After completing this chapter and related coursework, you will understand the anatomy and physiology, including the developmental changes during puberty and menopause, of the female reproductive system and identify and describe assessment and treatment for gynecologic emergencies. Special considerations and precautions that an EMT must observe when arriving at the scene of a suspected case of sexual assault or rape are also discussed.

National EMS Education Standard Competencies

Medicine

Applies fundamental knowledge to provide basic emergency care and transportation based on assessment findings for an acutely ill patient.

Gynecology

• Recognition and management of shock associated with

Vaginal bleeding

• Anatomy, physiology, assessment findings, and management of

Vaginal bleeding
Sexual assault (to include appropriate emotional support)
Infections

Knowledge Objectives

1. Describe the anatomy and physiology of the female reproductive system; include the developmental changes that occur during puberty and menopause.

2. Discuss the special, age-related patient management considerations EMTs should provide for both younger and older female patients who are experiencing gynecologic emergencies.

3. List three common examples of gynecologic emergencies; include the causes, risk factors, assessment findings, and patient management considerations.

4. Explain how an EMT would recognize conditions associated with hemorrhage during pregnancy.

5. Discuss the assessment and management of a patient who is experiencing a gynecologic emergency; include a discussion of specific assessment findings.

6. Explain the general management of a gynecologic emergency in relation to patient privacy and communication.

7. Give examples of the personal protective equipment EMTs should use when treating patients with gynecologic emergencies.

8. Discuss the special considerations and precautions EMTs must observe when arriving at the scene of a suspected case of sexual assault or rape.

9. Discuss the assessment and management of a patient who has been sexually assaulted or raped; include the additional steps EMTs must take on behalf of the patient.

Skills Objectives

There are no skills objectives for this chapter.

I. Introduction

A. Women are uniquely designed to conceive and give birth.

1. Women are susceptible to a number of problems that do not occur in men.

II. Anatomy and Physiology

A. The female reproductive system includes internal and external structures.

B. External female genitalia $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\Ch23\9781284080179_CH23_CP01.jpg$

1. The vaginal opening is just posterior to the urethral opening.

2. The labia majora and labia minora are folds of tissue that surround the urethral and vaginal opening.

3. The clitoris is at the anterior end of the labia.

4. The anus is at the posterior end of the labia.

5. The perineum is the area of skin between the vagina and the anus.

C. Internal structures $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\Ch23\9781284080179_CH23_CP02.jpg$

1. The ovaries are the primary female reproductive organs.

2. Ovaries lie on each side of the lower abdomen and produce an ovum (egg).

a. A fetus develops from a fertilized ovum.

3. Fallopian tubes connect each ovary with the uterus.

4. The uterus is the muscular organ where the fetus grows during pregnancy.

a. The narrowest part of the uterus is the cervix, which opens into the vagina.

5. The vagina is the outermost cavity of a woman’s reproductive system.

a. It forms the lower part of the birth canal.

b. Serves as a passage for the fetus during delivery

c. It is an outlet for blood during menstruation.

D. When a female reaches puberty, she begins to ovulate and experience menstruation.

1. The onset of menstruation is called menarche.

a. It usually occurs between age 11 and 16 years.

b. Any female who reaches menarche is capable of becoming pregnant.

E. Women continue the cycle of ovulation and menstruation until they reach menopause.

1. Menopause marks the end of menstrual activity and usually occurs around age 50.

F. Each ovary produces an ovum in alternating months.

1. Each month one ovum is released into the fallopian tube.

2. This process is called ovulation.

a. Some women experience minor cramping pain during this release period.

G. The process of fertilization begins in the vagina.

1. Sperm are deposited into the vagina from the male penis.

a. Sperm pass through the cervix into the uterus and eventually up the fallopian tubes.

b. When an ovum is fertilized in the fallopian tube, the developing embryo travels into the uterus.

c. The embryo attaches to the uterine wall and continues to grow.

H. If fertilization does not occur within about 14 days of ovulation, the lining of the uterus begins to separate, and menstruation occurs.

1. The menstrual flow consists of blood from the separated lining of the uterus and lasts about 1 week.

2. Female hormones, produced primarily in the ovaries, control the process of ovulation and menstruation.

III. Pathophysiology

A. The causes of gynecologic emergencies are varied, ranging from sexually transmitted diseases to trauma.

1. You should recognize and properly manage female patients with any kind of abdominal or pelvic pain.

B. Pelvic inflammatory disease (PID)

1. Infection of the upper organs of reproduction

a. Uterus, ovaries, fallopian tubes

b. Occurs almost exclusively in sexually active women

i. Disease-causing organisms enter the vagina and migrate into the uterine cavity.

c. If infection expands to fallopian tubes, it will cause scarring.

i. Can result in increased risk of ectopic pregnancy or sterility

ii. Ectopic pregnancy is pregnancy that develops outside the uterus and can be life threatening.

d. If infection expands to ovaries, it can lead to the development of a life-threatening abscess.

2. Most common presenting sign of PID is generalized lower abdominal pain.

a. Other signs include abnormal or foul-smelling vaginal discharge, increased pain with intercourse, fever, general malaise, and nausea and vomiting.

C. Sexually transmitted diseases (STDs)

1. STDs can lead to more serious conditions, such as PID.

2. Chlamydia

a. Most common STD in the United States

b. Caused by bacteria

c. Usually mild or absent symptoms

d. Some women may report lower abdominal pain, low back pain, nausea, fever, pain during sexual intercourse, or bleeding between menstrual periods.

e. Infection of the cervix can spread to the rectum and can progress to PID.

2. Bacterial vaginosis

a. The most common vaginal infection to afflict women ages 15–44 years

b. Normal bacteria in the vagina are replaced by an overgrowth of other bacteria.

c. Symptoms include itching; burning; pain; and a fishy, foul-smelling discharge.

d. Untreated, it can lead to premature birth or low birth weight in case of pregnancy, make the patient more susceptible to other serious infections, and cause PID.

3. Gonorrhea

a. Caused by bacteria that grow and multiply rapidly in warm, moist areas of reproductive tract

i. Cervix, uterus, fallopian tubes in women

ii. Urethra in men and women

b. Bacteria can also grow in the mouth, throat, eyes, and anus.

c. Symptoms are more severe in men than women.

d. Women may present with painful urination, burning or itching, yellowish or bloody vaginal discharge, and blood associated with sexual intercourse.

e. Severe infections present with cramping and abdominal pain, nausea, vomiting, and bleeding between periods.

i. These symptoms indicate it has progressed to PID.

f. Untreated, it can enter the bloodstream and spread to other parts of the body, including the brain.

D. Vaginal bleeding

1. Bleeding may be considered menstrual bleeding and overlooked.

2. Possible causes include:

a. Abnormal menstruation

b. Vaginal trauma

c. Ectopic pregnancy

d. Spontaneous abortion

e. Cervical polyps

f. Cancer

g. Rape

IV. Patient Assessment

A. Obtaining an accurate and detailed assessment is critical when dealing with gynecologic issues.

1. You will be able to gain only a primary impression of the problem in the field, but thorough patient assessment will help determine how sick the patient is and whether lifesaving measures are needed.

a. “Anyone who neglects to consider a gynecologic cause in a woman of childbearing age who complains of abdominal pain will miss the diagnosis at least 50% of the time.”

B. Scene size-up

1. Scene safety

a. Is the scene safe?

i. Will you need assistance?

ii. How many patients do you have?

iii. What is the nature of the illness?

iv. Have you taken standard precautions?

b. Gynecologic emergencies can involve large amounts of blood and body fluids potentially contaminated with organisms that can cause communicable diseases.

c. Where or in what position is the patient found?

d. If she is at home, what is the condition of the residence?

i. Is it clean, filthy, or wrecked?

ii. Do you see evidence of a fight?

iii. Are alcohol, tobacco products, or drug paraphernalia present?

iv. Does the patient live alone or with other people?

e. If at a crime scene, you may be required to testify in court regarding conditions on your arrival. Your documentation needs to be accurate and thorough.

f. Involve the police if any type of assault is suspected.

g. In cases of sexual assault, it is important to have a female EMT to provide patient care.

2. Mechanism of injury (MOI)

a. The MOI in some patients with gynecologic problems may be easily understood from the dispatch information, such as sexual assault.

b. In other patients, patient history may reveal the nature of the condition.

C. Primary Assessment

1. Form a general impression.

a. Is the patient stable or unstable?

b. Use the AVPU scale to determine the patient’s level of responsiveness.

2. Airway and breathing

a. Always evaluate the airway and breathing immediately to ensure they are adequate.

3. Circulation

a. Palpate a pulse and evaluate skin color, temperature, and moisture to help identify blood loss in a patient.

b. If there is significant blood loss, the patient may not be demonstrating obvious signs of shock, but may still be hypovolemic.

4. Most cases of gynecologic emergencies are not life threatening

a. If a patient has signs of shock; a weak or rapid pulse; or pale, cool, or diaphoretic skin, then rapid transport is warranted.

D. History taking

1. Investigate chief complaint.

a. Some questions may be extremely personal to the patient.

i. Be sensitive to the patient’s feelings and protect her privacy and dignity.

b. An adolescent girl may want to keep her sexual history private.

2. For abdominal pain, ask about onset, duration, quality, and radiation; provoking or relieving factors; and associated symptoms such as syncope, lightheadedness, nausea, vomiting, and fever.

3. For vaginal bleeding, ask about onset, duration, quantity (number of sanitary pads soaked), and associated symptoms such as syncope and lightheadedness.

4. SAMPLE history

a. Make a note of any allergies or medications she may be taking.

i. Birth control pills and devices

b. Ask patients about medical conditions and the last menstrual period.

i. This will help determine possible pregnancy.

ii. Also ask about the possibility of STDs.

E. Secondary assessment

1. Secondary assessment may be performed on scene; en route to the emergency department; or, if time is limited, not at all.

2. Pertinent secondary assessment findings should include:

a. Vital signs: blood pressure, pulse, skin color, orthostatic vital signs

b. Abdomen: distention and tenderness

c. Genitourinary: visible bleeding

d. Neurological: mental status

3. Physical examinations

a. Should be limited and professional

i. Only examine the genitalia if it is necessary to do so to treat the patient.

ii. Protect the woman’s privacy.

iii. Few women are comfortable with having their body exposed.

(a) Limit the personnel present.

(b) Be an advocate for her modesty.

b. Focus your physical examination on the NOI and the patient’s chief complaint.

c. For vaginal bleeding: visualize the bleeding and ask about quality and quantity.

i. Use external pads to control vaginal bleeding.

ii. Keep the possibility of hypoperfusion or shock in mind.

iii. Always ask if there is pain associated with the bleeding.

iv. Never insert anything into the vagina to control bleeding, even a tampon.

d. Observe vaginal discharge.

i. Make observations about the discharge.

e. Fever, nausea, and vomiting are considered significant in gynecologic emergencies.

f. Syncope is considered significant; treat as being in shock until proven otherwise.

3. Vital signs

a. Assess the patient’s:

i. Heart rate, rhythm, and quality

ii. Respiratory rate, rhythm, and quality

iii. Skin color, temperature, and condition

iv. Capillary refill time

v. Blood pressure

vi. Consider obtaining orthostatic vital signs if bleeding is known or suspected.

vii. Pay special attention to the presence of tachycardia and hypotension.

(a) Could indicate hemorrhagic shock

4. Monitoring devices

a. Use pulse oximetry.

b. Consider using noninvasive blood pressure monitoring to continuously track a patient's blood pressure.

i. It is always recommended to assess the patient’s first blood pressure with a sphygmomanometer and stethoscope.

F. Reassessment

1. Repeat the primary assessment.

a. Reassess the patient’s vital signs and the chief complaint.

b. Identify and treat any changes in the patient’s condition.

c. Pay specific attention to the needs of your patient.

i. Accommodate her desire for conversation or silence.

2. Interventions

a. There are very few interventions with a gynecologic emergency.

b. For vaginal bleeding:

i. Treat for hypoperfusion or shock.

ii. Keep the patient warm.

iii. Place the patient in a supine position.

iv. Provide supplemental oxygen.

v. Consider ALS intercept for fluid replacement.

vi. Transport promptly to hospital.

3. Communication and documentation

a. Communicate all relevant information to the staff at the receiving hospital, including the possibility of pregnancy

b. Carefully document everything, especially in cases of sexual assault.

i. Patient’s condition

ii. Chief complaint

iii. Scene

iv. All interventions

V. Emergency Medical Care

A. Maintain the patient’s privacy as much as possible.

1. If in a public place, move her to the ambulance.

2. Have a female EMT participate in the patient’s care if possible.

B. Excessive internal vaginal bleeding

1. Determining the cause of bleeding is of less importance than treating the patient for shock and transporting her.

2. Most women will use sanitary pads to control bleeding before you arrive.

3. Use sanitary pads on the external genitalia to absorb the blood.

4. Document the number of sanitary pads that were saturated with blood.

5. If the woman has a tampon in place, it is not necessary for it to be removed.

C. The external genitals have a rich nerve supply.

1. This makes injuries to the area very painful.

2. Treat external lacerations, abrasions, or tears with sterile compresses.

a. Use local pressure to control bleeding.

b. Use a diaper-type bandage to hold dressings in place.

c. Under no circumstances should you pack or place dressings in the vagina.

VI. Assessment and Management of Specific Conditions

A. Pelvic inflammatory disease (PID)

1. A patient with PID will complain of abdominal pain.

a. Pain usually starts during or after normal menstruation.

i. Inquiring about the date of last menstrual period is important.

b. The pain may be made worse by walking. Patients often present with a distinctive gait that appears as a shuffle.

2. Prehospital treatment is limited.

3. Non Emergency transport is usually recommended.

a. PID itself is seldom a threat to life but it is serious enough to require transport and evaluation in the hospital.

B. Sexual assault

1. Sexual assault and rape are common in the United States.

a. One in five women have reported being raped.

b. One in four women will be sexually molested, often before the age of 12 years.

2. EMTs called on to treat a victim of sexual assault face many complex issues.

a. Issues range from obvious medical ones to serious psychological and legal issues.

3. You may be the first person the victim has contact with after the encounter.

a. How you manage the situation may have lasting effects both for the patient and for yourself.

b. Professionalism, tact, kindness, and sensitivity are important.

c. If necessary to allay fear, let the patient know that the ambulance is a safe space.

4. When performing your assessment, be aware of drugs used during sexual assault or rape to incapacitate a person.

a. Inability to remember the event should create suspicion.

b. If these drugs are still in the patient’s system, you may see hypotension, bradycardia, abdominal complaints, difficulty breathing, seizures, coma, and even death.

5. You can generally expect law enforcement involvement.

6. Attempts to immediately gather a detailed report from the victim may cause her to “shut down.”

7. If possible, give the patient the option of being treated by a female EMT.

8. Your focus:

a. Medical treatment of patient

i. Is she physically injured?

ii. Are any life-threatening injuries present?

iii. Does the patient complain of any pain?

b. Psychological care of patient

i. Do not pass judgment on the patient.

ii. Protect her from judgment of others on scene.

c. Preserve evidence

i. Do not cut through any clothing.

ii. Do not throw away anything from the scene.

iii. Place bloodstained clothing and anything else that could be evidence in separate paper bags.

9. It may be necessary to persuade the patient not to clean herself.

a. Doing so can destroy evidence.

b. Patient should also be discouraged from urinating, changing clothes, moving her bowels, or rinsing out her mouth.

c. She will be photographed and examined by nurses trained in sexual assault examination and management.

10. Offer to call the local rape crisis center for the patient.

a. Getting a professional advocate to the scene may help the patient deal with the trauma.

11. Take the patient’s history and limit any physical examination to a brief survey for life-threatening injuries.

12. The patient report is a legal document and may be subpoenaed.

a. Keep the report concise, and record only what the patient stated in her own words.

i. Do not insert your own opinion.

ii. Use quotation marks when reporting the patient’s version of events.

iii. Focus on the facts.

b. Bear in mind that rape is a legal diagnosis, not a medical diagnosis.

$\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\Ch23\9781284080179_CH23_CPT01.jpg$

Chapter 24, Trauma Overview

Unit Summary

After completing this chapter and related coursework, you will have an understanding of the basic concepts of energy and its effect on the human body; the general injury patterns associated with different types of impacts, falls, and penetrating trauma; and the basic application of laws of physics on the assessment of trauma patients. You will begin to demonstrate critical thinking in making predictions of injuries and adjusting index of suspicion based on the analysis of evidence gathered in scene size-up simulations. You will also understand some common injury patterns to major body systems.

National EMS Education Standard Competencies

Trauma

Applies fundamental knowledge to provide basic emergency care and transportation based on assessment findings for an acutely injured patient.

Trauma Overview

Pathophysiology, assessment, and management of the trauma patient

• Trauma scoring

• Rapid transport and destination issues

• Transport mode

Multisystem Trauma

Recognition and management of

• Multisystem trauma

Pathophysiology, assessment, and management of

• Multisystem trauma

• Blast injuries

Knowledge Objectives

1. Define the terms mechanism of injury (MOI), blunt trauma, and penetrating trauma.

2. Explain the relationship of the MOI to potential energy, kinetic energy, and work.

3. Provide examples of the MOI that would cause blunt and penetrating trauma to occur.

4. Describe the five types of motor vehicle crashes, the injury patterns associated with each one, and how each relates to the index of suspicion of life-threatening injuries.

5. Discuss the three specific factors to consider during assessment of a patient who has been injured in a fall, plus additional considerations for pediatric and geriatric patients.

6. Discuss the effects of high-, medium-, and low-velocity penetrating trauma on the body and how an understanding of each type helps EMTs form an index of suspicion about unseen life-threatening injuries.

7. Discuss primary, secondary, tertiary, and miscellaneous blast injuries and the anticipated damage each one will cause to the body.

8. Describe multisystem trauma and the special considerations that are required for patients who fit this category.

9. Explain the major components of trauma patient assessment; include considerations related to whether the method of injury was significant or nonsignificant.

10. Discuss the special assessment considerations related to a trauma patient who has injuries in each of the following areas: head, neck and throat, chest, and abdomen.

11. Explain a general overview of multisystem trauma patient management.

12. Explain trauma patient management in relation to scene time and transport selection.

13. List the Association of Air Medical Services criteria for the appropriate use of emergency air medical services.

14. List the American College of Surgeons’ Committee on Trauma classification of trauma centers.

15. Explain the American College of Surgeons Committee on Trauma and the Centers for Disease Control and Prevention field triage decision scheme as it relates to making an appropriate destination selection for a trauma patient.

Skills Objectives

There are no skills objectives for this chapter.

I. Introduction

A. For people younger than age 44 years, traumatic injuries are the leading cause of death in the United States.

1. Proper prehospital evaluation and care can reduce suffering, long-term disability, and death from trauma.

2. Trauma emergencies occur as a result of physical forces applied to the body.

3. Medical emergencies occur from an illness or condition not caused by an outside force.

a. Traumatic injuries may be caused by underlying medical conditions or medical illnesses may result from recent or remote traumatic injuries.

4. Evaluation of the MOI for the trauma patient will provide you with an index of suspicion for different types of serious and/or life-threatening underlying injuries.

a. Index of suspicion is your awareness and concern for potentially serious underlying and unseen injuries.

II. Energy and Trauma

A. Traumatic injury occurs when the body’s tissues are exposed to energy levels beyond their tolerance.

1. Mechanism of injury is the way traumatic injuries occur.

a. Describes the forces (or energy transmission) acting on the body that cause injury

b. Can be used to guide your assessment and treatment of the patient.

2. Three concepts of energy are typically associated with injury:

a. Potential energy

b. Kinetic energy

c. Energy of work

3. Energy can be neither created nor destroyed, but can only be converted or transformed.

B. Work is defined as force acting over a distance.

1. Forces that bend, pull, or compress tissues beyond their inherent limits result in the work that causes injury.

C. Kinetic energy is the energy of a moving object

1. Reflects the relationship between the mass (weight) of the object and the velocity (speed) at which it is traveling

KE = ½ mass x velocity2

2. According to the equation for kinetic energy, the energy that is available to cause injury doubles when an object’s weight doubles but quadruples when its speed doubles.

D. Potential energy is the product of mass (weight), force of gravity, and height.

1. It is the stored energy an object has because of its position or state.

2. Mostly associated with the energy of falling objects

III. Mechanism of Injury Profiles

A. Different types of MOIs will produce many types of injuries.

1. Nonsignificant MOIs

a. Injury to an isolated body part

b. A fall without the loss of responsiveness

2. Significant MOIs

a. Injury to more than one body system (multisystem trauma)

b. Falls from heights greater than three times the patient’s height

c. Falls that result in any altered mental status

d. Unrestrained occupant in a motor vehicle or a motorcycle crash

e. High velocity motor vehicle crashes at or greater than 40 mph closing speed at impact

f. Motor vehicle crash with a death in the same vehicle

g. Ejection from a motor vehicle

h. Car versus pedestrian (or bicycle or motorcycle)

i. Gunshot wounds

j. Stabbings

IV. Blunt and Penetrating Trauma

A. Traumatic injuries can be divided into two separate categories: blunt trauma and penetrating trauma.

1. Blunt trauma is the result of force to the body that causes injury without penetrating the soft tissues or internal organs and cavities.

2. Penetrating trauma causes injury by objects that primarily pierce and penetrate the surface of the body and cause damage to soft tissues, internal organs, and body cavities.

3. Either type may occur from a variety of MOIs.

a. It is important to consider the unseen as well as visible, obvious injuries with either type of trauma.

V. Blunt Trauma

A. Blunt trauma results from an object making contact with the body.

1. Motor vehicle crashes and falls are the most common MOIs.

2. Be alert to skin discoloration and pain.

a. These may be the only signs of blunt trauma.

3. Maintain a high index of suspicion for hidden injuries.

B. Vehicular crashes

1. Motor vehicle crashes are classified as:

a. Frontal (head-on)

b. Rear-end

c. Lateral (T-bone)

d. Rollovers

e. Rotational (spins)

2. The principal difference is the direction of the force of impact.

3. A crash typically consists of three collisions.

a. Car against another car, tree, or object $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\Ch24\9781284080179_CH24_CP03.jpg$

i. Damage to the car does not directly affect patient care but does provide information about the severity of the collision.

ii. By assessing the vehicle that has crashed, you can often determine the MOI.

b. Passenger against the interior of the car

i. Kinetic energy produced by the passenger’s mass and velocity is converted into the work of stopping his or her body. $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\Ch24\9781284080179_CH24_CP06.jpg$

ii. Common passenger injuries include lower extremity fractures, rib fractures, and head trauma.

c. Passenger’s internal organs against the solid structures of the body

i. Internal injuries may not be as obvious as external injuries, but they are often the most life threatening.

4. Significant MOIs are suggested by:

a. Death of an occupant in the vehicle

b. Severe deformity of vehicle or intrusion into vehicle

c. Intrusion greater than 12 inches from a lateral crash

d. Severe damage from the rear

e. Crashes in which rotation is involved

f. Ejection from the vehicle

5. Frontal crashes

a. Evaluate the supplemental restraint system.

i. Determine whether the passenger was restrained by a full and properly applied three-point restraint.

ii. Determine whether the airbag was deployed.

b. Seatbelts and airbags are effective in preventing a second collision inside the motor vehicle.

i. Seatbelts may decrease the severity of the third collision.

ii. Airbags decrease the severity of deceleration injuries and decrease injury to the chest, face, and head.

c. Despite air bags, suspect injuries to:

i. Extremities (resulting from the second collision)

ii. Internal organs (resulting from the third collision)

d. Children shorter than 4'9″ should ride in the rear seat.

i. In a pickup truck or single-seated vehicle, the airbag should be turned off.

e. Remember that if the airbag did not inflate during the accident, it may deploy during extrication.

f. Remember that supplemental restraint systems can cause harm whether they are used properly or improperly. $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\Ch24\9781284080179_CH24_FIG04.jpg$

i. Hip dislocations may result if seatbelts are worn too low.

ii. Internal injuries can occur when the belt is worn too high.

iii. Lumbar spine fractures are also possible, particularly in children and older patients.

g. Passengers riding in vehicles equipped with airbags but not wearing seat belts are often thrown forward and come into contact with the air bag and/or the doors at the time of deployment.

h. Look for contact points between the patient and the vehicle as you perform a simple quick evaluation of the interior of the vehicle.

i. Passengers not wearing seat belts may present with deformity bilaterally to the hips and femurs and bruising to the knees from a down and under mechanism of injury.

j. A windshield with a star shaped pattern indicates an occupant’s head may have struck the windshield during the collision.

6. Rear-end crashes

a. Rear-end impacts cause whiplash-type injuries, particularly in the absence of an appropriately placed headrest.

b. As the body is propelled forward, the head and neck are left behind. $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\Ch24\9781284080179_CH24_CP10.jpg$

i. The cervical spine and surrounding area may be injured.

c. Acceleration-type injury to the brain is possible.

i. Third collision of the brain within the skull

7. Lateral crashes

a. Lateral or side impacts are a very common cause of death associated with motor vehicle crashes. $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\Ch24\9781284080179_CH24_CP11.jpg$

b. A vehicle struck from the side is usually struck above its center of gravity.

i. Begins to rock away from the side of impact

ii. This results in the passenger sustaining a lateral whiplash injury.

c. If there is substantial intrusion into the passenger compartment, suspect:

i. Lateral chest and abdomen injuries on the side of the impact

ii. Possible fractures of the lower extremities, pelvis, and ribs

iii. Organ damage from the third collision

d. Approximately 25% of all severe injuries to the aorta that occur in motor vehicle crashes are a result of lateral collisions.

8. Rollover crashes

a. Large trucks and sport utility vehicles are prone to rollovers because of their high center of gravity.

b. Injuries depend on whether the passenger was restrained.

c. The most unpredictable types of injuries are caused by rollover crashes in which a passenger is unrestrained.

d. The most common life-threatening event in a rollover is ejection or partial ejection of the passenger from the vehicle.

e. Even when restrained, passengers can sustain severe injuries because there are more impacts in a roll over.

9. Rotational crashes

a. Rotational crashes (spins) are conceptually similar to rollovers.

b. The rotation of the vehicle as it spins provides opportunities for the vehicle to strike objects, such as utility poles.

C. Car versus pedestrian

1. Injuries are often graphic and apparent.

2. There can also be serious unseen injuries to underlying body systems.

a. You must maintain a high index of suspicion for unseen injuries.

3. You should determine:

a. Speed of the vehicle

b. Whether the patient was thrown through the air and at what distance

c. Surface the patient landed on

d. Whether the patient was struck and pulled under the vehicle

4. Evaluate the vehicle that struck the patient for structural damage.

5. ALS backup should be summoned for any patients who have or are thought to have sustained a significant MOI.

D. Car versus bicycle

1. Evaluate the MOI in much the same manner as car-versus-pedestrian crashes. $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\Ch24\9781284080179_CH24_FIG07.jpg$

a. Evaluate the damage to, and position of the bicycle.

b. If the patient was wearing a helmet, inspect it for damage.

2. Presume that the patient has sustained an injury to the spinal column, or spinal cord, until proven otherwise at the hospital.

3. Spinal stabilization must be initiated and maintained during the encounter.

E. Car versus motorcycle

1. Protection provided by:

a. Helmet

i. Does not protect against severe cervical injury

b. Leather or abrasion-resistant clothing

i. Will protect against road abrasion but not against blunt trauma from secondary impacts

c. Boots

2. Collisions usually occur against larger vehicles or stationary objects.

3. When assessing the scene of a motorcycle crash, look for:

a. Deformity of the motorcycle

b. Side of most damage

c. Distance of skid in the road

d. Deformity of stationary objects or other vehicles

e. Extent and location of deformity in the helmet

4. There are four types of motorcycle impacts.

a. Head-on crash

i. The motorcycle strikes another object and stops its forward motion while the rider continues his or her forward motion until stopped by an outside force.

b. Angular crash

i. The motorcycle strikes an object or another vehicle at an angle so that the rider sustains direct crushing injuries to the lower extremity between the object and the motorcycle.

c. Ejection

i. The rider will travel at high speed until stopped by a stationary object, another vehicle, or road drag.

ii. Severe abrasion injuries (road rash) down to bone can occur with drag.

d. Controlled crash

i. A technique used to separate the rider from the body of the motorcycle and the object to be hit is referred to as laying the bike down.

F. Falls $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\Ch24\9781284080179_CH24_FIG08.jpg$

1. The injury potential of a fall is related to the height from which the patient fell.

a. The greater the height of the fall, the greater the potential for injury.

b. A fall from more than three times the patient’s height is considered significant.

c. A fall greater than three feet landing directly on the head or the buttocks is significant.

2. Internal injuries pose the greatest threat to life.

3. Patients who fall and land on their feet may have less severe internal injuries because their legs may have absorbed much of the energy of the fall.

a. However, they may have very serious injuries to the lower extremities and pelvic and spinal injuries.

4. Take into account:

a. The height of the fall

b. The type of surface struck

c. The part of the body that hit first, followed by the path of energy displacement

VI. Penetrating Trauma

A. Penetrating trauma is the second leading cause of trauma death in the United States after blunt trauma. $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\Ch24\9781284080179_CH24_FIG09.jpg$

1. Low-energy penetrating trauma may be caused:

a. Accidentally by impalement

b. Intentionally by a knife, ice pick, or other weapon

2. Many times it is difficult to determine entrance and exit wounds from projectiles in a prehospital setting.

a. Determine the number of penetrating injuries.

b. Combine that information with the important things you already know about the potential pathway of penetrating projectiles.

3. With low-energy penetrations, injuries are caused by the sharp edges of the object moving through the body and are, therefore, close to the object’s path.

4. Knives may have been deliberately moved around internally, causing more damage than the external wound suggests.

5. Try to determine the length of the penetrating object.

B. In medium- and high-velocity (speed) penetrating trauma, the path of the projectile (usually a bullet) may not be easy to predict.

1. The bullet may flatten out, tumble, or even ricochet within the body before exiting.

2. The path the projectile takes is its trajectory.

3. Fragmentation will increase damage.

4. The bullet’s speed is another factor in the resulting injury pattern.

5. Cavitation results from rapid changes in tissue and fluid pressure that occur with the passage of the projectile.

a. Can result in serious injury to internal organs distant to the actual path of the bullet $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\Ch24\9781284080179_CH24_FIG10.jpg$

b. Temporary cavitation injury results from a stretching of the tissues that occurs with pressure changes.

c. Permanent cavitation injury results closer to the bullet path and remains after the projectile has passed through the tissue.

C. The relationship between distance and the severity of injury varies depending on the type of weapon involved.

1. Air resistance, often referred to as drag, slows the projectile, decreasing the depth of penetration and energy of the projectile, and thus reducing damage to the tissues.

2. The area that is damaged by medium- and high-velocity projectiles is typically many times larger than the diameter of the projectile itself.

a. This is one reason that exit wounds are often many times larger than entrance wounds.

3. The energy available for a bullet to cause damage is more a function of its speed than its mass.

4. Any information regarding the type of weapon that was used should be relayed to medical control.

Recognizing Developing Problems in Trauma Patients
Mechanism of Injury	Signs & Symptoms	Index of Suspicion
Blunt or penetrating trauma to the neck	Noisy or labored breathing Increased respiratory rate Swelling face or neck Altered gag reflex Decreasing / low SpO2 Rapid weak pulse Decreasing / low BP	Significant bleeding or foreign bodies in the airway causing obstruction Be alert for airway compromise
Significant chest wall blunt trauma from motor vehicle crashes, car-versus-pedestrian, and other crashes; penetrating trauma to the chest wall	Significant chest pain Shortness of breath Increased respiratory rate Asymmetric chest wall movement Subcutaneous emphysema Decreasing/low SpO2 Jugular vein distention Rapid weak pulse Decreasing/low BP Loss of peripheral pulses during inspiration Narrowing pulse pressure	Cardiac or pulmonary contusion Pneumothorax or hemothorax Broken ribs causing respiratory compromise
Any significant blunt force trauma from motor vehicle crashes or penetrating injury	Blunt or penetrating trauma to the neck, chest, abdomen, or groin Blows to the head sustained during motor vehicle crashes, falls, or other incidents producing loss of responsiveness, altered mental status, combativeness, or changes in speech patterns	Injuries in these regions may tear and cause damage to the large blood vessels located in these body areas, resulting in significant internal and external bleeding Be alert to the possibility of bruising to the brain and bleeding in and around the brain tissue, which may cause the development of excess pressure inside the skull around the brain
Any significant blunt force trauma, falls from a significant height, or penetrating trauma	Severe back and/or neck pain, history of difficulty moving extremities, loss of sensation or tingling in the extremities Rapid, weak, or slow pulse	Injury to the bones of the spinal column or the spinal cord

VII. Blast Injuries

A. Although most commonly associated with military conflict, blast injuries are also seen in civilian practice in mines, shipyards, chemical plants, and in association with terrorist activities.

1. People who are injured in explosions may be injured by four different mechanisms.

a. Primary blast injuries

i. These are due entirely to the blast itself.

ii. Damage to the body is caused by the pressure wave generated by the explosion.

b. Secondary blast injuries

i. Damage to the body results from being struck by flying debris.

c. Tertiary blast injuries

i. The victim is hurled by the force of the explosion against a stationary object.

d. Quaternary (miscellaneous) blast injuries

i. Burns from hot gases or fires started by the blast

ii. Respiratory injury from inhaling toxic gases

iii. Crush injury from the collapse of buildings

iv. Suffocation, poisoning, other medical emergencies

v. Contamination of wounds from environmental, chemical, or toxic substances

2. Most patients who survive an explosion will have some combination of the four types of injury mentioned.

B. Tissues at risk $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\Ch24\9781284080179_CH24_FIG11.jpg$

1. Organs that contain air, such as the middle ear, lung, and gastrointestinal tract are the most susceptible to pressure changes.

2. Junctions between tissues of different densities and exposed areas such as head and neck tissues are prone to injury as well.

3. The ear is most sensitive to blast injuries.

a. The tympanic membrane evolved to detect minor changes in pressure and will rupture at pressures of 5 to 7 pounds per square inch above atmospheric pressure.

4. Pulmonary blast injuries are defined as pulmonary trauma that results from short-range exposure to the detonation of explosives.

a. Primary blast injury is often characterized by a lack of external visible injuries.

b. Pneumothorax is a common injury and may require emergency decompression in the field.

c. Pulmonary edema may ensue rapidly.

5. One of the most concerning pulmonary blast injuries is arterial air embolism, which occurs on alveolar disruption with subsequent air embolization into the pulmonary vasculature.

a. Can produce:

i. Disturbances in vision

ii. Changes in behavior

iii. Changes in state of responsiveness

iv. Variety of other neurologic signs

6. Solid organs are relatively protected from shock wave injury but may be injured by secondary missiles or a hurled body.

7. Neurologic injuries and head trauma are the most common causes of death from blast injuries.

a. Subarachnoid and subdural hematomas are often seen.

b. Bradycardia and hypotension are common.

8. Extremity injuries, including traumatic amputations, are common.

VIII. Multisystem Trauma

A. Multisystem trauma involves more than one body system.

1. Head and spinal trauma

2. Chest and abdominal trauma

3. Chest and multiple extremity trauma

4. You must alert medical control and transport rapidly.

B. Golden principles of prehospital trauma care

1. Your main priority is to ensure:

a. Your safety

b. Safety of your crew

c. Safety of the patient

2. Determine the need for additional personnel or equipment.

3. Evaluate the MOI.

4. Identify and manage life threats.

5. Then focus on patient care.

a. Assess and manage the airway.

b. Ensure that basic shock therapy is completed.

c. Control bleeding.

i. Consider the use of a tourniquet.

d. Protect the spine and proceed with spinal immobilization if indicated.

6. Transport the patient immediately to the appropriate facility.

7. In most patients with multisystem trauma, definitive care requires surgical intervention.

a. On-scene time should be limited to 10 minutes or less.

8. During transport, obtain a SAMPLE history and complete a secondary assessment.

9. Consider ALS intercept and/or air medical transportation.

IX. Patient Assessment

A. Patient assessment consists of:

1. Scene size-up

2. Primary assessment

3. Secondary assessment

Physical assessment
Vital signs
Verbal assessment

4. Reassessment

B. When you are caring for a patient who has experienced a significant MOI and the patient is considered to be in serious or critical condition, you should rapidly perform a physical examination.

1. With a patient who has experienced a nonsignificant MOI, focus on the chief complaint while assessing the patient as a whole.

C. Injuries to the head

1. Disability and unseen injury to the brain may occur.

2. Bleeding or swelling inside the skull is often life threatening.

3. Include frequent neurologic examinations in your assessment.

4. Some patients will not have obvious signs or symptoms until minutes or hours after the injury has occurred.

D. Injuries to the neck and throat

1. This is an area of serious or deadly injuries.

a. The trachea may become torn or swell.

2. Airway problems may result in a serious life threat.

3. Your assessment must include frequent physical examinations looking for DCAP-BTLS in the neck region.

a. DCAP-BTLS stands for deformity, contusion, abrasion, puncture/penetrating injury, burns, tenderness, laceration, and swelling.

b. Also assess for jugular vein distention and tracheal deviation.

4. Swelling may prevent blood flow to the brain and cause injury to the central nervous system.

5. A penetrating injury may result in an air embolism.

a. Use occlusive dressings to prevent this.

6. A crushing injury to the upper part of the neck may cause the cartilages of the upper airway and larynx to fracture.

E. Injuries to the chest

1. The chest contains the heart, lungs, and large blood vessels.

2. Many life-threatening injuries may occur.

a. Broken ribs may hinder breathing.

b. Bruising may occur to the heart and cause an irregular heartbeat.

c. Large vessels of the heart may be torn inside the chest, causing massive unseen bleeding.

d. Air may collect between the lung tissue and the chest wall, known as a pneumothorax.

3. A penetration or perforation of the integrity of the chest is called an open chest wound.

a. If left untreated, shock and/or death will result.

b. It is imperative that you assess the chest region every 5 minutes.

c. Assessment should include DCAP-BTLS, lung sounds, and chest rise and fall.

F. Injuries to the abdomen

1. The abdomen contains vital organs that require a very high amount of blood flow to perform the functions necessary for life.

2. The organs of the abdomen and retroperitoneum can be classified into two categories: solid and hollow.

a. Solid organs include the liver, spleen, pancreas, and kidneys.

b. Hollow organs include the stomach, large and small intestines, and urinary bladder.

3. When injuries from trauma occur in this region of the body, serious and life-threatening problems may occur.

a. Solid organs may tear, lacerate, or fracture, which can cause serious bleeding into the abdomen.

b. Hollow organs may rupture and leak toxic digestive chemicals.

i. The patient may eventually develop a life-threatening infection.

c. The rupture of large blood vessels can cause serious unseen bleeding.

4. Reassess the abdominal region using DCAP-BTLS.

X. Management: Transport and Destination

A. Call for ALS and helicopter assistance early to avoid delays in treatment and transport.

B. Scene time

1. Survival of critically injured trauma patients is time dependent.

2. Limit on-scene time to the minimum amount necessary to correct life-threatening injuries and package the patient.

a. On-scene time for critically injured patients should be less than 10 minutes.

b. This time is known as the Platinum 10 minutes.

3. The following criteria will help you identify a critically injured patient:

a. Dangerous MOI

b. Decreased level of responsiveness

c. Any threats to airway, breathing, or circulation

C. Type of transport

1. Modes of transport ultimately come in one of two categories: ground or air.

a. Ground EMS units are staffed by EMTs and paramedics.

b. Air EMS units or critical care transport units are staffed by critical care nurses and paramedics.

2. The Association of Air Medical Services (AAMS) and MedEvac Foundation International identify the following criteria for appropriate use of emergency air medical services for trauma patients:

a. There is an extended period required to access or extricate a remote or trapped patient.

b. The distance to the trauma center is more than 20 to 25 miles.

c. The patient needs ALS care and there is no ALS-level ground ambulance service available within a reasonable time frame.

d. Traffic conditions or hospital availability make it unlikely that the patient will get to a trauma center via ground ambulance within the ideal time frame.

e. There are multiple trauma patients who will overwhelm resources at the nearby trauma center(s).

f. EMS systems require bringing a patient to the nearest hospital, rather than bypassing facilities to go directly to a trauma center. This may add delay to receiving definitive surgical care.

g. There is a mass-casualty incident.

D. Destination selection

1. The goal of a trauma system is to get the right patient to the right facility in the right amount of time.

2. It is important for you to be familiar with how the American College of Surgeons’ Committee on Trauma classifies trauma care.

3. Trauma centers are classified into Levels I through IV, with Level I having the most resources.

a. Level I facility

i. Generally serves large cities or heavily populated areas

ii. Provides every aspect of trauma care

iii. Most Level I facilities are university-based teaching hospitals.

b. Level II facility

i. Located in less population-dense areas

ii. Provides initial definitive care

c. Level III facility

i. Provides assessment, resuscitation, emergency care, and stabilization

ii. Transfers patients to Level I or Level II facility when necessary

d. Level IV facility

i. Typically found in remote outlying areas where no higher level of care is available

ii. Provides advanced trauma life support

iii. Transfers to a higher-level trauma center

3. Trauma centers are categorized as either adult trauma centers or pediatric trauma centers, but not necessarily both.

a. Pediatric trauma centers are not nearly as common.

b. Do not make the mistake of transporting a pediatric patient to an adult trauma center when a pediatric trauma center is available.

4. In 2011, the ACS-COT and the CDC published an updated field triage decision scheme.

a. These criteria are intended to help prehospital care providers recognize injured patients who are likely to benefit from transport to a trauma center compared with transport to an emergency department.

E. Special considerations

1. Remain calm.

2. Complete an organized assessment.

3. Correct life-threatening injuries.

4. Do no harm.

5. Never hesitate to contact ALS backup or medical control for guidance.

Chapter 25, Bleeding

Unit Summary

After completing this chapter and related coursework, you will understand the structure and function of the circulatory system, the significance and characteristics of bleeding, the importance of personal protective equipment when treating a bleeding patient, the characteristics of external and internal bleeding, how to conduct a patient assessment, and methodologies for controlling bleeding.

National EMS Education Standard Competencies

Trauma

Applies fundamental knowledge to provide basic emergency care and transportation based on assessment findings for an acutely injured patient.

Bleeding

Recognition and management of

• Bleeding

Pathophysiology, assessment, and management of

• Bleeding

Pathophysiology

Applies fundamental knowledge of the pathophysiology of respiration and perfusion to patient assessment and management.

Knowledge Objectives

1. Describe the general structure of the circulatory system and the function of its different parts, including the heart, arteries, veins, and capillaries.

2. Explain the significance of bleeding caused by blunt force trauma, including the importance of perfusion.

3. Discuss hypovolemic shock as a result of bleeding, including the signs of shock.

4. Explain the importance of following standard precautions when treating a patient with external bleeding.

5. Describe the characteristics of external bleeding, including the identification of the following types of bleeding: arterial, venous, and capillary.

6. Explain how to determine the nature of the illness (NOI) for internal bleeding, including identifying possible traumatic and nontraumatic sources.

7. Identify the signs and symptoms of internal bleeding.

8. Discuss internal bleeding in terms of the different mechanisms of injury (MOI) and their associated internal bleeding sources.

9. Explain how to conduct a primary assessment, including identification of life threats beyond bleeding, ensuring a patent airway, and making a transport decision.

10. Explain how to assess a patient with external or internal bleeding, including physical examination, vital signs, and use of monitoring devices.

11. Explain the emergency medical care of the patient with external bleeding.

12. Explain the emergency medical care of the patient with internal bleeding.

Skill Objectives

1. Demonstrate the emergency medical care of the patient with external bleeding using direct pressure. (Skill Slide 25-1)

2. Demonstrate the emergency medical care of the patient with external bleeding using a commercial tourniquet. (Skill Slide 25-2)

3. Demonstrate the emergency medical care of the patient with epistaxis, or nosebleed. (Skill Slide 25-3)

4. Demonstrate the emergency medical care of the patient who shows signs and symptoms of internal bleeding. (Skill Slide 25-4)

I. Introduction

A. After managing the airway, recognizing bleeding and understanding how it affects the body are two of the most important skills you will learn as an EMT.

B. Bleeding can be external and obvious or internal and hidden.

1. Either type of bleeding is potentially dangerous and can cause:

a. Weakness

b. Shock

c. Death

2. Uncontrolled bleeding is the most common cause of shock following a traumatic injury.

3. Always suspect internal bleeding in a patient with the signs and symptoms of shock but no external bleeding.

4. The skin layers are subcutaneous, epidermis, dermis,

II. Anatomy and Physiology of the Cardiovascular System

A. The cardiovascular system circulates blood to all of the body’s cells and tissues.

1. Delivers oxygen and nutrients

2. Carries away metabolic waste products

3. Responsible for supplying and maintaining adequate blood flow

B. Components

1. Pump (heart)

2. Container (blood vessels)

3. Fluid (blood and bodily fluids)

C. Heart

1. Needs a rich and well-distributed blood supply

2. Works as two paired pumps

Upper chamber (atrium)
Lower chamber (ventricle)

3. Blood leaves each chamber through a one-way valve, which keeps the blood moving in the proper direction.

D. Blood vessels and blood

1. Types of blood vessels:

Arteries—carry blood away from the heart

i. Become smaller the farther they are from the heart

ii. As blood flows out of the heart, it passes into the aorta, the largest artery in the body

b. Arterioles—smaller vessels that connect the arteries and capillaries

c. Capillaries— pass among all the cells of the body and link arterioles and venules

d. Venules—very small, thin-walled vessels that empty into the veins

e. Veins—carry blood from the tissues to the heart

2. Oxygen and nutrients easily pass from the capillaries into the cells, and waste and carbon dioxide diffuses from the cells into the capillaries.

This transportation system allows the body to rid itself of waste products.

3. Blood contains:

Red blood cells—responsible for the transportation of oxygen to the cells and for transporting carbon dioxide away from the cells to the lungs
White blood cells—responsible for fighting infection
Platelets—responsible for forming blood clots
Plasma—the fluid portion of the blood

4. Blood clot formation depends on several factors:

a. Blood stasis

b. Changes in the blood vessel walls (such as a wound)

c. Blood’s ability to clot (affected by disease or medication)

5. When tissues are injured, platelets begin to collect at the site of injury

a. Red blood cells become sticky and clump together

b. Protein in plasma reinforces the developing clot

6. Autonomic nervous system

a. Monitors the body’s needs from moment to moment

b. Adjusts blood flow by constricting or dilating blood vessels

c. Automatically redirects blood away from other organs to the heart, brain,

lungs, and kidneys in an emergency

d. Adapts to changing conditions in the body to maintain homeostasis and perfusion

If the system fails to provide sufficient circulation for every body part to perform its function, shock results.

III. Pathophysiology and Perfusion

A. Perfusion is the circulation of blood within an organ or tissue in adequate amounts to meet the cells’ current needs for oxygen, nutrients, and waste removal.

1. Speed of blood flow

Must be fast enough to maintain adequate circulation throughout the body and to avoid clotting
Must be slow enough to allow cells time to exchange oxygen and nutrients for carbon dioxide and other waste products

2. Some tissues need a constant supply of blood, while others can survive with very little.

B. All organs and organ systems of the human body depend on adequate perfusion to function properly.

1. Some organs cannot tolerate interruption of blood supply for even a few minutes without sustaining damage.

2. Death of an organ system can quickly lead to death of the patient.

3. Emergency medical care is designed to support adequate perfusion until the patient arrives at the hospital.

C. The heart requires a constant supply of blood.

1. The brain and spinal cord may last 4 to 6 minutes without perfusion.

2. The lungs can survive only 15–20 minutes without perfusion.

3. Kidneys may survive 45 minutes.

4. Skeletal muscles may last 2–3 hours.

5. The gastrointestinal tract can tolerate slightly longer periods.

6. Times are based on a normal body temperature (98.6°F [37.0°C]).

Colder temperatures will lengthen survival times.

IV. External Bleeding

A. Hemorrhage means bleeding.

1. External bleeding is visible hemorrhage.

2. Examples: nosebleeds and bleeding from open wounds

B. The significance of external bleeding

1. With serious external bleeding, it may be difficult to tell the amount of blood loss.

Blood will look different on different surfaces (eg, absorbed in clothing vs diluted in water).
It is important to estimate the amount of external blood loss.
Treatment should be based on the patient’s presentation and MOI.

2. The body will not tolerate an acute blood loss of greater than 20% of blood volume (about 2 pints).

Typical adult male has approximately 70 mL of blood per kilogram of body weight
Typical adult female has approximately 65 mL of blood per kilogram of body weight
Adverse changes in vital signs may occur with significant blood loss

i. Increase in heart rate

ii. Increase in respiratory rate

iii. Decrease in blood pressure

d. Because infants and children have less blood volume to begin with, the same effect is seen with smaller amounts of blood loss.

3. How well people compensate for blood loss is related to how rapidly they bleed.

An adult can comfortably donate 1 unit (500 mL) of blood over a period of 15 to 20 minutes.
If a similar blood loss occurs in a much shorter period of time, the person may rapidly develop symptoms of hypovolemic shock.
The age and pre existing health of the patient should be considered.

4. Blood loss is an extremely serious problem that demands immediate attention, even before airway and breathing are addressed.

C. Characteristics of external bleeding

1. Injuries and some illnesses can disrupt blood vessels and cause bleeding.

2. You should consider bleeding to be serious if the following conditions are present:

Poor general appearance and no response to external stimuli
Signs and symptoms of shock (hypoperfusion)
Significant blood loss
Rapid blood loss
Uncontrolled bleeding
Significant MOI

3. Arterial bleeding

Pressure causes blood to spurt and makes bleeding difficult to control.
Typically brighter red (rich in oxygen) and spurts in time with the pulse
Decreases as the amount of blood circulating in the body drops and blood pressure drops

4. Venous bleeding

Dark red (low in oxygen)
Flows slowly or rapidly, depending on the size of the vein
Does not spurt and is easier to manage
Can be profuse and life threatening
More likely to clot spontaneously than arterial blood

5. Capillary bleeding

Bleeding from damaged capillary vessels
Dark red
Oozes from a wound steadily but slowly
More likely to clot spontaneously than arterial blood

6. Clotting process

Bleeding tends to stop rather quickly, within about 10 minutes, in response to internal mechanisms and exposure to air.
When the skin is broken, blood flows rapidly from the open vessel.
The cut ends of the vessel begin to narrow (vasoconstriction), reducing the amount of bleeding.
Next, a clot forms, plugging the hole and sealing the injured portions of the blood vessel (coagulation).
Bleeding will never stop if a clot does not form, unless the injured vessel is completely cut off from the main blood supply by direct pressure or a tourniquet.
Despite the efficiency of the circulatory system, it may fail in certain situations:

i. Movement

ii. Disease

Medications

iv. Removal of bandages

v. External environment

vi. Body temperature

vii. Severe injury

7. To aid in preventing blood loss, the blood vessels constrict quickly once they are injured.

8. Hemophilia

The patient lacks one or more of the blood’s clotting factors.
Several forms

i. Most are hereditary.

ii. Some are severe.

c. Bleeding may occur spontaneously and be profuse.

d. All injuries, no matter how trivial, are potentially serious.

e. Patients should be transported immediately.

