardium
- mediastinum
Pericardium: fibrous sac that surrounds the heart; this sac fills w blood or fluid when cardiac tamponade occurs
Myocardium: muscle tissue of the heart; membrane that lines the abdominal cavity is the peritoneum
Mediastinum: space btwn lungs that contains the heart, great vessels, esophagus, trachea, major bronchi, and many nerves
Left ventricular heart failure vs right
Left ventricular heart failure: causes fluid to back up in the lungs, which can cause pulmonary edema → signs and symptoms: dyspnea, hypoxia, crackles in the lungs
– As more fluid continues to build up, the blood further backs up into the heart – specifically the right ventricle → the most common cause of right ventricular heart failure is left ventricular heart failure
Right Ventricular heart failure: can result in JVD, hepatomegaly, portal hypertension, ascites, and peripheral edema
Splenic injury
pleen is made of delicate tissue (v vascular) and is particularly susceptible to injury, leading to severe internal bleeding
Can be indicated by left upper quadrant abdominal pain that occasionally radiates to the LEFT shoulder
If the abdomen becomes rigid / distended, the spleen may be lacerated
Lacerated liver
Lacerated liver w internal bleeding is indicated by RIGHT shoulder pain coupled w a rigid / distended abdomen
Gallbladder injury
Gallbladder injury generally causes pain in the RIGHT upper quadrant of the abdomen, just under the margin of the ribs
Tension pneumothorax
Tension pneumothorax is the buildup of air in the pleural space;; symptoms incl hypotension, shortness of breath, and tracheal deviation
the human body has how many liters of blood?
+ varying %’s of blood loss
THE HEALTHY HUMAN BODY HAS ABOUT 6 LITERS OF BLOOD AT ALL TIMES
10% loss of blood volume: generally well tolerated w resultant tachycardia
20-25%: failure of compensatory mechanisms (ie hypotension, orthostasis, decreased cardiac output)
> 40%: associated w overt shock (ie marked hypotension, decreased cardiac output, and lactic academia)
Hypovolemic shock
- causes
- signs and symptoms
- treatment
major contributor to early mortality from trauma (it’s also the number one cause of death in those under 45 years of age); result of inadequate amount of fluid or volume in the circulatory system
can have hemorrhagic or non hemorrhagic causes
Signs and symptoms: incl tachypnea; rapid, weak pulsel hypotension; altered mental status; cyanosis; and cool, clammy skin
Treatment: focus on ABCs and prompt transport
SHOCK
- early signs
- septic shock + common presentation
- cardiogenic shock + common presentation
acute widespread reduction in effective tissue perfusion, leading to hypoxia
Early signs: restlessness, agitation, anxiety
Septic shock: occurs due to a severe bacterial infection
– Common presentation: warm skin / fever ; tachycardia; hypotension
Cardiogenic shock: inability of the heart to pump sufficient blood for the needs of the body
– Common presentation: cool, clammy skin
shock
- compensated vs decompensated
- signs and symptoms of both
Compensated shock: state in which the body is able to compensate for blood loss by adjusting one or more of the three fundamentals of perfusion (heart rate, stroke volume, peripheral vascular resistance)
- Symptoms: feeling of impending doom, altered mental status, shallow / rapid breathing, shortness of breath, cool / clammy / diaphoretic skin, pallor / cyanosis, nausea / vomiting, marked thirst, tachycardia, tachypnea
- Signs: weak / rapid / absent pulse, narrowing pulse pressures, capillary refill greater than two seconds in infants / children
Decompensated Shock: occurs when the body is unable to compensate, noted by a deterioration of the patient’s condition
– Signs and symptoms: falling blood pressure, labored / irregular breathing, thready / absent peripheral pulses, dull eyes and dilated pupils, ashen / mottled / cyanotic skin, low urinary output, decreased mental status, extreme thirst, reduced body temperature
neurogenic shock
+ signs and symptoms
due to damage of the spinal cord (ie from brain conditions, tumors, pressure on the spinal cord, or spina bifida) → muscles in the walls of the blood vessels are cut from the sympathetic nervous system and the impulses that cause them to contract
– Thus, below level of injury, vessels dilate, increasing the size and capacity of the vascular system and causing blood to pool
Signs and symptoms: absence of sweating below the level of injury, bradycardia, hypotension, and warm skin
Hemodynamic instability
+ various fractures yield what amount of blood loss
primary concern in prehospital care; can be a result of fracture-related blood loss
Individual rib fracture: produces a loss of 100 to 200 mL of blood
Tibial fractures: 300 to 500 mL
Femur: easily 800 to 1000mL
Pelvic: significant blood loss of greater than 2000mL
EMERGENCY MOVES
Performed if there is a risk of serious harm or death, if there is an inability to gain access to other patients who need lifesaving care, or it life-threatening conditions cannot be assessed and/or treated
Patient should be dragged along long axis of the body, keeping the spinal column as in line as possible
It is inappropriate to wait for further assistance or use time to completely immobilize a patient onto a long backboard or scoop stretcher.