V. Internal Bleeding

A. Internal bleeding is any bleeding in a cavity or space inside the body.

B. Can be very serious, because it is not easy to detect immediately

1. Injury or damage to internal organs commonly results in extensive internal bleeding.

2. Can cause hypovolemic shock

C. Possible conditions causing internal bleeding include:

1. Stomach ulcer

2. Lacerated liver

3. Ruptured spleen

4. Broken bones, especially ribs or femur

5. Pelvic fracture

D. Often, the only signs of internal bleeding are contusion or ecchymosis.

E. Mechanism of injury for internal bleeding

1. A high-energy MOI should increase your index of suspicion for the possibility of serious unseen injuries.

2. Internal bleeding is possible whenever the MOI suggests that severe forces affected the body.

Blunt trauma
Penetrating trauma

3. Use mnemonic DCAP-BTLS to assess for signs of injury.

Deformities
Contusions
Abrasions
Punctures/penetrations
Burns
Tenderness
Lacerations
Swelling
Any other signs of injury

F. Nature of illness for internal bleeding

1. Internal bleeding is not always caused by trauma

2. Possible non traumatic causes include:

Bleeding ulcers
Bleeding from the colon
Ruptured ectopic pregnancy
Aneurysms

3. These signs are frequent but not always present:

Abdominal tenderness
Guarding
Rigidity
Pain
Distention

4. In older patients, signs include:

Dizziness
Faintness
Weakness

5. Ulcers or other gastrointestinal problems may cause:

Vomiting of blood
Bloody diarrhea or urine

6. It is not as important for you to know the specific organ involved as it is to recognize that the patient is in shock and respond appropriately.

G. Signs and symptoms of internal bleeding

1. Pain (most common)

2. Swelling in the area of bleeding

3. Distention

4. Bleeding into the chest cavity or lung may cause dyspnea, tachycardia, and hypotension, and hemoptysis (bright red blood that is coughed up)

5. Hematoma—a mass of blood in the soft tissues beneath the skin

6. Bruising—a contusion or ecchymosis (may not be present initially) indicates blood vessels in the dermal layer have ruptured.

7. Bleeding from any body opening

Bright red bleeding from the mouth or rectum
Hematuria—blood in the urine
Non Menstrual vaginal bleeding

8. Hematemesis—vomited blood

Bright red or dark red
Coffee-grounds appearance

9. Melena—black, foul-smelling, tarry stool with digested blood

10. Pain, tenderness, bruising, guarding, or swelling (possible closed fracture)

11. Broken ribs; bruises over the lower part of the chest; or a rigid, distended abdomen (indicate possible lacerated spleen or liver)

12. Hypoperfusion (hypovolemic shock)

Change in mental status, such as anxiety, restlessness, or combativeness
Weakness, faintness, or dizziness on standing
Changes in skin color or pallor (pale skin)
Later signs of hypoperfusion suggesting internal bleeding include:

i. Tachycardia

ii. Weakness, fainting, or dizziness at rest

iii. Thirst

iv. Nausea and vomiting

v. Cold, moist (clammy) skin

vi. Shallow, rapid breathing is inadequate and requires assistance with respirations

vii. Dull eyes

viii. Slightly dilated pupils that are slow to respond to light

ix. Capillary refill of more than 2 seconds in infants and children

x. Weak, rapid (thready) pulse

xi. Decreasing blood pressure is a late sign and an indication of deterioration

xii. Altered level of responsiveness

When a patient is experiencing shock, the cells are not getting enough oxygen and waste products are accumulating.

H. Patients with these signs and symptoms require prompt oxygen administration and transport.

VI. Patient Assessment for External and Internal Bleeding

A. Scene size-up

1. Scene safety

Be alert to potential hazards.
At vehicle crashes, ensure the absence of leaking fuel and energized electrical lines.
In violent incidents, make sure the police are on the scene.
Follow standard precautions, don PPE.

2. Mechanism of injury/nature of illness

Determine the MOI/NOI.
Consider the need for spinal immobilization and additional resources.
Consider environmental factors such as weather.

B. Primary assessment

1. Do not be distracted from identifying life threats.

2. Form a general impression.

Note important indicators that alert you to the seriousness of the patient’s condition.
Be aware of obvious signs of injury and distress (such as facial grimace).
Determine the patient’s gender and age.

3. Perform a rapid exam.

a. Look for life threats, and treat them as you find them.

b. If the patient has obvious, life-threatening external bleeding, address it first.

c. Assess skin color.

d. Determine the level of responsiveness using the AVPU scale.

4. Airway and breathing

Consider the need for spinal immobilization.
Ensure a patent airway.
Look for adequate breathing.
Check for breath sounds.
Provide high-flow oxygen or assist ventilations with a bag-valve mask or non rebreathing mask.
Insert an oropharyngeal airway to secure the airway if the patient is unconscious.

4. Circulation

Assess pulse rate and quality.
Determine skin condition, color, and temperature.
Check capillary refill time.
Control external bleeding.
Treat for shock.

i. Apply oxygen.

ii. Improve circulation.

iii. Maintain a normal body temperature.

5. Transport decision

Assessment of ABCs and life threats will determine the transport priority.
Patients who may have significant bleeding will quickly become unstable.
Signs that imply the need for rapid transport include:

i. Tachycardia

ii. Tachypnea

iii. Low blood pressure

iv. Weak pulse

v. Clammy skin

C. History taking

1. Investigate the chief complaint.

Look for signs or symptoms of other injuries due to the MOI and/or NOI.
Note obvious signs of internal bleeding—look more carefully in this step.
In a responsive trauma patient who has an isolated injury with a limited MOI, consider a focused assessment before assessing vital signs and obtaining a history.
Assess the entire patient, looking for the source of the problem, preexisting illness, and other issues.

2. SAMPLE history

Ask the patient about blood-thinning medications.
If the patient is unresponsive, obtain history information from medical alert tags or bystanders.
Look for signs and symptoms of shock.
Determine how much blood has been lost.

D. Secondary assessment

1. Record vital signs.

2. Complete a focused assessment of pain.

3. Attach appropriate monitoring devices.

4. With a critically injured patient or a short transport time, there may not be time to conduct a secondary assessment.

5. Assess all areas for DCAP-BTLS.

Head

i. Look for uncontrolled bleeding from large scalp lacerations.

b. Abdomen

i. Feel all four quadrants for tenderness or rigidity.

c. Extremities

i. Record circulation, sensation, and motor functions.

6. Vital signs

Assess baseline vital signs to observe the changes that may occur during treatment.
A systolic blood pressure of less than 100 mm Hg with a weak, rapid pulse should suggest the presence of hypoperfusion.
Cool, moist skin that is pale or gray is an important sign.
In geriatric patients and patients who take certain blood pressure medications, the pulse rate may not increase with early shock.

Try to determine the patient’s baseline blood pressure.
Quickly obtain a medical history and list of medications.

E. Reassessment

1. Reassess the patient frequently, especially in the areas that showed abnormal findings during the primary assessment.

Signs and symptoms of internal bleeding are often slow to present.
Children will compensate well for blood loss and then “crash” quickly.

2. Reassess an unstable patient every 5 minutes and a stable patient every 15 minutes.

3. Interventions

Provide high-flow oxygen.
Control external bleeding.
Provide treatment for shock (if applicable) and transport rapidly.
If internal bleeding is suspected, apply high-flow oxygen via a nonrebreathing mask and provide rapid transport.
Do not delay transport of a patient to complete an assessment.

5. Communication and documentation

Recognize, estimate, and report the amount of blood loss and how rapidly or over what period of time it occurred.
Communicate all relevant information to the staff at the receiving hospital.
Communicate your findings and any interventions used.
Document all injuries, the care provided, and the patient’s response.

VII. Emergency Medical Care for External Bleeding

A. Follow standard precautions.

1. Wear gloves, eye protection, and possibly a mask or gown.

2. Make sure that the patient has an open airway and is breathing adequately.

3. Provide high-flow oxygen.

4. If obvious, life-threatening bleeding is present, control it as quickly as possible.

B. Several methods are available to control external bleeding (Skill Slide 25-1).

1. Direct, even pressure and elevation

2. Pressure dressings and/or splints

3. Pack the wound with hemostatic agents

4. Tourniquets

C. Direct pressure and elevation

1. Most effective way to control external bleeding

2. Pressure stops the flow of blood and permits normal coagulation to occur.

3. Apply direct pressure with your gloved fingertip over the top of a sterile dressing.

4. For an object protruding from the wound, apply bulky dressings to stabilize the object in place and apply pressure as best you can.

i. Never remove an impaled object from a wound, unless it is in the cheek and blocking the patient’s airway, falls out of the wound, or interferes with dressing and bandaging.

5. Hold uninterrupted pressure for at least 5 minutes.

D. Wound packing

A packed dressing is a dressing that is packed down into an open wound instead of being placed over it.
Consider the use of a packed dressing in the following circumstances:

Direct pressure is unable to control bleeding on a large gaping wound.
The injury is located in the junctional areas-the groin and the axilla-where tourniquets can’t be used.

Hemostatic Dressings

Impregnated with an agent that speeds up the clotting process.
Folded so that you simply pull on one end to continuously pack it into the wound.

Packed Dressing Considerations

Pack the dressing tightly into the wound and directly on the point of bleeding. Push into every available space.
More than one dressing might be required. If needed, readjust the dressing in the wound to be more effective.
Anything that is absorbent, such as clothing or towels, can be used as an improvised packed dressing.

E. Hemostatic agents

1. Any chemical compound that slows or stops bleeding by assisting with clot formation

2. Two forms

Granular powder

Can be inserted into small wounds to create a tight seal

b. Gauze impregnated with a clay substance

3. Can be used together with direct pressure when direct pressure alone is ineffective

4. The use of hemostatic agents in EMS remains largely experimental.

Be aware of and follow your local protocols.

F. Pressure dressing

1. Firmly wrap a roller bandage around the entire wound.

2. Use 4" × 4" sterile gauze pads for small wounds and sterile universal dressings for larger wounds.

3. Cover the entire dressing above and below the wound.

4. Stretch the bandage tight enough to control bleeding.

5. You should still be able to palpate a distal pulse on the injured extremity after applying the dressing.

6. Do not remove a dressing until a physician has evaluated the patient.

Apply additional manual pressure through the dressing.
If necessary, add more dressings over the first.

7. Bleeding will almost always stop when the pressure of the dressing exceeds arterial pressure.

G. Tourniquet

The tourniquet is useful if a patient has bleeding from an extremity injury which cannot be controlled with the previously mentioned methods.

2. Several different types of commercial tourniquets are available.

a. Follow the manufacturer’s instructions

3. Follow the steps in to apply a commercial tourniquet (Skill Slide 25-2):

Apply the tourniquet approximately two inches proximal to the injury.
Do not put the tourniquet over a joint space, if the joint is close to the injury place the tourniquet above the joint.
Tighten the tourniquet until the bleeding has stopped.
Properly position the patient.
Apply high-flow oxygen as necessary. Keep the patient warm.
Transport promptly.

4. If a commercial tourniquet is unavailable, use direct pressure and wound packing to stop the bleeding.

5. Whenever you apply a tourniquet, make sure you observe the following precautions:

Do not apply a tourniquet directly over any joint.
Always place the tourniquet proximal to the injury.
Make sure the tourniquet is tightened securely.
Never use wire, rope, a belt, or any other narrow material because it could cut into the skin.
Place padding under the tourniquet if possible to protect the tissues and help with arterial compression.
Never cover a tourniquet with a bandage.
Do not loosen the tourniquet after you have applied it.

6. Mark the exact time the tourniquet was applied and be sure to communicate the time and site of application, and the rationale of application clearly and specifically to hospital personnel.

H. Splints

1. Air splints

Also known as soft splints or pressure splints
Can control internal or external bleeding associated with severe extremity injuries
Immobilize fractures
Act like a pressure dressing applied to an entire extremity rather than to a small, local area
Use only approved, clean, or disposable valve stems when orally inflating air splints.

2. Rigid splints

Help immobilize fractures
Reduce pain
Prevent further damage to soft-tissue injuries
Once the splint is applied, monitor pulse and motor and sensory function in the distal extremity.

I. Bleeding from the nose, ears, and mouth

1. Bleeding around the face presents a risk for airway obstruction or aspiration.

2. Several conditions can result in bleeding from the nose, ears, and/or mouth, including the following:

Skull fracture
Facial injuries, including those caused by a direct blow to the nose
Sinusitis, infections, use and abuse of nose drops, dried or cracked nasal mucosa, or other abnormalities
High blood pressure
Coagulation disorders
Digital trauma (nose picking)

3. Epistaxis (nosebleed)

Common emergency
Occasionally can cause enough blood loss to lead to shock
The blood you see may be only a small part of the total blood loss.

i. Much of the blood may pass down the throat into the stomach as the patient swallows.

ii. A person who swallows a large amount of blood may become nauseated and start vomiting (may be confused with internal bleeding).

d. Most nontraumatic nosebleeds occur from sites in the septum, the tissue dividing the nostrils.

e. To control epistaxis (Skill Slide 25-3):

Position the patient sitting, leaning forward. Apply direct pressure, pinching the fleshy part of the nostrils together.
Alternative method: Apply pressure with a rolled gauze bandage between the upper lip and gum. Calm the patient.
Apply ice over the nose.
Maintain pressure until bleeding is controlled.
Initiate prompt transport while you or the patient applies pressure.
Assess and treat for shock, including oxygen, as needed.

4. Bleeding from the nose or ears following a head injury

May indicate a skull fracture
May be difficult to control
Do not attempt to stop blood flow.

i. Applying excessive pressure to the injury may force the blood leaking through the ear or nose to collect within the head.

ii. This could increase the pressure on the brain and possibly cause permanent damage.

d. If you suspect a skull fracture:

i. Apply a diffuse dressing to the bleeding site to collect the blood and help keep contaminants away from the site.

ii. Apply light compression by wrapping the dressing loosely around the head.

e. A target or halo-shaped stain may occur on the dressing if blood or drainage contains cerebrospinal fluid.

VIII. Emergency Medical Care for Internal Bleeding

A. Controlling internal bleeding or bleeding from major organs usually requires surgery or other hospital procedures.

1. Keep the patient calm, reassured, and as still and quiet as possible.

2. Provide high-flow oxygen.

3. Maintain body temperature.

4. Splint the injured extremity (usually with an air splint).

5. Never use a tourniquet to control the bleeding from closed, internal, and/or soft-tissue injuries.

6. To control internal bleeding:

Follow standard precautions. Maintain the airway and be alert for cervical spine injury. Administer oxygen and provide ventilation as necessary.
Depending on local protocols, use a pelvic compression device or splint to control suspected internal bleeding in the pelvic region.
Monitor vital signs and keep the patient warm.
Follow the steps to care for patients with internal bleeding (Skill Slide 25-4).

Follow standard precautions.
Maintain the airway and be alert for cervical spine injury.
Administer oxygen and provide ventilation as necessary.
Control obvious external bleeding and treat suspected internal bleeding using a splint.
Apply a tourniquet for severe bleeding that cannot be controlled with direct pressure.
Depending on local protocols, use a pelvic compression device or splint to control suspected internal bleeding in the pelvic region.
Monitor vital signs and keep the patient warm.

Chapter 26, Soft-Tissue Injuries

Unit Summary

After you complete this chapter and the related course work, you will have an understanding of types of open and closed soft-tissue injuries; how to care for soft-tissue injuries, including the use of dressings and bandages; and the assessment and care of different types of burns, including thermal, chemical, and electrical burns.

National EMS Education Standard Competencies

Trauma

Applies fundamental knowledge to provide basic emergency care and transportation based on assessment findings for an acutely injured patient.

Soft-Tissue Trauma

Recognition and management of:

Wounds
Burns
Electrical
Chemical
Thermal
Chemicals in the eye and on the skin

Pathophysiology, assessment, and management of:

Wounds

Avulsions
Bite wounds
Lacerations
Puncture wounds
Incisions

Burns

Electrical
Chemical
Thermal
Radiation

Crush syndrome

Knowledge Objectives

1. Describe the anatomy of the skin; include the layers of the skin.

2. Know the functions of the skin.

3. Name the three types of soft-tissue injuries.

4. Describe the types of closed soft-tissue injuries.

5. Describe the types of open soft-tissue injuries.

6. Explain patient assessment of closed and open injuries.

7. Explain patient assessment of closed and open injuries in relation to airway management.

8. Explain the emergency medical care for closed and open injuries.

9. Explain the emergency medical care for a patient with an open wound to the abdomen.

10. Explain the emergency medical care for an impaled object.

11. Explain the emergency medical care for neck injuries.

12. Describe the steps of the emergency treatment of small animal bites, human bites, and rabies.

13. Explain how the seriousness of a burn is related to its depth and extent.

14. Define superficial, partial-thickness, and full-thickness burns; include the characteristics of each burn.

15. Explain the primary assessment of a burn patient.

16. Explain the emergency medical care for burn injuries.

17. Describe the emergency management of chemical, electrical, thermal, inhalation, and radiation burns.

18. Know the functions of sterile dressings and bandages.

Skill Objectives

1. Demonstrate the emergency medical care of closed soft-tissue injuries.

2. Demonstrate the emergency medical care of a patient with an open chest wound.

3. Demonstrate how to control bleeding from an open soft-tissue injury.

4. Demonstrate the emergency medical care of a patient with an open abdominal wound.

5. Demonstrate how to stabilize an impaled object.

6. Demonstrate how to care for a burn.

7. Demonstrate the emergency medical care of a patient with a chemical, electrical, thermal, inhalation, or radiation burn.

I. Introduction

A. Soft-tissue injuries are common.

1. They can be as simple as a cut or scrape.

2. They can be as serious as a life-threatening internal injury.

3. Do not become distracted by dramatic open wounds.

a. Do not make the critical mistake of neglecting other life-threatening conditions such as airway obstruction.

B. The soft tissues of the body can be injured through a variety of mechanisms.

1. A blunt injury occurs when the energy exchange between the patient and an object is more than the tissues can tolerate.

2. A penetrating injury occurs when an object breaks through the skin and enters the body.

3. Barotrauma, commonly seen in blast injury victims, refers to injuries that result from sudden or extreme changes in air pressure.

4. Burns may also result in soft-tissue injuries.

C. Soft-tissue trauma is a common form of injury.

1. Open wounds accounted for approximately 4.1 million emergency department (ED) visits in 2011.

2. Wound care is one of the most frequently performed procedures in EDs across the United States.

3. Most of these injuries require basic interventions:

a. Wound irrigation

b. Dressing

c. Bandaging

d. Limited suturing

D. Death is often related to hemorrhage or infection.

1. Uncontrolled hemorrhage can lead to shock and death.

2. When the skin barrier is breached, invading pathogens can cause local or systemic infection.

3. Infection can be life or limb threatening, especially in children, older adults, and people with diabetes or other conditions that may compromise the immune system.

E. Soft-tissue injuries and their complications can often be prevented by using simple protective actions.

1. Effective strategies to reduce injury and death from burns:

a. Smoke alarms

b. Controlling the temperature of hot water heaters

c. Enforcing building codes that regulate electrical and construction practices

II. The Anatomy and Physiology of the Skin

A. The skin is the body’s first line of defense against external forces and infection.

1. It is the largest organ in the body.

2. It is relatively tough, but still susceptible to injury.

a. Injuries range from simple bruises and abrasions to serious lacerations and amputations.

b. Injuries may expose blood vessels, nerves, and bones.

B. In all instances, the EMT must:

1. Control bleeding

2. Prevent further contamination to decrease the risk of infection

3. Protect wounds from further damage

4. Apply dressings and bandages to various parts of the patient’s body

C. Skin varies in thickness, depending on the person’s age and the skin’s location.

1. Skin is thinner in the very young and the very old.

2. Skin is thinner on the eyelids, lips, and ears than on the scalp, back, and soles of the feet.

3. Thin skin is more easily damaged than thick skin.

D. Anatomy

1. The skin has two principal layers: the epidermis and the dermis.

a. The epidermis is the tough, outermost layer that forms a watertight covering for the body.

i. The epidermis is composed of several layers.

b. The dermis is the inner layer of the skin.

i. It contains hair follicles, sweat glands, and sebaceous glands.

ii. Blood vessels in the dermis provide the skin with nutrients and oxygen.

2. Skin is the exterior of the human body.

a. The various openings in the body are lined with mucous membranes.

i. Mucous membranes provide a protective barrier against bacterial invasion.

ii. They secrete a watery substance that lubricates the openings.

iii. They are moist, whereas skin is generally dry.

E. Physiology

1. Skin serves many functions.

a. Keeps pathogens out

b. Keeps fluids in

c. Helps regulate body temperature

d. The nerves in the skin report to the brain on the environment and many sensations.

e. This nerve pathway connection allows the body to adapt to the environment through responses in the skin and surrounding tissues.

2. Any break in the skin may allow bacteria to enter and increases the possibility of infection, fluid loss, and loss of temperature control. $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\JPEG\Ch26\9781284080179_CH26_FIG01.jpg$

a. Any one of these conditions can cause serious illness and even death.

3. Three types of soft-tissue injuries:

a. Closed injuries

i. Damage occurs beneath the skin or mucous membrane.

ii. The surface of the skin or mucous membrane remains intact.

b. Open injuries

i. There is a break in the surface of the skin or mucous membrane.

ii. Exposes deeper tissues to contamination

c. Burns

i. Damage results from:

Thermal heat
Frictional heat
Toxic chemicals
Electricity
Nuclear radiation

III. Pathophysiology of Closed and Open Injuries

A. Pathophysiology

1. Healing of wounds is a natural process that involves several overlapping stages, all directed toward the larger goal of maintaining homeostasis (balance).

2. Cessation of bleeding is the primary concern.

a. Loss of blood hinders the provision of vital nutrients and oxygen to the affected area.

b. It also impairs the tissue’s ability to eliminate wastes.

c. The end result is abnormal or absent function, which interferes with homeostasis.

3. The next wound healing stage is inflammation.

a. Additional cells move into the damaged area to begin repair.

b. White blood cells migrate to the area to combat pathogens that have invaded the exposed tissue.

c. Lymphocytes destroy bacteria and other pathogens.

d. Mast cells release histamine.

e. Inflammation ultimately leads to removal of:

i. Foreign material

ii. Damaged cellular parts

iii. Invading microorganisms

4. To replace the area damaged in a soft-tissue injury, a new layer of cells must be moved into this region.

a. Cells quickly multiply and redevelop across the edges of the wound.

b. Except in cases of clean incisions, the appearance of the restructured area seldom returns to the preinjury state.

c. Despite the changed appearance, the function of the area may be restored to near normal.

5. New blood vessels form as the body attempts to bring oxygen and nutrients to the injured tissue.

a. New capillaries bud from intact capillaries that lie adjacent to the damaged skin.

b. These vessels provide a channel for oxygen and nutrients and serve as a pathway for waste removal.

6. In the last stage of wound healing, collagen provides stability to the damaged tissue and joins wound borders, thereby closing the open tissue.

a. Collagen is a tough, fibrous protein found in scar tissue, hair, bones, and connective tissue.

b. Collagen cannot restore the damaged tissue to its original strength.

B. Closed injuries

1. Closed soft-tissue injuries are characterized by:

a. History of blunt trauma

b. Pain at the site of injury

c. Swelling beneath the skin

d. Discoloration

2. A contusion (bruise) is an injury that causes bleeding beneath the skin but does not break the skin.

a. Contusions result from blunt forces striking the body.

b. The epidermis remains intact, but cells within the dermis are damaged, and small blood vessels are usually torn.

c. The buildup of blood produces a characteristic blue or black discoloration called ecchymosis.

3. A hematoma is blood that is collected within damaged tissue or in a body cavity.

a. It occurs whenever a large blood vessel is damaged and bleeds rapidly.

b. It is usually associated with extensive tissue damage.

4. A crushing injury occurs when significant force is applied to the body.

a. The extent of the damage depends on:

i. How much force is applied

ii. The amount of time that the force is applied

b. Continued compression of the soft tissues will cut off circulation, producing further tissue destruction.

5. When an area of the body is trapped for longer than 4 hours and arterial blood flow is compromised, crush syndrome can develop.

6. When a patient’s tissues are crushed beyond repair, muscle cells die and release harmful substances into the surrounding tissues.

a. Harmful substances are released into the body’s circulation after the limb is freed and blood flow is returned.

b. Advanced life support (ALS) providers should administer IV fluid before the crushing object is lifted off the body.

c. Freeing the body part from entrapment also creates the potential for cardiac arrest and renal failure.

d. Consider requesting ALS assistance for situations of prolonged entrapment prior to extrication.

7. Compartment syndrome develops when edema and swelling result in increased pressure within a closed soft-tissue compartment.

a. Pressure increases within the compartment, which interferes with circulation.

b. Delivery of nutrients and oxygen is impaired and by-products of normal metabolism accumulate.

c. There is pain, especially on passive movement.

d. The longer this situation persists, the greater the chance for tissue death.

e. EMTs must continually reassess skin color, temperature, and pulses distal to the injury site if crush injury is suspected.

8. Severe closed injuries can damage internal organs.

a. The greater the amount of energy absorbed from the blunt force, the greater the risk of injury to deeper structures.

b. You must assess all patients with closed injuries for more serious hidden injuries.

C. Open injuries

1. Open injuries differ from closed injuries in that the protective layer of the skin is damaged.

a. Can produce extensive bleeding

2. A break in the protective skin layer or mucous membrane means that the wound is contaminated and may become infected.

a. Contamination: the presence of infectious organisms or foreign bodies, such as dirt, gravel, or metal, in the wound

b. Address both excessive bleeding and contamination in your treatment of open soft-tissue wounds.

c. Four types of open soft-tissue wounds:

i. Abrasions

ii. Lacerations

iii. Avulsions

iv. Penetrating wounds $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\JPEG\Ch26\9781284080179_CH26_FIG02A.jpg$

3. An abrasion is a wound of the superficial layer of the skin, caused by friction when a body part rubs or scrapes across a rough or hard surface.

a. An abrasion usually does not penetrate completely through the dermis, but blood may ooze from the injured capillaries in the dermis.

i. Examples: road rash, road burn, strawberry, rug burn $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\JPEG\Ch26\9781284080179_CH26_FIG03A.jpg$

b. Abrasions can be extremely painful because the nerve endings are located in this area.

4. A laceration is a cut caused by a sharp object or a blunt force that tears the tissue.

a. An incision is a sharp, smooth cut.

b. The depth of the injury can vary.

c. Lacerations and incisions may appear linear (regular) or stellate (irregular).

d. Lacerations or incisions that involve arteries or large veins may result in severe bleeding.

5. An avulsion separates various layers of soft tissue (usually between the subcutaneous layer and fascia) so that they become either completely detached or hang as a flap.

a. Often there is significant bleeding.

b. Never remove an avulsion skin flap, regardless of its size.

c. An amputation is an injury in which part of the body is completely severed.

i. You can easily control the bleeding from some amputations, such as the fingers, with direct pressure and pressure dressings.

ii. If there is massive bleeding, you should stop the bleeding, which often requires a tourniquet, and treat the patient for hypovolemic shock.

6. A penetrating wound is an injury resulting from a piercing object, such as a knife, ice pick, splinter, or bullet.

a. These objects can damage structures deep within the body and cause unseen bleeding.

b. If the wound is to the chest or abdomen, the injury can cause rapid, fatal bleeding.

c. Monitor for signs of shock.

7. Impaled objects are objects that penetrate the skin but remain in place.

a. Concerns with this type of injury:

i. Damage to structures deep inside the body

ii. Presence of foreign materials inside the tissue that can lead to infection

8. Stabbings and shootings often result in multiple penetrating injuries.

a. Assess the patient carefully to identify all wounds.

b. Count the number of penetrating injuries, especially with gunshot wounds.

i. Leave the distinction between entrance and exit to the physician.

c. In a shooting, determine the type of gun when possible, but do not let this delay patient transport.

d. Sometimes patients or bystanders can tell you how many rounds were fired, but given the stress of the environment, their information may be unreliable.

e. You may have to testify in court.

i. Carefully document the circumstances surrounding the gunshot injury, the patient’s condition, and the treatment you give.

9. Blast injuries often result in multiple penetrating injuries.

10. The mechanism of injury from a blast injury is generally due to three factors:

a. Primary blast injury: Damage is caused by the blast wave itself and the sudden pressure changes of the explosion.

b. Secondary blast injury: Damage results from flying debris that causes multiple penetrating wounds.

c. Tertiary blast injury: The victim is thrown by the explosion, perhaps into an object.

IV. Patient Assessment of Closed and Open Injuries

A. It is more difficult to assess a closed injury than to assess an open injury.

1. Anytime you observe bruising, swelling, or deformity, or if the patient is reporting pain, the possibility of a closed injury should be considered.

2. An open injury is easier to assess because you can see the injury.

B. Scene size-up

1. Scene safety

a. Observe the scene for hazards to your crew, bystanders, and the patient.

b. Ensure that the scene is safe and consider the need for additional resources.

c. Take the necessary standard precautions before approaching the scene—a minimum of gloves and eye protection.

d. Open soft-tissue injuries can be messy but should not take priority over more serious life-threatening injuries.

e. Be careful where you put your hands, place your equipment, and how you package the patient for transport.

f. Focus on controlling the bleeding.

2. Mechanism of injury (MOI)

a. Look for indicators of the MOI as you assess the scene.

i. They can help you develop an early index of suspicion for underlying injuries.

ii. Interactions with the patient and your assessment will provide you with additional information about the extent of the injuries.

b. The MOI may provide information about potential safety threats.

c. Use all available information to evaluate scene safety and consider whether additional resources may be necessary.

C. Primary assessment

1. Focus on identifying and managing life-threatening concerns and identifying transport priority.

2. Form a general impression.

a. Important indicators will alert you to the seriousness of the patient’s condition.

i. Is the patient awake and interacting with his or her surroundings, or is the patient lying still, making no sounds?

ii. Is the patient responding to you appropriately or inappropriately?

iii. Is the patient’s breathing pattern rapid or slow, deep or shallow?

iv. What is the color and condition of the patient’s skin?

v. Does the patient have any apparent life threats?

b. Closed soft-tissue injuries may appear to be minor, but could indicate serious internal injuries.

i. Do not be distracted from looking for more serious hidden injuries.

c. Check for responsiveness.

i. If the patient is alert, ask about the chief complaint.

ii. Administer high-flow oxygen via a nonrebreathing mask to patients whose level of responsiveness is less than alert, treat for potential shock, and provide immediate transport.

iii. If the patient has significant trauma, perform a rapid exam, look for life threats, and treat them as you find them.

iv. If the patient has obvious life-threatening external bleeding, control the bleeding first (even before airway and breathing), then assess and treat the ABCs, and provide treatment for shock.

3. Airway and breathing

a. Providing high-flow oxygen may help reduce the effects of shock and assist in perfusion of damaged tissues, particularly in crush injuries.

b. Ensure that the patient has a clear and patent airway.

c. Protect the patient from further spinal injury by preventing the head and torso from moving.

d. Assess the patient for adequate breathing.

e. Inspect and palpate the chest wall for DCAP-BTLS.

f. Open soft-tissue injuries of the face and neck have a potential to interfere with the effectiveness of the airway and breathing.

Evaluate the patient’s voice and speaking ability.
If an open injury is found on the chest, evaluate for air movement through the wound that indicates a deep penetrating injury.

iii. Assess the patient’s back for injuries that might need treatment.

4. Circulation

a. Quickly assess the patient’s pulse rate, rhythm, and quality.

b. Determine the skin condition, color, and temperature.

c. Check capillary refill time.

d. Your assessment of the pulse and skin will give you an indication Your assessment of the pulse and skin will give you an indication for the need to aggressively treat the patient for shock.

5. Transport decision

a. Consider whether transport to the closest hospital is appropriate or whether the patient would be better served by transport to a trauma center.

b. Types of patients who need immediate transportation:

i. Poor initial general impression

ii. Altered level of responsiveness

iii. Dyspnea

iv. Abnormal vital signs

v. Shock

vi. Severe pain

c. Patients who have visible significant bleeding or signs of significant internal bleeding may quickly become unstable.

D. History taking

1. Investigate the chief complaint.

a. Obtain a medical history and be alert for injury-specific signs and symptoms and any pertinent negatives.

b. Obtain a SAMPLE history from your patient.

i. Using OPQRST may provide some background on isolated extremity injuries.

ii. When you use SAMPLE, OPQRST, and DCAP-BTLS together, your assessment will provide significant insight into the patient’s condition.

iii. Any information you receive will be very valuable if the patient loses responsiveness.

c. If the patient is unresponsive, attempt to obtain the history from other sources:

i. Friends or family members

ii. Bystanders

iii. Medical identification jewelry

iv. Cards in wallets

d. Typical signs of an open injury:

i. Bleeding

ii. Break(s) in the skin

iii. Shock

iv. Hemorrhage

v. Disfigurement or loss of a body part

e. Chronic medical conditions such as anemia and hemophilia as well as a host of other medical conditions can complicate open soft-tissue injuries.

E. Secondary assessment

1. After you evaluate ABCs and identify and treat immediate life threats, a more detailed assessment should follow.

2. The secondary assessment is a more systematic full-body scan or focused examination of the patient.

3. The secondary assessment, which includes assessing interventions and repeating vital signs, typically occurs en route to the ED.

4. Physical examination

a. Listen to breath sounds with a stethoscope.

b. Determine the patient’s respiratory rate.

c. Note the pattern and quality of respiratory effort.

d. Assess for asymmetric chest wall movement.

e. Assess the neurologic system:

i. Level of responsiveness

ii. Pupil size and reactivity

iii. Motor response

iv. Sensory response

f. Assess the musculoskeletal system by performing a detailed exam of the entire body.

Look for DCAP-BTLS.
Assess the chest, abdomen, and extremities for hidden bleeding and injuries.
Log roll the patient, and assess the posterior torso for injuries.
Once the back has been assessed, perform a complete spinal immobilization if indicated.

g. Assess all anatomic regions:

i. Check for jugular vein distention and tracheal deviation.

ii. Check the pelvis for stability.

iii. Check the abdomen.

iv. Check the extremities, and record pulse, motor, and sensory function.

5. Vital signs

a. Reassess the vital signs to identify how quickly the patient’s condition is changing.

b. Signs that indicate hypoperfusion and indicate the need for rapid transport:

i. Tachycardia

ii. Tachypnea

Low blood pressure
Weak pulse
Cool, moist, and pale skin

c. Reassessment of the patient’s vital signs will indicate how well the patient is tolerating the injury and the effectiveness of your interventions.

F. Reassessment

1. Reassessment should be conducted regularly during transport.

2. Repeat the primary assessment and pay extra attention to areas of concern identified in the initial assessment.

3. Assess the effectiveness of prior treatments.

4. Reassess vital signs and the chief complaint.

5. Recheck patient interventions.

6. Reassess the effectiveness of the bandaging.

7. Identify and treat changes in the patient’s condition.

8. Interventions

a. Assess and manage all threats to the patient’s airway, breathing, and circulation.

b. Give supplemental oxygen via a nonrebreathing mask to all patients with traumatic injuries impacting the airway or ventilation or those with a potential for shock.

c. Expose all wounds, control bleeding, and be prepared to treat the patient for shock.

d. Consider flushing small wound surfaces without significant bleeding with sterile saline prior to applying a dressing.

e. If any material is “stuck” in the wound, do not remove it, as this may worsen bleeding and shock.

f. Splint extremities that are painful, swollen, or deformed.

9. Communication and documentation

a. Your communication and documentation must include a description of the MOI and the position in which you found the patient when you arrived on scene.

b. Attempt to report blood loss using terms that you are comfortable with and that will be easily understood by other personnel.

c. Include the location and description of any soft-tissue injuries or other wounds you have located and treated.

d. Describe the size and depth of the injury.

e. Provide an accurate account of how you treated these injuries.

V. Emergency Medical Care for Closed Injuries

A. Small contusions generally require no special emergency medical care, but you should note their presence to determine the extent of the patient’s injuries.

B. More extensive closed injuries may involve significant swelling and bleeding beneath the skin, which could lead to hypovolemic shock.

C. The injuries might not have had time to cause swelling or bruising.

D. Closely watch any area of injury throughout the time you are caring for the patient, no matter how minor it may look upon initial assessment.

E. Manage closed soft-tissue injury pain by applying:

Ice
Compression
Elevation
Splinting

F. Be alert for signs of developing shock:

1. Anxiety or agitation

2. Changes in mental status

3. Increased heart rate

4. Increased respiratory rate

5. Diaphoresis

6. Cool or clammy skin

7. Decreased blood pressure

G. If the patient exhibits signs and symptoms of shock, treat accordingly and aggressively.

VI. Emergency Medical Care for Open Injuries

A. Before you begin to care for a patient with an open wound, follow standard precautions.

1. If life-threatening bleeding is observed, assign a team member to apply direct pressure over the wound to control the bleeding.

2. If the wound is in the chest, upper abdomen, or upper back, cover it with an occlusive dressing.

3. Control bleeding using:

a. Direct, even pressure and elevation

b. Pressure dressings and/or splints

c. Tourniquets

B. All open wounds are assumed to be contaminated and present a risk of infection.

1. Applying a sterile dressing reduces the risk of further contamination.

2. Do not remove material from an open wound, no matter how dirty the wound is.

3. Small wound surfaces without significant bleeding can be flushed with sterile saline prior to applying a dressing.

4. In most circumstances, hospital personnel, rather than EMTs, will clean open wounds.

C. In some cases, you can better control bleeding from open soft-tissue wounds by splinting the extremity, even if there is no fracture. $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\JPEG\Ch26\9781284080179_CH26_FIG06.jpg$

D. Abdominal wounds

1. An open wound in the abdominal cavity may expose internal organs.

2. In an evisceration, the organs protrude through the wound.

a. Cover the wound with sterile gauze moistened with sterile saline solution.

b. Secure the gauze with an occlusive dressing.

c. Keep the organs moist and warm.

3. Most patients with abdominal wounds require immediate transport to a trauma center.

E. Impaled objects (Skill Slide 26-1) 78286_CH24_SK02_01

1. Occasionally, a patient will have an object, such as a knife, fishhook, wood splinters, or pieces of glass, impaled in his or her body.

2. Stabilizing an impaled object

Do not attempt to move or remove the object.
Control bleeding, and stabilize the object in place using soft dressings, gauze, and/or tape.
Tape a rigid item over the stabilized object to prevent it from moving during transport.

3. Remove an impaled object only in two circumstances:

a. The object is in the cheek or mouth and obstructs the airway.

b. The object is in the chest and directly interferes with CPR.

4. If the object is very long, secure and then shorten it.

5. Provide rapid transport.

F. Amputations

1. Control bleeding and treat for shock.

2. Surgeons today can occasionally reattach amputated parts.

3. With partial amputations, make sure to immobilize the part with bulky compression dressings and a splint to prevent further injury.

a. Do not sever any partial amputations.

b. Control any bleeding from the stump.

c. If bleeding is severe, quickly apply a tourniquet.

4. With a complete amputation, make sure to wrap the clean part in a sterile dressing and place it in a plastic bag.

a. Follow local protocols regarding how to preserve amputated parts.

b. Put the bag in a cool container filled with ice.

c. The goal is to keep the part cool without allowing it to freeze or develop frostbite.

d. The amputated part should be transported with the patient to the appropriate resource hospital.

G. Neck injuries

1. Open neck injuries can be life threatening.

2. If the veins of the neck are open to the environment, they may suck in air.

a. If enough air is sucked into a blood vessel, it can block the flow of blood in the lungs, and cause cardiac arrest.

b. This condition is called air embolism.

3. Cover the wound with an occlusive dressing.

4. Apply manual pressure but do not compress both carotid arteries at the same time.

a. This could impair circulation to the brain and cause a stroke.

5. Use caution with patients suffering from a neck injury depending on the MOI involved.

a. Immobilize the C-spine if indicated, including placing a cervical collar.

H. Bites

1. Small-animal bites and rabies

a. Consider the scene and crew safety prior to entering the environment.

b. A small animal’s mouth is heavily contaminated with virulent bacteria.

c. Consider all small-animal bites to be contaminated and potentially infected wounds.

d. Treatment may require:

i. Debridement (removal of damaged tissue)

ii. Antibiotics

iii. Tetanus prophylaxis

iv. Surgical repair

e. All small-animal bites should be evaluated by a physician.

f. A major concern is the spread of rabies, an acute, potentially fatal viral infection of the central nervous system that can affect all warm-blooded animals.

i. The virus is in the saliva of a rabid, or infected, animal and is transmitted through biting or licking an open wound.

ii. Infection can be prevented only by a series of special vaccine injections.

g. Children, particularly young ones, may be seriously injured or even killed by dogs.

i. The animal may turn and attack you as well.

ii. Do not enter the scene until the animal has been secured by the police or an animal control officer.

2. Human bites

a. The human mouth, more so than even the small animal’s mouth, contains an exceptionally wide range of bacteria and viruses.

b. Regard any human bite that has penetrated the skin as a very serious injury.

c. Any laceration caused by a human tooth can result in a serious, spreading infection.

d. Emergency treatment consists of the following steps:

i. Apply a dry, sterile dressing.

ii. Promptly immobilize the area with a splint or bandage.

iii. Provide transport to the ED for surgical cleansing of the wound and antibiotic therapy.

VII. Burns

A. Burns account for approximately 3,400 deaths per year.

B. Burns are among the most serious and painful of all injuries.

1. A burn occurs when the body, or a body part, receives more radiant energy than it can absorb, resulting in an injury.

a. Potential sources of this energy:

i. Heat

ii. Toxic chemicals

iii. Electricity

2. Although a burn may be the patient’s most obvious injury, you should always perform a complete assessment to determine whether other serious injuries are present.

3. Children, older patients, and patients with chronic illnesses are more likely to experience shock from burn injuries.

C. Pathophysiology of burns

1. Burns are soft-tissue injuries that are spread out over a large area and are created by the transfer of radiation, thermal, or electrical energy.

a. Thermal burns can occur when skin is exposed to temperatures higher than 111°F (44°C).

b. The severity of a thermal injury correlates directly with:

i. Temperature

ii. Concentration

iii. Amount of heat energy possessed by the object or substance

iv. Duration of exposure

c. Burn injuries are progressive—the greater the heat energy, the deeper the wound.

2. People naturally limit the amount of time they are exposed to such heat.

a. If clothing is on fire or the person is trapped or unconscious, exposure time can be extended.

D. Complications of burns

1. The skin serves as a barrier between the environment and the body.

a. When a person is burned, this barrier is destroyed.

b. Burns create a high risk for:

i. Infection

ii. Hypothermia

iii. Hypovolemia

iv. Shock

2. Burns to the airway are of significant importance because the loose mucosa in the hypopharynx can swell and lead to complete airway obstruction.

3. Circumferential burns of the chest can compromise breathing.

4. Circumferential burns of an extremity can lead to compartment syndrome, resulting in neurovascular compromise and irreversible damage if not appropriately treated.

5. If you suspect any complications, call for ALS backup.

E. Burn severity

1. Five factors to help determine the severity of a burn (the first two factors are the most important):

a. What is the depth of the burn?

b. What is the extent of the burn?

c. Are any critical areas involved?

i. Face, upper airway, hands, feet, genitalia

d. Does the patient have any preexisting medical conditions or other injuries?

e. Is the patient younger than 5 years or older than 55 years?

2. Burns to the face are of particular importance owing to the potential of airway involvement.

3. Burns to the hands or feet or over joints are considered serious because of the potential for loss of function as the result of scarring.

4. Depth of burns

a. Superficial (first-degree) burns

i. Involve only the top layer of skin, the epidermis

ii. The skin turns red but does not blister or burn through this top layer.

iii. The burn site is often painful.

iv. Example: sunburn

b. Partial-thickness (second-degree) burns

i. Involve the epidermis and some portion of the dermis

ii. These burns do not destroy the entire thickness of the skin, nor is the subcutaneous tissue injured.

iii. Typically, the skin is moist, mottled, and white to red.

iv. Blisters are present.

v. Can cause intense pain

c. Full-thickness (third-degree) burns

i. Extend through all skin layers and may involve subcutaneous layers, muscle, bone, or internal organs

ii. The burned area is dry and leathery and may appear white, dark brown, or even charred.

iii. If the nerve endings have been destroyed, a severely burned area may have no feeling.

iv. The surrounding, less severely burned areas may be extremely painful.

d. Significant airway burns are serious. $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\JPEG\Ch26\9781284080179_CH26_FIG18.jpg$

i. May be associated with singed hair within the nostrils, soot around the nose and mouth, hoarseness, and hypoxia

ii. These patients should be rapidly transported to an ED or facility capable of advanced airway management.

5. Extent of burns $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\JPEG\Ch26\9781284080179_CH26_FIG09.jpg$

a. Rule of palms: estimates the surface area that has been burned by comparing it to the size of the patient’s palm (not to include the fingers or wrist), which is roughly equal to 1% of the patient’s total body surface area (TBSA).

b. Rule of nines: estimates the extent of a burn by dividing the body into sections, each representing approximately 9% of the total body surface area.

c. The proportions differ for infants, children, and adults.

d. When you calculate the extent of burn injury, include only partial- and full-thickness burns. Document superficial burns, but do not include them in the body surface area estimation of extent of burn injury.

VIII. Patient Assessment of Burns

A. When assessing a burn, it is important to classify the patient’s burns.

1. Classification of burns is based on:

a. Source of the burn

b. Depth of the burn

c. Severity of the burn

B. Scene size-up

1. Scene safety

a. Observe the scene for hazards and threats to the safety of you and your crew, bystanders, and the patient.

b. Ensure that the factors that led to the patient’s burn injury do not pose a hazard to you and your crew.

2. Mechanism of injury

a. Attempt to determine the type of burn that has been sustained and the MOI.

b. What the patient reports will often provide important information about the extent of the injury.

c. Assess the scene for any environmental hazards.

d. Determine the number of patients.

e. Call for additional resources early, if necessary.

f. Consider the potential for spinal injuries, broken bones, inhalation injuries, and other injuries.

C. Primary assessment

1. Begin with a rapid exam.

2. Form a general impression.

a. Look for clues to determine the severity of injuries and the need for rapid treatment.

b. Be suspicious of clues that may indicate abuse.

c. Consider the need for manual spinal stabilization.

d. Check for responsiveness using the AVPU scale.

e. In all patients whose level of responsiveness is less than alert and oriented, administer high-flow oxygen via a nonrebreathing mask and provide immediate transport.

3. Airway and breathing

a. Ensure that the patient has a clear and patent airway.

b. Be alert to signs that the patient has inhaled hot gases or vapors:

i. Singed facial hair

ii. Soot present in or around the airway

c. Heavy amounts of secretions and frequent coughing may indicate a respiratory burn.

d. Quickly assess for adequate breathing.

e. Inspect and palpate the chest wall for DCAP-BTLS.

4. Circulation

a. Quickly assess the pulse rate and quality.

b. Determine perfusion based on the patient’s skin condition, color, temperature, and capillary refill time.

c. Take steps to control significant bleeding.

d. If the patient has obvious life-threatening external hemorrhage, control the bleeding first (before airway and breathing); then treat the patient for shock as quickly as possible.

e. Treat shock in burn patients by preventing heat loss; cover the patient with a blanket.

5. Transport decision

a. Consider rapid transport for a patient who has:

i. An airway or breathing problem

ii. Significant burn injuries

iii. Significant external bleeding

iv. Signs and symptoms of internal bleeding

b. Consulting with ALS providers may be appropriate.

D. History taking

1. Investigate the chief complaint.

a. Be alert for signs or symptoms of other injuries due to the MOI.

b. If the patient was burned in a confined space, suspect an inhalation injury.

c. When burns result from explosive forces, be alert for other internal injuries and fractures.

d. Obtain a medical history and be alert for injury-specific signs and symptoms and pertinent negatives.

e. Typical signs of a burn:

i. Pain

ii. Redness

iii. Swelling

iv. Blisters

v. Charring

f. Symptoms may include pain or burning at the injury site.

g. Regardless of the type of burn injury:

i. Stop the burning process.

ii. Apply a dressing to prevent contamination.

iii. Treat the patient for shock.

2. SAMPLE history

a. Along with the SAMPLE history, ask the following questions:

i. Are you having any difficulty breathing?

ii. Are you having any difficulty swallowing?

iii. Are you having any pain?

b. Check whether the patient has an emergency medical identification device.

E. Secondary assessment

1. Physical examination

a. Perform an exam of the entire body.

b. Assess the patient from head to toe looking for DCAP-BTLS.

c. Make a rough estimate, using the rule of nines, of the extent of the burned area.

d. Determine the classification of the burns that the victim has sustained.

e. Determine the severity of the burns.

f. Package the patient for transport based on your findings.

g. Assessment of the respiratory system involves looking, listening, and feeling.

i. Look for soot around the mouth, soot around the nose, or singed nasal hairs.

ii. If any of those findings are present, open the patient’s mouth and examine for burns or swelling of the tongue.

iii. Ask the patient to cough and assess for black sputum, which indicates smoke inhalation.

iv. Listen to breath sounds with a stethoscope.

v. Assess pulse rate and quality; determine the skin condition, color, and temperature; and check capillary refill time.

h. Assess the patient’s neurologic system:

i. Level of responsiveness—use AVPU

ii. Pupil size and reactivity

iii. Motor response

iv. Sensory response

Assess the musculoskeletal system.

i. In the head, check for singed nasal or facial hair, burns or swelling of the face or ears, or burns or swelling in the mouth. In case of electrical injury, examine the scalp for entrance or exit wounds.

ii. In the neck, check for burns, especially if they encircle the entire neck, which can impair circulation.

iii. In the chest, check for burns that encircle the entire chest, which can impair normal chest rise.

iv. In the abdomen and pelvis, feel all four quadrants for tenderness or rigidity. If the abdomen is tender, expect internal bleeding. Look for burns of the genitalia, as burns to this area are considered high risk.

v. Look for burns that encircle an extremity, as they can impair circulation. If the patient sustained an electrical injury, assess thoroughly for entry or exit burn wounds. Record pulse and motor and sensory function.

vi. Examine the posterior surface of the body, as large burns or electrical exit burns may be located in this body area.

2. Vital signs

a. Determining an early set of vital signs will help you to know how the patient is tolerating his or her injuries.

b. Blood pressure, pulse, and skin assessment for perfusion are important signs to obtain.

c. Monitoring devices

i. Oxygen saturation monitor

ii. Carbon monoxide monitor

F. Reassessment

1. Repeat the primary assessment and reassess the patient’s vital signs.

2. Reassess the patient’s chief complaint.

3. Reevaluate interventions and treatments you have provided to the patient.

a. Stop the burning process.

b. Assess and treat breathing.

c. Support circulation.

d. Provide rapid transport.

e. Oxygen is mandatory for inhalation burns and large body surface area burns.

f. If the patient has signs of hypoperfusion, treat aggressively for shock and provide rapid transport.

4. Communication and documentation

a. Provide hospital personnel with a description of how the burn occurred.

b. Describe the extent of the burns:

i. Amount of body surface area involved

ii. Depth of the burn

iii. Location of the burn

c. If special areas are involved, they should be specifically mentioned and documented.

XI. Emergency Medical Care for Burns

A. Your first responsibility in caring for a patient with a burn is to stop the burning process and prevent additional injury.

B. When caring for a burn patient, follow the following steps (Skill Slide 26-2):

Follow standard precautions to help prevent infection.
If safe to do so, remove the patient from the burning area; extinguish or remove hot clothing and jewelry as necessary.
If the wound is still burning or hot, immerse the hot area in cool, sterile water, or cover with a wet, cool dressing.
Provide high-flow oxygen, and continue to assess the airway.
Estimate the severity of the burn, and then cover the area with a dry, sterile dressing or clean sheet. Assess and treat the patient for any other injuries.
Prepare for transport.
Treat for shock.
Cover the patient with blankets to prevent loss of body heat.
Transport promptly.

C. Thermal burns

1. Thermal burns are caused by heat.

2. Most commonly, they are caused by scalds or an open flame.

a. A flame burn is very often a deep burn, especially if a person’s clothing catches fire.

b. A scald burn is most commonly seen in children and handicapped adults but can happen to anyone, particularly while cooking.

i. Hot liquids produce scald injuries.

ii. Scald burns often cover large surface areas of the body because liquids can spread quickly.

3. Coming in contact with hot objects produces a contact burn.

a. Contact burns are rarely deep unless the patient was prevented from drawing away from the hot object.

4. A steam burn can produce a topical (scald) burn.

a. Minor steam burns are common when microwaving food covered with plastic wrap.

5. A flash burn is produced by an explosion, which may briefly expose a person to very intense heat.

a. Lightning strikes can also cause a flash burn.

6. Management of thermal burns

a. Stop the burning source, cool the burned area if appropriate, and remove all jewelry.

b. Maintain a high index of suspicion for inhalation injuries.

c. Increased exposure time will increase damage to the patient.

d. The larger the burn, the more likely the patient will be susceptible to hypothermia and/or hypovolemia.

e. All patients with large surface burns should have a dry sterile dressing applied to help:

i. Maintain body temperature

ii. Prevent infection

iii. Provide comfort

D. Inhalation burns

1. Inhalation injuries can occur when burning takes place in enclosed spaces without ventilation.

a. When the upper airway is exposed to excessive heat, the patient can experience rapid and serious airway compromise.

b. Upper airway damage is often associated with the inhalation of superheated gases.

c. Lower airway damage is often associated with the inhalation of chemicals and particulate matter.

2. When treating a patient for inhalation injuries, you may encounter severe upper airway swelling, which requires immediate intervention.

a. Consider requesting ALS backup if the patient has signs and symptoms of edema.

i. Stridor

ii. Hoarse voice

iii. Singed nasal hairs

iv. Burns of the face

v. Carbon particles in the sputum

b. Apply cool mist, aerosol therapy, or humidified oxygen to help reduce some minor edema.

c. Apply an ice pack to the throat to reduce swelling, provided the tissue in that area does not have burns.

3. The combustion process produces a variety of toxic gases.

a. The less efficient the combustion process, the more toxic gases may be created.

4. Carbon monoxide (CO) intoxication should be considered whenever a group of people in the same place all report a headache or nausea.

5. Cherry red skin, lips, and nail beds are commonly observed in patients who have died from CO exposure.

a. Do not rule out CO exposure simply because the patient’s skin is not cherry red.

6. Hydrogen cyanide (HCN) is generated by combustion.

a. Signs and symptoms involve the central nervous, respiratory, and cardiovascular systems:

i. Fainting

ii. Anxiety

iii. Abnormal vital signs

iv. Headache

vi. Seizures

vii. Paralysis

viii. Coma

6. Management of inhalation burns

a. You must first ensure your own safety and the safety of your coworkers.

b. Prehospital treatment of a patient with suspected hydrogen cyanide poisoning includes decontamination and supportive care until an antidote can be administered by ALS providers.

c. Care for any toxic gas exposure:

i. Recognition

ii. Identification

iii. Supportive treatment

E. Chemical burns $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\JPEG\Ch26\9781284080179_CH26_FIG21.jpg$

1. Chemical burns can occur whenever a toxic substance contacts the body.

2. Most chemical burns are caused by strong acids or strong alkalis.

3. The eyes are particularly vulnerable.

4. The severity of the burn is directly related to three factors:

a. Type of chemical

b. Concentration of the chemical

c. Duration of the exposure

5. To prevent exposure to hazardous materials, determine if you can safely approach the patient. In some cases, you must wait until a hazardous materials (HazMat) team has decontaminated the patient.

6. Wear appropriate chemical-resistant gloves and eye protection whenever you are caring for a patient with a chemical burn.

7. Treatment for chemical burns can be specific to the chemical agent.

8. Management of chemical burns

a. The severity of the burn will depend on the type of chemical, its strength, duration of exposure, and the area of the body exposed.

b. To stop the burning process, remove any chemicals from the patient.

c. Always brush dry chemicals off the skin and clothing before flushing the patient with water.

d. Remove the patient’s clothing, including shoes, stockings, gloves, and any jewelry or eyeglasses.

e. Take great care to ensure you do not come in contact with the chemical. The patient should be properly decontaminated by properly trained personnel.

f. For liquid chemicals, immediately begin to flush the burned area with large amounts of water.

g. Continue flooding the area with gallons of water for 15 to 20 minutes after the patient says the burning pain has stopped.

h. If the patient’s eye has been burned, hold the eyelid open (without applying pressure over the globe of the eye) while flooding the eye with a gentle stream of water.

i. As with any substance, once the fluid has been contaminated with the chemical, collect it and properly dispose of it.

j. Conduct a proper decontamination prior to loading any patient into the ambulance and again prior to entering a hospital.

F. Electrical burns $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\JPEG\Ch26\9781284080179_CH26_FIG11.jpg$

1. Electrical burns may be the result of contact with high- or low-voltage electricity.

a. High-voltage burns may occur when utility workers make direct contact with power lines.

b. Ordinary household current can cause severe burns and cardiac arrhythmias.

2. For electricity to flow, there must be a complete circuit between the electrical source and the ground.

a. Insulator; any substance that prevents this circuit from being completed

b. Conductor: any substance that allows a current to flow through it

c. The human body is a good conductor.

d. Electrical burns occur when the body, or a part of it, completes a circuit connecting a power source to the ground.

3. The type of electric current, the magnitude of current, and voltage have effects on the seriousness of burns.

4. Your safety is of particular importance when you are called to the scene of an emergency involving electricity.

a. You can be fatally injured by coming into contact with power lines.

b. You can be fatally injured by touching a patient who is still in contact with a live power line or any other electrical source.

c. Never attempt to remove someone from an electrical source unless you are specially trained to do so.

d. Always assume that any downed power line is live.

5. A burn injury appears where the electricity enters and exits the body.

a. Two dangers specifically associated with electrical burns:

i. There may be a large amount of deep tissue injury.

ii. The patient may go into cardiac or respiratory arrest from the electric shock.

(a) If the patient is not in cardiac arrest on your arrival, he or she is unlikely to experience this problem during transport.

6. Management of electrical burns

a. Electrical current can cross the chest and cause cardiac arrest or arrhythmias.

b. If indicated, begin CPR on the patient and apply the automated external defibrillator (AED).

c. Be prepared to defibrillate if necessary.

d. Give supplemental oxygen and monitor the patient closely for respiratory and cardiac arrest.

e. Treat the soft-tissue injuries by applying dry, sterile dressings on all burn wounds and splinting suspected fractures.

f. Provide prompt transport.

G. Taser injuries

1. In recent years, law enforcement has increased its use of Tasers.

2. These weapons fire two small darts (electrodes) that puncture the patient’s skin.

a. Barbs are generally treated as impaled objects and removed by a physician.

b. In some jurisdictions, depending on local protocol, EMTs are permitted to remove these barbs from patients.

3. There are potential complications for the patient when these devices have been used, particularly when the patient is experiencing certain underlying disorders.

a. Excited delirium is commonly associated with illegal drug ingestion.

b. Excited delirium is a true emergency and warrants assisted ALS response.

c. Using a Taser device in patients with true excited delirium has been previously associated with dysrhythmias and sudden cardiac arrest.

4. Make sure you have access to an AED when you respond to patients who have been exposed to Taser shots.

H. Radiation burns

1. Acute radiation exposure has become more than a theoretical issue because the use of radioactive materials has increased in industry and medicine.

2. Potential threats include incidents related to the use and transportation of radioactive isotopes and intentionally released radioactivity in terrorist attacks.

3. You must determine if there has been a radiation exposure and then attempt to determine whether ongoing exposure continues to exist.

4. Three types of ionizing radiation:

a. Alpha

i. Alpha particles have little penetrating energy.

ii. They are easily stopped by the skin.

b. Beta

i. Beta particles have greater penetrating power and can travel much farther in air than alpha particles.

ii. They can penetrate the skin but can be blocked by simple protective clothing designed for this purpose.

c. Gamma

i. The threat from gamma radiation is directly proportional to its wavelength.

ii. This type of radiation is very penetrating and easily passes through the body and solid materials

5. Most ionizing radiation accidents involve gamma radiation (x-rays).

6. People who have sustained radiation exposure generally do not pose a risk to others, but in incidents involving explosions, patients may be contaminated.

7. Management of radiation burns

a. Maintain a safe distance and wait for the HazMat team to decontaminate the patient before initiating care.

b. Most contaminants can be removed by simply removing the patient’s clothes. Call for additional resources.

c. Once there is no threat to you, begin treating the ABCs and treat the patient for any burns or trauma.

d. Irrigate open wounds.

e. Notify the emergency department.

f. Identify the radioactive source and the length of the patient’s exposure to it.

g. Limit your duration of exposure, increase your distance from the source, and attempt to place shielding between yourself and sources of gamma radiation.

X. Dressing and Bandaging $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\JPEG\Ch26\9781284080179_CH26_FIG12A.jpg$

A. All wounds require bandaging.

1. Splints can help control bleeding and provide firm support for dressing.

2. Many different types of dressings and bandages exist.

3. Dressings and bandages have three functions:

a. To control bleeding

b. To protect the wound from further damage

c. To prevent further contamination and infection

B. Sterile dressings

1. Most wounds will be covered by:

a. Universal dressings

b. Conventional 4″ × 4″ and 4″ × 8″ gauze pads

c. Assorted small adhesive-type dressings and soft self-adherent roller dressings

2. The universal dressing is ideal for covering large open wounds.

3. Gauze pads are appropriate for smaller wounds.

4. Adhesive-type dressings are useful for minor wounds.

5. Occlusive dressings prevent air and liquids from entering (or exiting) the wound.

a. Made of Vaseline gauze, aluminum foil, or plastic

b. Used to cover sucking chest wounds, abdominal eviscerations, penetrating back wounds, and neck injuries

C. Bandages

1. To keep dressings in place. You can use:

a. Soft roller bandages

b. Rolls of gauze

c. Triangular bandages

d. Adhesive tape

2. The self-adherent, soft roller bandages are easiest to use.

3. Adhesive tape holds small dressings in place and helps to secure larger dressings.

a. Some people are allergic to adhesive tape; with these individuals, use paper or plastic tape.

4. Do not use elastic bandages to secure dressings.

a. If the injury swells, the bandage may become a tourniquet and cause further damage.

b. Always check a limb distal to a bandage for signs of impaired circulation and loss of sensation.

Leave the tips of the fingers or toes exposed when bandaging the arm or leg so future assessment of circulation can be made.

c. Air splints and vacuum splints are useful in stabilizing broken extremities and can be used with dressings to help control bleeding from soft-tissue injuries.

5. Bandages are applied after bleeding has been controlled.

6. If a wound continues to bleed despite the use of direct pressure, apply a pressure dressing. Refer to Chapter 25, Bleeding to refresh yourself on bleeding control.

D. Hemostatic agents

1. Any chemical compound that slows or stops bleeding by assisting with clot formation

2. Two forms

Granular powder

Can be inserted into small wounds to create a tight seal

b. Gauze impregnated with a clay substance

3. Can be used together with direct pressure when direct pressure alone is ineffective

4. The use of hemostatic agents in EMS remains largely experimental.

Be aware of and follow your local protocols.

Chapter 27, Face and Neck Injuries

Unit Summary

After completing this chapter and related coursework, you will understand how to manage trauma-related issues with the face and neck. You will learn how to recognize life threats associated with these injuries and the correlation with head and spinal trauma. The curriculum includes detailed anatomy and physiology of the head, neck, and eye, and discusses injuries including trauma to the mouth, penetrating neck trauma, laryngotracheal injuries, and facial fractures. The chapter also includes information on dental injuries and blast injuries to the eye. Management of common eye injuries such as foreign objects, puncture wounds, lacerated eyelids, burns, impaled objects, and complications from blunt trauma are included.

National EMS Education Standard Competencies

Medicine

Applies fundamental knowledge to provide basic emergency care and transportation based on assessment findings for an acutely ill patient.

Diseases of the Eyes, Ears, Nose, and Throat

Recognition and management of

Nosebleed

Trauma

Applies fundamental knowledge to provide basic emergency care and transportation based on assessment findings for an acutely injured patient.

Head, Facial, Neck, and Spine Trauma

Recognition and management of:

Life threats
Spine trauma (Chapter 28, “Head and Spine Injuries”)

Pathophysiology, assessment, and management of:

Penetrating neck trauma
Laryngotracheal injuries
Spine trauma (Chapter 28, “Head and Spine Injuries”)
Facial fractures
Skull fractures (Chapter 28, “Head and Spine Injuries”)
Foreign bodies in the eyes
Dental trauma

Knowledge Objectives

1. Describe the anatomy and physiology of the head, face, and neck; include major structures and specific important landmarks of which EMTs must be aware.

2. Describe the factors that may cause obstruction of the upper airway following a facial injury.

3. Discuss the different types of facial injuries and patient care considerations related to each one.

4. Explain the emergency care of a patient who has sustained face and neck injuries; include assessment of the patient, review of signs and symptoms, and management of care.

5. Explain the emergency care of a patient with soft-tissue wounds of the face and neck.

6. Explain the emergency care of a patient with an eye injury based on the following scenarios: foreign object, impaled object, burns, lacerations, blunt trauma, closed head injuries, and blast injuries.

7. Describe the three different causes of a burn injury to the eye and patient management considerations related to each one.

8. Explain the emergency care of a patient with injuries of the nose.

9. Explain the emergency care of a patient with injuries of the ear; include lacerations and foreign body insertions.

10. Explain the physical findings and emergency care of a patient with a facial fracture.

11. Explain the emergency care of a patient with dental and cheek injuries; include how to deal with an avulsed tooth.

12. Explain the emergency care of a patient with an upper airway injury caused by blunt trauma.

13. Explain the emergency care of a patient with a penetrating injury to the neck; include how to control regular and life-threatening bleeding.

Skills Objectives

1. Demonstrate the removal of a foreign object from under a patient’s upper eyelid. (Skill Slide 27-1)

2. Demonstrate the stabilization of a foreign object that has been impaled in a patient’s eye. (Skill Slide 27-2)

3. Demonstrate irrigation of a patient’s eye using a nasal cannula, bottle, or basin.

4. Demonstrate the care of a patient who has a penetrating eye injury.

5. Demonstrate how to control bleeding from a neck injury. (Skill Slide 27-3)

I. Introduction

A. The face and neck are particularly vulnerable to injury because of their relatively unprotected positions on the body.

1. Soft-tissue injuries and fractures are common and vary in severity.

2. Some injuries are life threatening.

a. Penetrating trauma to the neck may cause severe bleeding.

b. An open injury may allow an air embolism to enter the circulatory system.

i. If a hematoma forms in this area, it may stop or slow blood flow to the brain, causing a stroke.

3. With appropriate prehospital and hospital care, a patient with a seemingly devastating injury can have a surprisingly good outcome.

II. Anatomy and Physiology

A. The head is divided into the following:

1. Cranium

a. Also referred to as the skull

b. Contains the brain

i. The brain connects to the spinal cord through the foramen magnum, a large opening at the base of the skull.

c. The most posterior portion of the cranium is called the occiput.

d. On each side of the cranium, the lateral portions are called the temples or temporal regions.

i. Between the temporal regions and the occiput lie the parietal regions.

e. The forehead is called the frontal region. $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\Ch27\9781284080179_CH27_CP01.jpg$

f. Anterior to the ear, in the temporal region, you can feel the pulse of the superficial temporal artery.

2. Face

a. Composed of:

i. Eyes

ii. Ears

iii. Nose

iv. Mouth

v. Cheeks

b. The six major bones of the face include:

i. Nasal bone

ii. Two zygomas $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\Ch27\9781284080179_CH27_FIG02.jpg$

iii. Two maxillae

iv. Mandible

c. The orbit of the eye is composed of:

i. Lower edge of the frontal bone of the skull

ii. Zygoma

iii. Maxilla

iv. Nasal bone

d. The bony orbit protects the eye from injury.

e. Only the proximal third of the nose is formed by bone.

i. The remaining two thirds are composed of cartilage.

f. The exposed portion of the ear is composed entirely of cartilage covered by skin.

i. The external, visible part is called the pinna.

ii. The tragus is a small, rounded, fleshy bulge immediately anterior to the ear canal.

iii. The superficial temporal artery can be palpated just anterior to the tragus.

g. About 1 inch posterior to the external opening of the ear is the mastoid process.

i. Bony mass at the base of the skull

h. The mandible forms the jaw and chin.

i. The jaw is the lower border of the mouth, where the tongue and 32 teeth are located.

ii. The only moveable bone of the face, motion of the mandible occurs at the temporomandibular joint, which lies just in front of the ear on either side of the face. $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\Ch27\9781284080179_CH27_FIG03.jpg$

iii. Below the ear and anterior to the mastoid process, the angle of the mandible is easily palpated.

B. Neck

1. Contains many important structures

2. Supported by the cervical spine

a. First seven vertebrae in the spinal column (C1 through C7)

b. The spinal cord exits from the foramen magnum and lies within the spinal canal formed by the vertebrae.

3. The upper part of the esophagus and the trachea lie in the midline of the neck.

a. The carotid arteries are found on either side of the trachea, along with the jugular veins and several nerves. $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\Ch27\9781284080179_CH27_CP04.jpg$

4. The larynx

a. Adam's apple is located in the center of the anterior of the neck.

i. Adam's apple is the upper part of the larynx.

ii. It is formed by the thyroid cartilage.

iii. More prominent in men than in women

b. The other portion of the larynx is the cricoid cartilage, a firm ridge of cartilage below the thyroid cartilage.

c. Cricothyroid membrane

i. Lies between the thyroid cartilage and the cricoid cartilage

ii. Soft depression in the midline of the neck

iii. A thin sheet of connective tissue that joins the two cartilages

5. The trachea

a. Below the larynx

b. The trachea connects both the oropharynx and larynx to the main passages of the lungs, the bronchi.

c. On either side of the lower larynx and the upper trachea lies the thyroid gland.

6. Sternocleidomastoid muscles

a. Originate from the mastoid process of the cranium and insert into the medial border of each collarbone and the sternum at the base of the neck

b. Allow movement of the head

C. The eye

1. Globe-shaped, approximately 1 inch in diameter

2. Located within a bony socket in the skull called the orbit

a. The orbit is composed of adjacent bones of the face and skull.

b. In adults, the orbit protects over 80% of the eyeball.

c. Between and below the orbits are the nasal bone and the sinuses.

3. The eyeball, or globe, keeps its shape as a result of pressure from the fluid contained within its two chambers.

a. Clear, jellylike fluid near the back of the eye is called the vitreous humor.

b. In front of the lens is a clear fluid called the aqueous humor. $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\Ch27\9781284080179_CH27_CP05.jpg$

i. In penetrating injuries of the eye, aqueous humor can leak out.

ii. With time and appropriate medical treatment, the body can make more.

4. The conjunctiva is a membrane that covers the eye.

5. The lacrimal glands, often called tear glands, produce fluid to keep the eyes moist.

a. When a person blinks, fluid is swept from the lacrimal glands over the surface of the eye, cleaning it.

b. The tears drain on the inner side of the eye through two lacrimal ducts into the nasal cavity. $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\Ch27\9781284080179_CH27_CP06.jpg$

6. The sclera is the white, fibrous tissue that helps maintain the globular shape and protects the more delicate inner structures.

7. On the front of the eye, the sclera is replaced by a clear, transparent membrane called the cornea.

a. Allows light to enter the eye

b. The iris is a circular muscle behind the cornea.

i. The iris acts like a camera to adjust the size of the opening to regulate the amount of light that enters the eye.

ii. The iris is pigmented, giving the eye its color.

8. The pupil is the opening in the center of the iris.

a. Allows light to move to the back of the eye

b. Anisocoria is a condition in which a person is born with different-sized pupils.

i. In unconscious patients, unequal pupil size may indicate serious injury or illness of the brain or eye.

9. The lens lies behind the iris.

a. The lens focuses images on the retina at the back of the globe.

10. The retina contains nerve endings, which respond to light by transmitting nerve impulses through the optic nerve to the brain.

a. The retina is nourished by a layer of blood vessels between it and the back of the globe.

i. Called the choroid

b. Retinal detachment is when the retina detaches from the underlying choroid and sclera.

i. Causes blindness

III. Injuries of the Face and Neck

A. Injuries about the face and neck can often lead to partial or complete obstruction of the upper airway.

1. Several factors may contribute to the obstruction.

a. Blood clots in the upper airway from heavy facial bleeding

i. Can lead to complete obstruction, especially in unconscious patients

b. Direct injuries to the nose and mouth, the larynx, and the trachea are often the source of significant bleeding and/or respiratory compromise.

i. May need to suction the airway

c. Injuries may cause teeth or dentures to become dislodged into the throat.

d. Swelling that accompanies direct and indirect injury to the soft tissues can also contribute to airway obstruction.

e. The airway may also be affected when the patient’s head is turned to the side.

i. This is often the case with altered levels of responsiveness or unconscious patients.

f. Possible injuries to the brain and/or cervical spine may interfere with normal respirations. $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\Ch27\9781284080179_CH27_FIG06.jpg$

i. If the great vessels in the neck are injured, significant bleeding and pressure on the upper airway are common.

B. Soft-tissue injuries

1. Soft-tissue injuries of the face and neck are very common.

2. The face and neck are extremely vascular.

a. Swelling in this area may be more severe.

b. Skin and tissues in these areas have a rich blood supply.

i. Bleeding from penetrating injuries may be heavy.

ii. Even minor soft-tissue wounds of the face and neck may bleed profusely.

c. A blunt injury can cause a hematoma.

i. Sometimes a flap of skin is peeled back, or avulsed.

C. Dental injuries

1. Mandible injuries are common because of its prominence.

a. Secondly only to nasal fractures in frequency.

2. Most of these fractures are the result of vehicle collisions and assaults.

a. Signs of mandible fracture include:

i. Misalignment of the teeth

ii. Numbness of the chin

iii. An inability to open the mouth

3. Maxillary fractures are usually found after blunt-force, high-energy impacts.

a. The signs of maxillary fractures include:

i. Massive facial swelling

ii. Instability of the facial bones

iii. Misalignment of teeth

4. Fractured and avulsed teeth are common following facial trauma.

a. Teeth fragments can become an airway obstruction and should be removed immediately.

IV. Patient Assessment

A. Scene size-up

1. Scene safety

a. Upon arrival, observe for hazards and threats to safety.

b. Assess for the potential of violence and environmental hazards.

c. Standard precautions require eye protection and a face mask, because of the potential for projectile blood.

d. Place several pairs of gloves in your pockets for easy access.

e. Determine the number of patients and consider the need for additional assistance.

2. Mechanism of injury

a. Assess the scene, looking for indicators of the mechanism of injury (MOI).

i. Consider how the MOI produced the injuries expected.

b. Common MOIs for face and neck injuries include:

i. Motor vehicle collisions

ii. Sports

iii. Falls

iv. Penetrating trauma

v. Blunt trauma

B. Primary assessment

1. Focuses on identifying and managing life-threatening concerns

2. Threats to ABCs must be treated immediately.

a. When there is life-threatening external hemorrhage, it should be addressed before airway and breathing.

3. Form a general impression.

a. Look for important indicators of the seriousness of the patient’s condition.

b. Injuries to the face and throat may be very obvious, but may also be hidden by collars or hats.

c. Control blood loss with direct pressure.

d. Consider the need for manual spinal stabilization.

e. Check for responsiveness using the AVPU scale.

4. Airway and breathing

a. Ensure a clear and patent airway.

b. If the patient is unresponsive or has a significantly altered level of responsiveness, consider a properly sized oropharyngeal airway.

i. The nasopharyngeal airway is controversial because of the possibility of insertion directly into the cranial vault and brain tissue if the patient has a facial or head trauma.

ii. Be aware of and follow local protocols.

c. Quickly assess for adequacy of breathing.

i. Palpate the chest wall for DCAP-BTLS.

ii. If penetrating trauma is discovered, place an occlusive dressing on the wound to prevent air from entering the circulatory system.

iii. Maintain the airway, provide supplemental oxygen, and initiate bag-valve mask (BVM) ventilation if necessary.

iv. Check for breath sounds and provide rapid transport to the hospital if abnormal.

d. Splinting or otherwise restricting chest wall motion is contraindicated.

i. Splinting is ineffective and can impair air exchange.

5. Circulation

a. You must quickly:

i. Assess the pulse rate and quality.

ii. Determine the skin condition, color, and temperature.

iii. Check capillary refill time.

b. Significant bleeding is an immediate life threat.

6. Transport decision

a. Consider quickly transporting patients with airway or breathing problems or with significant bleeding.

b. Stabilization and maintenance of an airway and breathing, as well as control of bleeding, can be very difficult in patients with facial or neck injuries.

c. Consider ALS backup if the transport time is long.

d. A patient with internal bleeding must be transported quickly for treatment by a physician.

i. Internal bleeding may compromise blood flow to the brain.

ii. Bleeding from major vessels of the throat can impact the patient’s airway.

e. Signs of hypoperfusion include:

i. Tachycardia

ii. Tachypnea

iii. Low blood pressure

iv. Weak pulse

v. Cool, moist, pale skin

f. The patient who has a significant MOI but whose condition appears stable should also be transported promptly.

g. Remember that any significant blow to the face or throat should increase your suspicion of spinal or brain injury.

h. Even if the patient has no signs of hypoperfusion or other life-threatening injuries, there is the possibility of eye injuries.

i. Considered serious

ii. The patient should be transported to the hospital as quickly and safely as possible.

iii. Surgery and/or restoration of circulation to the eye will need to be accomplished within 30 minutes or permanent blindness may result.

C. History taking

1. Investigate the chief complaint.

a. Obtain a medical history.

b. Be alert for injury-specific signs and symptoms.

c. Be aware of any pertinent negatives such as no pain or no loss of sensation.

2. SAMPLE history

a. Attempt to gather from friends or family if the patient is unresponsive

b. In unresponsive patients, you will only be able to notice signs of injuries.

i. Information may have to be obtained by someone who is knowledgeable about the patient.

ii. Information may or may not be accurate and may be incomplete.

D. Secondary assessment

1. More detailed, comprehensive examination of the patient that is used to uncover injuries that may have been missed during the primary assessment.

2. You may not always have time to conduct a secondary assessment.

3. Physical examinations

a. If multiple systems are likely to have been affected, start with an assessment of the entire body looking for DCAP-BTLS.

i. Perform a detailed examination of specific areas.

b. Do not delay transport to complete a thorough physical examination.

c. In a responsive patient who has an isolated injury with a limited MOI, consider focusing your physical examination on:

i. The isolated injury

ii. The patient’s chief complaint

iii. The body region affected

d. Ensure that control of bleeding is maintained, and note the location of the injury.

e. Inspect the open wound for any foreign matter and stabilize impaled objects.

f. During the physical examination, use both your eyes and your hands.

i. Your eyes will be looking for swelling, deformities of the bones, contusions, and discoloration.

ii. Your hands will be gently palpating the face, looking and feeling for any abnormalities.

g. If your patient is responsive, you should explain exactly what you are doing and what you are looking for.

i. Your discovery of an abnormality may be an old injury.

h. Assess all underlying systems, including:

i. Neurologic system, including the brain and major nerves

ii. Sensory organs, including the eyes and nose

iii. Respiratory system, including the mouth, nose, sinuses, and airway

iv. Circulatory system, focusing on carotid arteries and jugular veins.

i. When evaluating the eyes, start with the outer aspect and work toward the pupils.

i. Examine the eye for any obvious foreign matter.

ii. Visual acuity is considered the vital sign of the eye.

(a) Gently cover one eye and hold fingers up at arm’s length in front of the open eye.

(b) Test both eyes for the ability to see fingers.

iii. Note any discoloration of the eye, bleeding in the iris area, or redness.

iv. Look for eye symmetry because asymmetry indicates a possible brain injury.

v. Look at each pupil for equal size and reaction to light.

vi. If pupils are not symmetric, inquire about previous surgeries or injuries.

vii. Determine whether unequal pupils are caused by physiologic or pathologic issues.

viii. Brain injury, nerve disease, glaucoma, and meningitis are all possible causes of unequal pupils.

4. Vital signs

a. Assess vital signs to obtain a baseline so that you can observe any changes during treatment.

b. You must be concerned with visible bleeding and unseen bleeding inside a body cavity.

c. With facial and throat injuries, baseline information about respirations and pulse is very important.

d. Monitoring devices

i. Use appropriate monitoring devices to quantify your patient’s oxygenation and circulatory status.

ii. You may also use noninvasive methods to monitor blood pressure.

E. Reassessment

1. Repeat the primary assessment.

2. Reassess vital signs and the chief complaint.

a. Continually reassess the adequacy of airway, breathing, and circulation.

3. Recheck patient interventions.

a. This is particularly important in patients with facial or neck injuries because the ease in which injuries can affect associated systems.

b. The patient’s condition should be reassessed at least every 5 minutes.

4. Interventions

a. Provide complete spinal immobilization to any patient with suspected spinal injuries.

i. Spinal injuries should be suspected any time there is significant trauma to the face or neck.

b. Maintain an open airway, be prepared to suction the patient, and consider an oropharyngeal airway.

c. Whenever you suspect significant bleeding, provide high-flow oxygen.

i. If needed, provide assisted ventilation using a BVM with high-flow oxygen.

d. Control any significant visible bleeding.

e. If the patient has signs of hypoperfusion, treat the patient aggressively for shock and provide rapid transport.

f. Do not delay transport of a seriously injured patient to complete non-lifesaving treatments in the field.

5. Communication and documentation

a. In your documentation, include a description of the MOI and the position in which you found the patient.

i. In cases of motor vehicle crashes, document the method used to remove the patient from the vehicle.

ii. In patients with severe external bleeding, it is important to recognize, estimate, and report the amount of blood loss that has occurred.

iii. Inform the hospital about all injuries involving the head and neck.

iv. Specialists may be needed to manage injuries to the eyes, ears, teeth, mouth, sinuses, larynx, esophagus, or large vessels.

V. Emergency Medical Care

A. Treat soft-tissue injuries to the face and neck the same as soft-tissue injuries elsewhere on the body.

1. Assess ABCs and life threats first.

a. Follow standard precautions.

b. In the absence of life-threatening bleeding, the first step is to open and clear the airway.

i. The patient may need frequent suctioning of blood draining into the throat.

c. Avoid moving the neck in patients with suspected cervical spine injuries.

i. Use the jaw-thrust maneuver to open the airway and then suction the mouth.

ii. Once the patient is immobilized, you can turn the backboard to one side to allow blood or vomitus to drain from the mouth.

B. Control bleeding by applying direct manual pressure with a dry, sterile dressing.

1. Use roller gauze, wrapped around the circumference of the head, to hold a pressure dressing in place.

2. Do not apply excessive pressure if there is a possibility of an underlying skull fracture.

3. When an injury exposes the brain, eye, or other structures, cover the exposed parts with a moist, sterile dressing.

4. Apply ice locally to injuries that do not break the skin.

5. For soft-tissue injuries around the mouth, check for bleeding inside the mouth.

a. Broken teeth and lacerations to the tongue may cause profuse bleeding and obstruction of the upper airway.

b. Often, the patient will swallow the blood, so the hemorrhage may not be apparent.

c. Patients who swallow blood are prone to vomiting.

6. Physicians can sometimes graft a piece of avulsed skin back into the appropriate position.

a. If you find portions of avulsed skin, wrap them in a sterile dressing, place them in a plastic bag, and keep them cool.

i. Never place tissue on ice because freezing will destroy the tissue and make it unusable.

ii. Deliver the bag labeled with the patient’s name to the emergency department.

b. If the skin is still attached in a loose flap, place the flap in a position that is as close to normal as possible.

i. Hold it in place with a dry, sterile dressing.

VI. Emergency Medical Care for Specific Injuries

A. Injuries of the eyes

1. Eye injuries are common, particularly in sports.

a. Can produce lifelong complications, including blindness

b. Proper emergency treatment will minimize pain and may prevent a permanent loss of vision.

2. In a normal, uninjured eye, the entire circle of the iris is visible.

a. The pupils are round, usually equal in size, and react equally when exposed to light.

b. Both eyes move together in the same direction when following your moving finger.

3. After an injury, pupil reaction or shape and eye movement are often disturbed.

a. Abnormal pupil reactions sometimes are a sign of brain injury rather than an eye injury.

4. Treatment starts with a thorough examination.

5. Always use standard precautions.

a. Take care not to aggravate any problems.

6. Look for specific abnormalities or conditions that may suggest the nature of the injury.

a. A damaged cornea quickly loses its smooth, wet appearance.

7. Foreign objects $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\Ch27\9781284080179_CH27_CP08.jpg$

a. The orbit protects the eye from the penetration of large objects.

b. Even a very small object may produce severe irritation.

i. The conjunctiva becomes inflamed and red—a condition known as conjunctivitis—and the eye begins to produce tears in an attempt to flush out the object.

ii. Irritation of the cornea of conjunctiva causes intense pain.

c. Irrigation with a sterile saline solution will frequently flush away loose, small particles.

i. Use a bulb syringe, or a nasal airway or cannula, to direct saline into the affected eye.

ii. Always flush from the nose side of the eye toward the outside to avoid flushing material into the other eye.

d. d. A foreign body will leave a small abrasion on the conjunctiva.

i. The patient may still report irritation.

e. Gentle irrigation usually will not wash out foreign bodies stuck to the cornea or lying under the upper eyelid.

i. If you spot a foreign object on the surface of the eyelid, you may be able to remove it with a moist, sterile, cotton-tipped applicator.

ii. Have the patient look down, grasp the upper lashes, and gently pull the lid away from the eye.

iii. Place a cotton-tipped applicator on the outer surface of the upper lid.

iv. Pull the lid forward and up, folding it back over the applicator.

v. Gently remove the foreign object from the eyelid with a moistened, sterile, cotton-tipped applicator.

vi. Follow the steps in Skill Slide 27-1.

vii. Never attempt to remove an object that is stuck to the cornea.

f. Foreign bodies may be impaled in the eye.

i. Must be removed by a physician

g. Your care involves stabilizing the object and preparing the patient for transport.

i. Bandage the object in place to support it.

ii. Cover the eye with a moist, sterile dressing.

iii. Surround the object with a doughnut-shaped collar made from roller gauze or a small gauze pack. 78286_CH25_SKDSK02_01 78286_CH25_SKDSK02_02

(a) To prepare a doughnut ring, wrap a 2-inch roll around your fingers and thumb seven or eight times. Adjust the diameter by spreading your fingers or squeezing them together. 78286_CH25_SKDSK02_04 78286_CH25_SKDSK02_03

(b) Remove the gauze from your hand and wrap the remainder of the gauze roll radially around the ring that you have created.

(d) Place the dressing over the eye and impaled object to hold the impaled object in place, and then secure it with a roller bandage.

iv. Follow the steps in Skill Slide 27-2.

h. When you see or suspect an impaled object(s) in the eye, bandage both eyes with soft, bulky dressings to prevent further injury.

i. The bandage should be loose enough to hold the eyelid closed but not cause pressure on the eye itself.

ii. This type of injury must be handled by an ophthalmologist on an urgent basis.

8. Burns of the eye

a. Your role is to stop the burn and prevent further damage.

b. Chemical burns

i. Usually caused by acid or alkaline solutions

ii. Flush the eye with water or sterile saline irrigation solution. $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\Ch27\9781284080179_CH27_CP09B.jpg$

iii. Direct the greatest amount of irrigating solution or water into the eye as gently as possible.

iv. You may have to force the lids open to irrigate.

v. Use a bulb, irrigation syringe, nasal cannula, basin, or running faucet.

vi. You can even have the patient immerse his or her face in a large pan or basin of water and rapidly blink the affected eyelid.

vii. Flush from the inner corner of the affected eye toward the outside corner.

viii. If the burn was caused by an alkali or a strong acid, you should irrigate the eye continuously for at least 20 minutes.

ix. After irrigation, apply a clean, dry dressing to cover the eye, and transport the patient.

c. Thermal burns

i. During a fire, the eyes will close to protect from heat.

ii. Eyelids are frequently burned and require specialized care.

iii. Transport promptly without further examination.

iv. Cover both eyes with a sterile dressing moistened with sterile saline.

v. You may apply eye shields over the dressing.

d. Light burns

i. Infrared rays, eclipse light, and laser beams all can cause significant damage to the sensory cells of the eye.

ii. Retinal injuries caused by exposure to extremely bright light are generally not painful but may result in permanent damage.

iii. Superficial burns of the eye can result from ultraviolet rays from an arc welding unit; light from prolonged exposure to a sunlamp; or reflected light from a bright, snow-covered area.

iv. May not be painful at first, but may become so 3 to 5 hours later

v. Severe conjunctivitis usually develops, with redness, swelling, and excessive tear production.

vi. You can ease the pain by covering each eye with a sterile, moist pad and an eye shield.

vii. The patient should be examined by a physician as soon as possible.

9. Lacerations

a. Lacerations of the eyelids require very careful repair to restore appearance and function.

i. Bleeding may be heavy, but it usually can be controlled with gentle, manual pressure.

ii. Only wipe blood from the face and around the eye, do not wipe the eyeball.

b. If there is a laceration of the globe itself, apply no pressure to the eye.

i. Compression can interfere with the blood supply and result in loss of vision.

c. Follow these important guidelines in treating penetrating injuries of the eye:

i. Never exert pressure on or manipulate the injured globe.

ii. If part of the eyeball is exposed, gently apply a moist, sterile dressing to prevent drying.

iii. Cover the injured eye with a protective metal eye shield, cup, or sterile dressing soaked in saline. Apply soft dressings to both eyes, and provide prompt transport.

d. On rare occasions, the eyeball may be displaced from its socket.

i. Do not attempt to reposition it.

ii. Cover the eye and stabilize it with a moist sterile dressing.

iii. Cover both eyes to prevent further injury because of sympathetic movement.

iv. Have the patient lie supine to prevent loss of fluid from the eye.

10. Blunt trauma

a. Injuries range from the ordinary black eye to a severely damaged globe.

b. Hyphema (bleeding into the anterior chamber of the eye) obscures all or part of the iris.

i. Common in blunt trauma and may cause seriously impaired vision

ii. Cover both eyes to prevent further injury and provide transportation to the hospital.

c. Orbit fracture (blow-out fracture)

i. Fracture of bones that form the eye floor and support the globe

ii. Place on a stretcher and transport immediately.

iii. Protect the eye with a metal shield.

iv. Cover the other eye to minimize eye movement.

d. Retinal detachment

i. Often seen in sports, especially boxing

ii. Painless but produces flashing lights, specks, or “floaters”

iii. Requires prompt medical attention to preserve vision

e. Corneal Abrasion (Scratched Eye)

i. Common causes of abrasions to the eye's surface (corneal abrasions) are getting poked in the eye or rubbing the eye when a foreign body is present, such as dust or sand.

ii. Corneal abrasions are very uncomfortable and cause eye redness and severe sensitivity to light.

11. Eye injuries following head injury

a. Any of the following eye findings should alert you to the possibility of a head injury:

i. One pupil larger than the other

ii. Eyes not moving together or pointing in different directions

iii. Failure of the eyes to follow movement of your finger as instructed

iv. Bleeding under the conjunctiva

v. Protrusion or bulging of one eye

b. For an unconscious patient, keep the eyelids closed.

i. Cover the lids with moist gauze, or hold them closed with clear tape.

ii. Normal tears will then keep the tissues moist.

12. Blast injuries

a. Signs and symptoms of blast injuries range from severe pain and loss of vision to foreign bodies within the globe.

i. Before responding to patients after the blast, ensure that the scene is safe.

b. Management of injuries to the eye depends on the severity of the injury.

i. If there is a foreign body within the globe, do not attempt to remove it. Use a clean cup or similar item to protect the area.

ii. If only one eye is injured, follow local protocol.

iii. Patients with a sudden loss or decrease of vision will have to be verbally instructed on what is going on around them.

iv. If the patient has severe swelling or a hematoma to the eyelid, do not attempt to force the eyelid open to examine.

13. Contact lenses and artificial eyes

a. In general, do not attempt to remove contact lenses.

i. The only exception is for chemical burns.

b. To remove a hard contact lens, use a small suction cup, moistening the end with saline.

c. To remove soft contact lenses, place one or two drops of saline in the eye, gently pinch the lens between your gloved thumb and index finger, and lift it off the surface of the eye.

d. Place the lens in a container with sterile saline solution.

e. Advise the hospital staff if the patient is wearing contact lenses.

f. Occasionally, you may find yourself caring for a patient wearing an eye prosthesis.

i. You should suspect an eye of being artificial when it does not respond to light, move in concert with the opposite eye, or appear quite the same as the opposite eye.

ii. If you are not sure, ask about it.

B. Injuries of the nose

1. Nosebleeds (epistaxis) are a common problem.

a. One of the most common causes is digital trauma. $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\Ch27\9781284080179_CH27_CP12.jpg$

b. Nosebleeds are further categorized into anterior and posterior epistaxis.

c. Anterior nosebleeds usually originate from the area of the septum and bleed fairly slowly.

i. Usually self-limiting and resolve quickly

d. Posterior nosebleeds are usually more severe and often cause blood to drain into the patient’s throat.

i. Attempting to insert a nasopharyngeal airway in a patient with a suspected basilar skull fracture or with facial injuries is controversial; follow local protocols.

2. The nose often takes the brunt of physical assaults and car crashes.

a. Blunt injuries to the nose may be associated with fractures and soft-tissue injuries of the face, head injuries, and/or injuries to the cervical spine.

3. Assess the nose structures for injury.

a. It is helpful to picture the inside of the nose itself.

i. The nasal cavity is divided into two chambers by the nasal septum.

ii. Both chambers have a superior, middle, and inferior turbinate.

iii. Directly above the nose are the frontal sinuses and, on either side, the orbit of the eye.

b. Cerebrospinal fluid (CSF) may escape down through the nose following a fracture at the base of the skull.

i. Use a piece of gauze to absorb the blood.

ii. If CSF is present, the blood will be surrounded by a lighter ring of fluid (halo test).

4. Control bleeding by applying a sterile dressing.

a. If the patient is bleeding heavily, it could be the result of significant trauma.

i. Consider cervical spine injury.

ii. The patient should not be moved if the airway can be managed in the patient’s present position.

b. For a nontrauma patient who is bleeding from the nose, place the patient in a sitting position, leaning forward, and pinch the nostrils together.

i. See Skill Slide 25-3 from Chapter 25, “Bleeding.”

5. Children place foreign objects in their noses.

a. All foreign bodies should be removed by a physician.

b. If there are no other emergency medical concerns, transport non-emergent.

C. Injuries of the ear $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\Ch27\9781284080179_CH27_CP13.jpg$

1. The ear is complex and associated with hearing and balance.

2. Divided into three parts:

a. External ear (Outer ear)

i. The pinna, or auricle, lies outside of the head.

ii. The external auditory canal leads in toward the tympanic membrane (eardrum).

b. Middle ear

i. Contains three small bones (hammer, anvil, and stirrup) that move in response to sound waves hitting the tympanic membrane (eardrum).

ii. The middle ear is connected to the nasal cavity by the eustachian tube, which is the internal auditory canal.

c. Inner ear

i. Composed of bony chambers filled with fluid

ii. As the head moves, so does the fluid.

iii. In response, fine nerve endings within the fluid send impulses to the brain about the position of the head.

3. Ears are often injured, but they do not usually bleed very much.

a. If local pressure does not control bleeding, apply a roller dressing.

4. In case of an ear avulsion, wrap the avulsed part in a moist, sterile dressing and put it in a plastic bag labeled with the patient’s name.

5. Tympanic membrane rupture

a. Sudden changes in pressure created by a blast wave may cause rupture.

b. Patients will report severe pain, difficulty hearing, or ringing in the affected ear.

c. May be caused by insertion of objects too far into the ear

d. Patients with a suspected tympanic membrane injury should be transported to the hospital for evaluation.

6. Children place foreign bodies in the external auditory canal.

a. All foreign bodies should be removed by a physician.

b. Do not try to manipulate the foreign body; you may push it further into the ear.

7. Clear fluid coming from the ear may indicate a skull fracture.

D. Facial fractures

1. Typically result from blunt impact

2. You should assume that any patient who has sustained a direct blow to the mouth or nose has a facial fracture.

3. Other clues include:

a. Bleeding in the mouth

b. Inability to swallow or talk

c. Absent or loose teeth

d. Loose or movable bone fragments

4. Facial fractures alone are not acute emergencies unless there is serious bleeding.

a. In addition to external hemorrhage, there is the danger of blood clots lodging in the upper airway and causing an obstruction.

5. Plastic surgeons can repair the damage to the face and mouth if the injuries are treated within 7 to 10 days.

a. Remove and save loose teeth or bone fragments from the mouth because it is often possible to replant them.

b. Remove any loose dentures or dental bridges to protect against airway obstruction.

6. Another source of airway obstruction is swelling, which can be extreme within the first 24 hours after injury.

E. Dental injuries

1. Dental injuries can be traumatic to the patient.

a. The injury may be traumatic and the patient’s permanent teeth may be lost.

i. Can affect everything from eating to smiling

2. Bleeding will occur whenever a tooth is violently displaced from its socket.

a. Apply direct pressure to stop the bleeding.

b. Perform suctioning if needed.

c. Cracked or loose teeth are possible airway obstructions.

3. Save and transport an avulsed tooth, handling it by the crown rather than by the root.

a. Place the tooth in tooth storage solution, cold milk, or sterile saline.

b. Notify the receiving facility of avulsed teeth.

i. Reimplantation is recommended within 20 minutes to 1 hour after the trauma.

F. Injuries of the cheek

1. You may encounter an object impaled in the patient’s cheek.

a. If you are unable to control the bleeding and it compromises the airway, consider removing the object.

b. Then provide direct pressure both on the inside and outside of the cheek.

c. The amount of bandaging should not be so overwhelming that it occludes the mouth and makes it difficult to breathe.

G. Injuries of the neck

1. The neck contains many structures vulnerable to injury by blunt trauma, including:

a. Upper airway

b. Esophagus

c. Carotid arteries and jugular veins

d. Thyroid cartilage (Adam’s apple)

e. Cricoid cartilage

f. Upper part of the trachea

2. Blunt injuries

a. Any crushing injury of the upper part of the neck is likely to involve the larynx or trachea.

b. Examples include:

i. Collision with a steering wheel

ii. Attempted suicide by hanging

iii. Clothesline injury sustained while riding a bicycle

c. Once the cartilages of the upper airway and larynx are fractured, they do not spring back to their normal position.

i. Can lead to loss of voice, difficulty swallowing, severe and sometimes fatal airway obstruction, and leakage of air into the soft tissues of the neck

ii. Subcutaneous emphysema is a characteristic crackling sensation produced by the presence of air in the soft tissues of the neck.

iii. If you feel this when palpating the neck, maintain the airway as best you can and transport immediately.

iv. Complete airway obstruction can develop very rapidly.

v. ALS support either by air or intercept may be necessary.

d. It is possible that these incidents involving an injury to the throat may also have caused a cervical spine injury.

i. Spinal immobilization may be needed.

3. Penetrating injuries

a. Penetrating injuries to the neck can cause profuse bleeding from laceration of the great vessels in the neck.

b. Injuries to the carotid and jugular veins in the neck can cause the body to bleed out, also known as exsanguination.

i. Injuries to these large vessels may also allow air to enter the circulatory system.

ii. If a vein has been punctured, air may be sucked through it to the heart.

iii. This condition is called an air embolism.

iv. A large amount of air in the right atrium and right ventricle of the heart can lead to cardiac arrest.

c. The airway, the esophagus, and the spinal cord can be damaged by a penetrating injury. 78286_CH25_SKDSK03_02 78286_CH25_SKDSK03_01

d. Direct pressure over the bleeding site will control most neck bleeding.

i. Apply direct pressure to the bleeding site using a gloved fingertip if necessary to control bleeding.

ii. Apply a sterile occlusive dressing to ensure that air does not enter a vein or artery.

iii. Follow the steps in Skill Slide 27-3.

iv. You may find it necessary to apply pressure above and below the penetrating wound to control life-threatening bleeding.

v. Maintain cervical spine immobilization, if indicated.

H. Laryngeal injuries

1. Blunt force trauma to the larynx can occur when:

a. Unrestrained driver strikes the steering wheel

b. Snowmobile rider or off-road biker strikes a clothesline or a fixed wire

2. The larynx becomes crushed against the cervical spine, resulting in soft-tissue injury, fractures, and/or separation of the fascia.

a. These strangulation injuries can also be found in either intentional or unintentional hangings.

b. Any time there is a suspected injury to the larynx, suspect possible cervical spine injury.

3. Penetrating or impaled objects in the larynx should not be removed unless they interfere with cardiopulmonary resuscitation.

a. Stabilize all impaled objects if they are not obstructing the airway.

b. See Skill Slide 26-1 from Chapter 26, “Soft-Tissue Injuries.”

4. Significant injuries to the larynx pose an immediate risk of airway compromise.

a. Signs and symptoms of larynx injuries include:

i. Respiratory distress

ii. Hoarseness

iii. Pain

iv. Difficulty swallowing (dysphagia)

v. Cyanosis

vi. Pale skin

vii. Sputum in the wound

viii. Subcutaneous emphysema

ix. Bruising on the neck

x. Hematoma

xi. Bleeding

b. To manage a laryngeal injury:

i. Provide oxygen and ventilation.

ii. Apply cervical immobilization, but avoid the use of rigid collars.

Chapter 28, Head and Spine Injuries

Unit Summary

After completing this chapter and related coursework, you will understand how to manage trauma-related issues of the head and spine. You will learn how to recognize life threats associated with these injuries as well as the need for immediate spinal stabilization and, potentially, airway and breathing support. The curriculum includes detailed anatomy and physiology of the nervous system and the pathophysiology, assessment, and management of traumatic brain and spinal cord injuries. This chapter provides detail about traumatic brain injury (TBI), including initial mechanism of injury, and primary (direct) versus secondary (indirect) injury. Transport considerations are discussed with a focus on potential deterioration. This chapter is skills intensive with detail on bandaging; traumatic airway control; manual in-line stabilization; placement of a cervical collar; immobilization of the patient lying, sitting, or standing; and helmet removal.

National EMS Education Standard Competencies

Trauma

Applies fundamental knowledge to provide basic emergency care and transportation based on assessment findings for an acutely injured patient.

Head, Facial, Neck, and Spine Trauma

Recognition and management of:

Life threats
Spine trauma

Pathophysiology, assessment, and management of:

Penetrating neck trauma (Chapter 27, Face and Neck Injuries)
Laryngotracheal injuries (Chapter 27, Face and Neck Injuries)
Spine trauma
Facial fractures (Chapter 27, Face and Neck Injuries)
Skull fractures
Foreign bodies in the eyes (Chapter 27, Face and Neck Injuries)
Dental trauma (Chapter 27, Face and Neck Injuries)

Nervous System Trauma

Pathophysiology, assessment, and management of:

Traumatic brain injury
Spinal cord injury

Knowledge Objectives

1. Describe the anatomy and physiology of the nervous system, including its divisions into the central nervous system (CNS) and peripheral nervous system (PNS), and the structures and functions of each.

2. Explain the functions of both the somatic and autonomic nervous systems.

3. List the major bones of the skull and spinal column and their related structures; include their functions as they relate to the nervous system.

4. Explain the different types of head injuries, their potential mechanism of injury (MOI), and general signs and symptoms of a head injury that the EMT should consider when performing a patient assessment.

5. Define traumatic brain injury (TBI).

6. Explain the difference between a primary (direct) injury and a secondary (indirect) injury; include examples of possible MOIs that may cause each one.

7. Describe the different types of brain injuries and their corresponding signs and symptoms, including increased intracranial pressure (ICP), concussion, contusion, and injuries caused by medical conditions.

8. Describe the different types of injuries that may damage the cervical, thoracic, or lumbar spine; include examples of possible MOIs that may cause each one.