Subdural hematoma
+ symptoms
collection of blood due to rupture of “bridging veins” btwn dura mater and the arachnoid membrane (surrounding the cerebral cortex); most common type of traumatic intracranial hematoma
Clinical presentation depends on location and rate of development
Symptoms: comatose, headache, seizures, dizziness, nausea, vomiting, lethargy or excessive drowsiness, weakness, apathy, and seizures
Overstimulation of PARASYMPATHETIC NERVOUS SYSTEM does what?
- how does death occur
increases salivation, bronchorrhea, bronchospasm, sweating, abdominal pain, diarrhea, miosis, muscle paralysis, and bradycardia
ultimately, patient dies from systole ⇒ generally slows down the body
Stimulation of SYMPATHETIC NERVOUS SYSTEM does what?
produce effects opposite to parasympathetic response ;; ie constricted blood vessels causing pale / cool / clammy skin, tachycardia, increased force of heart contraction, and bronchodilation ⇒ FIGHT OR FLIGHT RESPONSE, hormone epinephrine involved, generally speeds up the body
Postictal state
period following a seizure, typically lasting five to thirty minutes, characterized by lethargy, confusion, nausea, hypertension, headache, and other symptoms of disorientation
Because of the lactic acidosis created by sustained muscular contraction, breathing typically becomes fast and deep in an effort to quickly reduce CO2 levels and compensate for changes in pH
define the following:
- aura
- status epileptics
- epilepsy
- postictal state
Aura: sensation experienced prior to a seizure, that can often serve as a warning sign that a seizure is about to occur
Status epileptics: condition in which seizures recur every few minutes or a seizure lasts longer than 30 minutes
Epilepsy: disorder in which abnormal electrical discharges occur in the brain, causing seizures and possibly unconsciousness
Postictal state: altered state of consciousness after an epileptic seizure, usually lasting btwn 5 and 30 minutes ;; characterized by drowsiness, confusion, nausea, hypertension, headache / migraine, other disorienting symptoms
Avulsion
open injury that separates various layers of soft tissue, typically btwn the subcutaneous layer and the fascia
“devolving” injury when an extensive section of skin is completely torn off the underlying tissue, severing its blood supply
Spina bifida
birth defect caused by the incomplete closure of the spinal column during fetal development, resulting in an exposed portion of the spinal cord ;; child may have spinal and neurological damage
Adequate maternal intake of folic acid reduces the risk of spina bifida
Patients may have partial or full paralysis, incontinence, and an extreme allergy to latex products
Acute myocardial infarction
vs. Angina pectoris
Both can present w chest pain. Discomfort that is typically described as pressure or heaviness, nausea / vomiting, and swearing ;; may or may not be alleviated w nitroglycerin
Acute myocardial infarction: heart muscle can be permanently damaged within 30 minutes ; can last several hours
Vs Angina pectoris: temporary chest pain associated w the heart’s need for oxygen that exceeds its supply; pain is commonly alleviated w rest and rarely lasts longer than 15 minutes
ALCOHOL
- symptoms
sedative and hypnotic, meaning it decreases activity and induces sleep (respectively) ; dulls the sense of awareness, slows reflexes, and reduces reaction times
Symptoms: respiratory depression, inadequate breathing, vomiting, internal bleeding
- severe acute alcohol ingestions can cause ____
- withdrawal + symptoms
Severe acute alcohol ingestions can cause hypoglycemia and the presentation thereof: pale, cool, moist skin (fr sweating); rapid, weak pulse; potential hypotension and shallow or ineffective breathing; altered mental status
Individuals coping with withdrawal (from alcohol) can experience delirium tremens.