9. Explain the steps in the patient assessment process for a person who has a suspected head or spine injury, including specific variations that may be required as related to the type of injury.

10. List the mechanisms of injury that cause a high index of suspicion for the possibility of a head or spinal injury.

11. Explain emergency medical care of a patient with a head injury; include the three general principles designed to protect and maintain the critical functions of the CNS and ways to determine if the patient has a traumatic brain injury.

12. Explain emergency medical care of a patient with a spinal injury; include the implications of not properly caring for patients with injuries of this nature, the steps for performing manual in-line stabilization, implications for sizing and using a cervical spine immobilization device, and key symptoms that contraindicate in-line stabilization.

13. Explain the process of preparing patients who have suspected head or spinal injuries for transport; include the use and functions of a long backboard, short backboard, and other short spinal extrication devices to immobilize the patient’s cervical and thoracic spine.

14. Explain the different circumstances in which a helmet should be left on or taken off a patient with a possible head or spinal injury.

15. List the steps EMTs must follow to remove a helmet, including the alternate method for removing a football helmet.

16. Discuss age-related variations that are required when providing emergency care to a pediatric patient who has a suspected head or spine injury.

Skill Objectives

1. Demonstrate how to perform a jaw-thrust maneuver on a patient with a suspected spinal injury.

2. Demonstrate how to perform manual in-line stabilization on a patient with a suspected spinal injury. (Skill Slide 28-1)

3. Demonstrate how to apply a cervical collar to a patient with a suspected spinal injury. (Skill Slide 28-2)

4. Demonstrate how to secure a patient with a suspected spinal injury to a long backboard. (Skill Slide 28-3)

5. Demonstrate how to secure a patient with a suspected spinal injury who was found in a sitting position. (Skill Slide 28-4)

6. Demonstrate how to remove a helmet from a patient with a suspected head or spinal injury. (Skill Slide 28-5)

7. Demonstrate the alternate method for removal of a football helmet from a patient with a suspected head or spinal injury.

I. Introduction

A. The nervous system is a complex network of nerve cells that enables all parts of the body to function.

B. The nervous system includes:

1. Brain

2. Spinal cord

3. Several billion nerve fibers that carry information to and from all parts of the body

C. Because the nervous system is so vital, it is well protected.

1. The brain is protected by the skull.

2. The spinal cord is protected by the bony spinal canal.

3. Despite this protection, serious injuries can damage the nervous system.

II. Anatomy and Physiology

A. The nervous system is divided into two anatomic parts.

1. Central nervous system

2. Peripheral nervous system

B. Central nervous system (CNS)

1. Includes the brain and spinal cord

2. The brain controls the body and is the center of consciousness.

3. The brain is divided into three major areas:

a. Cerebrum

b. Cerebellum

c. Brainstem

4. The cerebrum controls a wide variety of activities, including most voluntary motor function and conscious thought.

a. Contains about 75% of the brain’s total volume

b. Divided into two hemispheres with four lobes

5. The cerebellum coordinates balance and body movements.

6. The brainstem controls most functions necessary for life, including the cardiac and respiratory systems and nerve function transmissions.

a. Best-protected part of the CNS

7. The spinal cord is mostly made up of fibers that extend from the brain’s nerve cells.

a. Carries messages between the brain and the body via the gray and white matter of the spinal cord

b. Gray matter is composed of neural cell bodies and synapses.

c. White matter consists of fiber pathways.

8. Protective coverings

a. The cells of the brain and spinal cord are soft and easily injured.

b. The entire CNS is contained within a protective framework.

c. The thick, bony structures of the skull and spinal canal withstand injury very well.

i. Also covered by layers of muscle and skin

d. The CNS is further protected by the meninges, three distinct layers of tissue that suspend the brain and the spinal cord within the skull and spinal canal.

i. The outer layer, the dura mater, is a tough, fibrous layer that forms a sac to contain the CNS.

ii. The inner two layers, called the arachnoid mater and the pia mater, contain the blood vessels that nourish the brain and spinal cord.

e. Cerebrospinal fluid (CSF) is produced in a chamber inside the brain, called the third ventricle.

i. There are approximately 125 to 150 mL of CSF in the brain at any time.

ii. CSF primarily acts as a shock absorber.

iii. When an injury does penetrate all the protective layers, clear, watery CSF may leak from the nose, ears, or an open skull fracture.

C. Peripheral nervous system

1. 31 pairs of spinal nerves

a. Conduct impulses from the skin and other organs to the spinal cord

b. Conduct motor impulses from the spinal cord to the muscles

c. The spinal nerves serving the extremities are arranged in complex networks.

2. 12 pairs of cranial nerves

a. Transmit information directly to or from the brain

b. Perform special functions in the head and face, including sight, smell, taste, hearing, and facial expressions

3. There are two major types of peripheral nerves.

a. Sensory nerves

i. Carry only one type of information from the body to the brain via the spinal cord

b. Motor nerves

i. One for each muscle

ii. Carry information from the CNS to the muscles

4. The connecting nerves are found only in the brain and spinal cord.

a. Connect the sensory and motor nerves with short fibers

b. Allow the exchange of simple messages

D. How the nervous system works

1. The nervous system controls virtually all of the body’s activities, including:

a. Reflex activities

b. Voluntary activities

c. Involuntary activities

2. The connecting nerves in the spinal cord form a reflex arc.

a. If a sensory nerve in this arc detects an irritating stimulus, it bypasses the brain and sends the message directly to a motor nerve, causing a response.

3. Voluntary activities are activities that we consciously perform, in which sensory input determines the specific muscular activity.

4. Involuntary activities are the actions that are not under conscious control, such as breathing.

5. The somatic (voluntary) nervous system handles voluntary activities.

a. The brain interprets the sensory information that it receives from the peripheral and cranial nerves and responds by sending signals to the voluntary muscles.

6. The autonomic (involuntary) nervous system handles the body functions that occur without conscious effort.

a. Controls the functions of many of the body’s vital organs

b. Divided into two sections: sympathetic and parasympathetic nervous systems

i. When confronted with a threatening situation, the sympathetic nervous system reacts to the stress with a fight-or-flight response.

(a) This response causes the pupils to dilate, smooth muscle in the lungs to dilate, heart rate to increase, and blood pressure to rise.

(b) During this time of stress, a hormone called epinephrine (adrenaline) is released.

ii. The parasympathetic nervous system has the opposite effect on the body, causing blood vessels to dilate, slowing the heart rate, and relaxing the muscle sphincters.

iii. As the body attempts to maintain homeostasis, these two divisions of the autonomic nervous system tend to balance each other so that basic body functions remain stable and effective.

E. Skeletal system

1. Skull

a. The skull is composed of two groups of bones: the cranium, a thick shell above the eyes and ears that protects the brain, and the facial bones.

b. The cranium is occupied by 80% brain tissue, 10% blood supply, and 10% CSF.

c. The brain connects to the spinal cord through a large opening at the base of the skull called the foramen magnum.

d. Four major bones make up the cranium:

i. Occiput (most posterior portion)

ii. Temples or temporal regions (lateral portions on each side of the cranium)

iii. Parietal regions (between the temporal regions and the occiput)

iv. Frontal region (forehead)

e. The face is composed of 14 bones.

i. Maxillae (upper, non-moveable jawbones)

ii. Zygomas (cheekbones)

iii. Mandible (lower, moveable portion of the jaw)

iv. Orbit (eye socket) is made up of two facial bones: the maxilla and zygoma; it also includes the frontal bone of the cranium.

v. The nose mostly consists of flexible cartilage.

2. Spinal column

a. The spinal column is the body’s central supporting structure.

b. 33 vertebrae are divided into five sections:

i. Cervical

ii. Thoracic

iii. Lumbar

iv. Sacral

v. Coccygeal

c. Vertebrae are grouped into sections. The higher the injury on the spinal cord, the more dysfunction can occur.

i. High-Cervical Nerves (C1 – C4)

(a) Most severe of the spinal cord injury levels

(b) Paralysis in arms, hands, trunk and legs

(d) Ability to speak is sometimes impaired or reduced.

(e) When all four limbs are affected, this is called tetraplegia or quadriplegia.

ii. Low-Cervical Nerves (C5 – C8)

(a) Corresponding nerves control arms and hands.

(b) Can speak and use diaphragm, but breathing will be weakened

iii. Thoracic Nerves (T1 – T5)

(a) Corresponding nerves affect muscles, upper chest, mid-back and abdominal muscles.

(b) Injuries usually affect the trunk and legs, also known as paraplegia.

iv. Thoracic Nerves (T6 – T12)

(a) Nerves affect muscles of the trunk (abdominal and back muscles) depending on the level of injury.

(b) Usually results in paraplegia

v. Lumbar Nerves (L1 – L5)

(a) Injuries generally result in some loss of function in the hips and legs.

(b) Little or no voluntary control of bowel or bladder, but can manage on their own with special equipment

vi. Sacral Nerves (S1 – S5)

(a) Injuries generally result in some loss of functioning the hips and legs.

(b) Little or no voluntary control of bowel or bladder

d. The front part of each vertebra consists of a round, solid block of bone called the vertebral body; the back part forms a bony arch.

e. The series of arches form a tunnel called the spinal canal, which encases and protects the spinal cord.

f. The vertebrae are connected by ligaments and separated by cushions, called intervertebral disks.

g. The spinal column is almost entirely surrounded by muscles.

III. Head Injuries

A. A head injury is a traumatic insult to the head that may result in injury to soft tissue, bony structures, or the brain.

1. Approximately four million people experience head injuries of varying severity in the United States each year.

2. 52,000 deaths occur annually due to severe head injury.

3. Head injuries account for more than half of all traumatic deaths.

a. Fatal injuries invariably involve the brain.

4. Be alert to the fact that the patient may have sustained additional trauma such as:

a. Cervical spine injuries

b. Pelvic injuries

c. Chest injuries

B. There are two general types of head injuries: closed head injuries and open head injuries.

1. Closed head injuries are those in which the brain has been injured but there is no opening into the brain.

2. An open head injury is one in which an opening from the brain to the outside world exists.

a. Obvious skull deformity with a break in the skin is a sign of an open head injury, which is often caused by penetrating trauma.

b. There may be bleeding and exposed brain tissue.

C. Motor vehicle crashes are the most common Mechanism of Injury (MOI).

1. More than two thirds of people involved in motor vehicle crashes experience a head injury.

2. Head injuries also occur commonly:

a. In victims of assault

b. When elderly people fall

c. During sports-related incidents

d. In a variety of incidents involving children

3. Any head injury is potentially serious if not properly treated.

D. Scalp lacerations

1. Can be minor or serious

2. Even small lacerations can quickly lead to significant blood loss.

3. Occasionally, this blood loss may be severe enough to cause hypovolemic shock, particularly in children.

4. Because scalp lacerations are usually the result of direct blows to the head, they are often an indicator of deeper, more serious injuries.

E. Skull fracture

1. Significant force applied to the head may cause a skull fracture.

2. A skull fracture may be open or closed, depending on whether there is an overlying laceration of the scalp.

3. Injuries from bullets or other penetrating weapons frequently result in fracture of the skull.

4. Signs of a skull fracture include:

a. Patient’s head appears deformed

b. Visible cracks in the skull

c. Ecchymosis (bruising) that develops under the eyes (raccoon eyes)

d. Ecchymosis that develops behind one ear over the mastoid process (Battle’s sign)

5. Linear skull fractures

a. Nondisplaced skull fractures

b. Account for approximately 80% of all fractures to the skull

c. Radiographs are required to diagnose a linear skull fracture because there are often no physical signs such as deformity.

d. If the brain is uninjured and there are no scalp lacerations, then linear fractures are not life threatening.

6. Depressed skull fractures

a. Result from high-energy direct trauma to the head with a blunt object

b. The frontal and parietal bones of the skull are most susceptible.

c. Bony fragments may be driven into the brain, resulting in injury.

d. Patients often present with neurologic signs (such as loss of responsiveness).

7. Basilar skull fractures

a. Associated with high-energy trauma, but usually occur following diffuse impact to the head (falls, motor vehicle crashes)

b. These injuries generally result from extension of a linear fracture to the base of the skull and can be difficult to diagnose without radiography.

c. Signs of a basilar skull fracture include CSF drainage from the ears, raccoon eyes, and Battle’s sign.

8. Open skull fractures

a. Open fractures of the cranial vault result when severe forces are applied to the head and are often associated with trauma to multiple body systems.

b. Brain tissue may be exposed to the environment, which significantly increases the risk of a bacterial infection.

c. High mortality rate

F. Traumatic brain injuries (TBI)

1. The National Head Injury Foundation defines a TBI as “a traumatic insult to the brain capable of producing physical, intellectual, emotional, social, and vocational changes.”

2. Most serious of all head injuries

3. Symptoms include:

Thinking/Memory	Physical	Emotions/Mood	Sleep
Difficulty thinking clearly	Headache Fuzzy or blurry vision	Irritable Aggressive Combative	Sleeping more than usual
Feeling slowed down	Nausea or vomiting (early on) Dizziness	Sadness	Sleep less than usual
Difficulty concentrating	Sensitivity to noise or light Balance problems	More emotional	Trouble falling asleep
Difficulty remembering new information	Feeling tired, having no energy	Nervousness Anxiety

4. Classified into two broad categories: primary (direct) injury and secondary (indirect) injury

a. Primary brain injury results instantaneously from impact to the head.

b. Secondary brain injury increases the severity of the primary injury, and may be caused by:

i. Cerebral edema

ii. Intracranial hemorrhage

iii. Increased intracranial pressure

iv. Cerebral ischemia

v. Infection

c. Hypoxia and hypotension are the two most common causes of secondary brain injury and will increase death and disability significantly in a patient with head injury.

d. Secondary brain injury may occur a few minutes to several days following the initial head injury.

5. The brain can be injured directly by a penetrating object, such as a bullet, knife, or other sharp object, or indirectly, as a result of external forces exerted on the skull.

6. A coup-contrecoup injury can result from striking a windshield in a car crash.

a. The passenger’s head hits the windshield; the brain continues to move forward until it comes to an abrupt stop by striking the inside of the skull.

b. The head falls back against the headrest and/or seat, and the brain slams into the rear of the skull.

c. The ridges of the basilar skull can injure the brain as it moves back and forth.

7. Cerebral edema (swelling of the brain) may not develop until several hours following the initial injury.

8. Low blood oxygen levels aggravate cerebral edema and can be minimized by maintaining high oxygen saturations.

9. It is not uncommon for the patient with a head injury to have a convulsion, or seizure.

G. Intracranial pressure

1. Accumulations of blood within the skull or swelling of the brain can rapidly lead to an increase in intracranial pressure (ICP).

a. Increased ICP squeezes the brain against bony prominences within the cranium.

2. Signs of increased intracranial pressure:

a. Cheyne-Stokes respirations

b. Ataxic (Biot) respirations

c. Decreased pulse rate

d. Headache

e. Nausea

f. Vomiting

g. Decreased alertness

h. Bradycardia

i. Sluggish or nonreactive pupils

j. Decerebrate posturing

k. Increased or widened blood pressure

3. Cushing reflex (triad of increased systolic blood pressure, decreased pulse rate, and irregular respirations) signifies increased ICP.

4. Intracranial hemorrhage

a. Bleeding inside the skull also increases the ICP.

b. Bleeding can occur between the skull and dura mater, beneath the dura mater but outside the brain, or within the tissue of the brain itself.

5. Epidural hematoma

a. Accumulation of blood between the skull and dura mater

b. Nearly always the result of a blow to the head that produces a linear fracture of the thin temporal bone

c. Arterial bleeding into the epidural space will result in rapidly progressing symptoms.

d. Often, the patient loses responsiveness immediately following the injury.

i. This is often followed by a brief period of responsiveness (lucid interval), after which the patient lapses back into unresponsiveness.

ii. Death will follow very rapidly without surgery to evacuate the hematoma.

6. Subdural hematoma

a. Accumulation of blood beneath the dura mater but outside the brain

b. Usually occurs after falls or injuries involving strong deceleration forces

c. More common than epidural hematomas and may or may not be associated with a skull fracture

d. A subdural hematoma is associated with venous bleeding, so the signs typically develop more gradually than with an epidural hematoma.

e. The patient often experiences a fluctuating level of responsiveness or slurred speech.

f. Any patient with a suspected subdural hematoma needs to be evaluated by a physician.

7. Intracerebral hematoma

a. Involves bleeding within the brain tissue itself

b. Can occur following a penetrating injury to the head or because of rapid deceleration forces

c. Many small, deep intracerebral hemorrhages are associated with other brain injuries.

d. Intracerebral hematomas have a high mortality rate, even if the hematoma is surgically evacuated.

8. Subarachnoid hemorrhage

a. Bleeding occurs into the subarachnoid space, where the CSF circulates

b. Results in bloody CSF and signs of meningeal irritation

c. Common causes include trauma or rupture of an aneurysm.

d. Patient reports a sudden, severe headache.

e. A sudden, severe subarachnoid hematoma usually results in death; survivors often have permanent neurologic impairment.

H. Concussion

1. A blow to the head or face may cause concussion of the brain.

2. Concussions are also known as mild TBIs.

3. In general, it is a closed injury with a temporary loss or alteration of part or all of the brain’s ability to function without demonstrable physical damage to the brain.

4. Approximately 90% of patients who sustain a concussion do not experience a loss of responsiveness.

5. A patient with a concussion may be confused or have amnesia.

a. Occasionally, the patient may have retrograde amnesia, which means he or she can remember everything but the events leading up to the injury.

b. Inability to remember events after the injury is called anterograde (posttraumatic) amnesia.

6. Usually a concussion lasts only a short time.

a. You should ask about symptoms of concussion in any patient who has sustained an injury to the head, including:

i. Dizziness

ii. Weakness

iii. Visual changes

iv. Nausea

v. Vomiting

vi. Ringing in the ears

vii. Slurred speech

viii. Inability to focus

ix. Lack of coordination

x. Delay of motor functions

xi. Inappropriate emotional responses

xii. Temporary headache

xiii. Disorientation

7. You should assume that a patient with signs or symptoms of concussion has a more serious injury until proven otherwise.

a. All patients with signs or symptoms of a concussion should be evaluated by a physician.

I. Cerebral contusion

1. Like any other soft tissue in the body, the brain can sustain a contusion, or bruise, and swelling when the skull is struck.

2. A contusion is far more serious than a concussion.

a. Involves physical injury to the brain tissue

b. May produce long-lasting and even permanent damage

3. A patient who has sustained a brain contusion may exhibit any or all of the signs of brain injury.

J. Other brain injuries

1. Brain injuries can also arise from medical conditions, such as blood clots or hemorrhages.

2. Problems with the blood vessels, high blood pressure, or other problems may cause spontaneous bleeding into the brain, affecting the patient’s level of responsiveness.

a. This is known as altered mental status.

3. The signs and symptoms of nontraumatic injuries are often the same as those of TBIs, except there is no obvious history of MOI or any external evidence of trauma.

IV. Spine Injuries

A. The cervical, thoracic, and lumbar portions of the spine can be injured in a variety of ways.

1. Compression injuries can result from a fall, regardless of whether the patient landed on his or her feet or experienced a direct blow to the crown of the skull, coccyx, or top of the head.

a. Forces that compress the patient’s vertebral body can cause herniation of disks, subsequent compression on the spinal cord and nerve roots, and fragmentation into the spinal canal.

2. Motor vehicle crashes or other types of trauma can overextend (hyperflex) the cervical spine and damage the ligaments and joints.

3. Rotation-flexion injuries of the spine result from rapid acceleration forces.

a. More likely to happen at C1 and C2

b. Injuries to this area of the spine are considered unstable due to the location and lack of bony and soft-tissue support.

4. Any one of these unnatural motions, as well as excessive lateral bending, can result in fractures or neurologic deficits.

5. When the spine is pulled along its length (hyperextension), it can cause fractures in the spine as well as ligament and muscle injuries.

6. When bones of the spine are altered from traumatic forces, they can fracture or move out of place.

a. When injuries pinch, pull, or penetrate the spinal cord, permanent damage may occur.

b. Common findings include pain and tenderness on palpation.

c. You may feel or observe a deformity of the spine (“step-off”) where the spinous process may be palpable.

d. If you suspect these types of injuries, take extra precautions when stabilizing the spine.

V. Patient Assessment

A. Always suspect a possible head or spinal injury any time you encounter one of the following MOIs:

1. Motor vehicle collisions (including motorcycles, snowmobiles, and all-terrain vehicles)

2. Pedestrian–motor vehicle collisions

3. Falls greater than three times the height of the patient

4. Blunt trauma

5. Penetrating trauma to the head, neck, back, or torso

6. Rapid deceleration injuries

7. Hangings

8. Axial loading injuries: injuries where load is applied along the vertical or longitudinal axis of the spine

9. Diving accidents

B. Scene size-up

1. Scene safety

a. Evaluate every scene for hazards to your health and the health of your team or bystanders.

b. Be prepared with appropriate standard precautions before you approach the patient in a motor vehicle crash.

c. Gloves, a mask, and eye protection should be the minimum standard precautions that you use.

d. Call for ALS as soon as possible when a serious MOI or complicated presentation is evident.

e. Law enforcement may be needed to control traffic or crowds.

2. Mechanism of injury (MOI)

a. Look for indicators of the MOI.

b. Consider how the MOI produced the injuries expected.

c. Continue to consider the MOI while assessing a patient.

C. Primary assessment

1. Focus on identifying and managing life-threatening concerns.

a. Threats to circulation, airway, or breathing are considered life threatening and must be treated immediately.

b. Life-threatening external hemorrhage must be addressed before airway and breathing concerns.

c. Most head injuries are considered mild and result in no or limited permanent disability.

i. A number of patients with head or spine injuries will not require much intervention other than a thorough assessment and continued observation during transport.

d. In patients who have problems with ABCs or have other conditions for which you decide a rapid transport to the closest appropriate hospital is needed, rapid immobilization of the spine and quick loading into the ambulance may be indicated.

e. Reduction of on-scene time and recognition of a critical patient increases the patient’s chances for survival or a reduction in the amount of irreversible damage.

2. Spinal immobilization considerations

a. When assessing a patient, be aware that any unnecessary movement of the patient can cause additional injury.

i. Assess the patient in the position found.

ii. Determine whether or not a cervical collar needs to be applied.

b. Begin by assessing the scene to determine the risk of injury.

c. Then form a general impression of your patient based on his or her level of responsiveness and the chief complaint.

d. If the patient is absolutely clear in his or her thinking and does not have any neurologic deficits, spinal pain or tenderness, evidence of intoxication, or other illnesses or injuries that may mask a spinal injury, you may consider not placing the patient in spinal motion restriction (SMR).

i. Many jurisdictions allow EMTs to screen patients and to refrain from providing spinal motion restriction on the basis of specific criteria.

e. The backboard is rigid and often places the patient in an anatomically incorrect position for a long period of time.

i. Circulation to areas of skin may become compromised, leading to complaints of pain, ischemia to the skin, and, if left long enough, necrosis.

ii. Some patients, especially bariatric patients, could experience respiratory compromise while lying flat.

iii. Consider placing padding under the patient to help minimize the risk of injury, and try to minimize the amount of time a patient is on a long backboard.

f. If SMR is indicated, apply a soft or rigid cervical collar as soon as you have assessed the airway and breathing and provided necessary treatments.

i. Assists in reminding the patient not to flex the neck as you treat the airway and breathing

ii. The best time to apply the cervical collar depends on the patient’s injuries and the seriousness of the condition.

iii. Once the cervical collar is on, do not remove it unless it causes a problem with maintaining the airway.

3. Assessing for signs and symptoms of a head or spine injury

a. Begin by asking the responsive patient the following questions:

i. What happened?

ii. Where does it hurt?

iii. Does your neck or back hurt?

iv. Can you move your hands and feet?

v. Did you hit your head?

b. Confused or slurred speech, repetitive questioning, or amnesia in responsive patients are good indications of a head injury.

c. In the setting of trauma, assume your patient has a head injury until your assessment proves otherwise.

i. Decreased blood glucose level can mimic these symptoms.

d. If the patient is found unresponsive, emergency responders, family members, or bystanders may have helpful information.

e. Unresponsive trauma patients should be assumed to have a spinal injury.

f. Patients with a decreased level of responsiveness (AVPU scale) should be considered to have a spinal injury based on their chief complaint.

4. Airway, breathing, and circulation considerations

a. When a spinal injury is suspected, how you open and assess the airway is important.

i. Begin by manually holding the patient’s head still while you assess the airway.

ii. Use a jaw-thrust maneuver to open the airway.

iii. If the jaw-thrust maneuver is ineffective, it is acceptable to use the head tilt–chin lift maneuver as a last resort.

iv. An oropharyngeal or nasopharyngeal airway may assist in maintaining the airway.

b. Vomiting may occur in the patient with a head injury.

i. The patient may need to be log rolled to the side and the mouth swept of secretions.

ii. Suctioning should be performed immediately to remove smaller amounts of secretions.

c. Irregular breathing, such as Cheyne-Stokes respirations, may result from increased pressure on the brain because of bleeding or swelling in the cranium.

d. Prehospital administration of high-flow oxygen is indicated for patients with head and spinal injuries.

e. Pulse oximeter values should not fall below 90% and ideally should be 95% or higher.

f. Hyperventilation (ventilating too fast or with too much force)

i. Should be reserved for specific conditions and performed under specific guidelines

ii. Can increase the severity of head injuries

iii. Should be avoided except in cases where signs of herniation have been identified

g. Always assess airway and breathing prior to moving on to assessment of circulation.

h. A pulse that is too slow in the setting of a head injury can indicate a serious condition in your patient.

i. If the pulse is present and adequate, you can continue to evaluate your patient further.

j. A single episode of hypoperfusion in a patient with a head injury can lead to significant brain damage and even death.

k. Assess for signs and symptoms of shock and treat appropriately.

l. Control bleeding.

i. When bandaging the head:

(a) Be careful not to move the neck if spinal injuries are suspected.

(b) Apply a diffuse dressing to head wounds to collect fluids draining from the head.

5. Manner of transport

a. Several transport considerations should be kept in mind for patients with head trauma:

i. Patients with impaired airways, open head wounds, or abnormal vital signs, or patients who do not respond to painful stimuli, may need to be rapidly extracted from a motor vehicle and transported.

ii. Providing the patient with a patent airway and high-flow oxygen is paramount.

iii. There is a probability of vomiting and seizures, so suction should be readily available.

iv. A head trauma patient may deteriorate rapidly and require aeromedical transport.

v. In supine patients, the head should be elevated 30 degrees, if possible, to help reduce ICP.

vi. Remember to maintain immobilization of the spine.

b. The use of lights and sirens may increase the patient’s level of distress.

c. Patients who are conscious and aware of the inability to move their limbs need to be offered emotional support.

D. History taking

1. Investigate the chief complaint.

a. Obtain a medical history and be alert for injury-specific signs and symptoms as well as any pertinent negatives.

b. Using OPQRST may provide some background on isolated extremity injuries.

c. Any information you receive will be very valuable if the patient loses responsiveness.

d. If the patient is not responsive, attempt to obtain the history from other sources, such as friends, family members, medical identification jewelry, and cards in wallets.

e. Gather as much SAMPLE history as you can while preparing for transport.

E. Secondary assessment

1. Remember that the ability to walk, move the extremities, or feel sensation, as well as the absence of pain, does not necessarily rule out a spinal cord injury.

2. Instruct the patient to keep still and not to move the head or neck.

3. Physical examinations

a. May be a systematic head-to-toe, full-body scan or a systematic assessment that focuses on a certain area or region of the body

b. Patients with moderate or severe head injuries should receive life saving medical or surgical intervention at the closest appropriate trauma hospital.

c. If time allows, perform a secondary assessment while en route.

d. Obtaining a complete set of baseline vital signs is essential.

i. Significant head injuries may cause the pulse to slow and the blood pressure to rise.

ii. With neurogenic shock, the blood pressure may drop and the heart rate may increase to compensate.

iii. Respirations will become erratic with complications from both head and spine injuries.

iv. Hypotension may be present with cervical or high thoracic spine injuries. The heart rate may become slow or fail to increase in response to hypotension.

e. In addition to hands-on assessment, you should use monitoring devices to quantify your patient’s oxygenation and circulatory status.

i. Pulse oximetry and ETCO2 monitoring should be utilized, if available.

ii. Maintain ETCO2 between 35 and 40 mm Hg

iii. You may also use noninvasive methods to monitor the blood pressure.

5. Physical examination considerations

a. Examine the entire body using DCAP-BTLS and examine the head, chest, abdomen, extremities, and back.

b. Check circulation, sensation, and motor function in all extremities prior to moving the patient.

c. A decreased or altered level of responsiveness is the most reliable sign of a head injury.

d. Determine whether there is decreased movement and/or numbness and tingling in the extremities.

e. Look for blood or CSF leaking from the ears, nose, or mouth and for bruising around the eyes and behind the ears.

f. Assess pupil size and reaction to light and continue to monitor the pupils; any change in their reactions over time may indicate progressive brain injury.

g. Do not probe open scalp lacerations with your gloved finger because this may push bone fragments into the brain.

h. Do not remove an impaled object from an open head injury.

6. Neurologic examination

a. Perform a baseline assessment using the Glasgow Coma Scale (GCS).

b. Always use simple, easily understood terms when reporting the level of responsiveness.

c. If your jurisdiction uses the Revised Trauma Score (RTS), then the findings from the GCS will be used in determining the RTS value.

d. Record levels of responsiveness that fluctuate or deteriorate.

e. As you proceed with your assessment, ask:

i. Is the patient’s speech clear and appropriate?

ii. Does the patient answer in a logical manner, and is the patient able to make decisions?

iii. Is the patient aware of his or her current location?

iv. Is the patient alert to person, place, time, and event, why you are at the scene?

v. Can the patient recall the events leading up to the incident, or is there a period of memory lapse?

vi. Can the patient recall major current events?

vii. Any person with a head injury that has resulted in a change of responsiveness, progressive development of signs and symptoms of a concussion, or other causes of concern should be evaluated by a qualified healthcare provider.

7. Spine examination

a. Refer to department protocol to determine if spinal motion restriction (SMR) is indicated. Click here to see the LBJ Fire Academy protocol.

b. To determine if SMR is indicated, assess the patient as follows:

i. Neuro Exam: Does the patient have a CSM deficit in any extremity? Note new onset numbness / tingling / paralysis.

ii. Age: Is the patient >65y/o with Significant Mechanism of Injury (refer to paragraph c. below)?

iii. Alertness: Does the patient have an altered mental status, anything other than A/Ox4?

iv. Intoxication: Is the patient drunk or under the influence of any substance?

v. Distracting Injury: Does the patient have a painful injury which would not allow the patient to focus?

vi. Spinal Exam: Does the patient feel point tenderness on the spine, have a deformity, or loss of ROM?

c. Significant Mechanism of Injury Guidelines (Spinal Motion Restriction COG):

i. High velocity MVC ≥ 40 mph closing speed at impact

ii. Unrestrained occupant in MVC

iii. Passenger compartment intrusion > 12 inches

iv. Ejection from vehicle

v. Motorcycle collision > 20 mph

vi. Death in same vehicle

vii. Pedestrian struck by vehicle

viii. Falls ≥ 3 times the patient’s height

ix. Diving Injury

d. If the answers to all items in paragraph b. are negative then SMR is contraindicated.

e. If any one of the items in paragraph b. is a yes answer then SMR is indicated.

F. Reassessment

1. Repeat the primary assessment.

2. Reassess vital signs and the chief complaint.

3. Recheck patient interventions.

a. These injuries can suddenly affect the respiratory, circulatory, and nervous systems.

b. The patient’s condition should be reassessed at least every 5 minutes.

4. Interventions

a. Multiple interventions may be necessary in patients with head and spinal injuries; if something is not working, try something else.

i. Compare baseline vital signs with repeated vital signs; changes will often tell you if treatments have been effective.

ii. Watch carefully for changes in the pulse, blood pressure, and respirations.

iii. Document changes in the level of responsiveness.

b. Rapid deterioration of neurologic signs following a head injury is a sign of an expanding intracranial hematoma or rapidly progressing brain swelling.

i. You will notice deterioration in a conscious patient’s awareness of time, place, and person (self), in that order.

ii. You must act quickly to evaluate and treat these patients.

c. If CSF is present, cover the wound with sterile diffuse dressing to prevent further contamination, but do not bandage it tightly.

d. Your protocol should include the administration of high-flow oxygen and the application of a cervical collar, if indicated, as part of spinal immobilization.

e. Reassessment should take place as the patient is transported to an appropriate trauma facility.

5. Communication and documentation

a. It is essential to maintain good communication with other providers and give complete and detailed information to the destination facility.

b. Hospitals may better prepare for seriously injured patients with more advanced warning and a description of the most serious problems found during your assessment.

c. Your documentation should include:

i. The history you were able to obtain at the scene

ii. Your findings during your assessment

iii. Treatments you provided

iv. How the patient responded to them

d. More seriously injured patients should have documented vital signs every 5 minutes.

e. More stable patients should have documented vital signs every 15 minutes.

f. You may be requested to testify as a witness.

VI. Emergency Medical Care for Head Injuries

A. Three general principles are designed to protect and maintain the critical functions of the CNS:

1. Establish an adequate airway.

a. If necessary, begin and maintain ventilation, and always provide high-flow supplemental oxygen.

2. Control bleeding and provide adequate circulation to maintain cerebral perfusion.

a. Begin CPR, if necessary.

b. Be sure to follow standard precautions.

3. Assess the patient’s baseline level of responsiveness, and continuously monitor it.

B. Managing the airway

1. The most important step is establishing and maintaining an adequate airway.

a. If the patient has an airway obstruction, perform the jaw-thrust maneuver.

b. Once the airway is open, maintain the head and cervical spine in a neutral, in-line position until you have placed a cervical collar and have secured the patient on a backboard.

c. Remove any foreign bodies, secretions, or vomitus from the airway.

d. Make sure a suctioning unit is available.

2. Once you have cleared the airway, check ventilation.

3. Give supplemental oxygen to any patient with suspected head injury, particularly anyone who is having trouble breathing.

C. Circulation

1. If the heart is not beating, providing airway maintenance, ventilation, and oxygen accomplishes nothing.

2. You must begin CPR if the patient is in cardiac arrest.

3. Active blood loss aggravates hypoxia by reducing the available number of oxygen-carrying red blood cells.

a. Bleeding inside the skull may cause the ICP to rise to life-threatening levels.

4. Apply a dressing over a scalp laceration.

5. You can almost always control bleeding from a scalp laceration by applying direct pressure over the wound.

a. If you suspect a skull fracture, do not apply excessive pressure to the open wound.

b. If the dressing becomes soaked, do not remove it.

c. Instead, place a second dressing over the first.

6. Shock

a. Usually the result of hypovolemia caused by bleeding from other injuries

b. Indicates that the situation is critical

c. Transport immediately to a trauma center.

7. Cushing triad

a. Increased blood pressure (hypertension), decreased heart rate (bradycardia), and irregular respirations (Cheyne-Stokes or Biot)

b. If this process is allowed to continue, it is a fatal injury.

c. Perform controlled hyperventilation of your patient via positive-pressure ventilations at a rate of 20 breaths/min.

d. Follow local protocols and your medical direction in regard to hyperventilation in the presence of herniation.

VII. Emergency Medical Care for Suspected Spinal Injuries

A. Remember to follow standard precautions.

B. Maintain the patient’s airway while keeping the spine in the proper position, assess respirations, and give supplemental oxygen.

C. Managing the airway

1. Perform the jaw-thrust maneuver to open the airway.

a. Do not use the head tilt–chin lift maneuver because it extends the neck and may further damage the cervical spine.

2. After you open the airway, consider inserting an oropharyngeal airway.

3. Have a suctioning unit available.

4. Provide supplemental oxygen.

D. Restrict the Motion of the cervical spine

1. Establishing and maintaining the airway is your first priority. 78286_CH26_SKDSK01_02

2. Restrict the motion of the head and trunk so that bone fragments do not cause further damage.

3. Even small movements can cause significant injury to the spinal cord. 78286_CH26_SKDSK01_03

4. Follow the steps to return the head to neutral alignment (Skill Slide 28-1)

Take standard precautions.
Kneel behind the patient and firmly place your hands around the base of the skull on either side.
Support the lower jaw with your index and long fingers, and the head with your palms.
Gently lift the head into a neutral, eyes forward position, aligned with the torso.
Do not move the head or neck excessively, forcefully, or rapidly.
Continue to manually support the head while your partner places a rigid cervical collar around the neck.
Maintain manual support until you have completely secured the patient to a backboard.

5. Never force the head into a neutral, in-line position; do not move the head any further if the patient reports any of the following symptoms:

a. Muscle spasms in the neck

b. Substantial increased pain

c. Numbness, tingling, or weakness in the arms or legs

d. Compromised airway or ventilations

6. In these situations, stabilize the patient in his or her current position.

E. Cervical collars

1. Cervical collars may be rigid or soft.

2. Provide preliminary, partial support.

3. Should be applied to every patient who has a possible spinal injury based on the MOI, history, or signs and symptoms.

4. Cervical collars do not fully immobilize the cervical spine. Maintain manual support until the patient has been completely secured to a long backboard or vacuum mattress.

5. To be effective, a cervical collar must be the correct size for the patient.

6. The cervical collar should rest on the shoulder girdle and provide firm support under both sides of the mandible, without obstructing the airway or ventilation.

7. Follow the steps to apply a cervical collar (Skill Slide 28-2)

a. Apply in-line stabilization. 78286_CH26_SKDSK05_02

b. Measure the proper collar size.

c. Place the chin support first.

d. Wrap the collar around the neck and secure the collar.

e. Ensure proper fit and maintain neutral, in-line stabilization until the patient is secured to a backboard.

8. Once the patient’s head and neck have been manually stabilized, assess the circulation, sensation, and motor function (CSM) in all extremities. Then assess the cervical spine area and neck.

VIII. Preparation for Transport

A. Supine patients

1. Immobilize a supine patient by securing the patient to a long backboard or vacuum mattress.

2. You may also slide the patient onto a backboard or vacuum mattress.

3. To secure a patient to a backboard (Skill Slide 28-3)

a. Apply and maintain manual cervical stabilization. Assess distal functions in all extremities.

b. Apply a cervical collar.

c. Rescuers kneel on one side of the patient and place hands on the far side of the patient.

d. On command, rescuers roll the patient toward themselves, quickly examine the back, slide the backboard under the patient, and roll the patient onto the backboard.

e. Center the patient on the backboard.

f. Secure the upper torso first.

g. Secure the pelvis and upper legs.

h. Secure the patient’s head using a commercial immobilization device or rolled towels.

i. Place tape across the patient’s forehead to secure the immobilization device.

j. Check all straps and readjust as needed. Reassess distal functions in all extremities.

B. Vacuum mattress

1. An alternative to the long backboard is a vacuum mattress.

a. Molds to the specific contours of the patient’s body, reducing pressure-point tenderness and therefore providing better comfort

b. Also provides thermal insulation

c. Excellent for the elderly or a patient with abnormal curvature of the spine

d. Drawback to the device is its thickness

i. Requires careful patient movement to maintain spinal stabilization

e. Cannot be used for patients who weigh more than 350 pounds

f. Can be used on a supine, sitting, or standing patient

g. Patients can be moved onto the vacuum mattress with a scoop stretcher or a log roll.

C. Sitting patients

If a patient is found sitting and has experienced a significant event that raises the suspicion of a potential spinal injury, conduct the SMR examination after the initial assessment for life threats.
If SMR is not indicated, continue the patient assessment and transport as indicated.

3. If SMR is indicated, do the following:

a. Ask the patient to not move their head.

b. Apply a cervical collar.

c. Move the patient with a spine safe maneuver to the cot.

d. Secure with straps.

4. Securing a patient found in a sitting position (Skill Slide 28-4)

Take standard precautions.
Stabilize the head and neck in a neutral, in-line position.
Assess pulse, motor, and sensory function in each extremity.
Apply a cervical collar.
Insert an immobilization device between the patient’s upper back and the seat.
Open the side flaps, and position them around the patient’s torso, snug around the armpits.
Secure the upper torso flaps, then the mid-torso flaps.
Secure the groin (leg) straps. Check and adjust the torso straps.
Pad between the head and the device as needed.
Secure the forehead strap and fasten the lower head strap around the cervical collar.
Place a long backboard next to the patient’s buttocks, perpendicular to the trunk.
Turn and lower the patient onto the long backboard.
Secure the patient to the long backboard under the immobilization device.

5. The exceptions to this rule are situations in which you do not have time to prepare the patient for spine safe movement, including the following situations:

a. You or the patient is in danger

b. You need to gain immediate access to other patients

c. The patient’s injuries justify urgent removal

D. Standing patients

1. If a standing patient has experienced a significant event that raises the suspicion of a potential spinal injury, conduct the SMR examination after the initial assessment for life threats.

2. If SMR is not indicated, continue the patient assessment and transport as indicated.

3. If SMR is indicated, do the following:

a. Ask the patient to not move their head.

b. Apply a cervical collar.

c. Position the cot behind the patient.

d. Ask the patient to sit on the cot.

e. Ask the patient to lie back on the cot and secure it with straps.

E. Spinal motion restriction devices

1. If during the assessment for spinal injuries it is determined that the patient has a potential spinal injury, a SMR device is indicated.

2. Because any manipulation of the unstable cervical spine may cause permanent damage to the spinal cord, you must assume the presence of spinal injury in all patients who have sustained significant head injuries that resulted in an altered mental status or unresponsiveness.

3. Use manual in-line stabilization or a cervical collar and a long backboard.

4. Short backboards

a. The most common short backboards are the vest-type device and the rigid short board.

b. These devices are designed to immobilize and restrict movement of the head, neck, and torso.

c. Used to immobilize noncritical patients who are found in a sitting position and have possible spinal injuries

5. Long backboards

a. These devices provide full body spinal motion restriction to the head, neck, torso, pelvis, and extremities.

b. Long backboards are used for patients found in any position, sometimes in conjunction with short backboards.

IX. Helmet Removal

A. As you plan your care of a patient wearing a helmet, ask yourself the following questions:

1. Is the patient’s airway clear?

2. Is the patient breathing adequately?

3. Can I maintain the airway and assist ventilations if the helmet remains in place?

4. Can the face guard be easily removed to allow access to the airway without removing the helmet?

5. How well does the helmet fit?

6. Can the patient move within the helmet?

7. Can the spine be immobilized in a neutral position with the helmet on?

B. A helmet that fits well prevents the patient’s head from moving and should be left on, provided:

1. There are no impending airway or breathing problems.

2. It does not interfere with assessment and treatment of airway or ventilation problems.

3. You can properly immobilize the spine.

4. There is any chance that removing it will further injure the patient.

C. Remove a helmet if:

1. It is a full-face helmet.

2. It makes assessing or managing airway problems difficult, and removal of a face guard to improve airway access is not possible.

3. It prevents you from properly immobilizing the spine.

4. It allows excessive head movement.

5. The patient is in cardiac arrest.

D. Preferred method

1. Removing a helmet should always be at least a two-person job.

2. Technique for helmet removal depends on the actual type of helmet worn by the patient.

3. You and your partner should not move at the same time.

4. You should first consult with medical control about your decision to remove a helmet.

5. Follow these steps to remove a helmet (Skill Slide 28-5)

a. Kneel at the patient’s head with your partner at one side.

b. Open the face shield to assess the airway and breathing. Remove eyeglasses if present.

c. Prevent head movement by placing your hands on either side of the helmet and fingers on the lower jaw.

d. Have your partner loosen the strap.

e. Have your partner place one hand at the angle of the lower jaw and the other at the occiput.

f. Gently slip the helmet about halfway off, then stop.

g. Have your partner slide the hand from the occiput to the back of the head to prevent the head from snapping back.

h. Remove the helmet and stabilize the cervical spine.

i. Apply a cervical collar and secure the patient to a long backboard.

j. Pad as needed to prevent neck flexion or extension.

E. Alternate method

1. The advantage of this method is that it allows the helmet to be removed with the application of less force, thereby reducing the likelihood of motion occurring in the neck.

2. The disadvantage is that it is slightly more time consuming.

3. Steps to the alternate method:

a. Remove the chin strap.

b. Remove the face mask (cut or unscrew the plastic clips).

c. Pop the jaw pads out of place with a tongue depressor.

d. Place your fingers inside the helmet during removal of the helmet.

e. The person at the side of the patient controls the head by holding the jaw with one hand and the occiput with the other.

f. Insert padding behind the occiput to prevent neck extension.

g. The person at the side of the patient’s chest is responsible for making sure that the head and neck do not move during removal of the helmet.

h. Remember that small children may require additional padding to maintain the in-line neutral position.

Chapter 29, Chest Injuries

Unit Summary

After completing this chapter and related coursework, you will understand how to manage a patient with chest trauma. You will learn how to recognize life threats associated with these injuries and how to provide immediate intervention. The curriculum includes a detailed description of the anatomy and physiology of the chest and underlying organs as well as the pathophysiology, complications, assessment, and management of chest injuries. Age-related issues are discussed specific to pediatric and geriatric chest trauma. This chapter also provides information on incidence (morbidity and mortality) and a detailed discussion of blunt versus penetrating or open trauma. Specific injuries discussed include sucking chest wounds, pneumothorax, tension pneumothorax, hemothorax, flail chest, and pericardial tamponade.

National EMS Education Standard Competencies

Trauma

Applies fundamental knowledge to provide basic emergency care and transportation based on assessment findings for an acutely injured patient.

Chest Trauma

Recognition and management of:

• Blunt versus penetrating mechanisms

• Open chest wound

• Impaled object

Pathophysiology, assessment, and management of:

• Blunt versus penetrating mechanisms

• Hemothorax

• Pneumothorax

Open
Simple
Tension

• Cardiac tamponade

• Rib fractures

• Flail chest

• Commotio cordis

Knowledge Objectives

1. Explain the mechanics of ventilation in relation to chest injuries.

2. Describe the differences between an open and closed chest injury.

3. Recognize the signs of chest injury.

4. Describe the management of a patient with a suspected chest injury, including pneumothorax, hemothorax, cardiac tamponade, rib fractures, flail chest, pulmonary contusion, traumatic asphyxia, blunt myocardial injury, commotio cordis, and laceration of the great vessels.

5. Recognize the complications that can accompany chest injuries.

6. Explain the complications of a patient with an open pneumothorax (sucking chest wound).

7. Differentiate between a pneumothorax (open, simple, and tension) and hemothorax.

8. Describe the complications of cardiac tamponade.

9. Describe the complications of rib fractures.

10. Describe the complications of a patient with a flail chest.

Skills Objectives

1. Describe the steps to take in the assessment of a patient with a suspected chest injury.

2. Demonstrate the management of a patient with a sucking chest wound.

I. Introduction

A. Chest trauma causes more than 700,000 emergency department visits and more than 18,000 deaths in the United States each year.

1. Such injuries can involve the heart, lungs, and the great blood vessels.

2. They may be the result of blunt trauma, penetrating trauma, or both.

B. EMTs must treat any injuries that interfere with the body’s mechanics of normal breathing without delay.

1. Internal bleeding can collect in the chest cavity, compressing the lungs or heart.

2. Air may collect in the chest and prevent the lungs from expanding.

II. Anatomy and Physiology

A. Remember the difference between ventilation and oxygenation.

Ventilation is the body’s ability to move air in and out of chest and lung tissue.
Oxygenation is the process of delivering oxygen to the blood by diffusion from the alveoli following inhalation into the lungs.
Injuries affecting the patient’s ventilation or oxygenation are serious and may be life threatening.

B. The chest (thoracic cage) extends from the lower end of the neck to the diaphragm.

1. A penetrating injury to the chest may also penetrate the lungs and diaphragm and injure the liver or stomach.

C. Thoracic skin, muscle, and bones have similarities to skin, muscle, and bones in other regions of the body.

1. Unique features, such as striated (or skeletal) muscle, allow for ventilation.

a. Intercostal muscles extend between the ribs.

i. Not yet developed in very young children, who tend to breathe from the diaphragm (“belly breathing”)

ii. Innervated from the spinal nerves

iii. Allow the chest to expand on contraction and the active portion of ventilation to occur

2. The neurovascular bundle is a network of nerves, arteries, and veins lying closely along the inferior and slightly posterior to the lowest margin of each rib.

a. Can be a source of significant bleeding into the pleural space

D. The pleura covers each of the lungs and the thoracic cavity.

1. The parietal pleura is the inner chest wall lining.

2. The visceral pleura covers the lung.

3. A small amount of pleural fluid between the parietal and visceral pleura allows the lungs to move freely against the inner chest wall as a person breathes.

E. The ribs are connected, in the back, to the vertebrae and, in the front, to the sternum.

1. The trachea divides into the left and right main stem bronchi, which supply air to the lungs.

2. The thoracic cage contains the heart and the great vessels: the aorta, the right and left subclavian arteries and their branches, the pulmonary arteries, and the superior and inferior venae cavae.

3. The mediastinum is the central part of the chest containing the heart, great vessels, esophagus, and trachea.

a. This location is where a thoracic aortic dissection can occur—a severing of the aorta that can occur when the body is exposed to traumatic forces.

4. The diaphragm is a muscle that separates the thoracic cavity from the abdominal cavity.

III. Mechanics of Ventilation

A. The intercostal muscles (between the ribs) contract during inhalation.

1. The diaphragm contracts or flattens at the same time.

2. The intrathoracic pressure inside the chest decreases, creating a negative pressure differential.

3. Air then enters the lungs through the nose and mouth.

B. The intercostal muscles and diaphragm relax during exhalation, allowing air to be exhaled.

C. The body should not have to work to breathe when in a resting state.

D. A patient whose spinal cord is injured below the C5 level may lose the power to move the intercostal muscles.

1. The diaphragm should still contract.

2. The patient will still be able to breathe because the phrenic nerves remain intact.

3. Patients with a spinal injury at C3 or above can lose the ability to breathe entirely.

E. The minute ventilation, or minute volume, is the amount of air moved through the lungs in 1 minute.

1. It is calculated by multiplying the normal tidal volume by a patient’s respiratory rate.

2. Patients with decreased tidal volume will have an increased respiratory rate.

a. A 1,000- to 1,500-mL bag-valve mask might over inflate the lungs, causing gastric distention and impaired lung function.

b. Overventilation can increase intrathoracic pressure, reducing cardiac output and potentially worsening chest injuries, such as pneumothorax.

c. Additionally, rapid respirations can cause acid–base imbalance and blood–gas imbalance.

IV. Injuries of the Chest

A. There are two basic types of chest injuries: open and closed.

B. In closed chest injuries, the skin is not broken.

1. They are generally caused by blunt trauma.

2. They often cause significant contusions in cardiac muscle (cardiac contusion) and lung tissue (pulmonary contusion).

3. If the heart is damaged, it may not be able to refill with blood or blood may not be pumped with enough force out of the heart.

a. Results in cardiogenic shock

4. Lung tissue bruising can result in exponential loss of surface area.

a. Leads to decreased oxygen and carbon dioxide exchange

b. Can cause hypoxic and hypercarbic states

5. Rib fractures can lacerate lung tissues and cause further vessel damage with every chest wall movement.

a. Can rapidly lead to hypovolemic shock

C. In open chest injuries, an object (eg, knife, bullet, piece of metal, broken end of a fractured rib) penetrates the chest wall itself.

1. Such injuries cause instant damage, but symptoms develop over time.

2. An impaled object remains in place.

a. Do not attempt to move or remove the object.

i. May be occluding the hole in the punctured vessel; removal would cause heavy bleeding

ii. May cause damage during removal

D. Blunt trauma to the chest may fracture the ribs, sternum, and chest wall; bruise the lungs and heart; and even damage the aorta.

1. Almost one third of people killed immediately in car crashes die as a result of traumatic rupture of the aorta.

2. Vital organs can be torn from their attachment in the chest cavity, causing internal, life-threatening bleeding.

E. Signs and symptoms of chest injury

1. Pain at the site of injury

2. Pain localized at the site of injury that is aggravated by or increased with breathing

a. Irritation of or damage to the pleural surfaces causes sharp or a sticking pain with each breath (pleuritic pain or pleurisy).

3. Bruising to the chest wall

4. Crepitus with palpation of the chest

5. Any penetrating injury to the chest

6. Dyspnea (difficulty breathing, shortness of breath)

a. Can be caused by airway obstruction, damage to the chest wall, improper chest expansion, or lung compression

b. Prompt, vigorous support of oxygenation and ventilation with prompt transport are required.

7. Hemoptysis (spitting or coughing up blood)

a. Indicates damage to the lung or air passage

8. Failure of one or both sides of the chest to expand normally with inspiration

9. Rapid, weak pulse and low blood pressure

a. Principal signs of hypovolemic shock

b. Can result from extensive bleeding of lacerated structures within the chest cavity

10. Cyanosis around the lips or fingernails

a. Sign of inadequate respiration

b. Immediate ventilation and oxygenation are required.

11. The patient may only be able to speak a few words and before gasping.

F. Patients with chest injuries often have tachypnea (rapid respirations) and shallow respirations because it hurts to take a deep breath.

1. The patient may not actually be moving air, due to chest wall trauma.

a. Auscultate multiple locations on the chest wall to assess for adequate breath sounds.

V. Patient Assessment

A. Scene size-up

1. Scene safety

a. Observe for hazards and threats to the safety of the crew, bystanders, and the patient.

b. If the area is a crime scene, do not disturb evidence if possible.

c. Request law enforcement for scenes involving violence (eg, assault, gunshot wounds).

d. If needed, call for electrical utility, fire department, or advanced life support (ALS) units early.

e. At a minimum, use gloves and eye protection.

2. Mechanism of injury

a. Chest injuries are common in motor vehicle crashes, falls, industrial accidents, and assaults.

b. Determine the number of patients.

c. Consider spinal stabilization

B. Primary assessment

1. Form a general impression.

a. Life-threatening hemorrhage, when present, should be addressed immediately, even before airway concerns.

b. Note the patient’s level of responsiveness.

c. Perform a rapid physical examination.

i. Obvious injuries

ii. Appearance of blood

iii. Difficulty breathing

iv. Cyanosis

v. Irregular breathing

vi. Chest rise and fall on only one side

vii. Accessory muscle use

viii. Extended or engorged external jugular veins

ix. Assess airway, breathing, and circulation (the ABCs).

x. Assess overall appearance, and ask, “How sick is this patient?”

2. Airway and breathing

a. Addressing life threats begins with the airway and breathing unless life-threatening uncontrolled bleeding is seen.

b. Ensure that the patient has a clear and patent airway.

i. Normal breathing should be effortless, and any deviation from this pattern should be cause for concern.

c. Consider early cervical spinal stabilization when blunt trauma is present.

d. Note whether the jugular veins are distended.

i. Sign of pressure (tamponade) on the heart

(a) May result from tension pneumothorax

(b) May result from injury to the heart allowing bleeding into the pericardium (pericardial tamponade)

e. Determine whether breathing is present and adequate.

f. Inspect for DCAP-BTLS.

g. Look for equal expansion of the chest wall.

i. Unequal expansion indicates loss of muscle function.

(a) May be due to a direct injury to the chest wall

(b) May be related to an injury of the nerves controlling those muscles

h. Check for paradoxical motion, an abnormality associated with multiple fractured ribs.

i. Apply occlusive dressings to all penetrating injuries to the chest.

i. Support ventilations.

ii. Apply oxygen via a nonrebreathing mask at 15 L/min.

iii. If breathing is inadequate, provide positive-pressure ventilations.

(a) Do not use this type of ventilation for patients with pneumothorax.

iv. In the case of a gunshot wound, after covering the entrance wound look for an exit wound.

v. Continue to auscultate breath sounds and reassess the effectiveness of ventilatory support.

j. Be alert for decreasing oxygen saturation.

k. Can lead to hypoxia

l. Be alert for signs of impending tension pneumothorax (eg, increasingly poor compliance during ventilation).

3. Circulation

a. Assess the pulse and determine whether it is present and adequate.

i. If the pulse is too fast or too slow, or if the skin is pale, cool, or clammy, consider the patient to be in shock.

b. Address life-threatening external bleeding immediately.

i. Control external bleeding using direct pressure and a bulky trauma dressing.

4. Transport decision

a. Priority patients are those who have a problem with their airway, breathing, or circulation.

b. Pay attention to subtle clues:

i. Appearance of the skin

ii. Level of responsiveness

iii. A sense of impending doom in the patient

c. A delay on the scene to perform a lengthy assessment will reduce the chances of survival for the patient.

i. With chest injuries, when in doubt, transport rapidly to a hospital.

C. History taking

1. Investigate the chief complaint.

a. Further investigate the mechanism of injury (MOI).

b. Identify associated signs and symptoms and pertinent negatives.

i. Verify where the pain is located in relation to an area being touched.

ii. Pertinent negatives when examining the chest:

(a) No associated shortness of breath

(b) No rapid breathing

(d) No areas of deformity or abnormal movement

iii. Equal expansion of the chest and movement of the rib cage and the diaphragm can confirm that there is nerve conduction to that region of the body.

2. SAMPLE history

a. A basic evaluation should be completed when time allows, with a focus on:

i. Signs and symptoms

ii. Allergies

iii. Medications

iv. Pertinent medical problems, including respiratory or cardiovascular disease

v. Last oral intake

vi. Events leading to the emergency

b. Questions should focus on the MOI:

i. Speed of the vehicle or height of the fall

ii. Use of safety equipment

iii. Type of weapon used

iv. Number of penetrating wounds

D. Secondary assessment

1. Physical examinations

a. For an isolated injury with a limited MOI, focus on:

i. Isolated injury

ii. Patient’s complaint

iii. Body region affected

iv. Ensuring wounds are identified and bleeding controlled

v. Location and extent of injury

vi. Assessment of all underlying systems

vii. Anterior and posterior aspects of the chest wall

viii. Changes in the patient’s ability to maintain adequate respirations

b. For significant trauma likely affecting multiple systems, start with a rapid physical examination

i. Use DCAP-BTLS to determine the nature and extent of the thoracic injury.

2. Vital signs

a. This activity should include assessment of pulse, respirations, blood pressure, skin condition, and pupils.

b. Reevaluate the patient every 5 minutes or less.

c. A rapid pulse or respiratory rate may indicate that the chest injury is causing a decrease in available oxygen (hypoxia) or blood loss resulting in decreased red blood cell count (hypoxemia).

d. Increased work of breathing can be identified by the use of accessory muscles in the face, neck, and chest.

e. Pulse and respiratory rates may decrease at later stages of chest injury.

i. The myocardium becomes starved for oxygen and the body can no longer keep up with the demands.

ii. The brain becomes starved for oxygen and overloaded with carbon dioxide and other waste products.

E. Reassessment

1. Repeat the primary assessment.

2. Reassess the chief complaint.

3. Reevaluate:

a. Airway

b. Breathing

c. Pulse

d. Perfusion

e. Bleeding

4. Interventions

a. Reassess vital signs and observe trends.

b. Provide appropriate spinal stabilization for patients who have blunt trauma with suspected spinal injuries.

c. Maintain an open airway.

i. Be prepared to suction the patient.

ii. Consider an oropharyngeal or nasopharyngeal airway.

d. Control significant, visible bleeding.

i. Provide high-flow oxygen.

e. Place an occlusive dressing over penetrating trauma to the chest wall.

f. For patients with signs of hypoperfusion:

i. Provide aggressive treatment for shock.

ii. Provide rapid transport.

g. Do not delay transport to complete non-life-saving treatments; these can be performed en route to the hospital.

5. Communication and documentation

a. Communicate all relevant information to the staff at the receiving hospital.

i. Describe all injuries and the treatment given.

VI. Complications and Management of Chest Injuries

A. Pneumothorax

1. Commonly called a collapsed lung

2. Describes an accumulation of air in the pleural space

a. Air enters through a hole in the chest wall or surface of the lung.

b. The patient’s attempts to breathe cause the lung on that side to collapse.

3. Blood passing through the collapsed portion of the lung is not oxygenated.

4. Breath sounds on the affected side of the chest indicate different conditions.

a. If the lung collapses past 30% to 40%, you may hear diminished breath sounds.

b. Absent breath sounds may indicate a tension pneumothorax.

c. A sucking sound on inhalation and the sound of rushing air on exhalation indicate that the chest wall has been penetrated.

5. An open chest wound is often called an open pneumothorax or a sucking chest wound.

a. After clearing and maintaining a patient’s airway and then providing oxygen, these wounds must be rapidly sealed with an occlusive dressing or chest seal.

i. The dressing prevents air from being sucked into the chest through the wound.

ii. Two types of occlusive dressings available:

Commercial vented chest seals
Improvised occlusive dressings utilizing petroleum jelly – based gauze, aluminum foil, or plastic

6. A flutter valve is a one-way valve that allows air to leave the chest cavity on exhalation, but not return.

a. Classically, an occlusive dressing is applied and adhered to the chest on three sides with the dependent portion open to allow for blood and air to escape the wound.

b. Commercial devices work similarly but are designed to be adherent and allow for drainage and are simply applied over the wound.

c. In the military setting, they have elected to eliminate the three-sided dressing altogether and instead recommend a complete four-sided occlusive dressing with needle decompression if tension physiology were to develop.

7. After applying the dressing, carefully monitor the patient for signs of a tension pneumothorax indicated by difficulty breathing, tachypnea, and / or diminished breath sounds.

a. If it develops, open the occlusive dressing on one side during expiration for several seconds.

i. Consult local protocols and the manufacturer’s guidelines.

8. Simple pneumothorax

a. Does not result in major changes in a patient’s cardiac physiology

b. Commonly the result of blunt trauma that results in fractured ribs

i. Decreased breath sounds associated with significant lung collapse

c. Signs and symptoms:

i. Dyspnea, increased work of breathing, and increased respiratory rate

ii. Tachypnea and accessory muscle use

iii. Decreased oxygen saturation

iv. A crackling sensation felt on palpation of the skin (subcutaneous emphysema)

d. Late findings:

i. Decreased breath sounds on the injured side

ii. Lethargy

iii. Cyanosis

e. Be vigilant, because the simple pneumothorax can often worsen or deteriorate into a tension pneumothorax or develop complications like bleeding or hemothorax.

f. Prehospital treatment:

i. Provide high-flow oxygen.

ii. Monitor oximeter readings and breath sounds.

iii. Treat underlying causes of the injury.

iv. Do not withhold positive-pressure ventilation if the patient needs support.

(a) May cause tension pneumothorax

(b) Have a plan to resolve complications

9. Tension pneumothorax

a. Results from ongoing air accumulation in the pleural space

b. This air gradually increases the pressure in the chest.

i. Causes complete collapse of the unaffected lung

ii. Mediastinum is pushed into the opposite pleural cavity

(a) Blood cannot return through the venae cavae to the heart.

(b) Decreases cardiac output

(d) Ultimately, results in death

c. Tension pneumothorax is commonly caused by blunt injury in which a fractured rib lacerates a lung or bronchus.

d. Common signs and symptoms:

i. Chest pain

ii. Tachycardia

iii. Marked respiratory distress

iv. Absent or severely decreased lung sounds on the affected side

v. Hypotension

vi. Altered mental status

vii. Jugular vein distension (JVD)

viii. Cyanosis

ix. Tracheal deviation

e. Prehospital treatment:

i. Support ventilation with high-flow oxygen.

ii. Request ALS support or transport immediately.

iii. Needle decompression may be performed by ALS personnel or emergency department staff depending on local protocols.

B. Hemothorax

1. A condition in which blood collects in the pleural space from bleeding around the rib cage or from a lung or great vessel

2. Common signs and symptoms:

a. Signs and symptoms of shock without any obvious external bleeding or apparent reason for the shock state

b. Decreased breath sounds on the affected side (lung is being compressed by the blood)

3. Prehospital treatment:

a. Bleeding cannot be controlled in the prehospital setting.

b. Provide rapid transport to the nearest facility capable of performing surgery.

4. Hemopneumothorax: the presence of air and blood in the pleural space

C. Cardiac tamponade

1. Cardiac tamponade (pericardial tamponade) occurs more commonly with penetrating chest trauma, although it may occur in blunt trauma.

2. The protective membrane around the heart (pericardium) fills with blood or fluid.

3. The heart then cannot pump an adequate amount of blood.

4. Signs and symptoms:

a. Beck’s triad:

i. Distended or engorged jugular veins seen on both sides of the trachea

ii. Narrowing pulse pressure

iii. Muffled heart sounds

b. Altered mental status due to decreased blood flow to the brain

5. Prehospital treatment:

a. Support ventilations.

i. Provide positive-pressure ventilation to any patient who is hypoventilating or apneic.

b. Rapidly transport the patient to a facility capable of intervention.

D. Rib fractures

1. Common, particularly in older people whose bones are brittle

2. A fracture of one of the upper four ribs is a sign of a very substantial MOI.

3. A fractured rib may lacerate the surface of the lung, causing a pneumothorax, tension pneumothorax, hemothorax, or a hemopneumothorax.

4. Signs and symptoms:

a. Localized tenderness and pain when breathing

b. Rapid, shallow respirations

c. The patient holds the affected portion of the rib cage.

5. Prehospital treatment:

a. Supplemental oxygen

E. Flail chest

1. Caused by compound rib fractures that detach a segment of the chest wall from the rest of the thoracic cage

2. The detached portion of the chest wall moves opposite of normal (paradoxical motion).

a. In during exhalation

b. Out during inhalation

c. Paradoxical motion is a late sign of flail segment.

3. Prehospital treatment:

a. Maintain the airway.

b. Provide respiratory support, if needed.

c. Give supplemental oxygen.

d. Perform ongoing assessments for possible pneumothorax or other respiratory complications.

e. Treatment may also include positive-pressure ventilation with a bag-valve mask.

f. Stabilize the "flail segment" by applying manual pressure to prevent hypoventilation en route to the hospital.

g. Secure a pillow or a rolled towel over the fractured ribs.

4. Flail chest may indicate serious internal damage and possible spinal injury.

VII. Other Chest Injuries

A. Pulmonary contusion

1. Should always be suspected in a patient with a flail chest

2. The pulmonary alveoli become filled with blood, and fluid accumulates in the injured area, leaving the patient hypoxic.

3. Prehospital treatment:

a. Provide supplemental oxygen and positive-pressure ventilation as needed to ensure adequate oxygenation and ventilation.

B. Other fractures

1. Sternal fractures

a. Require a significant amount of force

b. Create an increased index of suspicion for injuries to underlying organs (lungs, great vessels, heart)

2. Clavicle fractures

a. Covered under skeletal injuries

b. Significant damage or disruption to the large neurovascular bundle the clavicle protects is possible.

c. Suspect upper rib fractures in medial clavicle fractures.

d. Be alert to possible signs of pneumothorax development.

C. Traumatic asphyxia

1. Characterized by:

a. Distended neck veins

b. Cyanosis in the face and neck

c. Hemorrhage into the sclera of the eye

2. Involves sudden, severe compression of the chest, which produces a rapid increase in pressure within the chest

a. Example: an unrestrained driver who hits a steering wheel

3. Suggests an underlying injury to the heart and possibly a pulmonary contusion

4. Prehospital treatment:

a. Provide ventilatory support with supplemental oxygen.

b. Monitor vital signs during immediate transport.

D. Blunt myocardial injury

1. Bruising of the heart muscle

2. Blunt trauma may injure the heart itself, making it unable to maintain adequate blood pressure.

3. Signs and symptoms:

a. Irregular pulse rate

i. Ventricular tachycardia and ventricular fibrillation are uncommon.

b. Patient may complain of chest pain or discomfort, similar to cardiac symptoms

4. Suspect myocardial contusion in all cases of severe blunt injury to the chest.

5. Prehospital treatment:

a. Monitor the patient’s pulse carefully.

b. Note any change in blood pressure.

c. Provide supplemental oxygen and transport immediately.

E. Commotio cordis

1. Blunt chest injury caused by a sudden, direct blow to the chest that occurs only during the critical portion of a person’s heartbeat

2. May result in immediate cardiac arrest

3. This phenomenon has been documented to have occurred after patients were struck with:

a. Softballs

b. Baseballs

c. Bats

d. Snowballs

e. Fists

f. Kicks

4. Resulting ventricular fibrillation responds positively to defibrillation within the first 2 minutes after the injury.

5. More commonly associated with sports-related injuries, but should be suspected in all cases in which the person is unconscious and unresponsive after a blow to the chest.

F. Laceration of the great vessels

1. May be accompanied by massive, rapidly fatal hemorrhage

2. The great vessels include:

a. Superior vena cava

b. Inferior vena cava

c. Pulmonary arteries

d. Four main pulmonary veins

e. Aorta and its major branches

3. Prehospital treatment:

a. Cardiopulmonary resuscitation

b. Ventilatory support and supplemental oxygen, if appropriate

b. Immediate transport

c. Remain alert to signs and symptoms of shock.

d. Closely monitor changes in baseline vital signs (eg, tachycardia and hypotension).

Chapter 30, Abdominal and Genitourinary Injuries

Unit Summary

After completing this chapter and related coursework, you will understand how to manage a patient with abdominal and genitourinary trauma. You will learn how to recognize life threats associated with these injuries and the need for immediate intervention. The curriculum includes detailed anatomy and physiology of the abdominal and genitourinary systems as well as the pathophysiology, complications, assessment, and management of abdominal and genitourinary injuries. The assessment section is very comprehensive and follows the primary and secondary model. Specific injuries discussed include blunt versus penetrating mechanisms, evisceration, impaled object, injuries to external genitalia, vaginal bleeding secondary to trauma, and sexual assault. Emergency care skills include management of blunt abdominal injury, penetrating abdominal injury, and abdominal evisceration.

National EMS Education Standard Competencies

Trauma

Applies fundamental knowledge to provide basic emergency care and transportation based on assessment findings for an acutely injured patient.

Abdominal and Genitourinary Trauma

Recognition and management of:

• Blunt versus penetrating mechanisms

• Evisceration

• Impaled object

Pathophysiology, assessment, and management of:

• Solid and hollow organ injuries

• Blunt versus penetrating mechanisms

• Evisceration

• Injuries to the external genitalia

• Vaginal bleeding due to trauma

• Sexual assault

Knowledge Objectives

1. Describe the anatomy and physiology of the abdomen; include an explanation of abdominal quadrants and boundaries and the difference between hollow and solid organs.

2. Describe some special considerations related to the care of pediatric patients and geriatric patients who have experienced abdominal trauma.

3. Define closed abdominal injuries; provide examples of the mechanisms of injury (MOI) likely to cause this type of trauma, and common signs and symptoms exhibited by patients who have experienced this type of injury.

4. Define open abdominal injuries; include the three common velocity levels that distinguish these injuries, provide examples of the MOI that would cause each, and common signs and symptoms exhibited by patients who have experienced this type of injury.

5. Describe the different ways hollow and solid organs of the abdomen can be injured, and include the common signs and symptoms exhibited by patients depending on the organ(s) involved.

6. Explain assessment of a patient who has experienced an abdominal injury; include common indicators that help determine the MOI and whether it is a significant or insignificant MOI.

7. Explain the emergency medical care of a patient who has sustained a closed abdominal injury, including blunt trauma caused by a seatbelt or air bag.

8. Explain the emergency medical care of a patient who has sustained an open abdominal injury, including penetrating injuries and abdominal evisceration.

9. Describe the anatomy and physiology of the female and male genitourinary systems; include the differences between hollow and solid organs.

10. Discuss the types of traumatic injuries sustained by the male and female genitourinary system, including the kidneys, urinary bladder, and internal and external genitalia.

11. Explain assessment of a patient who has experienced a genitourinary injury; include special considerations related to patient privacy and determining the MOI.

12. Explain the emergency medical care of a patient who has sustained a genitourinary injury to the kidneys, bladder, external male genitalia, female genitalia, and rectum.

13. Explain special considerations related to a patient who has experienced a genitourinary injury caused by a sexual assault, including patient treatment, criminal implications, and evidence management.

Skills Objectives

1. Demonstrate proper emergency medical care of a patient who has experienced a blunt abdominal injury.

2. Demonstrate proper emergency medical care of a patient who has a penetrating abdominal injury with an impaled object.

3. Demonstrate how to apply a dressing to an abdominal evisceration wound.

I. Introduction

A. The abdomen is the major body cavity, extending from the diaphragm to the pelvis.

1. The abdomen and thoracic cavities meet at the fifth intercostal space.

2. Contains the organs that make up the digestive, urinary, and genitourinary systems

3. It is important for the EMT to know the anatomy of the abdominal and pelvic cavities and where organs are located.

Understand the functions of the organs so you can assess the seriousness of an injury.

B. Significant trauma to the abdomen can occur from blunt trauma, penetrating trauma, or both.

1. Injuries to the abdomen that go unrecognized and are not repaired in surgery are a leading cause of traumatic death.

a. 10% of all trauma patients have some form of genitourinary tract injury.

II. Anatomy and Physiology of the Abdomen

A. Abdominal quadrants

1. The abdomen is divided into four quadrants.

2. The quadrant location of bruising or pain can delineate which organs are possibly involved in a traumatic injury.

Organs commonly found in the RUQ:

i. Liver

ii. Gallbladder

iii. Small intestine

iv. Small portion of the pancreas

v. Right kidney

b. Organs found in the LUQ:

i. Stomach

ii. Spleen

c. Organs found in the LLQ:

i. The descending colon

ii. The left half of the transverse colon

d. Organs found in the RLQ:

i. Large and small intestines

ii. The ascending colon and the right half of the transverse colon

iii. The appendix

e. The RLQ is a common location for swelling and inflammation.

f. The appendix is a source of infection, and can cause severe infection or septic shock if it ruptures.

B. Hollow and solid organs:

1. The abdomen contains hollow and solid organs.

2. The hollow organs of the abdomen include the stomach, intestines, ureters, and bladder.

a. Most of these organs contain food that is in the process of being digested, urine that is being passed to the bladder for release, or bile.

i. When ruptured or lacerated, the contents spill into the peritoneal cavity.

(a) Can cause an intense inflammatory reaction and possible infection

(b) Peritonitis is an inflammation of this type.

(1) Serious and may become life threatening

(2) Signs include severe abdominal pain, tenderness, and muscular spasm.

b. Intestinal blood supply comes from the mesentery (fold of tissue that connects the small intestine to the abdominal wall).

i. Patients with injuries to the mesentery can bleed significantly into the peritoneal cavity.

ii. Signs of this include abdominal rigidity and periumbilical bruising.

3. The solid organs of the abdomen include the liver, spleen, pancreas, and kidneys.

a. These organs perform the chemical work of the body.

i. Enzyme production

ii. Blood cleansing

iii. Energy production

b. Because of their rich blood supply, hemorrhage of solid organs can be severe.

III. Injuries to the Abdomen

A. Abdominal injuries are considered either open or closed and can involve hollow and/or solid organs.

B. Closed abdominal injuries

1. Blunt trauma to abdomen without breaking the skin

2. Some MOI examples:

Steering wheel
Bicycle handlebars
Motorcycle collisions
Falls
Blast injuries
Pedestrian injuries
Compression

i. Typically caused by a poorly placed lap belt

ii. Creates an injury pattern called a clasp-knife injury

iii. Can also be caused when a person is run or rolled over by vehicles or objects

h. Deceleration

i. Person or the vehicle that he or she is traveling in strikes a large, immovable mass such as a larger vehicle, a bridge abutment, or the ground

3. Signs and symptoms of a closed injury

Pain can be deceiving.

i. Often diffuse in nature

ii. May be referred to another body location

Liver and spleen injuries reveal referred pain in the shoulder.

iii. Tearing pain from the abdomen posteriorly may be dissected aneurysm.

iv. Pain following the angle from the lateral hip to the midline of the groin can be the result of damage to the kidneys or ureters.

v. Pain located in the RLQ can indicate an inflamed or ruptured appendix.

vi. Pain under the margin of the ribs on the right side or between the shoulder blades can indicate an injury to the gallbladder.

b. Blood or fluid in the peritoneal cavity produces acute pain in the entire abdomen.

i. Pain spreads as the blood or contaminant seeks out the voids in the peritoneal cavity.

ii. Often a jarring motion (rebound tenderness or Blumberg sign) will alert the patient to peritonitis or inflammation of the peritoneum.

c. Determining the location of the pain or referred pain can be difficult when the patient has voluntary or involuntary guarding.

i. Conscious or unintentional stiffening of the muscles of the surface of the abdomen to avoid further pain

ii. May be mistaken for abdominal rigidity

d. Abdominal distention or swelling between the xiphoid process and the groin is often the result of free fluid, blood, or organ contents spilling into the peritoneal cavity.

e. Additional signs of abdominal injury are bruising and discoloration.

f. Closed abdominal injuries may initially appear as abrasions.

C. Injuries from seatbelts and airbags

1. Seatbelts have prevented many injuries and saved many lives, but they occasionally cause blunt injuries to the abdominal organs.

a. When worn properly, the seatbelt lies below the anterior superior iliac spines of the pelvis and against the hip joints.

i. If the belt lies too high, it can squeeze abdominal organs or great vessels against the spine when the car decelerates or stops.

b. Can cause bladder injuries to pregnant patients who adjust the lap belt for comfort.

c. In all current-model vehicles, lap and diagonal belts are combined so they cannot be used independently.

i. People can still put the shoulder belt behind their backs.

D. Open abdominal injuries

1. Injuries in which a foreign object enters the abdomen and opens the peritoneal cavity to the outside

a. Also called penetrating injuries

b. Stab wounds and gunshot wounds are examples.

c. Open wounds can be deceiving; therefore, you should maintain a high index of suspicion for unseen injuries, internal damage to organs, and potential life-threatening injuries.

2. The velocity of the object can help predict the amount of damage to tissue.

Low-velocity injuries

i. Caused by handheld or hand-powered objects, such as knives and other edged weapons

b. Medium-velocity injuries

i. Caused by smaller caliber handguns and shotguns

c. High-velocity injuries

i. Caused by larger weapons, such as high-powered rifles and higher-powered handguns

d. High- and medium-velocity injuries have temporary wound channels in addition to exit and entrance wounds.

i. Caused by cavitation

(a) A cavity forms as the pressure wave from the projectile is transferred to the tissues.

(b) Causes microscopic tears to the blood vessels and nerves

ii. The higher the velocity of the projectile, the larger the cavity it produces.

e. Low-velocity penetrations also have the capacity to damage underlying organs.

i. Internal injury may not be apparent during physical examination.

(a) Bleeding may hide the fact that the object went farther and deeper into the peritoneal cavity and injured other organs and tissues.

ii. Any time a patient has an injury at or below the xiphoid process, it should be assumed that the thoracic and peritoneal cavities have been violated.

3. In evisceration, bowel protrudes from the peritoneum.

a. This can be extremely painful and is also visually shocking.

b. Do not push down on the patient’s abdomen.

c. Only perform a visual assessment when there is any suspicion of this type of injury.

d. Cut clothing close to the wound.

e. Never pull on any clothing stuck to or in the wound channel.

4. Signs and symptoms of an open injury

a. Patients with abdominal injury complain of pain.

b. Common sign of significant abdominal injury is tachycardia

i. The heart is increasing its pumping action to compensate for blood loss.

c. Later signs include:

i. Evidence of shock, such as decreased blood pressure and pale, cool, moist skin

ii. Changes in patient’s mental status

iii. Abdomen may become distended from accumulation of blood and fluid.

d. A patient may have both closed and open injuries.

i. Blunt injuries should guide your attention to underlying structures.

ii. Bruises in the RUQ may suggest injury to the liver.

iii. Bruises in the LUQ may suggest injury to the spleen.

iv. Bruises to the flank may suggest injury to the kidney.

v. Bruises around the umbilicus, called Cullen’s sign, are predictive of significant internal abdominal bleeding.

E. Hollow organ injuries

1. Often have delayed signs and symptoms

2. Hollow organs commonly spill contents into the abdomen.

a. Infection develops, which can take hours or days.

b. Stomach and intestines can leak highly toxic and acidic digestive liquids into the peritoneal cavity.

3. Both blunt and penetrating trauma can cause hollow organ injuries.

a. Blunt trauma causes the organ to “pop,” releasing fluids and air.

b. Penetrating trauma causes direct injury, such as lacerations and punctures.

4. The gallbladder and the urinary bladder are hollow organs whose contents (bile and urine) are potentially irritating and damaging if ruptured.

a. These fluids move into loose spaces and voids in the peritoneal cavity, eventually leading to infection.

5. Free air in the peritoneal cavity produces pain.

a. Usually indicates that a hollow organ or loop of bowel has perforated

b. If not rapidly identified and repaired, severe infection and septic shock may develop.

F. Solid organ injuries

1. Solid organs can bleed significantly and cause rapid blood loss and may lead to death.

a. Can be hard to identify from a physical exam because the patient is not experiencing significant pain.

b. Solid organs can also slowly ooze blood into the peritoneal cavity, causing pain to increase slowly over time.

2. The liver is the largest organ in the abdomen.

a. Very vascular and can contribute to hypoperfusion if injured

b. Often injured by a fractured lower right rib or a penetrating trauma

c. A common finding during assessment of patients with an injured liver is referred pain to the right shoulder.

3. The spleen and pancreas are also very vascular.

a. Both are prone to heavy bleeding when fractured, lacerated, or punctured.

b. The spleen is often injured from:

i. Motor vehicle collisions, especially in cases of improperly placed seatbelts

ii. Steering wheel trauma

iii. Falls from heights or onto sharp objects

iv. Bicycle and motorcycle accidents where the patient hits the handlebars on impact.

4. If the diaphragm is penetrated or ruptured, loops of bowels may herniate into the thoracic cavity.

a. Patients may exhibit dyspnea (feel short of breath).

5. The kidneys can also be impacted or penetrated by trauma.

a. Can cause significant amounts of blood loss

b. Common finding is blood in the urine (hematuria)

c. Blood visible on inspection of the urinary meatus indicates significant trauma to the genitourinary system.

IV. Patient Assessment of Abdominal Injuries

A. Assessment of abdominal injuries is one of the more difficult assessments that you will perform.

1. Causes of injury may be apparent, but resulting tissue damage may not be so apparent.

2. Patients may be overwhelmed with other, more painful injuries.

3. Some abdominal injuries develop and worsen over time, making reassessment critical.

B. Scene size-up

1. Standard precautions should be taken at the scene; gloves and eye protection should be a minimum.

2. Be sure the scene is safe for you.

3. Call for additional resources early if needed.

4. Mechanism of injury/nature of illness

a. Observe the scene for early indicators of the MOI.

b. Consider early spinal precautions.

c. Consider all of the injuries the MOI could have produced.

C. Primary assessment

1. First perform a rapid scan.

a. Will help establish the seriousness of the patient’s condition

b. Some abdominal injuries will be obvious and graphic, but most will be very subtle and will go unnoticed.

c. Remember that in some cases of abdominal injuries, the injury may have occurred hours or days earlier.

2. Form a general impression.

a. Important indicators will alert you to the seriousness of the patient’s condition.

b. Trauma patients with closed abdominal injuries may have what appear to be minor injuries. You should not be distracted from looking for more serious hidden injuries.

c. Check for responsiveness using the AVPU scale.

i. Provide high-flow oxygen via nonrebreathing mask to all patients whose level of responsiveness is less than alert and oriented.

ii. Unresponsiveness may indicate a life-threatening condition.

3. In trauma patients, life-threatening external hemorrhage must be addressed before airway or breathing concerns.

4. Airway and breathing

a. Ensure that the patient has a clear and patent airway.

b. If a spinal injury is suspected, prevent the patient from moving.

c. Clear the airway of vomitus so it is not aspirated into the lungs.

i. Note the nature of the vomitus.

d. A distended abdomen may prevent adequate inhalation.

i. Providing supplemental oxygen will help improve oxygenation.

5. Circulation

a. Superficial abdominal injuries usually do not produce significant external bleeding.

i. Internal bleeding can be profound.

ii. Trauma to the liver, kidneys, and spleen can cause significant internal bleeding.

b. Evaluate pulse, skin color, temperature, and condition to determine the stage of shock.

c. Treat aggressively if the patient is in shock.

6. Transport decision

a. Abdominal injuries generally indicate a quick transport to the hospital.

i. A delay in medical evaluation may result in an unnecessary and dangerous progression of shock.

b. Patients with abdominal injuries should be evaluated at the highest level of trauma center available.

D. History taking

1. Clarify the chief complaint and MOI.

a. Also identify associated signs and symptoms and pertinent negatives.

i. Note the position in which the patient is lying.

b. Movement of the body or the abdominal organs irritates the inflamed peritoneum, causing additional pain.

i. To minimize this pain, patients will lie still, usually with their knees drawn up.

ii. Breathing will be rapid and shallow.

2. SAMPLE history

a. Use OPQRST to help explain an abdominal injury.

b. Ask if the patient has experienced any nausea, vomiting, or diarrhea.

i. How many times and over what period

c. Ask about the appearance of any bowel movements and urinary output.

i. Determine if there was any blood in the urine or black, tarry stools (melena).

ii. This will help determine if the patient has gastrointestinal bleeding and if there is bleeding in the lower intestinal tract.

E. Secondary assessment

1. May not have time to perform this detailed, comprehensive exam in critically injured patients

2. Physical examinations

a. Remove or loosen clothes to expose injured regions of the body.

i. Inspect the patient for bleeding before removing the clothing to prevent damaging exposed tissues.

ii. Provide privacy or perform in the back of the ambulance.

b. Patients should be able to stay in a position of comfort unless spinal injury is suspected.

i. Will relieve some of the tension

ii. Place padding under the knees of a patient with a suspected spine injury.

Can worsen pain if you are too aggressive

iii. Fetal position may be the position of most comfort for a patient without spinal injury.

c. Examine the entire abdomen, including all posterior, anterior, and lateral surfaces.

i. Critical step for patients with an entrance wound

d. Use DCAP-BTLS to help identify specific signs and symptoms of injury.

i. Inspect and palpate the abdomen for the presence of deformities.

ii. Look for the presence of contusions and abrasions.

iii. Puncture wounds and other penetrating injuries cannot be overlooked; the intra-abdominal extent of these injuries may be life threatening.

iv. Note the presence of burns.

v. Palpate for tenderness and attempt to localize to a specific quadrant of the abdomen.

vi. Treat lacerations with appropriate dressings.

vii. Swelling may involve the abdomen globally and indicate significant intra-abdominal injury.

e. Palpate the abdomen when examining the region.

i. Palpate the quadrant farthest away from the quadrant that is exhibiting signs and symptoms of injury and pain.

ii. This technique allows you to investigate the possibility of radiation and extension of the pain into other quadrants.

f. Perform a full-body scan to identify injuries other than abdominal injuries.

i. Begin with the head and finish with the lower extremities, moving in a systematic manner.

(a) Goal is to identify the presence of other injuries, not the extent of those injuries

ii. If you find a life-threatening issue, stop and treat it immediately.

iii. Assess the patient’s need for spinal immobilization and apply per local protocol.

g. Inspect and palpate the kidney area for tenderness, bruising, swelling, or other signs of trauma.

i. Hollow organs will spill their contents into the peritoneal cavity.

ii. These injuries will typically present as diffuse pain with guarding and reaction to sudden jarring movements.

3. Obtain vital signs

a. Many abdominal emergencies can cause a rapid pulse and low blood pressure.

b. Your record of vital signs will help you identify changes in the patient’s condition.

c. Use appropriate monitoring devices when available.

i. Pulse oximetry

ii. Noninvasive blood pressure devices

iii. It is recommended that you always assess the patient’s first blood pressure manually with a sphygmomanometer and stethoscope.

4. If the MOI suggests an isolated injury to the abdomen, focus your physical examination on the injured area only.

a. Inspect the skin of the abdomen for wounds through which bullets, knives, or other missile-type foreign bodies may have passed.

i. If you find an entry wound, you must always check for a corresponding exit wound.

b. Do not attempt to remove a knife or other impaled object.

i. Instead, stabilize the object with supportive bandaging.

F. Reassessment

1. Repeat the primary assessment and vital signs.

a. Reassess the interventions and treatment you have provided.

2. Interventions

a. Manage airway and breathing problems based on signs and symptoms found during the primary assessment.

b. Provide complete spinal immobilization to the patient with suspected spinal injuries.

c. If the patient has signs of hypoperfusion, provide aggressive treatment for shock and rapid transport.

d. If an evisceration is found, place a saline-moistened dressing over the wound and transport.

i. Never attempt to push eviscerated tissue or organs back into the abdominal cavity.

ii. Transport the patient supine with knees flexed to the chest.

e. A patient with a ruptured diaphragm may have an abdomen with a sunken anterior wall.

i. These patients should receive positive-pressure ventilations with a bag-valve mask.

3. Communication and documentation

a. Communicate all relevant information to staff at the receiving hospital.

b. Document the results of the physical examination and any pertinent negatives.

c. It is imperative that you be able to describe the scene in enough detail to give the trauma team a clear idea of the circumstances.

d. Be cautious and diligent when dealing with patients who refuse transport after sustaining an injury to the abdomen or genitourinary system.

i. These patients are at high risk for complications.

V. Emergency Medical Care of Abdominal Injuries

A. Closed abdominal injuries

1. The EMT’s biggest concern is not knowing the true extent of the closed abdominal injury.

a. The patient requires rapid transport to the nearest and highest level of care, primarily to a trauma center with a surgeon

b. Position the patient for comfort.

c. Apply high-flow oxygen if the patient has signs of hypoxia or shock.

d. Treat for shock.

2. A patient with blunt abdominal wounds may have:

a. Severe bruising of abdominal wall

b. Liver and spleen laceration resulting in hemorrhage

c. Rupture of intestine resulting in contents be spilled in the peritoneal space

d. Tears in the mesentery

e. Rupture of kidneys or avulsion of kidneys from their arteries and veins

f. Rupture of the urinary bladder resulting in hematuria, pelvic pain, lower abdominal pain, and difficulty voiding.

g. Severe intra-abdominal hemorrhage

h. Peritoneal irritation and inflammation

3. A patient with blunt abdominal injury should be log rolled to a supine position on a backboard.

a. Protect the spine.

b. Monitor the patient’s vital signs for any indication of shock and treat them appropriately.

B. Open abdominal injuries

1. Patients with penetrating injuries

a. Generally obvious wounds and external bleeding; however, significant external bleeding is not always present

b. Maintain a high index of suspicion for serious, unseen blood loss.

i. Only a surgeon can accurately assess the damage.

ii. You should assume the object has penetrated the peritoneum and possibly injured organs.

c. Follow the general procedures described previously for care of a blunt abdominal injury, as well as:

i. Inspect the patient’s back and sides for an exit wound.

ii. Apply a dry, sterile dressing to all open wounds.

iii. If the penetrating object is still in place, apply a stabilizing bandage around it to control external bleeding and to minimize movement of the object.

d. Severe lacerations of the abdominal wall may result in evisceration.

i. Internal organs or fat protrude through the wound

ii. Never try to replace a protruding organ.

(a) Keep the organs moist and warm.

(b) Cover the wound with moistened, sterile dressings.

(d) Secure the bandage with tape.

VI. Anatomy of the Genitourinary System

A. The genitourinary system controls reproductive functions and waste discharge.

1. Organs of the genitourinary system are located in the abdomen

a. Kidneys are solid organs.

b. Ureters, bladder, and urethra are hollow organs.

2. The genital system controls reproductive processes.

a. The male genitalia lies outside the pelvic cavity, except for the prostate gland and seminal vesicles.

b. The female genitalia are contained entirely within the pelvis, except the vulva, clitoris, and labia.

VII. Genitourinary System Injuries

A. Kidney injuries

1. Not unusual and rarely occur in isolation

a. A forceful blow or penetrating injury is often involved.

b. Less significant injuries can result from an indirect blow or even a football tackle.

2. Suspect kidney damage if the patient has a history or physical evidence of any of the following:

a. An abrasion, laceration, or contusion on the flank

b. A penetrating wound in the region of the lower rib cage and above the hip (flank) or the upper abdomen

c. Fractures on either side of the lower rib cage or of the lower thoracic or upper lumbar vertebrae

d. A hematoma in the flank region

B. Urinary bladder injuries

1. May result in rupture

a. Urine spills into surrounding tissues.

b. Blunt injuries to the lower abdomen or pelvis can cause rupture to the urinary bladder, particularly when the bladder is full and distended.

c. Penetrating wounds of the lower mid-abdomen or the perineum can directly involve the urinary bladder.

2. In males, sudden deceleration from a motor vehicle or motorcycle crash can shear the bladder from the urethra.

3. In later trimesters of pregnancy, bladder injuries increase from displacement of the uterus.

C. External male genitalia injuries

1. Soft-tissue wounds

2. Painful and of great concern for the patient, but rarely life threatening

a. Should not be given priority over more severe wounds unless there is significant bleeding

D. Female genitalia injuries

1. Internal female genitalia

a. The uterus, ovaries, and fallopian tubes are rarely damaged.

i. Small, deep in the pelvis, and well protected

b. Exception is the pregnant uterus

i. Uterus enlarges substantially and rises out of the pelvis.

ii. Injuries can be serious because the uterus has a rich blood supply during pregnancy.

iii. Also keep the fetus in mind.

iv. In the last trimester of pregnancy, the uterus is large and may obstruct the vena cava.

(a) Blood pressure may decrease.

(b) Patient should be placed on her left side so the uterus will not lie on the vena cava.

2. External female genitalia

a. Includes the vulva, clitoris, and the major and minor labia at the entrance of the vagina

b. Very rich nerve supply, so injuries are very painful

c. Vaginal bleeding may occur because of penetrating or blunt trauma.

d. Consider sexual assault and pregnancy.

i. Ask the patient about the last known menstrual period.

ii. Ask about sexual history.

iii. Assume all women of childbearing age are possibly pregnant.

(a) This information is relevant because some medications and tests are harmful for a fetus.

e. In cases of external bleeding and trauma, a sterile absorbent sanitary napkin or pad may be applied to the labia.

f. Do not insert instruments, gloved fingers, or a tampon into the vagina.

i. Can cause further damage

VIII. Patient Assessment of the Genitourinary System

A. Potential for patient embarrassment

1. Maintain a professional presence.

2. Provide privacy during assessment.

3. When possible, have an EMT of the same gender perform the assessment.

4. Look for blood on the patient’s undergarments, and only inspect the external genitalia when there are complaints of pain or external signs of injury.

B. Scene size-up

1. Assess the scene for hazards and threats to crew safety.

a. Assess the impact of hazards on patient care.

b. At minimum, gloves and eye protection are required.

i. Minimize your direct contact with bodily fluids.

ii. Blood can be hidden under thick layers of clothing.

2. Mechanism of injury/nature of illness

a. Look for indicators of the MOI.

i. Consider information from dispatch, your observations of the scene, and the MOI to help develop your list of expected injuries.

ii. Patients may avoid the discussion to avoid undergoing a physical examination.

iii. Patients may also provide an MOI that seems “less embarrassing” than the actual MOI.

C. Primary assessment

1. Quickly scan the patient to identify and treat life threats.

a. Genitourinary system is very vascular.

i. Injuries can produce a significant volume of blood.

b. Do not avoid this area in the rapid scan.

i. Life-threatening hemorrhage must be addressed immediately.

ii. If bleeding is present, maintain privacy for the patient and inspect exterior genitals for visible injury.

2. Form a general impression.

3. Airway and breathing

a. Ensure that the patient has a clear and patent airway.

i. Protect the patient from further spinal injury if trauma was involved.

b. If a patient is unresponsive or has a significant altered level of responsiveness, consider inserting an oropharyngeal airway or nasopharyngeal airway.

4. Circulation

a. Genitourinary system can be a significant source of bleeding.

i. Assess pulse rate and quality.

ii. Determine skin condition, color, and temperature.

iii. Check capillary refill time.

b. Closed injuries do not have visible signs of bleeding.

i. Shock may be present.

ii. Assessment of pulse and skin will indicate how aggressively to treat for shock.

c. Control bleeding if visible bleeding is seen.

i. Significant bleeding is a life threat and must be controlled quickly.

5. Transport decision

a. Any injury to the genitourinary system can be life altering.

i. Often requires medical specialist for specialized care

D. History taking

1. Investigate chief complaint.

a. Common associated complaints with genitourinary injuries are:

i. Nausea and vomiting

ii. Diarrhea

iii. Blood in urine (hematuria)

iv. Vomiting blood (hematemesis)

v. Abnormal bowel and bladder habits

2. SAMPLE history

a. Use OPQRST to learn about the patient’s pain.

b. Ask patient about output from the genitourinary system.

i. Especially blood in the urine

c. Ask about allergies to medications or environmental triggers.

d. The importance of past medical history cannot be overstated.

i. Repeated or previous injuries or illness can help determine the extent of the current injury or illness.

e. Last intake of food and fluids is important because it can predict the contents of the genitourinary system.

f. Address the events leading up to the injury.

E. Secondary assessment

1. Physical examinations

a. Genitourinary system injuries can be awkward to assess and treat.

i. Privacy is a genuine concern.

b. When the patient has an isolated injury, focus on that and the body region affected.

c. Look for DCAP-BTLS.

d. Identify wounds and control bleeding.

e. For significant trauma, start with a full-body scan to see if there is trauma affecting multiple systems.

i. Presence of penetrating injury indicates possible internal injury that should be managed accordingly.

ii. Presence of burns must be noted and managed immediately.

iii. Palpate for tenderness to localize the injury and presence of fractures.

iv. Look for lacerations and local swelling.

2. Vital signs

a. Obtain the patient’s vital signs.

i. It is important to reassess vital signs to identify how quickly the patient’s condition is changing.

ii. Signs such as tachycardia; tachypnea; low blood pressure; weak pulse; and cool, moist, and pale skin indicate hypoperfusion.

(a) Evaluate the need for rapid transport.

b. Use pulse oximetry and noninvasive blood pressure devices when available.

F. Reassessment

1. Repeat the primary assessment and vital signs.

a. Reassess the interventions and treatment you have provided.

2. Interventions

a. Provide oxygen if there are signs of dyspnea or shock and maintain a patent airway.

b. Attempt to control bleeding and treat for shock.

c. Place patients in a position of comfort and transport.

3. Communication and documentation

a. Communicate your concerns to the hospital staff.

b. Describe all injuries and treatment given.

c. Documentation should be complete and thorough.

IX. Emergency Medical Care of Genitourinary Injuries

A. Kidneys

1. Damage may not be obvious upon inspection.

a. However, you will see:

i. Signs of shock

ii. Blood in the urine (hematuria)

2. Treat for shock, transport promptly, and monitor vital signs en route to the hospital.

B. Urinary bladder

1. Suspect a urinary bladder injury if you see:

a. Blood at urethral opening

b. Signs of trauma to the lower abdomen, pelvis, or perineum

2. If shock or associated injuries are present, transport promptly and monitor vital signs en route.

C. External male genitalia

1. A few general rules for the treatment of injuries to the external male genitalia:

a. Injuries are painful; make the patient comfortable.

b. Use sterile, moist compresses to cover areas stripped of skin.

c. Apply direct pressure with dry, sterile gauze dressings to control bleeding.

d. Never move or manipulate foreign objects in the urethra.

e. Identify and take avulsed parts to the hospital with patients.

i. If patient has an avulsion of skin on the penis:

(a) Wrap the penis in a soft, sterile dressing moistened with sterile saline.

(b) Transport promptly.

(d) Try to save and preserve the avulsed skin.

2. Amputation of penile shaft

a. Managing blood loss is the top priority.

i. Use local pressure with a sterile dressing on the remaining stump.

b. Never apply a constricting device.

c. Surgical reconstruction is possible if you can locate the amputated part.

i. Wrap it in a moist, sterile dressing.

ii. Place it in a bag.

iii. Transport it in a cooled container without it directly touching ice.

3. If the connective tissue surrounding the erectile tissue is severely damaged, the shaft can be fractured or severely angled.

a. Sometimes requires surgical repair

b. Injury may occur during particularly active sexual intercourse.

c. Associated with intense pain, bleeding into the tissues, and fear.

4. Accidental laceration of the head of the penis is associated with heavy bleeding.

a. Local pressure with a sterile dressing usually stops the hemorrhage.

5. Skin of the shaft or foreskin can get caught in the zipper of pants.

a. Not uncommon event

b. If a small segment of the zipper is involved, you can try to unzip the pants.

c. If a longer segment is involved, use heavy scissors to cut the zipper out of the pants to make the patient more comfortable.

i. Explain what you are going to be cutting.

ii. Be careful not to injure the scrotum while cutting.

6. Urethral injuries in the male are not uncommon.

a. Lacerations of the urethra can result from:

i. Straddle injuries

ii. Pelvic fractures

iii. Penetrating wounds of the perineum

b. It is important to know if the patient can urinate and if there is blood in the urine.

i. Save any urination for later examination at the hospital.

c. Any foreign bodies protruding from the urethra will have to be surgically removed.

7. Avulsion of the skin of the scrotum may damage the scrotal contents.

a. Preserve the avulsed skin in a moist sterile dressing for possible use in reconstruction.

b. Wrap the scrotal contents or the perineal area with a sterile moist compress, and use a local pressure dressing to control bleeding.

8. Direct blows to the scrotum can result in the rupture of a testicle or significant accumulation of blood around the testes.

a. Place cool compresses to the scrotal area during transport.

D. Female genitalia

1. Treat lacerations, abrasions, and avulsions with moist, sterile compresses.

a. Use local pressure to control bleeding.

b. If the bleeding doesn’t stop, place another dressing over the first and maintain direct pressure.

c. Hold dressings in place with diaper-type bandages.

2. Do not pack dressings into the vagina.

3. Leave any foreign bodies in place after stabilizing with bandages.

4. Injuries are painful but generally not life threatening.

a. In-hospital evaluation required

b. Transport urgency is determined by associated injuries, the amount of hemorrhage, and the presence of shock.

E. Rectal bleeding

1. Common complaint

a. Bleeding from the rectum may present as blood in or soaking through undergarments, or may be passed into the toilet with a bowel movement.

2. Possible causes include sexual assault, rectal foreign bodies, hemorrhoids, colitis, and ulcers in the digestive tract.

3. Significant rectal bleeding can occur after hemorrhoid surgery.

a. Can lead to significant blood loss and shock

X. Sexual Assault

A. Sexual assault and rape are all too common.

1. Victims are generally women.

2. Sometimes men and children are victims.

B. Often there is little that you can do beyond providing compassion and transport.

1. The patient may have sustained multisystem trauma and need treatment for shock

C. Do not examine the genitalia unless obvious bleeding requires application of a dressing.

D. Follow appropriate procedures and protocol.

1. Shield the patient from curious onlookers.

2. Document the patient’s history, assessment, treatment, and response to treatment for possible court appearances.

a. Do not speculate.

b. Record only the facts.

3. Follow any crime scene policy of your EMS system.

a. Advise the patient not to wash, bathe, shower, douche, urinate, or defecate until after a physical examination.

b. If oral penetration occurred, advise the patient not to eat, drink, brush the teeth, or use mouthwash until after a physical examination.

c. Handle the patient’s clothes as little as possible

i. Place articles of clothing or other evidence in paper bags.

ii. Do not use plastic bags because mold can grow and destroy evidence.