– Symptoms: agitation, restlessness, sweating, tremors, confusion, disorientation, hallucinations, delusions, seizures
PATIENTS WHO CANNOT LEGALLY REFUSE TRANSPORT
Mental illness
Medical condition
Intoxication
Internal cardiac pacemaker
- what is it
- common locations
- considerations for care
device implanted beneath a patient’s skin to regulate their heart rate
– Commonly placed in non dominant side; but can also be placed in abdomen
AED and Defib paddles should NOT be placed directly over pacemakers during Defib
OVERDOSES AND THEIR SYMPTOMS
- opiate / opiod
- sedative-hypnotic
+ examples
Opiate / opiod: hypoventilation / respiratory arrest, hypotension (leading to cyanosis), pinpoint / constricted pupils, sedation / coma
– eg. Morphine, codeine, oxycodone, methadone, heroin
Sedative-hypnotic: hypoventilation, hypotension, slurred speech, sedation / coma ;; do not affect pupil diameter
– eg diazepam, secobarbital, flunitrazepam, midazolam
OVERDOSES AND THEIR SYMPTOMS
- anticholinergic
- sympathomimetic
Anticholinergic: tachycardia, hypertension, hyperthermia, dilated pupils, dry skin / mucous membranes, decreased bowel sounds, sedation / coma
– eg diphenhydramine, atropine, chloropheniramine, doxyalmine
Sympathomimetic: tachycardia, hypertension, hyperthermia, dilated pupils, agitation or seizures
– eg epinephrine, albuterol, cocaine, [meth]amphetamine
Supplemental oxygen should be administered to patients experiencing
signs of myocardial infarction or shock
when they have signs of heart failure
Are short of breath
Have an oxygen saturation less than 94% on room air
Dislocation
+ signs / symptoms
occurs when the bone ends within a joint are no longer in contact due to the tearing of supporting ligaments
Signs and symptoms: marked deformity, swelling, pain with movement, tenderness on palpation, loss of joint motion, and numbness or impaired circulation to the imp or digit
Note that some of the signs and symptoms may be seen in alternate conditions, ie sprains, fractures, etc
Retinal detachment
+ early symptoms
requires prompt surgical intervention; retina is pulled away from the choroid (thin layer of vessels that supply nutrients and oxygen to the retina) ;; PAINLESS
Early symptoms: include sudden increase or change in floaters, flashes of light (photopsia), description of a “curtain” or “veil” falling across the visual field, and blurred vision
Permanent vision loss is possible
Cataracts vs Macular degeneration
- risk factors
clouding of the visual lenses; causes interference with vision, decreased tear production, and difficulty distinguishing colors and seeing clearly
Macular degeneration: most common cause of irreversible central vision loss in elderly patients
Risk factors: smoking, hypertension, obesity, sun exposure, diet low in omega-3 fatty acids, and/or dark green leafy vegetables
Intracranial pressure (ICP)
- what is it
- when does it become dangerous
- indications
Intracranial pressure (ICP) is increased by the accumulation of blood within the skull or swelling of the brain. As ICP increases, blood pressure must also rise, otherwise cerebral ischemia will result. Prompt recognition of ICP is critical.
Indications of increased ICP: Irregular breathing / Bradycardia / widened pulse pressure / headache / nausea / vomiting / altered mental status / sluggish or absent pupillary response / decerebrate posturing
Also Cushing’s Triad (increased systolic / mean arterial blood pressure, Bradycardia, irregular respiration) signifies increased ICP.
Cushing’s Triad
increased systolic / mean arterial blood pressure, Bradycardia, irregular respiration
Suctioning must not be done for more than ___ seconds for a ____
15 seconds for an adult
10 seconds for a child
5 seconds for an infant
ASPIRIN
- what is it / what does it do
- pros
- cons
- what is its opposite
non selectively and irreversibly inhibits cycloosygenase, thereby reducing platelet aggregation and producing anti-inflammatory effects
Significantly reduces risk of having another heart attack or stroke, or of dying from cardiovascular disease in patients who have had such before
Adverse effects: GI pain, ulceration, bleeding, hepatoxicity, hearing loss, nausea
** Nitroglycerin is able to fully reverse aspirin-induced collateral vasoconstriction and restore flow to the baseline levels.