4. Make sure that the EMT caring for the patient is of the same gender as the patient whenever possible.

5. Treat medical injuries and provide privacy, support, and reassurance.

Chapter 31, Orthopaedic Injuries

Unit Summary

After completing this chapter and related coursework, you will understand the anatomy and physiology of the musculoskeletal system. You will have learned the proper assessment for a suspected and obvious injury. You will have learned general and specific types of musculoskeletal injuries including fractures, sprains, and dislocations, with associated signs, symptoms, and emergency treatment including the use of splints, PASG, and traction splints.

National EMS Education Standard Competencies

Trauma

Applies fundamental knowledge to provide basic emergency care and transportation based on assessment findings for an acutely injured patient.

Orthopaedic Trauma

• Recognition and management of:

Open fractures
Closed fractures
Dislocations
Amputations

• Pathophysiology, assessment, and management of

Upper and lower extremity orthopaedic trauma
Open fractures
Closed fractures
Dislocations
Sprains/strains
Pelvic fractures
Amputations/replantation

Medicine

Applies fundamental knowledge to provide basic emergency care and transportation based on assessment findings for an acutely ill patient.

Nontraumatic Musculoskeletal Disorders

Anatomy, physiology, pathophysiology, assessment, and management of

• Nontraumatic fractures

Knowledge Objectives

Describe the anatomy and physiology of the musculoskeletal system.
Name the four mechanisms of injury.
Describe the different types of musculoskeletal injuries, including fractures, dislocations, amputations, sprains, and strains.
Recognize the characteristics of specific types of musculoskeletal injuries.
Differentiate between open and closed fractures.

6. Explain how to assess the severity of an injury.

7. Describe the emergency medical care of the patient with an orthopaedic injury.

8. Describe the emergency medical care of the patient with a swollen, painful, deformed extremity (fracture).

9. Discuss the need for, general rules of, and possible complications of splinting.

10. Explain the reasons for splinting fractures, dislocations, and sprains at the scene versus transporting the patient immediately.

11. Describe the emergency medical care of the patient with an amputation.

Skills Objectives

1. Demonstrate the care of musculoskeletal injuries. (Skill Slide 31-1)

2. Demonstrate how to apply a rigid splint. (Skill Slide 31-2)

3. Demonstrate how to apply a zippered air splint. (Skill Slide 31-3)

4. Demonstrate how to apply a non-zippered air splint. (Skill Slide 31-4)

5. Demonstrate how to apply a vacuum splint. (Skill Slide 31-5)

6. Demonstrate how to apply a Hare traction splint. (Skill Slide 31-6)

7. Demonstrate how to apply a Sager traction splint. (Skill Slide 31-7)

8. Demonstrate how to splint the clavicle, scapula, the shoulder, the humerus, the elbow, and the forearm.

9. Demonstrate how to splint the hand and wrist. (Skill Slide 31-8)

10. Demonstrate how to care for a patient with an amputation.

I. Introduction

A. The human body is a well-designed system in which form, upright posture, and movement are provided by the musculoskeletal system.

B. The system also protects the vital internal organs of the body.

1. The bones and muscles are susceptible to external forces that can cause injury.

2. Also at risk are the tendons, cartilage, and ligaments.

C. Musculoskeletal injuries are among the most common reasons why patients seek medical attention.

1. Musculoskeletal injuries are often easily identified because of pain, swelling, and deformity.

2. Although musculoskeletal injuries are rarely fatal, they often result in short- or long-term disability.

D. Do not focus solely on a musculoskeletal injury without first determining that no life-threatening injuries exist.

II. Anatomy and Physiology of the Musculoskeletal System

A. The muscular system includes three types of muscle: skeletal, smooth, and cardiac. $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\Ch31\9781284080179_CH31_CP01.jpg$

1. Skeletal muscle, also called striated muscle because of its characteristic stripes, attaches to the bones and usually crosses at least one joint.

a. Referred to as voluntary muscle because it is under direct voluntary control of the brain, responding to commands to move specific body parts

b. Skeletal muscle makes up the largest portion of the body’s muscle mass.

c. All skeletal muscles are supplied with arteries, veins, and nerves.

i. Blood from the arteries brings oxygen, glucose, and nutrients to the muscles.

ii. Waste products, including carbon dioxide and lactic acid, are carried away in the veins.

d. Skeletal muscle tissue is directly attached to the bone by tough, ropelike fibrous structures known as tendons. $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\Ch31\9781284080179_CH31_CP02.jpg$

i. Tendons are extensions of the fascia, which covers all skeletal muscles.

2. Smooth muscle performs much of the automatic work of the body.

a. Also called involuntary muscles because it is not under voluntary control of the brain

b. Found in the walls of most tubular structures of the body, such as the gastrointestinal tract and blood vessels

c. Contracts and relaxes to control the movement of the contents within these structures

3. Cardiac muscle composes the heart, and is a specially adapted involuntary muscle with its own regulatory system. $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\Ch31\9781284080179_CH31_CP03.jpg$

B. The skeleton

1. The skeleton gives us our recognizable human form, protects our vital internal organs, and allows us to move.

a. Made up of approximately 206 bones

b. The bones also produce blood cells (in the bone marrow) and serve as a reservoir for important minerals and electrolytes.

2. The skull is a solid vault-like structure that surrounds and protects the brain. $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\Ch31\9781284080179_CH31_CP05B.jpg$

3. The thoracic cage protects the heart, lungs, and great vessels

a. The lower ribs protect the liver and spleen.

b. The bony spinal canal encases and protects the spinal cord.

4. The pectoral (shoulder) girdle consists of two scapulae and two clavicles.

a. The scapula (shoulder blade) is a flat, triangular bone held to the rib cage by powerful muscles that buffer it against injury. $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\Ch31\9781284080179_CH31_CP06.jpg$

b. The clavicle (collarbone) is a slender, S-shaped bone attached by ligaments to the sternum on one end and to the acromion process on the other.

i. The clavicle acts as a strut to keep the shoulder propped up.

ii. Because it is slender and very exposed, this bone is vulnerable to injury.

5. The upper extremity extends from the shoulder to the fingertips and is composed of the upper arm (humerus), elbow, and forearm (radius and ulna).

a. The upper extremity joins the shoulder girdle at the glenohumeral joint.

c. The humerus connects with the bones of the forearm to form the hinged elbow joint.

d. The radius and ulna make up the forearm.

i. The radius, the larger of the two forearm bones, lies on the thumb side of the forearm. $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\Ch31\9781284080179_CH31_CP07.jpg$

ii. The ulna is narrow and is on the little-finger side of the forearm.

iii. When one is broken, the other is often broken as well.

e. The hand contains three sets of bones.

i. Wrist bones (carpals)

ii. Hand bones (metacarpals)

iii. Finger bones (phalanges)

6. The pelvis supports the body weight and protects the structures within the pelvis: the bladder, rectum, and female reproductive organs.

a. The pelvic girdle is actually three separate bones fused together to form the innominate bone:

i. Ischium

ii. Ilium

iii. Pubis

7. The lower extremity consists of the bones of the thigh, leg, and foot. $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\Ch31\9781284080179_CH31_CP08.jpg$

a. The femur (thigh bone) is a long, powerful bone that connects in the ball-and-socket joint of the pelvis and in the hinge joint of the knee.

b. The femoral head is the ball-shaped part that fits into the acetabulum.

i. Connected to the shaft (diaphysis) by the femoral neck

ii. The femoral neck is a common site for fractures, especially in the older population.

c. The lower leg consists of two bones, the tibia and the fibula.

i. The tibia (shinbone) connects to the patella (kneecap) to form the knee joint and runs down the front of the lower leg.

ii. The much smaller fibula runs behind and beside the tibia.

d. The foot consists of three classes of bones: ankle bones (tarsals), foot bones (metatarsals), and toe bones (phalanges).

$\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\Ch31\9781284080179_CH31_CP09.jpg$

i. The largest of the tarsal bones is the heel bone, or calcaneus, which is subject to injury with axial loading injuries, such as when a person jumps from a height and lands on the feet.

8. The bones of the skeleton provide a framework to which the muscles and tendons are attached.

a. Bone is a living tissue that contains nerves and receives oxygen and nutrients from the arterial system.

b. When a bone breaks, a patient typically experiences severe pain and bleeding.

9. A joint is formed wherever two bones come into contact.

a. Joints are held together in a tough fibrous structure known as a capsule, which is supported and strengthened in certain key areas by bands of fibrous tissue called ligaments.

b. In moving joints, the ends of bones are covered with a thin layer of cartilage known as articular cartilage.

c. Joints are bathed and lubricated by synovial (joint) fluid.

d. Joints allow circular motion (shoulder), hinge motion (knee and elbow), minimum motion (sacroiliac and sternoclavicular joints), or no motion (sutures in the skull).

III. Musculoskeletal Injuries

A. Injury to bones and joints is often associated with injury to the surrounding soft tissues, known as the zone of injury.

B. Mechanism of injury (MOI)

1. Significant force is generally required to cause fractures and dislocations.

a. Direct force

b. Indirect forces

c. Twisting forces

d. High-energy forces

2. A direct force can fracture the bone at the point of impact.

3. Indirect force may cause a fracture or dislocation at a distant point. For example, a fall landing on the wrist could result in a shoulder dislocation.

4. Twisting forces are a common cause of musculoskeletal injury, especially to the anterior cruciate ligament or the medial collateral ligament in the knee. An example is a person gets a foot caught and falls.

5. High-energy injuries produce severe damage to the skeleton, surrounding soft tissues, and vital internal organs.

a. A patient may have multiple injuries to many body parts.

b. Can occur in automobile crashes, falls from heights, gunshot wounds, and other extreme forces

6. A significant MOI is not always necessary to fracture a bone.

a. A slight force can easily fracture a bone that is weakened by a tumor, infection, or osteoporosis. $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\Ch31\9781284080179_CH31_CP10.jpg$

C. Fractures

1. A fracture is a break in the continuity of the bone, often occurring as a result of an external force.

a. Can occur anywhere on the surface of the bone and in many different types of patterns

b. There is no difference between a broken bone and a fractured bone.

2. A potential complication of fractures is compartment syndrome.

a. Elevated pressure within a fascial compartment

3. Fractures are classified as either closed or open.

4. Your first priority is to determine whether the overlying skin is damaged.

a. If not, the patient has a closed fracture.

b. With an open fracture, there is an open wound, caused either by the same blow that fractured the bone or by the broken bone ends lacerating the skin.

c. You should treat any injury that breaks the skin as a possible open fracture.

d. Complications of open fractures include increased blood loss and higher likelihood of infection.

5. Fractures are also described by whether the bone is moved from its normal position.

a. A nondisplaced fracture (also known as a hairline fracture) is a simple crack in the bone that may be difficult to distinguish from a sprain or simple contusion.

i. Radiograph examinations are required.

b. A displaced fracture produces an actual deformity, or distortion, of the limb by shortening, rotating, or angulating it.

6. Medical personnel often use special terms to describe particular types of fractures:

a. Comminuted: A fracture in which the bone is broken into more than two fragments

b. Epiphyseal: A fracture that occurs in a growth section of a child’s bone and may lead to growth abnormalities.

c. Greenstick: An incomplete fracture that passes only part way through the shaft of a bone

i. Occurs in children

d. Incomplete: A fracture that does not run completely through the bone

e. Oblique: A fracture in which the bone is broken at an angle across the bone

i. Usually a result of a sharp-angled blow to the bone

f. Pathologic: A fracture of weakened or diseased bone generally produced by minimal force

i. Seen in patients with osteoporosis or cancer

g. Spiral: A fracture caused by a twisting force, causing an oblique fracture around the bone and through the bone

i. Often the result of abuse in very young children

h. Transverse: A fracture that occurs straight across the bone

i. Usually the result of a direct blow or stress fracture caused by prolonged running

5. Suspect a fracture if one or more of the following signs are present: $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\Ch31\9781284080179_CH31_CP11.jpg$

a. Deformity

i. The limb may appear to be shortened, rotated, or angulated at a point where there is no joint.

ii. Always use the opposite, uninjured limb as a mirror image for comparison.

b. Tenderness

i. Point tenderness on palpation in the zone of injury is the most reliable indicator of an underlying fracture.

c. Guarding

i. An inability to use the extremity is the patient’s way of immobilizing it to minimize pain.

ii. The muscles around the fracture contract in an attempt to prevent any movement of the broken bone.

d. Swelling

i. Rapid swelling usually indicates bleeding from a fracture and is typically followed by substantial pain.

e. Bruising

i. Fractures are almost always associated with ecchymosis of the surrounding soft tissues. $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\Ch31\9781284080179_CH31_CP13.jpg$

ii. Bruising may be present after almost any injury and may take hours to develop.

f. Crepitus

i. A grating or grinding sensation can be felt and sometimes even heard when fractured bone ends rub together.

g. False motion

i. Motion at a point in the limb where there is no joint

h. Exposed fragments

i. In open fractures, bone ends may protrude through the skin or be visible within the wound.

ii. Never attempt to push the end of a protruding bone back into place.

i. Pain

j. Locked joint

i. A joint that is locked into position is difficult and painful to move.

D. Dislocations

1. A disruption of a joint in which the bone ends are no longer in contact

2. The supporting ligaments are often torn, usually completely, allowing the bone ends to separate completely from each other.

3. A fracture-dislocation is a combination injury at the joint in which the joint is dislocated and there is a fracture of the end of one or more of the bones.

4. Sometimes a dislocated joint will spontaneously reduce, or return to its normal position, before your assessment.

a. You will be able to confirm the dislocation only by taking a patient history.

b. A dislocation that does not spontaneously reduce is a serious problem.

c. Commonly dislocated joints include the fingers, shoulder, elbow, and knee.

5. The signs and symptoms of a dislocated joint are similar to those of a fracture.

a. Marked deformity

b. Swelling

c. Pain that is aggravated by any attempt at movement

d. Tenderness on palpation

e. Virtually complete loss of normal joint motion (locked joint)

f. Numbness or impaired circulation to the limb or digit

E. Sprains

1. A sprain occurs when a joint is twisted or stretched beyond its normal range of motion.

2. As a result, the supporting capsule and ligaments are stretched or torn.

3. A sprain should be considered a partial dislocation.

4. Sprains can range from mild to severe.

5. The most vulnerable joints are the knees, shoulders, and ankles.

6. After the injury, the alignment generally returns to a fairly normal position.

7. Sprains do not usually involve deformity, and joint mobility is limited by pain, not joint incongruity.

8. The following signs and symptoms often indicate that the patient may have a sprain:

a. The patient is unwilling to use the limb (guarding).

b. Swelling and ecchymosis

c. Pain prevents the patient from moving or using the limb.

d. Instability of the joint

9. You will frequently not be able to distinguish a nondisplaced fracture from a sprain. An x-ray will provide a definitive prognosis.

a. Remember to document the MOI.

F. Strain

1. A strain (pulled muscle) is a stretching or tearing of the muscle, causing pain, swelling, and bruising of the soft tissues in the area.

2. It occurs because of an abnormal contraction or from excessive stretching.

3. Strains may range from minute separation to complete rupture.

4. Unlike a sprain, no ligament or joint damage typically occurs.

5. Often no deformity is present and only minor swelling is noted at the site of the injury.

6. Some patients may complain of increased pain with passive movement of the injured extremity.

7. Most patients will have extreme point tenderness. $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\Ch31\9781284080179_CH31_CP15.jpg$

G. Amputations

1. An amputation is an injury in which an extremity is completely severed from the body.

2. This injury can damage every aspect of the musculoskeletal system—from bone to ligament to muscle.

H. Complications

1. Orthopaedic injuries can lead to numerous complications—not just those involving the skeletal system, but also systemic changes or illnesses.

a. It is essential that you do not focus all of your attention on the skeletal injury.

2. The likelihood of having a complication is often related to the:

a. Strength of the force that caused the injury

b. Injury’s location

c. Patient’s overall health

3. To prevent contamination following an open fracture, you should brush away any obvious debris on the skin surrounding an open fracture before applying a dressing.

a. Do not enter or probe the open fracture site.

4. Long-term disability is one of the most devastating consequences of an orthopaedic injury.

a. You can help reduce the risk or duration of long-term disability by:

i. Preventing further injury

ii. Reducing the risk of wound infection

iii. Minimizing pain by the use of cold and analgesia

iv. Transporting patients to an appropriate medical facility

I. Assessing the severity of injury

1. When assessing a suspected musculoskeletal injury, palpate in all directions from the injury.

2. The Golden Period is critical not only for life, but also for preserving limb viability.

a. In an extremity with anything less than complete circulation, prolonged hypoperfusion can cause significant damage.

b. Any suspected open fracture or vascular injury is considered a critical emergency.

3. Remember that most injuries are not critical.

a. You can use the musculoskeletal injury grading system to identify critical injuries.

Musculoskeletal Injury Grading System

Minor Injuries

Minor sprains
Fractures or dislocations of digits

Moderate Injuries

Open fractures of digits
Nondisplaced long bone fractures
Nondisplaced pelvic fractures
Major sprains of a major joint

Serious injuries

Displaced long bone fractures
Multiple hand and foot fractures
Open long bone fractures
Displaced pelvic fractures
Dislocations of major joints
Multiple digit amputations
Laceration of major nerves or blood vessels

Severe Life Threatening Injuries

Multiple closed fractures
Limb amputations
Fractures of both long bones of the legs (bilateral femur fractures)

Critical injuries

Multiple open fractures of the limbs
Suspected pelvic fractures with hemodynamic instability

IV. Patient Assessment

A. Always look at the big picture, evaluating the overall complexity of the situation to determine and treat any life threats.

1. You must be able to distinguish mild injuries from severe injuries because some severe injuries may compromise neurovascular function, which could threaten long-term function.

B. Scene size-up

1. Scene safety

a. Information from dispatch may indicate the MOI, the number of patients involved, and any first aid procedures used prior to your arrival.

b. Try to identify the forces associated with the MOI.

c. Standard precautions may be as simple as gloves, but a mask and gown may be necessary.

d. Consider the possibility that there may be hidden bleeding.

e. Evaluate the need for law enforcement support, advanced life support, or additional ambulances.

2. Mechanism of injury/nature of illness

a. Look for indicators of the MOI.

b. Be alert for both primary and secondary injuries.

i. Primary injuries occur as a result of the MOI.

ii. Secondary injuries are the result of what happens after the initial injury.

c. Consider what injuries the MOI would lead you to expect.

C. Primary assessment

1. Focus on identifying and managing life threats.

2. Treating the patient according to his or her level of responsiveness and ABCs is always the priority.

a. Address significant internal or external bleeding, and treat for shock.

b. Check for responsiveness using the AVPU scale.

c. Ask the patient about his or her chief complaint.

d. Administer high-flow oxygen via a nonrebreathing mask or a BVM to all patients whose level of responsiveness is less than alert and oriented.

e. Ask about MOI.

f. If there was significant trauma and multiple body systems are affected, musculoskeletal injuries may be a lower priority.

i. Scene time should not be wasted on prolonged musculoskeletal assessment or splinting.

3. Airway and breathing

a. Fractures and sprains usually do not create airway and breathing problems.

b. Little else matters if the patient’s airway and breathing are inadequate.

4. Circulation

a. Focus on determining whether the patient has a pulse, has adequate perfusion, or is bleeding.

i. Hypoperfusion and bleeding problems will most likely be your primary concern.

b. If the skin is pale, cool, or clammy and capillary refill time is slow, treat your patient for shock immediately.

c. Maintain a normal body temperature.

d. If musculoskeletal injuries in the extremities are suspected, they must be at least initially stabilized, if not splinted, prior to moving.

5. Transport decision

a. If the patient you are treating has an airway or breathing problem, or significant bleeding, provide rapid transport to the hospital for treatment.

b. A patient who has a significant MOI but whose condition appears otherwise stable should also be transported promptly.

c. When a decision for rapid transport is made, you can use a backboard as a splinting device to splint the whole body rather than splinting each extremity individually.

i. Individual splints should be applied en route if the ABCs are stable and time permits.

d. Patients with a simple MOI may be further assessed and their condition stabilized on scene prior to transport if no other problems exist.

6. Fractures can break through the skin and cause external bleeding.

a. Careful handling of the extremity minimizes this risk.

b. If external bleeding is present, bandage the extremity quickly to control bleeding.

c. The bandage should be secure enough to control bleeding without restricting circulation

distal to the injury.

d. Monitor bandage tightness by assessing the circulation, sensation, and movement distal

to the bandage.

e. If bleeding cannot be controlled, quickly apply a tourniquet.

D. History taking

1. Obtain a medical history and be alert for injury-specific signs and symptoms and any pertinent negatives.

2. Obtain a SAMPLE history for all trauma patients.

a. How much and in what detail you explore this history depends on the seriousness of the patient’s condition and how quickly you need to transport him or her to the hospital.

b. Make an attempt to obtain this history without delaying time to definitive care.

c. OPQRST can be of limited use in cases of severe injury and is usually too lengthy when matters of airway, breathing, circulation, and rapid transport require immediate attention.

i. It may be useful when the MOI is unclear, the patient’s condition is stable, or details of the injury are uncertain.

E. Secondary assessment

1. Physical examinations

a. If significant trauma has likely affected multiple systems, start with a secondary assessment of the entire body to be sure that you have found all of the problems and injuries.

b. Begin with the head and work systematically toward the feet, checking the head, chest, abdomen, extremities, and back.

c. The goal is to identify hidden and potentially life-threatening injuries.

d. Use the DCAP-BTLS approach to assess the musculoskeletal system.

e. When lacerations are present in an extremity, an open fracture must be considered, bleeding controlled, and dressings applied.

f. If your assessment finds no external signs of injury, ask the patient to move each limb carefully, stopping immediately if a movement causes pain.

i. Skip this step if the patient reports neck or back pain.

g. When nonsignificant trauma has occurred and you suspect that your patient has a simple strain, sprain, dislocation, or fracture, you can take the time to focus your secondary assessment on that particular injury.

i. Look for DCAP-BTLS.

ii. Evaluate the circulation, motor function, and abnormal sensations distal to the injury.

iii. Be sure to assess the entire zone of injury.

h. Any injury or deformity of the bone may be associated with vessel or nerve injury.

i. You must assess neurovascular function every 5 to 10 minutes during the assessment, depending on the patient’s condition, until he or she is in the hospital.

ii. Always recheck the neurovascular function before and after you splint or otherwise manipulate the limb.

iii. Examination of the injured limb should include the 6 Ps of musculoskeletal assessment—pain, paralysis, paresthesias (numbness or tingling), pulselessness, pallor, and pressure.

2. Vital signs

a. Determine a baseline set of vital signs, including pulse rate, rhythm, and quality; respiratory rate, rhythm, and quality; blood pressure; skin condition; and pupil size and reaction to light.

b. Trending these vital signs helps you to understand whether your patient’s condition is improving or getting worse over time.

F. Reassessment

1. Repeat the primary assessment to ensure your interventions are working as they should.

a. A reassessment should be performed every 5 minutes for an unstable patient and every 15 minutes for a stable patient.

2. Interventions

a. Because trauma patients often have multiple injuries, you must assess their overall condition, stabilize the ABCs, and control any serious bleeding.

b. In a critically injured patient, you should secure the patient to a long backboard to immobilize the spine, pelvis, and extremities and provide prompt transport to a trauma center.

i. In this situation, a secondary assessment is a waste of valuable time.

ii. Reassess the patient en route to the emergency department.

iii. Do not splint individual extremity fractures.

c. If the patient has no life-threatening injuries, you may take extra time at the scene to stabilize the patient’s overall condition.

i. Remove the patient’s clothing to look for open fractures or dislocations, severe deformity, swelling, and/or ecchymosis.

d. When you have finished assessing the extremity, apply a secure splint, commercial or otherwise, to stabilize the injury prior to transport.

i. A comfortable and secure splint will reduce pain, reduce shock, and minimize compromised circulation.

ii. Check the patient’s circulation, sensation, and motor function prior to and after splinting.

iii. The main goal in providing care in musculoskeletal injuries is stabilization in the most comfortable position that allows maintaining good circulation distal to the injury.

3. Communication and documentation

a. Include a description of the problems found during your assessment.

b. Report problems with the patient’s ABCs, open fractures, and compromised circulation that occurred before or after splinting.

c. Document complete descriptions of injuries and the MOIs associated with them.

d. Your careful documentation may protect you from legal action that patients may take later.

V. Emergency Medical Care

A. Perform a primary assessment and stabilize the patient’s ABCs.

1. If needed, perform a secondary assessment of either the entire body or the specific area of injury.

2. Always follow standard precautions.

3. Be alert for signs and symptoms of internal bleeding.

4. Follow the steps when caring for patients with musculoskeletal injuries (Skill Slide 31-1)

a. Cover open wounds with a dry, sterile dressing, and apply pressure to control bleeding.

b. Assess distal circulation, sensation, and motor function.

c. If bleeding cannot be controlled, quickly apply a tourniquet.

d. Apply a splint, and elevate the extremity slightly above the level of the heart.

e. Assess distal circulation, sensation, and motor function.

f. Apply cold packs if there is swelling, but do not place them directly on the skin.

g. Position the patient for transport, and secure the injured area.

B. Splinting

1. A splint is a flexible or rigid device that is used to protect and maintain the position of an injured extremity. 78286_CH29_SKDSK02_04

2. Unless the patient’s life is in immediate danger, you should splint all fractures, dislocations, and sprains before moving the patient.

3. Splinting reduces pain and makes it easier to transfer and transport the patient.

4. In addition, splinting will help to prevent the following:

a. Further damage to muscles, the spinal cord, peripheral nerves, and blood vessels from broken bone ends

b. Laceration of the skin by broken bone ends

i. One of the primary indications for splinting is to prevent a closed fracture from becoming an open fracture.

c. Restriction of distal blood flow resulting from pressure of the bone ends on blood vessels

d. Excessive bleeding of the tissues at the injury site caused by broken bone ends

e. Increased pain from movement of bone ends

f. Paralysis of extremities resulting from a damaged spine

5. A splint is simply a device to prevent motion of the injured part.

a. It can be made from any material on occasions when you need to improvise.

b. The three basic types of splints are rigid, formable, and traction splints.

6. General principles of splinting

a. Remove clothing from the area of any suspected fracture or dislocation so that you can inspect the extremity for DCAP-BTLS.

b. Note and record the patient’s neurovascular status distal to the site of the injury, including circulation, sensation, and movement before and after applying a splint.

c. Cover open wounds with a dry, sterile dressing before splinting.

d. Do not move the patient before splinting an extremity unless there is an immediate danger to the patient or you.

e. In a suspected fracture of the shaft of any bone, be sure to stabilize the joints above and below the fracture.

f. With injuries in and around the joint, be sure to stabilize the bones above and below the injured joint.

g. Pad all rigid splints to prevent local pressure and discomfort to the patient.

h. While applying the splint, maintain manual stabilization to minimize movement of the limb and to support the injury site.

i. If fracture of a long-bone shaft has resulted in severe deformity, use constant, gentle manual traction to align the limb so that it can be splinted. Also known as traction in-line (TIL).

j. If you encounter resistance to limb alignment, splint the limb in its deformed position.

k. Immobilize all suspected spinal injuries in a neutral in-line position on a backboard.

l. If the patient has signs of shock, align the limb in the normal anatomic position, and provide transport.

m. When in doubt, splint.

7. Rigid splints

a. Rigid (non formable) splints are made from firm material and are applied to the sides, front, and/or back of an injured extremity to prevent motion at the injury site.

b. It takes two EMTs to apply a rigid splint.

c. Follow these steps to apply rigid splints (Skill Slide 31-2)

i. Provide gentle support and in-line traction for the limb.

ii. Assess distal circulation, sensation, and motor function.

iii. Place the splint alongside or under the limb.

iv. Pad between the limb and the splint as needed to ensure even pressure and contact.

v. Secure the splint to the limb with bindings.

vi. Assess and record distal neurovascular function, circulation, sensation, and motor function.

d. There are two situations in which you must splint the limb in the position of deformity:

i. When the deformity is severe

ii. When you encounter resistance or extreme pain when applying gentle traction to the fracture of a shaft of a long bone

e. Most dislocations should be splinted as found, but follow local protocols.

8. Formable splints

a. The most commonly used formable or soft splint is the precontoured, inflatable, clear plastic air splint.

b. Always inflate the splint after applying it.

c. The air splint is comfortable, provides uniform contact, and has the added advantage of applying firm pressure to a bleeding wound.

d. Air splints are used to stabilize injuries below the elbow or below the knee.

e. Air splints have some drawbacks, particularly in cold weather areas.

i. The zipper can stick, clog with dirt, or freeze.

ii. Significant changes in the weather or altitude affect the pressure of the air in the splint.

f. You must first cover all wounds with a dry, sterile dressing, making sure that you use standard precautions.

g. Follow these steps to apply a splint that has a zipper (Skill Slide 31-3)

i. Assess distal circulation, sensation, and motor function.

ii. Support the injured limb, and apply gentle traction as your partner applies the open, deflated splint

iii. Zip up the splint, inflate it by pump or by mouth, and test the pressure.

iv. Check and record distal neurovascular function.

h. Follow these steps to apply an unzippered or partially zippered air splint (Skill Slide 31-4)

i. Assess distal circulation, sensation, and motor function.

ii. Your partner supports the injured limb.

iii. Place your arm through the splint to grasp the patient’s hand or foot.

iv. Apply gentle traction while sliding the splint onto the injured limb.

v. Your partner inflates the splint by pump or by mouth.

vi. Assess distal circulation, sensation, and motor function.

i. Other formable splints include vacuum splints, pillow splints, structural aluminum malleable (SAM) splints, a sling and swathe, and pelvic binders for pelvic fractures.

j. Follow these steps to apply a vacuum splint (Skill Slide 31-5)

i. Assess distal circulation, sensation, and motor function.

ii. Your partner stabilizes and supports the injury.

iii. Place the splint, and wrap it around the limb.

iv. Draw the air out of the splint through the suction valve, and then seal the valve.

v. Assess distal circulation, sensation, and motor function.

9. Traction splints

a. Application of in-line traction is the act of pulling on a body structure in the direction of its normal alignment. $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\Ch31\9781284080179_CH31_CP16.jpg$

b. It is the most effective way to realign a fracture of the shaft of a long bone so that the limb can be splinted more effectively.

c. Traction splints are used primarily to secure fractures of the shaft of the femur, which are characterized by pain, swelling, and deformity of the mid-thigh.

d. When applied correctly, traction stabilizes the bone fragments and improves the overall alignment of the limb.

e. Do not attempt to force the bone fragments back into alignment.

f. In the field, the goals of in-line traction are as follows:

i. To stabilize the fracture fragments to prevent excessive movement

ii. To align the limb sufficiently to allow it to be placed in a splint

iii. To avoid potential neurovascular compromise

g. Do not use traction splints for any of the following conditions:

i. Injuries of the upper extremity

ii. Injuries close to or involving the knee

iii. Injuries of the pelvis

iv. Partial amputations or avulsions with bone separation

v. Lower leg, foot, or ankle injury

h. Proper application requires two EMTs.

i. Before you apply a traction splint, be sure to control any external bleeding.

j. The amount of traction that is required varies, but often does not exceed 15 lb.

k. You should use the least amount of force necessary, continue to apply mechanical traction until the patient experiences a reduction in pain.

l. Grasp the foot or hand at the end of the injured limb firmly; once you start pulling, you should not stop until the limb is fully splinted.

m. Imagine where the uninjured limb would lie, and pull gently along the line of that imaginary limb until the injured limb is in approximately that position.

n. If a patient strongly resists the traction, or it causes more pain that persists, stop and splint the limb in the deformed position.

o. Follow these steps to apply a Hare splint (Skill Slide 31-6)

i. Expose the injured limb and check pulse and motor and sensory function.

ii. Place the splint beside the uninjured limb, adjust the splint to proper length, and prepare the straps.

iii. Support the injured limb as your partner fastens the ankle hitch about the foot and ankle.

iv. Continue to support the limb as your partner applies gentle in-line traction to the ankle hitch and foot.

v. Slide the splint into position under the injured limb.

vi. Pad the groin and fasten the ischial strap.

vii. Connect the loops of the ankle hitch to the end of the splint as your partner continues to maintain traction.

viii. Carefully tighten the ratchet to the point that the splint holds adequate traction.

ix. Secure and check support straps.

x. Assess distal circulation, sensation, and motor function.

xi. Secure the patient and splint to the backboard in a way that will prevent movement of the splint during patient movement and transport.

p. The Sager splint is lightweight and easy to store and applies a measurable amount of traction, and can be applied by one person if necessary.

q. Follow these steps to apply a Sager splint (Skill Slide 31-7)

i. After exposing the injured area, assess distal circulation, sensation, and motor function.

ii. Adjust the thigh strap so that it lies anteriorly when secured.

iii. Estimate the proper length of the splint by placing it next to the uninjured limb.

iv. Fit the ankle pads to the ankle.

v. Place the splint at the inner thigh, apply the thigh strap at the upper thigh, and secure snugly.

vi. Tighten the ankle harness just above the malleoli.

vii. Secure the cable ring against the bottom of the foot.

viii. Extend the splint’s inner shaft to apply traction to about 10% of the patient’s body weight.

ix. Secure the splint with elastic bandages.

x. Secure the patient to a backboard.

xi. Assess distal circulation, sensation, and motor function.

10. Pelvic binders

a. Pelvic binders are used to splint the bony pelvis to reduce hemorrhage from bone ends, venous disruption, and pain.

b. Pelvic binders are meant to provide temporary stabilization until definitive stabilization can be achieved.

c. Generally, pelvic binders should be light, made of soft material, and easily applied by one person, and they should allow access to the abdomen, perineum, anus, and groin for examination.

11. Hazards of improper splinting

a. Compression of nerves, tissues, and blood vessels

b. Delay in transport of a patient with a life-threatening injury

c. Reduction of distal circulation

d. Aggravation of the injury

e. Injury to tissue, nerves, blood vessels, or muscles as a result of excessive movement of the bone or joint

C. Transportation

1. Very few, if any, musculoskeletal injuries justify the use of excessive speed during transport.

a. The limb will be stable once a dressing and splint have been applied.

2. A patient with a pulseless limb must be given a higher priority.

3. If the treatment facility is an hour or more away, a patient with a pulseless limb should be transported by helicopter or immediate ground transportation.

VI. Specific Musculoskeletal Injuries

A. Injuries of the clavicle and scapula

1. The clavicle, or collarbone, is one of the most commonly fractured bones in the body.

a. Fractures of the clavicle occur commonly in children when they fall on an outstretched hand.

b. A patient with a fracture of the clavicle will report pain in the shoulder and will usually hold the arm across the front of his or her body.

c. Generally, swelling and point tenderness occur over the clavicle.

d. Because the clavicle is subcutaneous, the skin will occasionally “tent” over the fracture fragments.

2. Fractures of the scapula, or shoulder blade, occur much less frequently because the bone is well protected by many large muscles.

a. Fractures of the scapula are almost always the result of a forceful, direct blow to the back, directly over the scapula.

b. Provide supplemental oxygen and prompt transport for patients who are having difficulty breathing.

c. It is the associated chest injuries, not the fractured scapula itself, that pose the greatest threat of long-term disability.

d. Abrasions, contusions, and significant swelling may occur, and the patient will often limit use of the arm because of pain at the fracture site.

3. The joint between the outer end of the clavicle and the acromion process of the scapula is called the acromioclavicular (AC) joint.

a. This joint is frequently separated during sports, such as football or hockey, when a player falls and lands on the point of the shoulder, driving the scapula away from the outer end of the clavicle.

b. This dislocation is often called an AC separation.

4. These fractures can all be splinted effectively with a sling and swathe.

$\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\Ch31\9781284080179_CH31_CP17A.jpg$ $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\Ch31\9781284080179_CH31_CP17B.jpg$

a. A sling is any bandage or material that helps support the weight of an injured upper extremity, relieving the downward pull of gravity on the injured site.

b. To fully stabilize the shoulder region, a swathe, which is a bandage that passes completely around the chest, must be used to bind the arm to the chest wall.

c. Leave the patient’s fingers exposed so that you can assess neurovascular function at regular intervals.

B. Dislocation of the shoulder

1. The glenohumeral joint (shoulder joint) is where the head of the humerus meets the glenoid fossa of the scapula. $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\Ch31\9781284080179_CH31_CP18.jpg$

2. The glenoid fossa joins with the humeral head to form the glenohumeral joint.

3. In shoulder dislocations, the humeral head is most commonly dislocated anteriorly, coming to lie in front of the scapula as a result of forced abduction and external rotation of the arm.

4. Shoulder dislocations are extremely painful.

a. The patient will guard the shoulder and try to protect it by holding the dislocated arm in a fixed position away from the chest wall.

b. The shoulder joint will usually be locked, and the shoulder will appear squared off or flattened.

c. Some patients may report numbness in the hand because of either nervous or circulatory compromise.

5. Stabilizing an anterior shoulder dislocation is difficult because any attempt to bring the arm in toward the chest wall produces pain.

a. You must splint the joint in whatever position is most comfortable for the patient.

b. If necessary, place a pillow or rolled blankets or towels between the arm and the chest to fill up the space and stabilize the arm.

c. Apply a sling to the forearm and wrist to support the weight of the arm.

d. Secure the arm in the sling to the pillow and chest with a swathe.

e. Transport the patient in a seated or semi-seated position.

C. Fracture of the humerus

1. Fractures of the humerus occur either proximally, in the midshaft, or distally at the elbow.

2. Fractures of the proximal humerus resulting from falls are common among older people.

3. Fractures of the midshaft occur more often in young patients, usually as the result of a violent injury.

4. With any severely angulated fracture, you should consider applying traction to realign the fracture fragments before splinting them.

a. Support the site of the fracture with one hand, and with the other hand, grasp the two humeral condyles just above the elbow.

b. Pull gently in line with the normal axis of the limb.

c. Splint the arm with a sling and swathe, supplemented by a padded board splint on the lateral aspect of the arm.

D. Elbow injuries

1. Fractures and dislocations often occur around the elbow, and the different types of injuries are difficult to distinguish without radiographic examinations.

a. They all produce similar limb deformities and require the same emergency care.

2. Fracture of the distal humerus

a. This type of fracture, also known as a supracondylar or intercondylar fracture, is common in children.

b. Frequently, the fracture fragments rotate significantly, producing deformity and causing injuries to nearby vessels and nerves.

c. Swelling occurs rapidly and is often severe.

3. Dislocation of the elbow

a. This type of injury typically occurs in athletes and rarely in young children.

b. The ulna and radius are most often displaced posteriorly relative to the humerus.

c. The posterior displacement makes the olecranon process of the ulna much more prominent.

d. As with a fracture of the distal humerus, there is swelling and significant potential for vessel or nerve injury.

4. Elbow joint sprain

a. This diagnosis is often mistakenly applied to an occult, nondisplaced fracture.

5. Fracture of the olecranon process of the ulna

a. This fracture can result from direct or indirect forces and is often associated with lacerations and abrasions.

b. The patient will be unable to actively extend the elbow.

6. Fractures of the radial head

a. Often missed during diagnosis, this fracture generally occurs as a result of a fall on an outstretched arm or a direct blow to the lateral aspect of the elbow.

b. Attempts to rotate the elbow or wrist cause discomfort.

7. Care of elbow injuries

a. All elbow injuries are potentially serious and require careful management.

b. Always assess distal neurovascular functions periodically in patients with elbow injuries.

c. If you find strong pulses and good capillary refill, splint the elbow injury in the position in which you found it, adding a wrist sling if this seems helpful.

d. A cold, pale hand or a weak or absent pulse and poor capillary refill indicate that the blood vessels have likely been injured.

i. Further care of this patient must be dictated by a physician.

ii. Notify medical control immediately.

e. If the limb is pulseless and significantly deformed at the elbow, apply gentle manual traction in line with the long axis of the limb to decrease the deformity.

f. Provide prompt transport for all patients with impaired distal circulation.

E. Fractures of the forearm

1. Fractures of the shaft of the radius and ulna are common in people of all age groups but are seen most often in children and older people.

2. Usually, both bones break at the same time when the injury is the result of a fall on an outstretched hand.

3. An isolated fracture of the shaft of the ulna may occur as a result of a direct blow to it (nightstick fracture).

4. Fractures of the distal radius, which are especially common in elderly patients with osteoporosis, are often known as Colles fractures.

a. The term “silver fork deformity” is used to describe the distinctive appearance of the patient’s arm.

5. To stabilize fractures of the forearm or wrist, you can use a padded board, air, vacuum, or pillow splint.

a. If the shaft of the bone has been fractured, be sure to include the elbow joint in the splint.

b. If possible, elevate the injured extremity above the heart to help alleviate swelling.

F. Injuries of the wrist and hand

1. Injuries of the wrist, ranging from dislocation to sprains, must be confirmed by radiographic examination.

2. Dislocations are usually associated with a fracture, resulting in a fracture-dislocation.

3. Another common wrist injury is the isolated, nondisplaced fracture of a carpal bone, especially the scaphoid.

4. Any questionable wrist sprain or fracture should be splinted and evaluated in the emergency department.

5. Hand injuries vary widely, some with potentially serious consequences.

6. Because the fingers and hands are required to function in such intricate ways, any injury that is not treated properly may result in permanent disability, as well as deformity.

a. For this reason, all injuries to the hand, including simple lacerations, should be evaluated by a physician.

b. Do not attempt to “pop” a dislocated finger joint back into place.

c. Always take any amputated parts to the hospital with the patient.

7. Follow these steps to splint the hand and wrist (Skill Slide 31-8). 78286_CH29_SKDSK10_02

a. Support the injured limb and move the hand into the position of function.

b. Place a soft roller bandage in the palm.

c. Apply a padded board splint on the palmar side with fingers exposed.

d. Secure the splint with a roller bandage.

G. Fractures of the pelvis

1. Fracture of the pelvis often results from direct compression in the form of a heavy blow that literally crushes the pelvis.

a. The blow may be from a motor vehicle crash, a weapon, a falling object, or a fall from a height.

2. Injuries to the pelvis can also be caused by indirect forces.

3. However, not all pelvis fractures result from violent trauma.

4. Fractures of the pelvis may be accompanied by life-threatening loss of blood from the laceration of blood vessels affixed to the pelvis at certain key points.

a. Up to several liters of blood may drain into the pelvic space and the retroperitoneal space, which lies between the abdominal cavity and the posterior abdominal wall.

b. The result is significant hypotension, shock, and sometimes death.

c. You must take immediate steps to treat shock, even if there is only minimal swelling.

5. Because the pelvis is surrounded by heavy muscle, open fractures of the pelvis are uncommon.

a. However, pelvis fracture fragments can lacerate the rectum and vagina, creating an open fracture that is often overlooked.

6. You should suspect a fracture of the pelvis in any patient who has sustained a high-velocity injury and complains of discomfort in the lower back or abdomen. $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\Ch31\9781284080179_CH31_CP19A.jpg$

a. Deformity or swelling may be very difficult to see.

b. The most reliable sign of fracture of the pelvis is simple tenderness or instability on firm compression and palpation.

c. Assess for tenderness by placing the palms of your hands over the lateral aspect of each iliac crest, and apply firm but gentle inward pressure on the pelvic ring.

7. If there has been injury to the bladder or urethra, the patient will have lower abdominal tenderness and may have evidence of hematuria or blood at the urethral opening.

8. Patients in stable condition can be secured to a long backboard or scoop stretcher to stabilize isolated fractures of the pelvis.

H. Dislocation of the hip

1. The hip is a very stable ball-and-socket joint that dislocates only after significant injury.

2. Most dislocations of the hip are posterior, most commonly occurring as a result of a motor vehicle crash in which the knee meets with a direct force and the entire femur is driven posteriorly.

3. You should suspect a hip dislocation in any patient who has been in an automobile crash and has a contusion, laceration, or obvious fracture in the knee region.

4. Posterior dislocation of the hip is frequently complicated by injury to the sciatic nerve, which is located directly behind the hip joint.

a. The sciatic nerve is the largest nerve in the lower extremity.

b. It controls the activity of muscles in the posterior thigh and below the knee and the sensation in most of the leg and foot.

c. When the head of the femur is forced out of the hip socket, it may compress or stretch the sciatic nerve, leading to partial or complete paralysis of the nerve.

d. Patients typically lie with the hip joint flexed and the thigh rotated inward toward the midline of the body over the top of the opposite thigh.

e. With the less common anterior dislocation, the limb is in the opposite position, extended straight out, externally rotated, and pointing away from the midline of the body.

5. Dislocation of the hip is associated with very distinctive signs.

a. The patient will have severe pain in the hip and will strongly resist any attempt to move the joint.

b. The lateral and posterior aspects of the hip region will be tender on palpation.

c. Occasionally, sciatic nerve function will be normal at first and then slowly diminish.

6. As with any other extremity injury, do not attempt to reduce the dislocated hip in the field unless medical control directs you to do so.

a. Splint the dislocation in the position of the deformity.

b. Place the patient supine on a long backboard.

c. Support the affected limb with pillows and rolled blankets.

d. Secure the entire limb to the backboard with long straps.

e. Provide prompt transport.

I. Fractures of the proximal femur

1. Fractures of the proximal end of the femur are common fractures, especially in older people and patients with osteoporosis.

2. The break goes through the neck of the femur, the intertrochanteric region, or across the proximal shaft of the femur.

3. Patients display a very characteristic deformity.

a. They lie with the leg externally rotated, and the injured limb is usually shorter than the opposite, uninjured limb.

b. Patients typically are unable to walk or move their leg.

c. The hip region is usually tender on palpation, and gentle rolling of the leg will cause pain but will not do further damage.

4. Assess the pelvis for any soft-tissue injury and bandage appropriately.

5. Assess pulses and motor and sensory functions, looking for signs of vascular and nerve damage.

6. Splint the lower extremity and transport to the emergency department.

7. The age of the patient and the severity of the injury will dictate how you splint the fracture.

8. All patients with hip fractures may lose significant amounts of blood.

a. You should treat it with high-flow oxygen and monitor vital signs frequently.

b. Be alert for signs of shock.

J. Femoral shaft fractures

1. Fractures of the femur can occur in any part of the shaft, from the hip region to the femoral condyles just above the knee joint.

2. Following a fracture, the large muscles of the thigh spasm in an attempt to “splint” the unstable limb.

a. The muscle spasm often produces significant deformity of the limb.

b. Usually, the limb also shortens significantly.

3. Fractures may be open, and fragments of bone may protrude through the skin.

a. Never attempt to push the bone(s) back into the skin.

4. There is often a significant amount of blood loss, as much as 500 to 1,000 mL, after a fracture.

a. It is not unusual for hypovolemic shock to develop.

5. Because of the severe deformity that occurs with these fractures, bone fragments may penetrate or press on important nerves and vessels and produce significant damage.

a. You must carefully and periodically assess the distal neurovascular function in these patients.

6. Cover any wound with a dry, sterile dressing.

7. If the foot or leg below the level of the fracture shows signs of impaired circulation, apply gentle longitudinal traction to the deformed limb in line with the long axis and gradually turn the leg from the deformed position.

8. A fracture of the femoral shaft is best stabilized with a traction splint.

K. Injuries of knee ligaments

1. The knee is very vulnerable to injury; therefore, many different types of injuries occur in this region.

a. Ligament injuries range from mild sprains to complete dislocation of the joint.

b. The patella can also dislocate.

c. All the bony elements of the knee can fracture.

2. The knee is especially susceptible to ligament injuries, which occur when abnormal bending or twisting forces are applied to the joint.

a. When you examine the patient, you will generally find:

i. Swelling

ii. Occasional ecchymosis

iii. Point tenderness at the injury site

iv. A joint effusion

3. You should splint all suspected knee ligament injuries.

a. The splint should extend from the hip joint to the foot, stabilizing the bone above the injured joint and the bone below it.

b. A variety of splints can be used, including a padded, rigid, long leg splint or two padded board splints.

L. Dislocation of the knee

1. Dislocations of the knee are true emergencies that may threaten the limb.

2. When the knee is dislocated, the ligaments that provide support to it may be damaged or torn.

a. The proximal end of the tibia is completely displaced from its juncture with the lower end of the femur, usually producing a significant deformity.

b. Always check the distal circulation carefully before taking any other step.

3. The direction of dislocation refers to the position of the tibia with respect to the femur.

a. Posterior knee dislocations are the most common, occurring in almost half of all cases.

b. Commonly, the anterior and posterior cruciate ligaments are damaged, but there is also a high risk of injury to the popliteal artery.

c. Medial dislocations result from a direct blow to the lateral part of the leg.

4. Patients will typically complain of pain in the knee and report that the knee “gave out.”

a. Complications may include:

i. Limb-threatening popliteal artery disruption

ii. Injuries to the nerves

iii. Joint instability

5. If adequate distal pulses are present, splint the knee in the position in which you found it, and transport the patient promptly.

M. Fractures about the knee

1. Fractures about the knee may occur at the distal end of the femur, at the proximal end of the tibia, or in the patella.

2. It is easy to confuse a nondisplaced or minimally displaced fracture about the knee with a ligament injury.

3. Management of the two types of injuries is as follows:

a. If there is an adequate distal pulse and no significant deformity, splint the limb with the knee straight.

b. If there is an adequate pulse and significant deformity, splint the joint in the position of deformity.

c. If the pulse is absent below the level of the injury, suspect possible vascular and nerve damage, and contact medical control.

d. Never use a traction splint if you suspect a fractured knee.

N. Dislocation of the patella

1. A dislocated patella most commonly occurs in teenagers and young adults who are engaged in athletic activities.

2. Usually, the dislocated patella is displaced to the lateral side.

3. The displacement produces a significant deformity in which the knee is held in a moderately flexed position, and the patella is displaced to the lateral side of the knee.

4. Splint the knee in the position in which you found it.

a. Most often, this is with the knee flexed to a moderate degree.

b. Apply padded board splints to the medial and lateral aspects of the joint, extending from the hip to the ankle.

O. Injuries of the tibia and fibula

1. Fracture of the shaft of the tibia or the fibula may occur at any place between the knee joint and the ankle joint.

a. Often, both bones fracture at the same time.

b. Even a single fracture may result in a severe deformity, with significant angulation or rotation.

c. Open fractures of the tibia are relatively common.

4. These fractures should be stabilized with a padded, rigid long leg splint or an air splint that extends from the foot to the upper thigh.

a. Correct severe deformity before splinting by applying gentle longitudinal traction.

5. These fractures are sometimes associated with vascular injury as a result of the distorted position of the limb following injury.

a. Realigning the limb frequently restores an adequate blood supply to the foot.

b. If it does not, transport promptly and notify medical control.

P. Ankle injuries

1. The ankle is a commonly injured joint.

2. Ankle injuries occur in people of all ages and range in severity from a simple sprain to severe fracture-dislocations.

3. Any ankle injury that produces pain, swelling, localized tenderness, or the inability to bear weight must be evaluated by a physician.

4. The most frequent mechanism of ankle injury is twisting, which stretches or tears the supporting ligaments.

5. You can manage the wide spectrum of injuries to the ankle in the same way, as follows:

a. Dress all open wounds.

b. Assess distal neurovascular function.

c. Correct any gross deformity by applying gentle longitudinal traction to the heel.

d. Before releasing traction, apply a splint.

Q. Foot injuries

1. Injuries to the foot can result in the dislocation or fracture of one or more of the tarsals, metatarsals, or phalanges of the toes. $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\Ch31\9781284080179_CH31_CP20.jpg$

a. Toe fractures are especially common.

b. Of the tarsal bones, the calcaneus (heel bone) is the most frequently fractured.

c. Injury often occurs when the patient falls or jumps from a height and lands directly on the heel.

2. Frequently, the force of injury is transmitted up the legs to the spine and produce a fracture of the lumbar spine.

3. If you suspect that the foot is dislocated, immediately assess for pulses and motor and sensory functions.

a. If pulses are present, immobilize the extremity using a commercially available splint.

b. If pulses are absent, contact medical control.

4. Injuries of the foot are associated with significant swelling but rarely with gross deformity.

a. Vascular injuries are not common.

b. Lacerations about the ankle and foot may damage important underlying nerves and tendons.

c. Puncture wounds of the foot are common and may cause serious infection if not treated early.

5. To splint the foot, apply a rigid padded board splint, an air splint, or a pillow splint, stabilizing the ankle joint and the foot.

a. Leave the toes exposed.

b. When the patient is lying on the stretcher, elevate the foot approximately 6 inches to minimize swelling.

R. Strains and sprains

1. Treat every severe sprain as if it is a fracture.

2. General pain management is similar to that of fractures and includes:

a. Rest

b. Ice

c. Compression

d. Elevation

e. Splinting

S. Amputations

1. Control bleeding and treat for shock.

2. Surgeons today can occasionally reattach amputated parts.

3. With partial amputations, make sure to immobilize the part with bulky compression dressings and a splint to prevent further injury.

a. Do not sever any partial amputations.

b. Control any bleeding from the stump.

c. If bleeding is severe, quickly apply a tourniquet.

4. With a complete amputation, make sure to wrap the clean part in a sterile dressing and place it in a plastic bag.

a. Follow local protocols regarding how to preserve amputated parts.

b. Put the bag in a cool container filled with ice.

c. The goal is to keep the part cool without allowing it to freeze or develop frostbite.

d. The amputated part should be transported with the patient to the appropriate resource hospital.

VII. Compartment Syndrome

A. Compartment syndrome most often occurs with a fractured tibia or forearm of children.

1. Often overlooked, especially in patients with an altered level of responsiveness

2. Compartment syndrome typically develops within 6 to 12 hours after injury, usually as a result of:

a. Excessive bleeding

b. A severely crushed extremity

c. The rapid return of blood to an ischemic limb

3. This syndrome is characterized by:

a. Pain that is out of proportion to the injury

b. Pain on passive stretching of muscles within the compartment

c. Pallor

d. Decreased sensation

e. Decreased power

4. If you have a pediatric patient with a fracture below the elbow or the knee, be on the lookout for these signs and symptoms:

a. Extreme pain

b. Decreased pain sensation

c. Pain on stretching of affected muscles

d. Decreased power

5. These are indicators that the pressure within a fascial compartment is elevated.

6. If you suspect that a patient has compartment syndrome, splint the affected limb, keeping it at the level of the heart, and provide immediate transport.

a. Reassess neurovascular status frequently during transport.

Chapter 32, Environmental Emergencies

Unit Summary

After completing this chapter and related coursework, you will understand the physiology of environmental injuries. You will have learned the proper assessment and management of general and specific types of environmental emergencies including hypothermia, local cold injuries such as frostbite, and heat exposure illnesses such as heat stroke. You will learn the associated signs and symptoms and emergency treatment of drowning; diving emergencies; high-altitude sickness; lightning strikes; and bites and envenomations from spiders, hymenoptera (eg, bees, yellow jackets, wasps, and ants), snakes, scorpions, ticks, and marine life.

National EMS Education Standard Competencies

Trauma

Applies fundamental knowledge to provide basic emergency care and transportation based on assessment findings for an acutely injured patient.

Environmental Emergencies

Recognition and management of

• Submersion incidents

• Temperature-related illness

Pathophysiology, assessment, and management of

• Near drowning

• Temperature-related illness

• Bites and envenomations

• Dysbarism

High altitude
Diving injuries

• Electrical injury

• Radiation exposure (Chapter 40, “Terrorism Response and Disaster Management”)

Knowledge Objectives

1. Identify the four factors that affect how a person deals with exposure to a cold or hot environment.

2. Describe the five ways heat loss occurs in the body, and how the rate and amount of heat loss or gain can be modified in an emergency situation.

3. Describe the four general stages of hypothermia.

4. Describe local cold injuries and their underlying causes.

5. Describe the process of providing emergency care to a patient who has sustained a cold injury, including assessment of the patient, review of signs and symptoms, and management of care.

6. Explain the importance of following local protocols when rewarming a patient who is experiencing moderate or severe hypothermia.

7. Describe the three emergencies that are caused by heat exposure, including the risk factors, signs, and symptoms.

8. Describe the process of providing emergency care to a patient who is experiencing a heat emergency, including assessment of the patient, review of signs and symptoms, and management of care.

9. Define drowning, including its incidence, risk factors, and prevention.

10. List the basic rules of performing a water and ice rescue.

11. Explain why EMTs should have a prearranged rescue plan based on the environment in which they work.

12. List five conditions that may result in a spinal injury following a submersion incident and the steps for stabilizing a patient with a suspected spinal injury in the water.

13. Discuss recovery techniques and resuscitation efforts EMTs may need to follow when managing a patient who has been involved in a submersion incident.

14. Describe the three types of diving emergencies, how they may occur, and their signs and symptoms.

15. Describe the process of providing emergency care to a patient who has been involved in a drowning or diving emergency, including assessment of the patient, review of signs and symptoms, and management of care.

16. Discuss the types of dysbarism injuries, including their incidence, risk factors, signs and symptoms, and emergency medical treatment.

17. Discuss lightning injuries, including their incidence, risk factors, signs and symptoms, and emergency medical treatment.

18. Describe the process of providing emergency care to patients who have been bitten by each of the following venomous spiders:

Black widow spider
Brown recluse spider

19. Describe the process of providing emergency care to a patient who has sustained a bite or sting from each of the following insects and arachnids, including steps the EMT should follow if a patient develops a severe reaction to the sting or bite:

Hymenoptera (bees, wasps, yellow jackets, and ants)
Scorpions
Ticks

20. Describe the process of providing emergency care to a patient who has been bitten by each of the following types of snake and is showing signs of envenomation.

Pit viper
Coral snake

21. Describe the process of providing emergency care to a patient who has been stung by a coelenterate or other marine animal.

Skills Objectives

1. Demonstrate the emergency medical treatment of local cold injuries in the field.

2. Demonstrate using a warm-water bath to rewarm the limb of a patient who has sustained a local cold injury.

3. Demonstrate how to treat a patient with heat cramps.

4. Demonstrate how to treat a patient with heat exhaustion. (Skill Slide 32-1)

5. Demonstrate how to treat a patient with heat stroke.

6. Demonstrate how to stabilize a patient with a suspected spinal injury in the water. (Skill Slide 32-2)

7. Demonstrate how to care for a patient who is suspected of having an air embolism or decompression sickness following a drowning or diving emergency.

8. Demonstrate how to care for a patient who has been bitten by a pit viper and is showing signs of envenomation.

9. Demonstrate how to care for a patient who has been bitten by a coral snake and is showing signs of envenomation.

10. Demonstrate how to care for a patient who has sustained a coelenterate envenomation.

I. Introduction

A. Environmental factors such as temperature and atmospheric pressure can overwhelm the body’s ability to cope with its surroundings.

1. The human body functions best within a narrow temperature range of 97.7°F and 99.5°F.

B. Medical emergencies can result.

C. Certain populations are at higher risk:

1. Children

2. Older people

3. People with chronic illnesses

4. Young adults who overexert themselves

D. Environmental emergencies often accompany other illnesses and injuries that require treatment at the same time.

E. Environmental emergencies include:

1. Heat- and cold-related emergencies

2. Water emergencies

3. Pressure-related injuries caused by diving and high-altitude climbing

4. Injuries caused by lightning

5. Envenomation caused by bites and stings

II. Factors Affecting Exposure

A. There are five ways the body can gain or lose heat:

1. Conduction

a. Direct transfer of heat from a part of the body to a colder object by direct contact

b. Heat can also be gained if the substance being touched is warm.

2. Convection

a. Transfer of heat to circulating air, as when cool air moves across the body

b. Heat can be gained if the air moving across the body is hotter than the temperature of the environment.

3. Evaporation

a. Conversion of any liquid to a gas

b. Natural mechanism by which sweating cools the body

4. Radiation

a. Transfer of heat by radiant energy

b. The most significant mechanism by which the body can lose heat

c. Heat loss caused when a person stands in a cold room

d. Heat can also be gained by radiation.

5. Respiration

a. Loss of body heat during normal breathing

b. Warm air in the lungs is exhaled into the atmosphere and cooler air is inhaled.

c. If the air temperature is above body temperature, an individual can gain heat with each breath.

6. The body is constantly generating heat through metabolic output.

a. When exercising the body generates additional heat.

B. The rate and amount of heat loss or gain by the body can be modified in three ways.

1. Increase or decrease in heat production

a. Shivering and increasing movement when cold

b. Decreasing and limiting movement when hot

2. Move to an area where heat loss can be decreased or increased.

a. Seek shelter from the wind in cold environments.

b. Seek shade in a hot environment to cool a patient down.

3. Wear the appropriate clothing for the environment.

a. Layers of clothing provide good insulation.

b. Protective clothing traps perspiration and prevents evaporation.

c. Loosen or remove clothing to cool down.

C. A number of factors affect how a person deals with heat or cold.

1. Physical condition

a. Patients who are ill or in poor physical condition will not tolerate extreme temperatures well.

2. Age

a. Children and older adults are more likely to experience temperature-related illness.

b. Infants

i. Poor thermoregulation and inability to shiver

ii. Cannot generate heat when needed until about 12 to 18 months of age

iii. Larger surface area and smaller mass

c. Children

i. May not think to or be able to put on extra clothing

d. Older adults

i. Loss of subcutaneous tissues (reduced insulation)

ii. Poor circulation

iii. Medications may affect thermoregulation.

3. Nutrition and hydration

a. A lack of food or water will aggravate hot or cold stress.

b. Calories provide fuel to burn, creating heat during the cold.

c. Water provides sweat for evaporation and removing heat.

d. Alcohol will change the body’s ability to regulate temperature.

4. Environmental conditions

a. Conditions that can complicate or improve environmental situations:

i. Air temperature

ii. Humidity level

iii. Wind

b. Extremes in temperature and humidity are not needed to produce hot or cold injuries.

i. Most hypothermia occurs at temperatures between 30°F and 50°F.

ii. Most heat stroke occurs when the temperature is 80°F and the humidity is 80%.

c. Examine the environmental temperature of your patient.

i. Older patients may not heat or cool their homes sufficiently.

III. Cold Exposure

A. If the body, or any part of it, is exposed to cold environments, temperature regulatory mechanisms may be overwhelmed.

B. Cold exposure may cause injury to:

1. Feet

2. Hands

3. Ears

4. Nose

5. Whole body (hypothermia)

C. Hypothermia

1. Core temperature of the body falls below 95°F

a. Temperature of the heart, lungs, and vital organs

2. The body loses the ability to regulate its temperature and generate body heat.

3. Physiology

a. To protect against heat loss, the body constricts blood vessels in the skin, resulting in blue lips and/or fingertips.

b. The body shivers to generate heat.

c. As these mechanisms are overwhelmed, body functions begin to slow down and mental status deteriorates.

d. Eventually key organs such as the heart begins to slow down.

e. This can lead to death.

4. Development of hypothermia

a. Can develop quickly, as with cold water immersion

b. Can develop gradually, as with exposure to the cold environment for several hours

c. Air temperature does not have to be below freezing for hypothermia to occur.

5. People at risk

a. Homeless people and those whose homes lack heating

b. Swimmers, even in the summer

c. Geriatric, pediatric, and ill individuals who are less able to adjust to temperature extremes

d. Patients with injuries or illness, such as:

i. Burns

ii. Shock

iii. Head injury

iv. Stroke

v. Generalized infection

vi. Injuries to the spinal cord

vii. Diabetes

viii. Hypoglycemia

e. Patients who have taken certain drugs or consumed alcohol

6. Signs and symptoms

a. Become more severe as the body’s core temperature falls

b. Hypothermia generally progresses through four stages.

i. No clear distinction between the stages

ii. The different signs and symptoms will help to estimate the severity of the problem

Characteristics of Systemic Hypothermia
Core Temperature	93F to 95F	82F to 92F	80F to 88F	<80F
Signs & Symptoms	Shivering, foot stamping	Loss of coordination, muscle stiffness	Coma	Apparent death
Cardiorespiratory response	Constricted blood vessels, rapid breathing	Slowing respirations, slow pulse	Weak pulse, dysrhythmias, very slow respirations	Cardiac arrest
Level of Consciousness	Withdrawn	Confused, lethargic, sleepy	Unresponsive	Unresponsive

c. Assess general temperature.

i. Pull back your glove and place the back of your hand on the patient’s abdomen. $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\Ch32\9781284080179_CH32_CP01.jpg$

ii. If the abdomen feels cool, the patient is likely experiencing a generalized cold emergency.

iii. You may carry a hypothermia thermometer, which registers lower body temperatures.

d. Mild hypothermia occurs when the core temperature is between 90°F and 95°F (32°C and 35°C).

i. The patient is usually alert and shivering, an early sign of hypothermia.

ii. Pulse rate and respirations are usually rapid.

iii. Skin may appear red, pale, or cyanotic.

e. More severe hypothermia occurs when the core temperature is less than 90°F (32°C).

i. Shivering stops.

ii. Muscular activity decreases.

iii. Eventually, all muscle activity stops and mental status deteriorates.

f. As the core drops toward 85°F (29°C):

i. The patient becomes lethargic and stops fighting the cold.

ii. The level of responsiveness decreases.

iii. The patient may try to undress.

iv. Poor coordination and memory loss follow, along with reduced or complete loss of sensation to touch.

v. Mood changes occur.

vi. The patient shows impaired judgment.

vii. The patient becomes less communicative.

viii. The patient experiences joint or muscle stiffness.

ix. The patient has trouble speaking.

x. The patient appears stiff or rigid.

g. If the body temperature continues to fall to 80°F (27°C):

i. Vital signs slow.

ii. Pulse becomes slower and weaker.

iii. Respirations slow to shallow or become absent.

iv. Cardiac dysrhythmias may occur as the blood pressure decreases or disappears.

h. At a core temperature of less than 80°F (27°C):

i. All cardiorespiratory activity may cease.

ii. Pupillary reaction is slow.

iii. Patient may appear dead (or be in a coma).

i. Never assume that a cold, pulseless patient is dead.

D. Local cold injuries $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\Ch32\9781284080179_CH32_CP02B.jpg$

1. Most injuries from cold are confined to exposed parts of the body.

a. Extremities (especially the feet and hands)

b. Ears

c. Nose

d. Face $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\Ch32\9781284080179_CH32_CP02C.jpg$

2. When exposed parts of the body become very cold but not frozen, the condition is called frostnip, chilblains, or immersion foot (trench foot).

3. When the parts become frozen, the injury is called frostbite.

4. Important factors in determining the severity of a local cold injury:

a. Duration of the exposure

b. Temperature to which the body part was exposed

c. Wind velocity during exposure

5. You should also investigate a number of underlying factors:

a. Exposure to wet conditions

b. Inadequate insulation from cold or wind

c. Restricted circulation from tight clothing or shoes or circulatory disease

d. Fatigue

e. Poor nutrition

f. Alcohol or drug abuse

g. Hypothermia

h. Diabetes

i. Cardiovascular disease

j. Age

6. Patients with hypothermia should also be assessed for frostbite or other local cold injury.

7. Local and systemic cold exposure problems can occur in the same patient.

8. Frostnip and immersion foot

a. Frostnip

i. After prolonged exposure to the cold, skin may freeze while deeper tissues are unaffected.

ii. Usually affects the ears, nose, and fingers

iii. Usually not painful, so the patient often is unaware that a cold injury has occurred

b. Immersion foot

i. Occurs after prolonged exposure to cold water

ii. Common in hikers or hunters who stand for a long time in a river or lake

c. Signs and symptoms

i. Skin is pale (blanched) and cold to the touch.

ii. Normal color does not return after palpation of the skin.

iii. The skin of the foot may be wrinkled but can also remain soft.

iv. The patient reports loss of feeling and sensation in the injured area.

9. Frostbite

a. Most serious local cold injury because the tissues are actually frozen $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\Ch32\9781284080179_CH32_FIG03.jpg$

i. Freezing permanently damages cells.

ii. Impedes blood flow to the cells.

iii. The exact mechanism by which damage occurs is unknown.

b. Gangrene (permanent damage or cell death) requires surgical removal of dead tissue.

i. The exposed part will become inflamed, tender to touch, and unable to tolerate exposure to cold.

c. Signs and symptoms

i. Most frostbitten parts are hard and waxy.

ii. The injured part feels firm to frozen as you gently touch it.

iii. Blisters and swelling may be present.

iv. In light-skinned individuals with a deep injury that has thawed or partially thawed, the skin may appear red with purple and white, or it may be mottled and cyanotic.

d. The depth of skin damage will vary.

i. With superficial frostbite, only the skin is frozen.

ii. With deep frostbite, deeper tissues are frozen.

iii. You may not be able to tell superficial from deep frostbite in the field.

IV. Assessment of Cold Injuries

A. Management of hypothermia in the field, regardless of severity, consists of stabilizing the ABCs and preventing further heat loss.

B. Scene size-up

1. Scene safety

a. Note the environmental conditions.

i. Air temperature

ii. Wind chill

iii. Wet or dry

b. Ensure that the scene is safe for you and other responders.

c. Identify safety hazards such as icy roads, mud, or wet grass.

d. Use appropriate standard precautions.

e. Consider the number of patients you may have.

f. Summon additional help as quickly as possible.

2. Mechanism of injury/nature of illness

a. Look for indicators of the MOI.

C. Primary assessment

1. Form a general impression.

a. Perform a rapid scan to determine whether a life threat exists and, if so, treat it.

b. If the chief complaint is simply being cold, quickly assess how cold the patient actually is.

i. Check temperature by feeling the patient’s skin on the abdomen.

c. Evaluate the patient’s mental status quickly using the AVPU scale.

d. An altered mental status indicates the intensity of the cold injury.

2. Airway, breathing, and circulation

a. If you believe the patient is in cardiac arrest, proceed directly to the circulation step by providing high-quality chest compressions, then address airway and breathing.

b. Ensure that the patient has an adequate airway and is breathing.

c. If your patient’s breathing is slow or shallow, ventilation with a bag-valve mask may be necessary.

d. Warmed, humidified oxygen helps warm the patient from the inside out.

3. Circulation

a. Palpate for a carotid pulse and wait for up to 60 seconds to decide if the patient is pulseless.

b. The American Heart Association recommends that CPR be started on a patient who has no detectable pulse or breathing.

c. Perfusion will be compromised based on the degree of cold the patient is experiencing.

d. The patient’s skin will not be helpful in determining shock—assume that shock is present and treat accordingly.

e. Bleeding may be difficult to find because of the slow-moving circulation and thick clothing.

4. Transport decision

a. Complications can include cardiac dysrhythmias and blood clotting abnormalities.

b. All patients with hypothermia require immediate transport.

c. Assess the scene for the safest way to quickly move your patient from the cold environment.

d. Rough handling of a hypothermic patient may cause a cold, slow, weak heart to fibrillate and the patient to lose any pulse.

e. If transportation is delayed, protect the patient from further heat loss.

D. History taking

1. Investigate the chief complaint.

a. Obtain a medical history.

b. Be alert for injury-specific signs and symptoms as well as any pertinent negatives.

2. SAMPLE history

a. If possible, find out how long your patient has been exposed to the cold environment.

b. Exposures may be short or prolonged.

c. Medications and underlying medical problems may have an impact on the way cold affects the patient’s metabolism.

d. The patient’s last oral intake and what the patient was doing prior to the exposure will help to determine the severity of the cold problem.

E. Secondary assessment

1. Physical examinations

a. Focus your physical examination on the severity of hypothermia.

b. Assess the areas of the body directly affected by cold exposure.

c. Assess the degree and extent of damage.

d. The numbing effect of cold, both on the brain and on the body, may impair your patient’s ability to tell you about other injuries or illnesses.

2. Vital signs

a. Vital signs may be altered by the effects of hypothermia and can be an indicator of its severity.

b. Respirations may be slow and shallow, resulting in low oxygen levels in the body.

c. Low blood pressure and a slow pulse also indicate moderate to severe hypothermia.

d. Evaluate your patient for changes in mental status using the AVPU scale.

e. Monitoring devices

i. Determine a core body temperature using a hypothermia thermometer, based on local protocol.

ii. Pulse oximetry will often be inaccurate due to the lack of perfusion in the extremities.

F. Reassessment

1. Repeat the primary assessment.

2. Reassess vital signs and the chief complaint.

3. Monitor the patient’s level of responsiveness and vital signs.

4. Rewarming can lead to cardiac dysrhythmias.

5. Interventions

a. Review all treatments that have been performed.

b. Reassess oxygen delivery.

c. Remove any wet or frozen clothing

i. Do not remove any clothing that has frozen to the patient’s skin.

6. Communication and documentation

a. Communicate all of the information you have gathered to the receiving facility.

i. Patient’s physical status

ii. Conditions at the scene

iii. Any changes in the patient’s mental status during treatment and transport

V. General Management of Cold Emergencies

A. Move the patient from the cold environment to prevent further heat loss.

1. To prevent further damage to the feet, do not allow the patient to walk. $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\Ch32\9781284080179_CH32_CP04.jpg$

2. Remove any wet clothing.

3. Place dry blankets over and under the patient.

4. If available, give the patient warm, humidified oxygen.

5. Handle the patient gently.

6. Do not massage the extremities.

7. Do not allow the patient to eat or use any stimulants (eg, coffee, tea, soda, or tobacco)

B. Mild hypothermia

1. Patient is alert, shivering, and responds appropriately.

a. Core body temperature between 90°F and 95°F

2. Treatment involves passive rewarming

a. Place the patient in a warm environment.

b. Remove wet clothing.

c. Apply heat packs or hot water bottles to the groin, axillary, and cervical regions.

d. Turn up the heat to high in the patient compartment of the ambulance.

e. To avoid burns, do not place heat packs directly on skin.

f. Give warm fluids by mouth (if the patient can swallow).

C. Moderate or severe hypothermia

1. Do not try to actively rewarm the patient—rewarming may cause a fatal cardiac dysrhythmia.

2. Local protocols may dictate the appropriate type of rewarming strategies based on the patient’s body temperature.

3. The goal is to prevent further heat loss.

4. Remove the patient immediately from the cold environment.

5. Place the patient in the ambulance.

6. Remove wet clothing.

7. Cover the patient with a blanket and transport.

8. Handle the patient gently to decrease the risk of ventricular fibrillation.

9. If you cannot get the patient out of the cold immediately:

a. Move the patient out of the wind and away from contact with any object that will conduct heat away from the body.

b. Place blankets and a waterproof protective cover on the patient.

c. Cover the head and neck with a towel.

10. Always remember that even an unresponsive patient may be able to hear you.

D. Emergency care of local cold injuries

1. Emergency treatment of local cold injuries in the field should include the following steps:

a. Remove the patient from further exposure to the cold.

b. Handle the injured part gently, and protect it from further injury.

c. Remove any wet or restricting clothing from the patient, especially over the injured part.

2. If there is no chance of reinjury or if transport to the ED will be significantly delayed, consider active rewarming if local protocols allow.

a. Consult medical control if available.

b. With frostnip, contact with a warm object may be all that is needed.

i. Your hands

ii. Your breath

iii. The patient’s own body

c. The affected part will often tingle and become red in light-skinned individuals.

d. With immersion foot, remove wet shoes, boots, and socks.

i. Rewarm the foot gradually, protecting it from further cold exposure.

ii. Splint the extremity, and cover it loosely with a dry, sterile dressing.

iii. Never rub or massage injured tissues; rubbing can cause further damage.

iv. Do not re-expose the injury to cold.

e. With a late or deep cold injury (frostbite), remove any jewelry from the injured part.

i. Cover the injury loosely with a dry, sterile dressing.

ii. Do not break blisters or rub or massage the area.

iii. Do not apply heat or rewarm the part.

iv. Do not allow the patient to stand or walk on a frostbitten foot.

v. Splinting a frostbitten extremity may help prevent secondary injury.

vi. Evaluate for signs or symptoms of systemic hypothermia.

vii. Transport the patient promptly to the hospital.

3. Rewarming in the field

a. If prompt hospital care is not available and medical control instructs you to begin rewarming in the field, use a warm-water bath.

b. Immerse the frostbitten part in water with a temperature of between 102°F and 104°F (38°C and 40.5°C).

i. Check the water temperature with a thermometer before immersing the limb.

ii. Recheck the temperature frequently during the rewarming process.

iii. The water temperature should never exceed 105°F (40.5°C).

iv. Stir the water continuously.

v. Keep the frostbitten part in the water until it feels warm and sensation has returned.

c. Dress the area with dry, sterile dressings (including between injured fingers or toes).

d. Expect the patient to report severe pain.

e. Never attempt rewarming if there is any chance that the part may freeze again before the patient reaches the hospital.

f. Cover the frostbitten part with soft, padded, sterile cotton dressings.

g. If blisters have formed, do not break them.

VI. Cold Exposure and You

A. You are at risk for hypothermia yourself if you work in a cold environment.

1. If cold weather search-and-rescue is possible in your area, then you need survival training and precautionary tips.

2. Stay on top of weather forecasts.

3. Make sure proper clothing is available, and wear it whenever appropriate.

4. Your vehicle must also be properly equipped and maintained.

5. You cannot help others if you do not protect yourself.

VII. Heat Exposure

A. In a hot environment or during vigorous physical activity, the body tries to rid itself of excess heat.

1. Sweating (and evaporation of the sweat)

2. Dilation of skin blood vessels

3. Removal of clothing and relocation to a cooler environment

B. Hyperthermia is a core temperature of 101°F (38.3°C) or higher.

1. When heat gain exceeds heat loss, hyperthermia results.

C. Risk factors of heat illness

1. High air temperature (reduces radiation)

2. High humidity (reduces evaporation)

3. Lack of acclimation to the heat

4. Vigorous exercise (loss of fluid and electrolytes)

D. A heat emergency can take the following three forms:

1. Heat cramps

2. Heat exhaustion

3. Heat stroke

4. All three forms may be present in the same patient.

E. Persons at greatest risk for heat illnesses are:

1. Children (especially newborns and infants)

2. Geriatric patients

3. Patients with heart disease, COPD, diabetes, dehydration, and obesity

4. Patients with limited mobility

5. Alcohol and certain drugs also make a person more susceptible to heat illnesses.

F. Heat cramps

1. Painful muscle spasms that occur after vigorous exercise

2. Do not occur only when it is hot outdoors

3. Exact cause is not well understood

4. Dehydration may play a role in the development of muscle cramps.

5. Usually occur in the leg or abdominal muscles

G. Heat exhaustion

1. Also called heat prostration or heat collapse

2. Most common heat emergency

3. Causes

a. Heat exposure

b. Stress

c. Fatigue

d. Hypovolemia as the result of the loss of water and electrolytes from heavy sweating

4. People who work or exercise vigorously and those who wear heavy clothing in a warm, humid, or poorly ventilated environment are particularly prone to heat exhaustion.

5. Signs and symptoms

a. Dizziness, weakness, or syncope

b. Muscle cramping

c. Onset while working hard or exercising in a hot, humid, or poorly ventilated environment and sweating heavily

d. Onset, even at rest, in the older and infant age groups in hot, humid, and poorly ventilated environments or extended time in hot, humid environments

e. Cold, clammy skin with ashen pallor

f. Dry tongue and thirst

g. Normal vital signs, although the pulse is often rapid and weak, and the diastolic blood pressure may be low

h. Normal or slightly elevated body temperature; on rare occasions, as high as 104°F (40°C)

H. Heat stroke

1. Least common but most serious illness caused by heat exposure

2. Occurs when the body is subjected to more heat than it can handle and normal mechanisms for getting rid of the excess heat are overwhelmed

3. Untreated heat stroke always results in death.

4. Typical onset situations

a. During vigorous physical activity

b. Outdoors or in a closed, poorly ventilated, humid space

c. During heat waves in buildings without sufficient air conditioning or with poor ventilation

d. Children left unattended in a locked car on a hot day

5. Signs and symptoms

a. Altered mental status including hallucinations,

b. Ataxia

c. Seizures

d. Quickly rising body temperature (106°F or higher)

e. Falling level of responsiveness (leading to unresponsiveness)

f. Change in behavior

g. Unresponsiveness

h. Strong, rapid pulse at first, becoming weaker with falling blood pressure

i. Increasing respiratory rate

j. Skin may be moist or wet due to exertion by the patient.

k. Lack of perspiration (body has lost its thermoregulatory mechanisms)

VIII. Assessment of Heat Injuries

A. Scene size-up

1. Scene safety

a. Perform an environmental assessment.

b. Remember that the heat emergency may be secondary to a medical or trauma emergency.

c. If the patient is unconscious, has an altered mental status, or requires intravenous fluids to treat shock, consider calling for ALS assistance.

d. Look for indicators of the MOI.

e. If the patient is immersed in a cold-water immersion bath upon your arrival, monitor the patient in the water and assist as necessary.

i. Do not remove the patient until the temperature has normalized to the appropriate level, between 101°F and 102°F (38.3°C and 38.9°C).

ii. Do not overcool the patient.

f. Protect yourself from heat and stay hydrated.

i. Use appropriate standard precautions, including gloves and eye protection.

B. Primary assessment

1. Form a general impression.

a. Observe how the patient interacts with you and the environment.

b. Introduce yourself and ask about the chief complaint.

c. A heat emergency may be the primary or secondary condition.

d. Perform a rapid scan and avoid tunnel vision.

e. Assess the patient’s mental status using the AVPU scale.

i. The more altered the patient’s mental status is, the more serious the heat problem.

2. Airway and breathing

a. Unless the patient is unresponsive, the airway should be patent.

b. Nausea and vomiting may occur.

c. Position the patient to protect the airway as necessary.

d. If the patient is unresponsive, be cautious of how you open the airway and consider spinal immobilization if trauma is a possibility.

e. If the patient is unresponsive, insert an airway and provide bag-valve mask ventilations.

3. Circulation

a. If adequate, assess for perfusion and bleeding.

b. Assess the patient’s skin condition.

Skin Condition
Skin Condition	Indicates
Pale, cool and clammy	Excessive fluid and salt loss
Hot, dry skin	Body is unable to regulate core temperature
Hot moist skin	Body is unable to regulate core temperature

c. Treat for shock by removing the patient from the heat and positioning the patient to improve circulation.

d. If the patient is bleeding, bandage according to protocol.

e. If the patient has any signs of heat stroke, provide rapid transport.

C. History taking

1. Investigate the chief complaint.

a. Be alert for specific signs and symptoms.

i. Absence of perspiration

ii. Decreased level of responsiveness

iii. Confusion

iv. Muscle cramping

v. Nausea

vi. Vomiting

2. SAMPLE history

a. Note any activities, conditions, or medications that may predispose a patient to dehydration or heat-related problems.

i. Inadequate oral intake

ii. Diuretics

iii. Many medications used by geriatric patients

b. Determine your patient’s exposure to heat and humidity and activities prior to the onset of symptoms.

D. Secondary assessment

1. Physical examination

a. If the patient is unresponsive, perform a secondary assessment on the entire body.

b. If the patient is conscious, perform an assessment of specific areas of the body.

c. Assess the patient for muscle cramps or confusion.

d. Examine the patient’s mental status and take vital signs.

e. Pay special attention to the patient’s skin temperature, turgor, and level of moisture.

f. Gently pinch the skin on the forehead or back of the hand.

i. Normally the skin will quickly flatten out.

ii. In dehydration, with poor skin turgor, the skin will remain tented.

g. Perform a careful neurologic examination.

2. Vital signs

a. Patients who are hyperthermic will be tachycardic and tachypneic.

b. Falling blood pressure indicates that the patient is going into shock.

c. In heat exhaustion, the skin temperature may be normal or cool and clammy.

d. In heat stroke, the skin is hot.

e. Monitoring devices

i. Check the patient’s temperature with a thermometer, depending on protocols.

ii. In patients with a heat-related emergency, pulse oximetry is also indicated.

E. Reassessment

1. Watch carefully for deterioration (especially decline in level of responsiveness).

2. Patients with symptoms of heat stroke should be transported immediately.

a. Transport in a cool ambulance.

b. Passively cool with clothing removal.

c. Actively cool by spraying the patient with water and fanning to enhance evaporation.

3. Monitor vital signs at least every 5 minutes.

4. Evaluate the effectiveness of your interventions.

5. Be careful not to overcool a patient.

6. Communication and documentation

a. Inform the staff at the receiving facility early on that your patient is experiencing a heat stroke because additional resources may be required.

b. Document environmental conditions and the activities the patient was performing prior to onset.

IX. Management of Heat Emergencies

A. Heat cramps

1. Take the following steps to treat heat cramps in the field:

a. Remove the patient from the hot environment and loosen any tight clothing.

b. Administer high-flow oxygen if indicated.

c. Rest the cramping muscles.

i. Have the patient sit or lie down until the cramps subside.

d. Replace fluids by mouth.

i. Use water or a diluted balanced electrolyte solution.

ii. Do not give salt tablets or solutions that have a high salt concentration.

e. Cool the patient with water spray or mist and add convection by manually or mechanically fanning the patient.

2. When the heat cramps are gone, the patient may resume activity.

3. The best preventive and treatment strategy is hydration by drinking water.

4. If the cramps do not go away after these measures, transport the patient to the hospital.

B. Heat exhaustion

1. To treat the patient with heat exhaustion (Skill Slide 32-1).

a. Move the patient to a cooler environment.

b. Remove extra clothing.

c. Give oxygen if indicated.

d. Check the patient’s blood glucose level if indicated.

e. Perform cold-water immersion or other cooling measures as available.

f. Place the patient in a supine position and fan the patient.

g. If the patient is fully alert, give water by mouth.

h. If nausea develops, secure and transport the patient on his or her left side.

C. Heat stroke

1. Recovery from heat stroke depends on the speed with which treatment is administered.

a. You must be able to identify the patient quickly.

2. Emergency treatment has one objective: Aggressively lower the body temperature by any means available.

3. Take the following steps when treating a patient with heat stroke:

a. Move the patient out of the hot environment and into the ambulance.

b. Set the air conditioning to maximum cooling.

c. Remove the patient’s clothing.

d. Administer high-flow oxygen if indicated.

i. If needed, assist ventilations with a bag-valve mask and appropriate airway adjuncts per local protocols.

e. Provide cold water immersion, if possible.

f. Cover the patient with wet towels or sheets, or spray the patient with cool water and fan him or her to quickly evaporate the moisture on the skin.

g. Aggressively and repeatedly fan the patient.

h. Exclude other causes of altered mental status and check blood glucose level, if possible.

i. Transport immediately to the hospital.

j. Notify the hospital of an arriving heat stroke patient.

k. Call for ALS assistance if the patient begins to shiver.

X. Drowning

A. Drowning is the process of experiencing respiratory impairment from submersion or immersion in liquid.

1. Some agencies may still use the term “near drowning” to refer to a patient who survives at least temporarily (24 hours) after suffocation in water.

B. Risk factors

1. Alcohol consumption

2. Preexisting seizure disorders

3. Geriatric patients with cardiovascular disease

4. Unsupervised access to water (for children)

C. Drowning is often the last in a cycle of events caused by panic in the water.

1. It can happen to anyone who is submerged in water for even a short period of time.

2. Struggling toward the surface or the shore, the person becomes fatigued or exhausted, which leads him or her to sink even deeper.

3. Drowning also occurs in buckets, puddles, bathtubs, etc.

a. Young children can drown in as little as one inch of water.

D. Laryngospasm

1. Inhaling very small amounts of either freshwater or salt water can severely irritate the larynx.

2. The muscles of the larynx and the vocal cords spasm.

3. Prevents more water from entering the lungs

4. In severe cases, progressive hypoxia occurs until the patient becomes unconscious.

a. The spasm relaxes.

b. The patient may now inhale deeply.

c. More water may enter the lungs.

E. Spinal injuries in submersion incidents

1. Submersion incidents may be complicated by spinal fractures and spinal cord injuries.

2. Assume that spinal injury exists with the following conditions:

a. The submersion has resulted from a diving mishap or significant fall.

b. The patient is unconscious, and no information is available to rule out the possibility of a neck injury.

c. The patient is conscious but complains of weakness, paralysis, or numbness in the arms or legs.

d. You suspect the possibility of spinal injury despite what witnesses say.

3. Most spinal injuries in diving incidents affect the cervical spine.

4. Stabilize the suspected injury while the patient is still in the water (Skill Slide 32-2).

a. Turn the patient to a supine position by rotating the entire upper half of the body as a single unit.

b. As soon as the patient is turned, begin artificial ventilation using the mouth-to-mouth method or a pocket mask.

c. Float a buoyant backboard under the patient.

d. Secure the patient to the backboard.

e. Remove the patient from the water.

f. Maintain the body’s normal temperature and apply oxygen if the patient is breathing.

g. Begin CPR if breathing and pulse are absent. $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\Ch32\9781284080179_CH32_CP05.jpg$

F. Safety

1. Ensure the safety of rescue personnel and request additional resources for a water rescue.

a. Water rescues are usually handled by specialized rescue personnel.

2. The basic rule of water rescue is, “reach, throw, and row, and only then go.”

a. Reach for the person from the shore or wade into the water.

b. If an object that floats is available, throw it to the person.

c. Use a boat if available.

d. If you must swim to the person, use a towel or board for her or him to hold onto.

3. Do not attempt a swimming rescue unless you are trained and experienced in the proper techniques.

4. If you work in an area near lakes, rivers, or the ocean, you should have a prearranged plan for water rescue.

G. Recovery techniques

1. If the patient is not floating or visible in the water, an organized rescue effort is necessary.

2. Specialized personnel are required (with snorkel, mask, and scuba gear).

a. Scuba (self-contained underwater breathing apparatus) gear is a system that delivers air to the mouth and lungs at atmospheric pressures that increase with the depth of the dive.

H. Resuscitation efforts

1. Never give up on resuscitating a cold-water drowning victim.

a. Hypothermia can protect vital organs from the lack of oxygen.

b. Exposure to cold water will occasionally activate certain primitive reflexes, which may preserve basic body functions for prolonged periods.

2. The diving reflex (slowing of the heart rate caused by submersion in cold water) may cause immediate bradycardia (slow heart rhythm).

a. The person may be able to survive for an extended period of time under water, thanks to a lowering of the metabolic rate associated with hypothermia.

b. Local protocols often dictate that resuscitative efforts continue for up to 1 hour after submersion, while simultaneously rewarming the patient.

XI. Diving Emergencies

A. Most serious water-related injuries are associated with dives, with or without scuba gear.

1. Some of these problems are related to the nature of the dive; others result from panic.

2. Panic can happen even to the experienced diver or swimmer.

B. Medical emergencies relating to scuba diving techniques and equipment are becoming increasingly common.

1. Separated into three phases: descent, bottom, and ascent

C. Descent emergencies

1. Caused by the sudden increase in pressure on the body as the person dives deeper into the water

2. Typical areas affected:

a. Lungs

b. Sinus cavities

c. Middle ear

d. Teeth

e. Area of the face surrounded by the diving mask

3. Usually, the pain caused by these “squeeze problems” forces the diver to return to the surface to equalize the pressures, and the problem clears up by itself.

4. Divers with continued pain (particularly in the ear) after returning to the surface should be transported to the hospital.

5. Perforated tympanic membrane (ruptured eardrum)

a. Cold water may enter the middle ear through a ruptured eardrum.

b. The diver may lose his or her balance and orientation.

c. The diver may then shoot to the surface and run into ascent problems.

D. Emergencies at the bottom

1. Rarely occur

2. Caused by faulty connections in the diving gear

a. Inadequate mixing of oxygen and carbon dioxide in the air the diver breathes

b. Accidental feeding of poisonous carbon monoxide into the breathing apparatus

3. Can cause drowning or rapid ascent

4. Require emergency resuscitation and transport

E. Ascent emergencies

1. Most serious injuries and usually require aggressive resuscitation

2. Air embolism

a. Most dangerous and most common scuba-diving emergency

b. Bubbles of air in the blood vessels $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\Ch32\9781284080179_CH32_FIG06.jpg$

c. The problem starts when the diver holds his or her breath during a rapid ascent.

i. The air pressure in the lungs remains at a high level while the external pressure on the chest decreases.

ii. The air inside the lungs expands rapidly, causing the alveoli in the lungs to rupture.

d. Complications

i. Air may enter the pleural space and compress the lungs (pneumothorax).

ii. Air may enter the mediastinum (the space within the thorax that contains the heart and great vessels), causing a condition called pneumomediastinum.

iii. Air may enter the bloodstream and create bubbles of air in the vessels, called air emboli.

e. Signs and symptoms of air embolism

i. Blotching (mottling of the skin)

ii. Froth (often pink or bloody) at the nose and mouth

iii. Severe pain in muscles, joints, or abdomen

iv. Dyspnea and/or chest pain

v. Dizziness, nausea, and vomiting

vi. Dysphasia (difficulty speaking)

vii. Cough

viii. Cyanosis

ix. Difficulty with vision

x. Paralysis and/or coma

xi. Irregular pulse and even cardiac arrest

3. Decompression sickness (“the bends”)

a. Bubbles of gas, especially nitrogen, obstruct the blood vessels.

b. Conditions that can cause decompression sickness:

i. Too rapid an ascent from a dive

ii. Too long a dive at too deep a depth

iii. Repeated dives within a short period of time

iv. Driving a car up a mountain or flying in an unpressurized airplane that climbs too rapidly soon after a dive

c. Nitrogen that is being breathed dissolves in the blood and tissues.

i. The diver ascends and the external pressure is decreased.

ii. Dissolved nitrogen forms small bubbles within those tissues.

d. Complications

i. Blockage of tiny blood vessels

ii. Depriving parts of the body of their normal blood supply

iii. Severe pain in certain tissues or spaces

e. Signs and symptoms

i. Abdominal/joint pain so severe that the patient doubles up (“bends”)

4. You may find it difficult to distinguish between air embolism and decompression sickness.

a. Air embolism generally occurs immediately upon return to the surface.

b. Symptoms of decompression sickness may not occur for several hours.

c. Emergency treatment is the same for both.

i. Basic life support (BLS)

ii. Recompression in a hyperbaric chamber

XII. Assessment of Drowning and Diving Emergencies

A. Scene size-up

1. Scene safety

a. Your standard precautions should include gloves and eye protection at a minimum.

b. Never drive through moving water; be cautious when driving through still water.

c. Never attempt a water rescue without the proper training and equipment.

d. Call for additional resources early.

e. Trauma and spinal immobilization must be considered in recreational settings.

f. Check for additional patients depending upon the situation.

2. Mechanism of injury/nature of illness

a. Look for indicators of the MOI.

b. Consider how the MOI produced the injuries expected.

B. Primary assessment

1. Form a general impression

a. Pay attention to chest pain, dyspnea, and complaints of sensory changes when a diving emergency is suspected.

b. Determine the patient’s level of responsiveness using the AVPU scale.

c. Be suspicious of drug or alcohol use.

2. Airway and breathing

a. Open the airway and assess breathing in unresponsive patients.

b. Consider the possibility of spinal trauma, and take appropriate actions.

c. The airway may be obstructed with water.

d. Suction if the patient has vomited.

e. Provide ventilations with a bag-valve mask for inadequate breathing.

i. Use an airway adjunct as necessary.

f. If the patient is responsive, provide high-flow oxygen with a nonrebreathing mask.

g. Auscultation and frequent reassessment of breath sounds in drowning patients is a key part of your assessment.

3. Circulation

a. It may be difficult to find a pulse.

b. If the pulse is not detectable, the patient may be in cardiac arrest.

c. Begin CPR and apply your AED.

d. Evaluate for shock and adequate perfusion.

e. If the MOI suggests trauma, assess for bleeding and treat appropriately.

4. Transport decision

a. If possible, transport patients to the hospital with a hyperbaric chamber, or recompression chamber.

b. Inhalation of any amount of fluid can lead to delayed complications lasting for days or weeks.

c. Decompression sickness and air embolism must be treated in a recompression chamber.

d. Perform all interventions en route.

C. History taking

1. Investigate the chief complaint.

a. Obtain a medical history.

b. Be alert for injury-specific signs and symptoms as well as any pertinent negatives.

2. SAMPLE history

a. Determine the depth of the dive, the length of time the patient was underwater, the time of onset of symptoms, and previous diving activity.

b. Note any physical activity, alcohol or drug use, or other medical conditions.

D. Secondary assessment

1. Physical examinations

a. If the patient is responsive, thoroughly examine his or her lungs, including breath sounds.

b. If unresponsive, look for hidden life threats and potential trauma, even if trauma is not suspected.

c. For scuba divers, look for indications of decompression sickness or air embolism.

d. Check for signs of hypothermia.

e. Complete a detailed assessment en route to the hospital.

f. Assess for:

i. Peripheral pulses

ii. Skin color and discoloration

iii. Itching

iv. Pain

v. Paresthesia (numbness and tingling)

2. Vital signs

a. Check the patient’s pulse rate, quality, and rhythm.

i. May be difficult to palpate in the hypothermic patient

ii. Check for both peripheral and central pulses.

iii. Listen over the chest for a heartbeat if pulses are weak.

b. Check the respiratory rate, quality, and rhythm, and listen for lung sounds.

c. Assess and document pupil size and reactivity.

d. Monitoring devices

i. Oxygen saturation readings may produce a false low reading because of hypoperfusion or shivering.

E. Reassessment

1. Repeat the primary assessment

a. Drowning patients may deteriorate rapidly due to:

i. Pulmonary injury

ii. Fluid shifts in the body

iii. Cerebral hypoxia

iv. Hypothermia

b. Patients with pneumothorax, air embolism or decompression sickness may decompensate quickly.

c. Assess your patient’s mental status constantly.

d. Assess vital signs at least every 5 minutes, paying particular attention to respirations and breath sounds.

2. Communication and documentation

a. Document the circumstances of the drowning and extrication:

i. How the patient was submerged

ii. Temperature of the water

iii. Clarity of the water

iv. Possible spinal injury

b. Bring a dive log or dive computer if available to record the dive history.

c. Bring all dive equipment to the hospital and document the disposition of these materials.

XIII. Emergency Care for Drowning or Diving Emergencies

A. Treatment for drowning begins with rescue and removal from the water.

1. Immobilize and protect the patient’s spine when a fall from a significant height or suspected diving injury is possible.

2. Artificial ventilation should begin as soon as possible, even before the victim is removed from the water.

B. If the patient is not breathing:

1. Remove any vomit from the airway manually or by suction.

2. Assist ventilations with a bag-valve mask or pocket mask.

3. Rolling patients onto their side or performing abdominal thrusts will not remove water from the lungs and should not be done unless the airway is obstructed.

4. Address airway and breathing concerns first, then begin compressions and use the AED.

5. Administer oxygen if the patient is breathing spontaneously.

6. Use pulse oximetry to titrate oxygen delivery, according to local protocols.

7. Treat for hypothermia.

C. When treating conscious patients who are suspected of having an air embolism or decompression sickness from scuba diving, follow these treatment steps:

1. Remove the patient from the water and try to keep him or her calm.

2. Administer oxygen.

3. Consider the possibility of pneumothorax and monitor breath sounds.

4. Provide prompt transport to the ED or to the nearest recompression facility for treatment based on local protocols.

D. Other water hazards

1. Pay close attention to the body temperature of a person who is rescued from cold water.

2. Treat hypothermia caused by immersion in cold water the same way you treat hypothermia caused by cold exposure.

3. Breath-holding syncope

a. A person swimming in shallow water may experience a loss of responsiveness caused by a decreased stimulus for breathing.

b. Happens to swimmers who breathe in and out rapidly and deeply before entering the water in an effort to expand their capacity to stay underwater

c. Hyperventilation lowers the carbon dioxide level.

d. The swimmer may not feel the need to breathe even after using up all the oxygen in his or her lungs.

d. Treatment is the same as that for a drowning patient.

E. Prevention

1. Appropriate precautions can prevent most immersion incidents.

a. All pools should be surrounded by a fence.

b. The most common problem in child drowning is lack of adult supervision.

c. Half of all teenage and adult drowning is associated with the use of alcohol.

XIV. High Altitude

A. Dysbarism injuries

1. Caused by the difference between the surrounding atmospheric pressure and the total gas pressure in various tissues, fluids, and cavities of the body

B. Altitude illnesses

1. Occur when an unacclimatized person is exposed to diminished oxygen pressure in the air at high altitudes.

2. Illnesses affect the central nervous system and pulmonary system

C. Acute mountain sickness (above 5,000 feet)

1. Diminished oxygen in the blood (hypoxia)

2. Caused by ascending too high, too fast or not being acclimatized to high altitudes

3. Signs and symptoms

a. Headache

b. Lightheadedness

c. Fatigue

d. Loss of appetite

e. Nausea

f. Difficulty sleeping

g. Shortness of breath during physical exertion

h. Swollen face

4. Treatment primarily consists of stopping the ascent and descending to a lower altitude.

D. High-altitude pulmonary edema (HAPE) (above 8,000 feet)

1. Fluid collects in the lungs, hindering the passage of oxygen into the bloodstream.

2. Signs and symptoms

a. Shortness of breath

b. Cough with pink sputum

c. Cyanosis

d. Rapid pulse

E. High-altitude cerebral edema (HACE) (above 12,000 feet)

1. May accompany HAPE and can quickly become life threatening

2. Symptoms of HACE and HAPE may overlap.

a. Severe, constant, throbbing headache

b. Ataxia (lack of muscle coordination and balance)

c. Extreme fatigue

d. Vomiting

e. Loss of responsiveness

F. Treatment of HAPE and/or HACE

1. Provide high flow oxygen.

2. Descend from the elevation.

3. Transport promptly.

4. Provide positive-pressure ventilation with a bag-valve mask for inadequate respirations.

a. CPAP may be helpful if allowed by local protocols.

XV. Lightning

A. There are an estimated 25 million cloud-to-ground lightning strikes each year in the United States.

B. Lightning is the third-most-common cause of death from isolated environmental phenomena.

C. Targets of direct lightning strikes:

1. People engaged in outdoor activities (boaters, swimmers, golfers)

2. Anyone in a large, open area

D. Many individuals are indirectly struck when standing near an object that has been struck by lightning, such as a tree (splash effect).

E. The cardiovascular and nervous systems are most commonly injured.

1. Respiratory or cardiac arrest is the most common cause of lightning-related deaths.

2. The tissue damage pathway usually occurs over the skin, rather than through it.

3. Look for not only the entrance wound but also the exit wound.

4. Because the duration of a lightning strike is short, skin burns are usually superficial.

F. Categories of lightning injuries

1. Mild

a. Loss of responsiveness

b. Amnesia

c. Confusion

d. Tingling

e. Other nonspecific signs and symptoms

f. Burns, if present, are typically superficial.

2. Moderate

a. Seizures

b. Respiratory arrest

c. Dysrhythmias that spontaneously resolve

d. Superficial burns

3. Severe

a. Cardiopulmonary arrest

b. Many of these patients do not survive.

G. Emergency medical care

1. Take measures to protect yourself from being struck by lightning.

2. Move the patient to a sheltered area.

a. If shelter is not available, recognize the signs of an impending lightning strike and take immediate action to protect yourself.

b. If you suddenly feel a tingling sensation or your hair stands on end, the area around you has become charged (sign of an imminent lightning strike).

c. Make yourself as small a target as possible by squatting down into a ball, close to but not touching the ground.

d. Move away from trees or other tall objects.

3. Use reverse triage.

a. Anyone who is in cardiac or respiratory arrest is the first priority.

b. Other people who may have been struck will not develop cardiac complications.