Hyperventilation as controversial
controversial treatment sometimes used in patients who have a brainstem herniation (potentially deadly side effect of very high pressure within the skull that occurs when a part of the brain is squeezed across structures within the skull)
Should only be performed if allowed by local protocols
Waveform capnography should be available to ensure that end-tidal carbon dioxide levels are between 30 and 35 mmHg while hyperventilating
An appropriately sized sphygmomanometer will …
- what about obese patients
- when is it not appropriate to use a BP cuff
wrap around the arm 1 to 1.5 times and take up two-thirds the length from the armpit to the crease in the elbow; an inaccurate blood pressure reading may occur if a sphygmomanometer is inappropriately sized
Thigh sized sphygmomanometer is used in obese patients, patients w exceptionally well developed arm muscles, or to take a blood pressure reading of the thigh in patients who have injuries to both arms
Is it not appropriate to avoid obtaining a BP reading over an injury due to the possibility of increasing damage to the affected area
ALLERGIC REACTION; signs and symptoms (20)
Chest tightness Tachycardia Rapid / labored breathing Itchy / red skin Sneezing Rhinorrhea Dyspnea Persistent cough Hoarseness Wheezing / stridor Hypotension Flushing Cyanosis / pallor Tingling sensations Altered mental status Anxiety Gastrointestinal complaints Headache Itchy / watery eyes Dizziness
SEIZURES
neurological episode caused by a surge of electrical activity in the brain
usually but not always accompanied by an aura (ie visual changes or hallucinations)
some patients w a history of seizures actually know their auras and take steps to prevent / prepare for the seizure
Generalized seizures
- definition only
- absence seizures
patient may exhibit bilateral muscle movement characterized by a cycle of muscle rigidity and relaxation usually lasting 1 to 3 minutes
– The patient exhibits tachycardia, hyperventilation, sweating, and intense salivation.
Absence seizures: aka petit mal seizure; most common in children under 14; feelings of being disconnected from others around you, without responding to them; stare blankly into space and eyes might roll back into their head
Generalized seizures
- tonic clonic
Tonic clonic seizures: aka grand mal seizure; may / may not be preceded by an aura; often followed by headache, confusion, and sleep
- Tonic: entire body becomes rigid
- Clonic: uncontrolled jerking
Generalized seizures
- febrile
Febrile seizures: common in children btwn six months and six years of age; characterized by generalized tonic-clonic seizure, do not last longer than 15 minutes, have a short / absent postictal phase → assessment and treatment of ABCs, cooling measures, and rapid transport are appropriate
– Children often refuse an oxygen mask, so the blow-by method (in which the responders / guardians may have to hold the mask in front of the child’s face) may be used
Partial seizures
- simple
- complex
Simple partial seizure
- No change in the patient’s level of consciousness
- Patients may have numbness, weakness, dizziness, visual changes, or unusual smells and tastes
- May also cause some twitching or brief paralysis
Complex partial seizure
- The patient has an altered mental status and does not interact normally with his or her environment.
- Results from abnormal discharges from the temporal lobe of the brain
- Other characteristics may be lip smacking, eye blinking, and isolated jerking.
- Patients also may experience unpleasant smells and visual hallucinations, exhibit uncontrollable fear, or perform repetitive physical behavior.
Viral Hepatitis
+ symptoms
referring to the inflammation of the liver → A / B / C viruses can all result in acute disease, presenting w nausea / abdominal pain / fatigue / malaise / jaundice
Symptoms: right upper quadrant pain and jaundice (yellowing of skin and sclera of eyes)
inhalation vs exhalation
Inhalation: active process; diaphragm and intercostal muscles contract, increasing the size of the thoracic cavity, creating a negative pressure space, thus pushing air into the lungs
Exhalation: passive process; diaphragm and intercostal muscles relax, decreasing the size of the thoracic cavity, creating a positive pressure space, thus pushing air out of the lungs
BURNS
- superficial
- partial thickness
- full thickness
Superficial: involves epidermis; skin will turn red but does not blister; burn site can be quite painful → ie sunburn
Partial-thickness: involves epidermis and some portion of the dermis; skin is moist, mottled, and white to red ;; blisters are common ;; cause intense pain when air currents pass over the burned surface
– Gently cover burn area with clean sheets to relieve pain and deflect air currents
Full thickness burns: extend thru all skin layers and may involve the subcutaneous tissue, muscle, bone, or internal organs ;; skin is dry and leathery, may appear white / dark / brown / even charred ;; some full thickness burns are hard to the touch
– If the nerve endings are destroyed, the severely burned section may not have sensation, while the surrounding area is extremely painful
Flail chest
- indicators
- treatment
occurs when a segment of the chest well does not have bony continuity with the rest of the thoracic cage (ie when two or more ribs are broken in two or more places)
Indicators: dyspnea and hypoxia in a patient with significant mechanism of injury and chest trauma; paradoxical movement of the chest
Treatment: airway / ventilation support, oxygen supplementation, assessment for a possible pneumothorax and other respiratory complications
IN A SITUATION WITH MULTIPLE PATIENTS, how do you tag them based off priority?
Immediate priority patients: RED TAG ; those w airway / breathing compromise, uncontrolled / severe bleeding, severe medical conditions, signs of shock, severe burns, or open chest / abdominal injuries
Delayed priority: YELLOW TAG; those w burns without airway compromise, major / multiple bone / joint injuries, or back injuries (with or without spinal cord damage)
Minimal priority: GREEN TAG ; those w minor fracture or minor soft tissue injuries
Expectant: BLACK TAG ; those who are obviously dead, have an obviously non survivable injuries (ie major open brain trauma), respiratory arrest (if resources are limited), or cardiac arrest
Congestive heart failure
+ indicators
when damaged ventricular heart muscles are no longer able to keep up w the return flow of blood from the atria; thus blood backs up in the pulmonary veins, causing lung congestion and subsequence pulmonary edema
Indicators: tachycardia / hypertension / tachypnea / dyspnea that is alleviated when sitting up ;; retractions ;; rales heard on lung auscultation ;; chest pain / distended neck veins / peripheral edema ;; pale / cyanotic / sweaty skin
Emphysema + indicators
type of COPD (chronic obstructive pulmonary disease); loss of elastic material within the alveolar air space ;; more common than chronic bronchitis
Indicators: adventitious breath sounds (ie crackles, rhonchi, wheezing) ay be heard on auscultation ;; chronic cough / chronic sputum / long expiration phases
Chronic renal failure
may present w lethargy, nausea, headaches, cramps, and extremity edema if untreated → may progress to seizures or coma in later stages
Pancreatitis
+ causes
+ indicators
inflammation of the pancreas ;; commonly presents with upper left and right quadrant pain
Causes: gallstones, alcohol abuse, disease
Indicators: nausea, vomiting, abdominal distension, tenderness
Appendicitis
+ indicators
commonly presents w localized right lower quadrant pain
Indicators: nausea, vomiting, anorexia, fever, chills, and rebound tenderness
Tuberculosis
communicable disease that primarily affects the lungs; most common sign is a cough and is most commonly spread via airborne transmission
An N95 or HEPA mask should be used by providers treating patients with suspected or obvious tuberculosis; any patient with tuberculosis shuold be provided with a surgical mask.
Infection is typically not serious in patients older than one year of age → after primary infection, the bacillus is rendered dormant
HOWEVER, reactivation is common and more difficult to treat
Ranges of Respiration by Age
Ages 0 to 12 months: 30 to 60 breaths per minute
Ages 1 to 3 years: 24 to 40 bpm
Ages 4 to 5 years: 22 to 34
Ages 6 to 12 years: 18 to 30
Ages 13 to 18: 12 to 16
Ages 18 and up: 12 to 20
Severe dehydration in infants may present with … (7)
Very dry gums / lips Sunken eyes Loose skin without elasticity Sunken fontanelle Lethargy Irritability Refusal of bottles
WHAT POSITION SHOULD MY PATIENT BE IN?
Shock patients should be placed in the supine position
Blunt force patients should have cervical spine immobilization.
Patients with chest pain or respiratory distress but no suspected injury or hypotension should be placed in a position of comfort, commonly the Fowler or semi-Fowler position
** no patient should ever be in the prone position
Common reasons for inaccurate pulse oximetry reading (6)
Hypovolemia Severe peripheral vasoconstriction Time delay in detecting respiratory insufficiency Dark / metallic nail polish Dirty fingers Carbon monoxide poisoning
TYPES OF HEAD TRAUMA
- definition
any patients with head trauma should be transported to a hospital with a dedicated trauma team, if feasible, bc this is associated with significantly better outcomes
TYPES OF HEAD TRAUMA
- subdural hematoma
- what is it
- at risk populations
typically occurs with a sudden acceleration/deceleration injury, and tearing of the bridging veins of the dura, resulting in a hematoma btwn the dura mater and the arachnoid → commonly venous injuries, thus will present more slowly; acute symptoms develop gradually 1-2 days after the initial injury
Due to MOI, will typically have accompanying parenchymal damage
Elderly and alcoholics tend to have more extensive brain atrophy, and are more susceptible to development of acute SDH
Children under 2 years of age are also at increased risk
Immediate evaluation is critical, as diagnosis is based on CT scan
TYPES OF HEAD TRAUMA
- epidural hematoma
results from collection of blood in the potential space btwn the skull and dura mater
Main MOI: blunt trauma to temporal or temporoparietal area w an associated skull fracture, w disruption of the middle meningeal artery
Classic presentation: significant blunt trauma w loss of consciousness or altered mental status, followed by a “lucid interval” of indeterminate duration; the patient then quickly declines in status, w a rapid neurologic demise → while the “lucid interval” is regularly taught to healthcare practitioners, this “classic” presentation occurs in a minority of cases
High Pressure arterial bleeding can lead to herniation of the brain within hours after injury
TYPES OF HEAD TRAUMA
- basilar skull fracture
associated w high energy trauma and occurs following diffuse impact to the head
– Signs and symptoms: incl cerebrospinal fluid draining from the ears, “raccoon eyes” or a battle sign (ecchymosis behind one ear over the mastoid process) → may not occur until 24 hours after the incident
TYPES OF HEAD TRAUMA
- concussion
milk traumatic brain injury, leading to impairment of brain function without overt hemorrhage or gross lesion, and results in a GCS score of 14 or 15
Signs and symptoms: confusion and alterations in consciousness ; patient may refer to the incident in terms of having had their “bell rung” or “seeing stars”
Increased risk for serious injury is indicated by: vomiting, headache, loss of consciousness, focal neurologic deficit, or a dangerous MOI
Kidneys
anterior to the costovertebral angle; tenderness in that area is common in patients with kidney insult
If blood loss is significant, patient may show signs of shock
Due to uncertainty of diagnosis in patients with hematuria and flank pain, rapid transportation is appropriate
Atherosclerosis
buildup of plaque, formed by cholesterol, within the walls of blood vessels, obstructing flow and interfering w their ability to dilate or contract ;; obstruction can form a complete occlusion, leading to acute coronary syndrome or acute myocardial infarction
Pleural effusion
- what is it
- common causes
- symptoms
- what makes patients feel better
collection of fluid around the lung(s)
Common causes: irritation, infection, congestive heart failure, and cancer
Can build up over days or weeks → can compress the lungs, causing dyspnea
Breath sounds may be DECREASED in affected region
Patients often feel better if they are sitting upright
Hyperventilation as a medical condition
overbreathing to the point of lower-than-appropriate level of arterial carbon dioxide
May occur due to an elevated level of CO2 such as in diabetic ketoacidosis, overdose of aspirin, or severe infection
May also occur with anxiety, dizziness, numbness / tingling and painful spasms in the hands and feet → aka hyperventilation syndrome (panic attack)
Treatment: instruct a responsive patient ot slow his or her breathing, giving supplemental oxygen, and providing transport
Vagus nerve stimulation
- vasal vagal response
ability of the GI tract to move feces thru the system slows w age, thus older patients may often have to strain to complete a bowel movement
– This straining may cause stimulation of the vagus nerve, causing a vasovagal response
Vasovagal response: drop in heart rate with dizziness or passing out
Patients are stable but should be worked up for alternative causes to their symptoms
WHICH PULSE SHOULD I ASSESS?
Brachial pulse is assessed in an infant to determine pulse rate; CPR should be initiated on an infant without a palpable pulse or a pulse of fewer than 60 bpm
Carotid or femoral pulse are NOT TYPICALLY palpable in a child less than one year of age
Radial pulse is NOT USED to assess the need for CPR in ANY AGE group
define the following:
- pelvic binders
- air splints
- traction splints
PELVIC BINDERS: simple devices for rapid reduction and stabilization of pelvic ring disruptions; designed to reduce hemorrhage, vascular disruption, and pain as well as provide temporary stabilization until definitive immobilization can be completed
VS. AIR SPLINTS: type of formable splint that are used to stabilize injuries below the elbow or knee
VS. TRACTION SPLINTS: used to pull a body structure in the direction of its normal alignment
Improper splinting complications (5)
reduction of distal circulation
Compression of nerves / tissues / blood vessels
Delay in transporting
Further aggravation of injuries
Injuries as a result of excessive movement of the splinted area
Aspiration of a foreign body may …
Aspiration of a foreign body may lodge in the larynx or trachea and can be a life-threatening emergency if the object is large enough to cause a complete obstruction of the airway.
Smaller objects create less obstruction and may pass beyond the carina, resulting in less severe signs
– Most likely to enter the right main bronchus