4. Treatment

a. Stabilize the spine and open the airway with the jaw-thrust maneuver.

b. If a pulse is present, assist ventilations.

c. If the patient is in cardiac arrest, use an AED as soon as possible.

d. If severe bleeding is present, control it immediately.

e. Transport to the nearest facility.

f. A patient with signs and symptoms of a lightning strike, but no obvious life threats, should still be transported for evaluation.

XVII. Bites and Envenomations

A. Spider bites

1. Spiders are numerous and widespread in the United States.

a. Many species of spiders bite.

b. Only two spiders—the female black widow spider and the brown recluse spider—deliver serious, even life-threatening bites. $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\Ch32\9781284080179_CH32_FIG07.jpg$

c. Be alert to the possibility that the spider may still be in the area. Your safety is of paramount importance.

2. Black widow spider

a. The female black widow spider is fairly large, measuring approximately two inches with its legs extended.

b. Usually black with a distinctive, bright red-orange marking in the shape of an hourglass on its abdomen

c. The female is larger and more toxic than the male.

d. Found in every state except Alaska

e. Prefers dry, dim places around buildings, in woodpiles, and among debris

f. The bite is sometimes overlooked.

i. If the site becomes numb right away, the patient may not even recall being bit; however, most black widow spider bites cause localized pain and symptoms, including agonizing muscle spasms.

ii. A bite on the abdomen may cause muscle spasms so severe that they resemble an acute abdominal condition.

iii. The main danger is the venom, which can damage nerve tissues.

g. Other systemic symptoms include:

i. Dizziness

ii. Sweating

iii. Nausea

iv. Vomiting

v. Rashes

vi. Tightness in the chest

vii. Difficulty breathing

viii. Severe cramps

h. Generally, these signs and symptoms subside over 48 hours.

i. A physician can administer a specific antivenin, but because of a high incidence of side effects, its use is reserved for:

i. Very severe bites

ii. The aged or very feeble

iii. Children younger than 5 years

j. Emergency treatment consists of BLS for the patient in respiratory distress.

k. Transport to the emergency department as soon as possible.

l. If possible, safely bring the spider to the hospital or take a photo of the spider with a cell phone and send it to the hospital ahead of time. $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\Ch32\9781284080179_CH32_CP08.jpg$

3. Brown recluse spider

a. Dull brown in color and one inch long

b. The short-haired body has a violin-shaped mark, brown to yellow in color, on its back.

c. Lives mostly in the southern and central parts of the country, but may be found throughout the continental United States

d. Tends to live in dark areas, such as in the corners of old, unused buildings; under rocks; and in woodpiles

e. In cooler areas, it moves indoors to closets, drawers, cellars, and clothing.

f. The venom is not neurotoxic but cytotoxic; it causes severe local tissue damage.

g. Typically, the bite is not painful at first but becomes so within hours.

h. The area becomes swollen and tender, developing a pale, mottled, cyanotic center and possibly a small blister.

i. A scab of dead skin, fat, and debris will form and dig down into the skin, producing a large ulcer that may not heal unless treated promptly.

j. Transport patients with such symptoms as soon as possible.

k. These bites rarely cause systemic symptoms and signs

l. When they do, the initial treatment is BLS and transportation to the emergency department.

m. If possible, safely bring the spider to the hospital or take a photo of the spider with a cell phone and send it to the hospital ahead of time.

B. Hymenoptera stings

1. Bees, wasps, yellow jackets, and ants

2. Stings are painful but are not a medical emergency.

a. Remove the stinger and venom sac using a firm-edged item such as a credit card to scrape the stinger and sac off the skin.

b. Remove jewelry from the affected limb

c. Use ice packs to assist in controlling pain from a hymenoptera sting.

3. Anaphylaxis may occur if the patient is allergic to the venom.

a. Signs and symptoms

i. Flushed skin

ii. Low blood pressure

iii. Difficulty breathing (usually associated with reactive airway sounds)

iv. Swelling to the throat and tongue (dire emergency, can be fatal)

v. Hives (urticaria) near the site of envenomation or centrally on the body

b. Be prepared to assist the patient in administering an EpiPen auto-injector and support the airway and breathing.

C. Snakebites

1. Snakebites are a worldwide problem.

a. Snakebite fatalities in the United States are extremely rare—about 15 a year for the entire country.

b. Of the approximately 115 different species of snakes native to the United States, only 19 are venomous.

i. These include the rattlesnake, the copperhead, the cottonmouth or water moccasin, and coral snakes.

ii. At least one of these poisonous species is found in every state except Alaska, Hawaii, and Maine.

c. Snakes usually do not bite unless provoked, angered, or accidentally injured, as when they are stepped on (except for cottonmouths, which are often aggressive).

d. Most snakebites occur between April and October and tend to involve young men who have been drinking alcohol.

e. Protect yourself from getting bitten; use extreme caution on these calls and wear the proper protective equipment for the area.

f. Only one third of snakebites result in significant local or systemic injuries.

g. Often, envenomation does not occur because the snake recently struck another animal and exhausted its supply of venom.

2. Venomous snakes native to the United States have hollow fangs in the roof of the mouth that inject the poison from two sacs at the back of the head.

a. The classic presentation of a poisonous snakebite is two small puncture wounds, usually about 0.5 inch apart, with discoloration, swelling, and pain.

b. Nonpoisonous snakes can also bite, usually leaving a horseshoe of tooth marks.

c. Fang marks are a clear indication of a poisonous snakebite.

3. Pit vipers $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\Ch32\9781284080179_CH32_CP11.jpg$

a. Rattlesnakes, copperheads, and cottonmouths are all pit vipers, with triangular-shaped, flat heads.

b. They have small pits that contain poison located just behind each nostril and in front of each eye.

c. The pit is a heat-sensing organ that allows the snake to strike accurately at any warm target.

d. The fangs are special hollow teeth that act much like hypodermic needles connected to a sac containing a reservoir of venom. $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\Ch32\9781284080179_CH32_CP09A.jpg$

e. Rattlesnake

i. Most common form of pit viper

ii. Have many patterns of color, often with a diamond pattern

iii. Can grow to six feet or more in length

f. Copperheads

i. Smaller than rattlesnakes, usually two to three feet long

ii. Red-copper color crossed with brown or red bands

iii. Typically inhabit woodpiles and abandoned dwellings

iv. Account for most of the venomous snakebites in the eastern United States $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\Ch32\9781284080179_CH32_CP09B.jpg$

v. Their bites are almost never fatal, but the venom can cause significant damage to tissues in the extremities.

g. Cottonmouths

i. Grow to about four feet in length

ii. Also called water moccasins

iii. Olive or brown, with black cross-bands and a yellow undersurface $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\Ch32\9781284080179_CH32_CP09C.jpg$

iv. They are water snakes with an aggressive pattern of behavior.

v. Although fatalities from these snakebites are rare, tissue destruction from the venom may be severe.

h. The signs of envenomation by a pit viper are severe burning pain at the site of injury, followed by swelling with a bluish discoloration (ecchymosis).

i. Signs are evident within 5 to 10 minutes and spread over the next 36 hours.

j. In addition to destroying tissues locally, the venom of the pit viper can also interfere with the body’s clotting mechanism and cause bleeding at various distant sites.

k. Other signs that may or may not occur include:

i. Weakness

ii. Nausea

iii. Vomiting

iv. Sweating

v. Seizures

vi. Fainting

vii. Vision problems

viii. Changes in level of responsiveness

ix. Shock

l. If the patient has no local signs an hour after being bitten, it is safe to assume that envenomation did not take place.

m. When treating a bite from a pit viper, take the following steps:

i. Calm the patient.

ii. Place the patient in a supine position and explain that staying quiet will slow the spread of any venom through the system.

iii. Locate the bite area and clean it gently with soap and water.

iv. Do not apply ice.

v. If the bite occurred on an arm or leg, consider the use of a pressure immobilization bandage of the extremity, then place the affected extremity below the level of the heart.

vi. Be alert for an anaphylactic reaction to the venom and treat with an epinephrine auto-injector, as appropriate.

vii. Do not give anything by mouth, and be alert for vomiting.

viii. If the patient was bitten on the trunk, keep him or her supine and quiet and transport as quickly as possible.

ix. Monitor vital signs and mark the skin with a pen over the area that is swollen to note whether swelling is spreading.

x. If there are any signs of shock, treat it.

xi. If the snake has been killed, bring it with you. Alternatively, take a picture of the snake with a cell phone and send it to the hospital ahead of time.

xii. Notify the hospital that the patient has been bitten by a snake; if possible, describe the snake.

xiii. Transport promptly.

n. If the patient shows no signs of envenomation, provide BLS as needed, place a sterile dressing over the suspected bite area, and immobilize the injury site.

o. All patients with a suspected snakebite should be taken to the emergency department.

p. Treat the wound as you would any deep puncture wound to prevent infection.

q. Familiarize yourself with the venomous snakes in your region, as well as any local protocols for handling snakebites.

4. Coral snakes

a. Small reptile with a series of bright red, yellow, and black bands completely encircling the body $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\Ch32\9781284080179_CH32_CP09D.jpg$

b. The saying “Red on yellow will kill a fellow; red on black, venom will lack” is not accurate.

c. A relative of the cobra snake, it lives in most southern states and in the Southwest.

d. It injects the venom with its teeth and tiny fangs by a chewing motion, leaving puncture or scratch-like wounds.

e. Because of its small mouth and teeth and limited jaw expansion, the coral snake usually bites its victims on a small part of the body, such as a finger or toe.

f. Coral snake venom is a powerful toxin that causes paralysis of the nervous system.

g. Within a few hours of being bitten, a patient will exhibit bizarre behavior, followed by progressive paralysis of eye movements and respiration.

h. Successful treatment depends on positive identification of the snake and support of respiration.

i. Antivenin is available, but most hospitals do not stock it.

j. Emergency care of a coral snake bite are the same as a pit viper bite.

D. Scorpion stings

1. Scorpions are eight-legged arachnids with a venom gland and a stinger at the end of their tail.

2. They are rare and live primarily in the southwestern United States and in deserts.

3. With one exception, a scorpion’s sting is usually very painful but not dangerous, causing localized swelling and discoloration.

a. The exception is the Centruroides sculpturatus. $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\Ch32\9781284080179_CH32_CP12.jpg$

b. The venom of this species may produce a severe systemic reaction that brings about:

i. Circulatory collapse

ii. Severe muscle contractions

iii. Excessive salivation

iv. Hypertension

v. Convulsions

vi. Cardiac failure

c. If you are called to care for a patient with a suspected sting from C. sculpturatus, notify medical control as soon as possible.

d. Administer BLS and transport the patient as rapidly as possible.

E. Tick bites

1. Ticks are tiny insects that usually attach themselves directly to the skin.

2. They are found most often on brush, shrubs, trees, sand dunes, or other animals.

3. Only a fraction of an inch in length, they can easily be mistaken for freckles.

4. The bite is not painful.

5. The danger with a tick bite is from the infectious diseases spread through the tick’s saliva.

6. Rocky Mountain spotted fever $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\Ch32\9781284080179_CH32_CP13.jpg$

a. Occurs within 7 to 10 days after the bite

b. Symptoms

i. Nausea

ii. Vomiting

iii. Headache

iv. Weakness

v. Paralysis

vi. Cardiorespiratory collapse

7. Lyme disease

a. Reported in all states with the exception of Hawaii

i. Occurs most commonly in the Northeast and the Great Lakes states.

b. The first symptoms are generally fever and flu-like symptoms, sometimes associated with a bull’s-eye rash that may spread to several parts of the body.

c. After a few more days or weeks, painful swelling of the joints, particularly the knees, occurs.

d. Lyme disease may be confused with rheumatoid arthritis and may result in permanent disability.

e. If it is recognized and treated promptly with antibiotics, the patient may recover completely.

8. Tick bites occur most commonly during the summer months.

a. In a conventional EMS setting with tick bite or signs and symptoms of Lyme disease, provide any necessary supportive emergency care and transport the patient for further evaluation.

b. In situations where access to care is delayed, remove the tick by using fine tweezers to grasp the tick by the head and pull it straight out of the skin.

c. Once the tick is removed, cleanse the area with antiseptic and save the tick in a glass jar for identification.

e. Do not handle the tick with your fingers.

f. The patient should follow up with their health care provider as soon as possible.

XVIII. Injuries From Marine Animals

A. Coelenterates are responsible for more envenomations than any other marine animals. $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\Ch32\9781284080179_CH32_CP14A.jpg$

B. Examples of coelenterates

1. Fire coral

2. Portuguese man-of-war

3. Sea wasp

4. Sea nettles

5. True jellyfish

6. Sea anemones

7. True coral

8. Soft coral

C. The stinging cells are called nematocysts.

D. Signs and symptoms

1. Very painful, reddish lesions in light-skinned individuals

2. Lesions extended in a line from the site of the sting

3. Headache

4. Dizziness $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\Ch32\9781284080179_CH32_CP14B.jpg$

5. Muscle cramps

6. Fainting

E. To treat a sting from the tentacles of a jellyfish, a Portuguese man-of-war, various anemones, corals, or hydras:

1. Remove the patient from the water.

2. Remove the tentacles by scraping them off with the edge of a sharp, stiff object such as a credit card.

3. Do not try to manipulate the remaining tentacles; this will only cause further discharge from the nematocysts.

4. On rare occasions, a patient may have a systemic allergic reaction.

a. Treat such a patient for anaphylactic shock.

b. Give BLS and provide immediate transport to the hospital.

F. Toxins from the spines of urchins, stingrays, and certain spiny fish such as the lionfish, scorpionfish, or stonefish are heat sensitive.

1. The best treatment is to immobilize the affected area and soak it in hot water for 30 minutes.

2. The patient still needs to be transported.

G. If you work near the ocean, you should be familiar with the marine life in your area. $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\Ch32\9781284080179_CH32_CP14C.jpg$

H. The emergency treatment of common coelenterate envenomations consists of the following steps:

1. Limit further discharge of nematocysts by avoiding fresh water, wet sand, showers, or careless manipulation of the tentacles.

2. Keep the patient calm and reduce motion of the affected extremity.

3. Remove the remaining tentacles by scraping them off with the edge of a sharp, stiff object.

4. Immersion in vinegar may also help alleviate the symptoms.

5. Provide transport to the emergency department.

Chapter 33, Obstetrics and Neonatal Care

Unit Summary

After completing this chapter and related coursework, you will understand the anatomy and physiology of the female reproductive system as it relates to pregnancy. You will learn the assessment and emergency treatment for childbirth, including stages of labor, normal delivery, complications of pregnancy, and neonatal evaluations and resuscitation.

National EMS Education Standard Competencies

Special Patient Populations

Applies a fundamental knowledge of growth, development, and aging and assessment findings to provide basic emergency care and transportation for a patient with special needs.

Obstetrics

• Recognition and management of

• Normal delivery

• Vaginal bleeding in the pregnant patient

• Anatomy and physiology of normal pregnancy

• Pathophysiology of complications of pregnancy

• Assessment of the pregnant patient

• Management of

• Normal delivery

• Abnormal delivery

- Nuchal cord

- Prolapsed cord

- Breech delivery

• Third trimester bleeding

- Placenta previa

- Abruptio placenta

• Spontaneous abortion/miscarriage

• Ectopic pregnancy

• Preeclampsia/eclampsia

Neonatal care

Assessment and management of

• Newborn care

• Neonatal resuscitation

Trauma

Applies fundamental knowledge to provide basic emergency care and transportation based on assessment findings for an acutely injured patient.

Special Considerations in Trauma

• Recognition and management of trauma in the:

• Pregnant patient

• Pediatric patient (Chapter 34, “Pediatric Emergencies”)

• Geriatric patient (Chapter 35, “Geriatric Emergencies”)

• Pathophysiology, assessment, and management of trauma in the

• Pregnant patient

• Pediatric patient (Chapter 34, “Pediatric Emergencies”)

• Geriatric patient (Chapter 35, “Geriatric Emergencies”)

• Cognitively impaired patient (Chapter 36, “Patients With Special Challenges”)

Knowledge Objectives

1. Identify the anatomy and physiology of the female reproductive system.

2. Explain the normal changes that occur in the body during pregnancy.

3. Recognize complications of pregnancy including abuse, substance abuse, hypertensive disorders, bleeding, spontaneous abortion (miscarriage), and gestational diabetes.

4. Discuss the need to consider two patients—the woman and the unborn fetus—when treating a pregnant trauma patient.

5. Discuss special considerations involving pregnancy in different cultures and with teenage patients.

6. Explain assessment of the pregnant patient.

7. Explain the significance of meconium in the amniotic fluid.

8. Differentiate among the three stages of labor.

9. Describe the indications of an imminent delivery.

10. Explain the steps involved in normal delivery management.

11. List the contents of an obstetrics kit.

12. Explain the necessary care of the fetus as the head appears.

13. Describe the procedure followed to clamp and cut the umbilical cord.

14. Describe delivery of the placenta.

15. Understand the steps to take in neonatal assessment and resuscitation.

16. Recognize complicated delivery emergencies including breech presentations, limb presentations, umbilical cord prolapse, spina bifida, multiple gestation, premature newborns, postterm pregnancy, fetal demise, and delivery without sterile supplies.

17. Describe postpartum complications and how to treat them.

Skill Objectives

1. Demonstrate the procedure to assist with a normal cephalic delivery. (Skill Slide 33-1, Delivering the Newborn)

2. Demonstrate care procedures of the fetus as the head appears.

3. Demonstrate the steps to follow in post-delivery care of the newborn.

4. Demonstrate how to clamp and cut the umbilical cord.

5. Demonstrate how to assist with the delivery of the placenta.

6. Demonstrate the post-delivery care of the woman.

7. Demonstrate procedures to follow for complicated delivery emergencies including vaginal bleeding, breech presentation, limb presentation, and prolapsed umbilical cord.

I. Introduction

A. Most deliveries occur in a hospital, with doctors and nurses in attendance.

B. Occasionally, the birth process moves faster than the pregnant woman expects or she is unable to get to a hospital.

C. You must then decide whether to:

1. Assist the delivery on scene.

2. Transport the patient to the hospital

II. Anatomy and Physiology of the Female Reproductive System

A. The female reproductive system includes:

1. Ovaries

2. Fallopian tubes

3. Uterus

4. Cervix

5. Vagina

6. Breasts

B. The ovaries are two glands, one on each side of the uterus, that are similar in function to the male testes.

1. Each ovary contains thousands of follicles, and each follicle contains an egg.

2. During each menstrual cycle, there will only be one follicle that is successful at maturing and releasing an egg.

3. Ovulation occurs approximately two weeks prior to menstruation.

4. If fertilized, the egg implants in the endometrium, the lining of the inside of the uterus.

5. If the egg is not fertilized within 36 to 48 hours after it has been released, it will die, and the lining is shed as menstrual flow.

a. Occurs around the 28th day of a woman’s cycle

C. The fallopian tubes extend out laterally from the uterus, with one tube associated with each ovary.

1. Fertilization occurs when a sperm meets the egg, usually when the egg is inside the fallopian tube.

2. The fertilized egg then continues to the uterus where, if implantation occurs, it develops into an embryo and then a fetus and grows until the time of delivery.

D. The uterus is a muscular organ that encloses and protects the developing fetus for approximately nine months (40 weeks).

1. The uterus produces contractions during labor and ultimately helps to push the fetus through the birth canal.

2. The birth canal is made up of the vagina and the lower third of the uterus, called the cervix.

a. During pregnancy, the cervix contains a mucous plug that seals the uterine opening, preventing contamination.

b. When the cervix begins to dilate, this plug is discharged into the vagina as pink-tinged mucus, or bloody show.

c. This small amount of bloody discharge often signals the beginning of labor.

E. The vagina is the outermost cavity of the female reproductive system and forms the lower part of the birth canal.

1. It begins at the cervix and ends as an external opening of the body.

2. The vagina completes the passageway from the uterus to the outside world for the newborn.

3. The perineum is the area between the vagina and the anus.

F. In a pregnant woman, the breasts produce milk that is carried through small ducts to the nipple to provide nourishment to the newborn once it is born.

1. Early signs of pregnancy in the breasts include increased size and tenderness.

G. The placenta is a disk-shaped structure attached to the uterine wall that provides nourishment to the fetus.

1. It is connected to the fetus by the umbilical cord.

2. The placental barrier consists of two layers of cells, keeping the circulation of the woman and fetus separated but allowing substances to pass between them.

3. Anything ingested by a pregnant woman has the potential to affect the fetus, including:

a. Nutrients

b. Oxygen

c. Waste

d. Carbon dioxide

e. Many toxins

f. Most medications

4. After delivery, the placenta separates from the uterus and is delivered.

5. The umbilical cord is the lifeline of the fetus, connecting the woman and fetus through the placenta.

a. The umbilical vein carries oxygenated blood from the placenta to the heart of the fetus.

b. The umbilical arteries carry deoxygenated blood from the heart of the fetus to the placenta.

H. The fetus develops inside a fluid-filled, baglike membrane called the amniotic sac.

1. The sac contains about 500 to 1,000 mL of amniotic fluid, which helps insulate and protect the floating fetus.

2. The amniotic fluid is clear and colorless.

3. The amniotic fluid is released in a gush when the sac ruptures, usually at the beginning of labor.

III. Normal Changes in Pregnancy

A. During pregnancy, many normal changes occur in the body that are not all directly related to the reproductive system.

1. The primary systems involved with these changes are the respiratory, cardiovascular, and musculoskeletal systems.

B. In the reproductive system, hormone levels increase to support fetal development and prepare the body for childbirth.

1. This puts pregnant women at an increased risk for complications from trauma, bleeding, and some medical conditions.

2. As the fetus develops and grows, the uterus also grows, stretching to accommodate a full-term fetus.

3. As the size of the uterus increases, so does the amount of fluid it contains.

a. Uterus is displaced out of its normally well-protected position within the pelvic area.

b. This increases the chance of direct fetal injury in trauma.

C. Rapid uterine growth occurs during the second trimester of pregnancy.

1. As the uterus grows, it pushes up on the diaphragm, displacing it from its normal position.

2. Respiratory capacity changes, with increased respiratory rates and decreased minute volumes.

3. Overall blood volume gradually increases throughout the pregnancy to:

a. Allow for adequate perfusion of the uterus

b. Prepare for the blood loss that will occur during childbirth

4. Blood volume may eventually increase as much as 50% by the end of the pregnancy.

5. The number of red blood cells also increases.

6. The speed of clotting increases to protect against excessive bleeding during delivery.

7. By the end of pregnancy, the pregnant patient’s heart rate increases up to 20% to accommodate the increase in blood volume.

8. Cardiac output is significantly increased.

D. In the third trimester, there is an increased risk of vomiting and potential aspiration following trauma because of changes that occur in the gastrointestinal tract.

1. Changes in gastrointestinal motility and the displacement of the stomach upward significantly increase the chance that a pregnant trauma patient will vomit and aspirate if you are unable to clear her airway.

E. Changes in the cardiovascular system and the increased demands of supporting the fetus significantly increase the workload of the heart.

1. Remember, not all women are healthy when they begin pregnancy.

2. Cardiac compromise is a life-threatening possibility.

3. The weight of the fetus can put pressure on the vena cava causing the patient to feel dizzy and even faint while lying down. To prevent this, ask the patient to roll onto the left side.

F. Weight gain during pregnancy is normal.

1. The increase in body weight will eventually challenge the heart and impact the musculoskeletal system.

2. Increased hormones affect the musculoskeletal system by making the joints “looser” or less stable.

3. In the third trimester, changes in the body’s center of gravity increases the risk of slips and falls.

IV. Complications of Pregnancy

A. Most pregnant women are healthy, but some may be ill when they conceive or become ill during pregnancy.

1. You may safely use oxygen to treat any heart or lung disease in a pregnant patient without harm to the fetus.

B. Diabetes

1. Diabetes develops during pregnancy in many women who have not had diabetes previously.

2. This condition, called gestational diabetes, resolves in most women after delivery.

3. The treatment is the same as for any other patient with diabetes.

a. A pregnant woman may control her blood glucose level with diet and exercise or may take medication.

b. In some cases, the woman will have to manage her condition with insulin injections.

c. A pregnant woman experiencing hyperglycemia or hypoglycemia should be cared for in the same manner as any patient with diabetes.

C. Hypertensive disorders

1. One complication that occasionally occurs, typically in patients who are pregnant for the first time, is preeclampsia, or pregnancy-induced hypertension.

a. This condition can develop after the 20th week of gestation.

b. Characterized by the following signs and symptoms:

i. Severe hypertension

ii. Severe or persistent headache

iii. Visual abnormalities such as seeing spots, blurred vision, or sensitivity to light

iv. Swelling in the hands and feet (edema)

v. Anxiety

2. A related condition, eclampsia, is characterized by seizures that occur as a result of hypertension.

a. To treat a patent having seizures caused by eclampsia:

i. Lay the patient on her left side.

ii. Maintain her airway.

iii. Administer supplemental oxygen if necessary.

iv. If vomiting occurs, suction the airway.

v. Provide rapid transport.

vi. Call for an ALS intercept, if available.

3. Transporting the patient on her left side can also prevent supine hypotensive syndrome.

a. This condition is caused by compression of the descending aorta and the inferior vena cava by the pregnant uterus when the patient lies supine.

b. Hypotension may result.

D. Bleeding

1. Internal bleeding may be a sign of an ectopic pregnancy, when an embryo develops outside the uterus, most often in a fallopian tube.

a. Occurs about once in every 300 pregnancies

b. The leading cause of maternal death in the first trimester is internal hemorrhage into the abdomen following rupture of an ectopic pregnancy.

c. Consider the possibility of an ectopic pregnancy in a woman who has missed a menstrual cycle and complains of sudden, severe, usually unilateral pain in the lower abdomen.

2. Hemorrhage from the vagina that occurs before labor begins may be very serious; call for ALS backup.

a. In early pregnancy, it may be a sign of a spontaneous abortion, or miscarriage.

b. In the later stages of pregnancy, vaginal hemorrhage may indicate a serious condition involving the placenta.

i. In abruptio placenta, the placenta separates prematurely from the wall of the uterus, most commonly caused by hypertension or trauma.

(a) Patient often reports severe pain but vaginal bleeding may not be heavy

ii. In placenta previa, the placenta develops over and covers the cervix.

(a) Patient may experience heavy vaginal bleeding without significant pain

3. Decreasing the patient’s anxiety during these situations can impact how she and the fetus may respond during the emergency.

4. In all cases of bleeding, collect all blood soaked sanitary napkins or other dressings and take them to the hospital so that blood loss can be estimated.

E. Abortion

1. Passage of the fetus and placenta before 20 weeks is called abortion.

2. Abortions may be spontaneous (miscarriage) or induced.

3. Deliberate abortions may be self-induced, or planned and performed in a hospital or clinic.

4. The most serious complications are bleeding and infection.

a. Bleeding can result from portions of the fetus or placenta being left in the uterus (incomplete abortion) or from injury to the wall of the uterus.

b. Infection can result from such perforation and from the use of nonsterile instruments.

5. If the woman is in shock, treat and transport her promptly to the hospital.

a. Never try to pull the tissue out of the vagina.

b. Place a sterile pad on the vagina.

F. Abuse

1. Pregnant women have an increased chance of being victims of domestic violence and abuse.

2. Abuse during pregnancy increases the chance of spontaneous abortion, premature delivery, and low birth weight.

3. The woman is at risk from bleeding, infection, and uterine rupture.

4. Use a calm, professional approach.

a. Pay attention to the environment for any signs of abuse.

b. Your attention to detail will be helpful in your documentation.

5. Pregnant patients who are abused are often scared and may not be honest as to how their injuries may have occurred.

a. Talk to the patient in a private area, away from the potential abuser if possible.

b. The best way for you to care for the fetus is to treat the pregnant woman.

G. Substance abuse

1. Some pregnant women are addicted to alcohol or other drugs.

2. The effects of the addiction on the fetus include:

a. Prematurity

b. Low birth weight

c. Severe respiratory distress

d. Death

3. Fetal alcohol syndrome describes the condition of infants born to women who have abused alcohol.

4. If you are called to handle a delivery of an addicted woman, pay special attention to your own safety.

5. Follow standard precautions.

a. Wear eye protection, a face mask, and gloves at all times.

6. Clues that you are dealing with an addicted patient may include:

a. The presence of drug paraphernalia

b. Empty wine or liquor bottles

c. Statements made by family or bystanders or by the patient herself

7. The newborn will probably need immediate resuscitation.

a. Assist with the delivery, and be prepared to support the newborn’s respirations and administer oxygen during transport.

V. Special Considerations for Trauma and Pregnancy

A. With a trauma call involving a pregnant woman, you have two patients to consider—the woman and the unborn fetus.

1. Trauma to a pregnant woman may have a direct effect on the condition of the fetus.

2. Pregnant women may be victims of many types of trauma, including:

a. Assaults

b. Motor vehicle crashes

c. Shootings

B. Pregnant women also have an increased risk of falling compared with nonpregnant women.

1. Hormonal changes loosen the joints in the musculoskeletal system.

2. The increased weight of the uterus and displacement of abdominal organs can affect a woman’s balance.

C. Pregnant women have an increased amount of overall total blood volume and an approximate 20% increase in their heart rate by the third trimester.

1. A pregnant trauma patient may experience a significant amount of blood loss before you detect signs of shock.

2. The fetus also may be in trouble well before signs of shock are present.

3. The body of a woman who has sustained serious trauma often reduces the blood supply to the fetus.

D. Be alert to additional concerns and ready to assess and manage unique types of injuries when responding to a pregnant trauma patient.

1. The uterus is especially vulnerable to penetrating trauma and blunt injuries.

2. A trauma injury to the pregnant uterus can be life threatening to the woman and fetus because the uterus has a rich blood supply.

3. In most cases, the only chance to save the fetus is to adequately resuscitate the woman.

E. When a pregnant woman is involved in a motor vehicle crash or a similarly violent mechanism of injury (MOI), severe hemorrhage may result from injuries to the pregnant uterus.

1. Trauma is one of the leading causes of abruptio placenta.

2. You should suspect abruptio placenta when the MOI is blunt trauma to the abdomen and the patient’s signs and symptoms are suggestive of shock.

3. Common symptoms include vaginal bleeding and severe abdominal pain.

a. Quickly assess and transport the patient.

b. Support the airway.

c. Administer high-flow oxygen.

d. Place sanitary pads on the vagina.

e. Position the patient on her left side or left lateral recumbent.

f. Call for ALS backup.

4. If spinal movement restriction is indicated, use a KED extrication device to immobilize the patient’s spine then lay her on your gurney.

5. Improper positioning of the seat belt can result in injury to a pregnant woman and the fetus if they are involved in a motor vehicle crash.

a. Carefully assess a pregnant woman’s abdomen and chest for seatbelt marks, bruising, and obvious trauma.

F. If a pregnant trauma patient goes into cardiac arrest, your focus is the same as with other patients in cardiac arrest.

1. Remember that the only chance you have to save the fetus is to do all you can to save the woman.

2. Perform CPR and provide transport to the hospital according to local protocol.

3. If a woman is in the last month or two of pregnancy, compressions may need to be applied a little higher on the sternum than usual.

a. If possible, one provider should be assigned to manually displace the uterus toward the patient’s left side to facilitate blood return to the right side of the heart.

4. You should notify the receiving facility personnel as soon as possible that you are en route with a pregnant trauma patient in cardiac arrest.

G. Assessment and management

1. Your focus is on the assessment and the management of the woman.

a. You should suspect shock based on the MOI.

b. Be prepared for vomiting, and anticipate the need to manage the airway to protect the patient from aspirating.

c. Attempt to determine the gestational age to assist you with determining the size of the fetus and the position of the uterus.

2. Follow these guidelines when treating a pregnant trauma patient:

a. Maintain an open airway.

i. Be prepared for and anticipate vomiting.

ii. Keep your suction unit readily available.

b. Administer high-flow oxygen.

i. Keep the oxygen saturation level high.

ii. Administer high-flow, 100% oxygen by nonrebreather mask.

c. Ensure adequate ventilation.

i. Auscultate breath sounds and confirm that bilateral breath sounds are present.

ii. If the patient’s ventilations are inadequate, provide or assist ventilation with a bag-valve mask and 100% oxygen.

d. Assess circulation.

i. Control external bleeding.

ii. Maintain a high index of suspicion for internal bleeding and shock based on the MOI.

iii. Keep the patient warm.

e. Transport considerations

i. Transport the patient on her left side.

ii. If spinal injury is suspected, tilt the backboard 30° to the left.

iii. Transport the patient to a trauma center if one is available in your area.

VI. Cultural Value Considerations

A. Cultural sensitivity is important when you are assessing and treating a pregnant patient.

1. Women of some cultures may have a value system that will affect:

a. The choice of how they care for themselves during pregnancy

b. How they have planned the childbirth process

2. Some cultures may not permit a male health care provider, especially in the prehospital setting, to assess or examine a female patient.

3. You should respect these differences and honor requests from the patients.

4. Your responsibility is to the patient and is limited to providing care and transport.

5. A competent, rational adult has the right to refuse all or any part of your assessment or care.

VII. Teenage Pregnancy

A. The United States has one of the highest teenage pregnancy rates among developed countries.

1. It is likely that, during your career, you will respond to a pregnant teenager who may or may not be in labor.

B. Pregnant teenagers may not know they are pregnant or may be in denial about it.

1. As you begin to assess all female teenagers, remember that pregnancy is a possibility.

2. Respect the teenager’s privacy and need for independence.

a. If possible, perform your assessment and obtain the history away from the teenager’s parents.

b. Become familiar with the laws in your state so that you will know when pregnant teenagers can give or refuse consent for themselves.

VIII. Patient Assessment

A. Childbirth is seldom an unexpected event, but there are occasions when childbirth becomes an emergency.

1. Dispatch protocols usually include the dispatcher asking simple questions to determine whether birth is imminent.

2. Premature contractions may be caused by trauma or medical conditions.

B. Scene size-up

1. Take standard precautions.

a. Gloves and eye and face protection are a minimum when delivery has already begun or is complete.

b. If the call is going to result in a field delivery and time allows, a gown should also be used.

c. Do not be lax in your safety observations and precautions.

d. Remain calm and professional.

e. Consider calling for additional or specialized resources.

2. Mechanism of injury/nature of illness

a. You will encounter pregnant patients who are not in labor, so it is important to determine the MOI or NOI.

b. Do not develop tunnel vision during a call.

c. Falls and the necessity for spinal immobilization must be considered.

C. Primary assessment

1. Form a general impression.

a. Whether the patient is in active labor or whether you have time to assess for imminent delivery and address other possible life threats

b. Perform a rapid examination of the patient.

c. Take a moment to confirm whether the fetus will be delivered in the next few minutes or whether you have time to continue to evaluate the situation.

d. When trauma or other medical problems are the presenting complaint, evaluate these first and then assess the impact of these problems on the fetus.

2. Airway and breathing

a. During an uncomplicated birth, life-threatening conditions involving the woman’s airway and breathing are not usually an issue.

b. However, a motor vehicle crash, an assault, or any number of medical conditions may cause a life threat to exist, and may result in a complicated delivery.

i. Assess the airway and breathing to ensure they are adequate.

ii. If needed, provide airway management and high-flow oxygen.

3. Circulation

a. External and internal bleeding are potential life threats to the patient and should be assessed early.

b. Blood loss after delivery is expected, but significant bleeding is not.

c. Quickly assess for any potential life-threatening bleeding, and begin treatment immediately.

d. Assess the skin for color, temperature, and moisture.

e. Check the pulse to determine if it is too fast or too slow.

f. If there are signs of shock, control the bleeding, give oxygen, and keep the patient warm.

4. Transport decision

a. If delivery is imminent, you must prepare to deliver at the scene.

i. The ideal place to deliver is in the security of your ambulance or the privacy of the woman’s home.

ii. The area should be warm and private with plenty of room to move around.

b. If delivery is not imminent, prepare the patient for transport and perform the remainder of the assessment en route to the emergency department.

i. Administer oxygen.

ii. Women in the second and third trimesters of pregnancy should be transported lying on the left side or left lateral recumbent when possible.

iii. If spinal immobilization is indicated, secure the woman to the backboard and elevate the right side of the board with rolled towels or blankets.

c. Provide rapid transport for pregnant patients who:

i. Have significant bleeding and pain

ii. Are hypertensive

iii. Are having a seizure

iv. Have an altered mental status

D. History taking

1. You should obtain a thorough obstetric history, including:

a. Her expected due date

b. Any complications that she is aware of

c. If she has been receiving prenatal care

d. A complete medical history

2. Obtain a SAMPLE history.

a. Some pregnant women have a history of medical problems for which they take prescription medications.

b. Some women with no history of medical problems require medications during pregnancy.

c. Pertinent history should include questions related specifically to prenatal care.

i. Identify any complications the patient may have had during the pregnancy or potential complications during delivery.

ii. Determine the due date, fetal movements, frequency of contractions, and a history of previous pregnancies and deliveries and their complications.

iii. Determine whether there is a possibility of multiples and whether the woman has taken any drugs or medications.

d. If her water is broken, ask whether the fluid was green.

i. Green fluid is due to meconium (fetal stool).

ii. The presence of meconium can indicate newborn distress, and it is possible for the fetus to aspirate meconium during delivery.

E. Secondary assessment

1. Physical examinations

a. Perform complete assessment of the major body systems as needed, with emphasis on the patient’s chief complaint.

b. Assess for fetal movement by asking the patient whether she can feel the baby moving.

c. If the patient is in labor, the physical examination should be focused on contractions and possible delivery.

d. If at any point you suspect that delivery is imminent, you should check for crowning.

e. If you do not suspect an imminent delivery and the patient reports other problems unrelated to delivery, you should not visually inspect the vaginal area.

2. Vital signs should include pulse; respirations; skin color, temperature, and condition; and blood pressure.

a. Be especially alert for tachycardia and hypo- or hypertension.

b. It is typical for a woman’s blood pressure to drop slightly during the first two trimesters of pregnancy but return to normal during the third trimester.

c. Hypertension, even mild, may indicate more serious problems.

F. Reassessment

1. Repeat the primary assessment with a focus on the patient’s ABCs and vaginal bleeding, particularly after delivery.

2. Obtain another set of vital signs and compare with those obtained earlier.

3. Recheck interventions and treatments to see whether they were effective.

a. Is vaginal bleeding slowing with uterine massage?

b. In most cases, childbirth is a natural process that does not require your assistance.

c. When childbirth is complicated by trauma or other conditions, however, any interventions you provide for the patient will benefit the fetus.

4. Communication and documentation

a. If your assessment determines that delivery is imminent, notify staff at the receiving hospital.

i. Provide an update on the status of the woman and the newborn after delivery.

b. On the rare occasions that delivery of the placenta does not occur within 30 minutes or you determine that a complication is occurring that cannot be treated in the field, notify the hospital and provide rapid transport.

c. For a pregnant patient with a complaint unrelated to childbirth, be sure to include the pregnancy status of the patient in your radio report.

d. The hospital staff will want to know:

i. The number of weeks of gestation

ii. Her due date

iii. Any known complications of the pregnancy

e. If delivery occurred in the field, you will have two patient care reports to complete.

IX. Stages of Labor

A. The three stages of labor are:

dilation of the cervix,
delivery of the fetus, and
delivery of the placenta.

B. The first stage begins with the onset of contractions and ends when the cervix is fully dilated.

1. The first stage is usually the longest, lasting an average of 16 hours for a first delivery.

2. The onset of labor starts with contractions of the uterus.

a. Other signs of the beginning of labor are the bloody show and the rupture of the amniotic sac.

b. The frequency and intensity of contractions in true labor increase with time.

c. The uterine contractions become more regular and last about 30 to 60 seconds each.

3. Labor is generally longer in a primigravida (a woman experiencing her first pregnancy) than in a multigravida (a woman who has experienced previous pregnancies).

4. A woman may experience preterm or false labor, or Braxton-Hicks contractions.

a. You should provide transport for the patient.

b. If true labor is occurring, you may need to prepare for delivery.

False Labor versus True Labor
False Labor (Braxton-Hicks Contractions)	True Labor
Contractions are not regular and do not increase in intensity or frequency. Contractions come and go.	Contractions one started, consistently get stronger and closer together.
Pain and contractions start and stay in the lower abdomen.	Pain and contractions may start in the lower back and “wrap around” the lower abdomen.
Physical activity or a change in position may alleviate the pain and contraction.	Physical activity may intensify the contractions. A change in position does not relieve the contractions.
Bloody show, if present, is brownish.	The bloody show is pink or red and generally accompanied by mucus.
If leakage of fluid occurs, it is usually urine. It will be in small amounts and smell of ammonia.	The amniotic sac may have broken just before the contractions. A moderate amount of fluid that may smell sweet will be present, and fluid will continue to leak.

5. Some women experience a premature rupture of the membranes, in which the amniotic sac ruptures too early and the fetus is not developed or ready to be born.

a. The patient may or may not go into labor.

b. You will need to provide supportive care and transport to the hospital.

6. Toward the end of the third trimester, the head of the fetus normally descends into the woman’s pelvis as the fetus positions for delivery.

a. This movement down into the pelvis and the sensation that may accompany the descent is called lightening.

C. The second stage of labor begins when the fetus begins to encounter the birth canal and ends with the delivery of the newborn (spontaneous birth).

1. During this stage, you will have to make a decision about helping the woman to deliver at the scene or providing transport to the hospital.

2. Uterine contractions are usually closer together and last longer.

3. The mother feels the need to move her bowels.

4. Under no circumstances should you let the woman sit on the toilet.

5. The perineum will begin to bulge significantly, and the top of the fetus’s head should begin to appear at the vaginal opening.

a. This is called crowning.

D. The third stage of labor begins with the birth of the newborn and ends with the delivery of the placenta.

1. During this stage, the placenta must completely separate from the uterine wall.

2. This may take up to 30 minutes.

X. Normal Delivery Management

A. Preparing for delivery

1. Consider delivery at the scene when:

a. Delivery is imminent (will occur within a few minutes)

b. A natural disaster, inclement weather, or other environmental factor makes it impossible to reach the hospital

2. To determine if delivery is imminent, ask the patient the following questions:

a. How long have you been pregnant?

b. When are you due?

c. Is this your first pregnancy?

d. Are you having contractions?

i. How far apart are they?

ii. How long do they last?

e. Have you had any spotting or bleeding?

f. Has your water broken?

g. Do you feel as though you need to have a bowel movement?

h. Do you feel the need to push?

3. To help determine potential complications, ask these questions:

a. Were any of your previous deliveries by cesarean section?

b. Have you had problems in this or any previous pregnancies?

c. Do you use drugs, drink alcohol, or take any medications?

d. Do you know if there is a chance you will have multiple deliveries?

e. Does your physician expect any complications?

4. If the patient says that she is about to deliver, says she has to move her bowels, or feels the need to push, you should immediately prepare for delivery.

a. Otherwise, does she have an extremely firm abdomen?

b. Visually inspect the vagina to check for crowning.

c. Do not touch the vaginal area until you have determined that delivery is imminent.

5. Once labor has begun, it cannot be slowed or stopped.

a. Never attempt to hold the patient’s legs together.

b. Do not let her go to the bathroom.

c. Instead, reassure her that the sensation of needing to move her bowels is normal and that it means she is about to deliver.

6. If your decision is to deliver at the scene, remember that you are only assisting the woman with the delivery.

a. Your part is to help, guide, and support the baby as it is born.

b. You want to appear calm and reassuring while protecting the woman’s modesty.

c. Recognize when the situation is beyond your level of training.

d. If there is any doubt, contact medical control for a decision to deliver on the scene or to transport.

7. Your emergency vehicle should always be equipped with a sterile emergency obstetric (OB) kit, including:

a. Surgical scissors or scalpel

b. Umbilical cord clamps

c. Umbilical tape

d. A small rubber bulb syringe

e. Towels, drapes, or sheets

f. 4˝ × 4˝ and / or 2˝ × 10˝ gauze pads

g. Sterile gloves

h. Infant blanket

i. Sanitary pads

j. An infant-sized BVM

k. Goggles

l. A plastic bag

8. Patient position

a. The patient’s clothing should be removed or pushed up to her waist, and pants and undergarments should be removed.

b. Remember to preserve the patient’s privacy as much as possible.

c. Place the patient on a firm surface that is padded with blankets, folded sheets, or towels.

d. Lay the patient supine with her knees drawn up and spread apart.

e. Elevate the hips about 2" to 4" with a pillow or blankets.

f. Support the head, neck, and upper back with pillows and blankets.

g. Have her keep her legs and hips flexed, with her feet flat on the surface beneath her and her knees spread apart.

h. Communicate with your crew and plan who will be responsible for caring for the mother and newborn after delivery.

i. If the emergency delivery is occurring at home, you should move the patient to a sturdy, flat surface or the floor if she will allow it.

j. Track the progression of the delivery closely at all times.

9. Preparing the delivery field

a. Put on a protective face shield and gown. As time allows, place towels or sheets on the floor around the delivery area to help soak up body fluids and to protect the woman and the newborn.

b. Open the OB kit carefully so that its contents remain sterile.

c. Put on the sterile gloves. After this, handle only sterile materials.

d. Use the sterile sheets from the OB kit to make a sterile delivery field.

i. Place one sheet under the patient’s buttocks, and unfold it toward her feet.

ii. Place a second sheet on her abdomen and drape it over each thigh.

B. Delivery

1. Your partner should be at the patient’s head to comfort, soothe, and reassure her during the delivery.

2. If the patient will allow it, administer oxygen.

3. It is common for patients to become nauseated during delivery, and some may vomit.

a. If this occurs, have your partner assist her and clear out her airway.

4. Continually check the patient for crowning.

a. Some patients may experience precipitous labor and birth.

b. Position yourself so that you can see the perineal area at all times.

c. Time the patient’s contractions.

d. Remind the patient to take quick, short breaths during each contraction but not to strain.

e. Between contractions, encourage the patient to rest and breathe deeply through her mouth.

5. Follow these steps to deliver the newborn (Skill Slide 33-1).

a. Crowning is the definitive sign that delivery is imminent and transport should be delayed until after the child has been born.

b. Use your hands to support the bony parts of the head as it emerges.

c. The child’s body will naturally rotate to the right or left at this point in the delivery.

d. Continue to support the head to allow it to turn in the same direction.

e. As the upper shoulder appears, guide the head down slightly by applying gentle downward traction to deliver the shoulder.

f. Support the head and upper body as the lower shoulder delivers, guide the head up if needed.

g. Handle the newborn firmly but gently, support the head and keep the neck in a neutral position to maintain the airway.

h. Consider placing the newborn on the mother’s abdomen with the umbilical cord still intact, allowing skin-to-skin contact to warm the newborn.

i. Otherwise, keep the newborn approximately at the level of the vagina until the cord has been cut.

j. After delivery and prior to cutting the cord, if the child is gurgling or shows other signs of respiratory distress, suction the mouth and oropharynx to clear any amniotic fluid and ease the infant’s initiation of air exchange.

k. Wait for the umbilical cord to stop pulsing.

l. Place a clamp on the cord.

m. Milk the blood from a small section of the cord on the placental side of the clamp.

n. Place a second clamp 2 to 3 inches away from the first.

o. Cut between the clamps.

p. Allow the placenta to deliver itself.

q. Do not pull on the cord to speed delivery.

6. Delivering the head

a. Observe the head as it begins to exit the vagina so you can provide support as it emerges.

b. Place your sterile gloved hand over the emerging bony parts of the head to control the delivery of the head.

c. Continue to support the head as it rotates.

d. Apply gentle pressure across the perineum with a sterile gauze pad to reduce the risk of perineal tearing.

e. Be prepared for the possibility of the patient having a bowel movement because of the increased pressure on the rectum.

f. Be careful that you do not poke your fingers into the newborn’s eyes or into the fontanelles.

7. Unruptured amniotic sac

a. Usually, the amniotic sac will rupture at the beginning of labor or during contractions.

b. If it has not ruptured by the time the fetal head is crowning, it will appear as a fluid-filled sac emerging from the vagina.

c. The sac will suffocate the fetus if it is not removed.

d. You may puncture the sac with a clamp or tear it by twisting it between your fingers.

e. Make sure that the puncture site is away from the fetus’s face and only perform this procedure as the head is crowning.

f. Clear the newborn’s mouth and nose, using the bulb syringe if required by your protocols, and wipe the mouth and nose with gauze.

g. If the amniotic fluid is greenish, notify the receiving hospital.

8. Umbilical cord around the neck

a. As soon as the head is delivered, use one finger to feel whether the umbilical cord is wrapped around the neck.

b. This commonly is called a nuchal cord.

c. A nuchal cord that is wound tightly around the neck could strangle the fetus.

d. Usually, you can slip the cord gently over the delivered head.

e If not, you must cut it.

f. Once the cord is cut, you must attempt to speed the delivery by encouraging the woman to push harder and possibly more often because the fetus will now have no oxygen supply until it is delivered and breathing spontaneously.

9. Delivering the body

a. Once the head has been delivered, it usually rotates to one side or the other.

b. This rotation places the body in a better position for delivery.

c. The head is the largest part of the fetus.

i. Once it is born, the body usually delivers easily.

d. Support the head and upper body as the shoulders deliver.

e. Do not pull the fetus from the birth canal.

f. The newborn will be slippery and covered with a white, cheesy substance called vernix caseosa.

C. Post delivery care

1. If the mother is able and willing, hand the newborn to her or place the newborn on her abdomen so skin-to-skin contact can begin immediately.

2. Dry off the newborn and wrap him or her in a blanket or towel.

3. Wrap the newborn so that only the face is exposed, making sure that the top of the head is covered.

4. Place the newborn on one side, with the head slightly lower than the rest of the body.

5. You can pick up and cradle the newborn.

a. If local protocols specify, keep the newborn at the level of the woman’s vagina until the umbilical cord is cut.

b. Always keep the head slightly downward to help prevent aspiration.

6. Wipe the newborn’s mouth with a sterile gauze pad as needed.

7. Post delivery care of the umbilical cord is important because infection is easily transmitted through the cord to the newborn.

a. Once the cord has stopped pulsing, clamp and cut the cord.

8. Evaluate the newborn for term gestation, good muscle tone, and breathing/crying, and obtain the 1-minute Apgar score.

9. Give the wrapped newborn to your partner to complete the initial care.

a. You can give the newborn to the mother if she is alert and in stable condition.

10. Delivery of the placenta

a. The placenta is attached to the end of the umbilical cord that is coming out of the woman’s vagina.

b. Again, your job is only to assist.

c. The placenta delivers itself, usually within a few minutes of the birth, although it may take as long as 30 minutes.

i. Do not delay transport waiting for the placenta to deliver.

d. Never pull on the end of the umbilical cord.

e. Some bleeding, usually less than 500 mL, occurs before the placenta delivers and is normal and expected.

f. Wrap the entire placenta and cord in a towel, place them in a plastic bag, and take them to the hospital.

g. After delivery of the placenta and before transport, place a sterile pad or sanitary napkin over the vagina and straighten the woman’s legs.

i. You can help to slow bleeding by gently massaging the woman’s abdomen with a firm, circular, “kneading” motion.

ii. You should be able to feel a firm, grapefruit-sized mass in the lower abdomen, called the fundus.

h. Record the time of birth in your patient care report.

i. The following are emergency situations:

i. More than 30 minutes elapse and the placenta has not delivered.

ii. More than 500 mL of blood loss prior to delivery of the placenta.

iii. There is significant bleeding after the delivery of the placenta.

j. If one or more of these events occur, transport the woman and the newborn to the hospital promptly.

XI. Neonatal Assessment and Resuscitation

A. Follow standard precautions, and always put on gloves before handling a newborn.

1. A newborn will usually begin breathing spontaneously within 15 to 30 seconds after birth, and the heart rate will be 120 beats/min or higher.

2. If you do not observe these responses:

a. Gently tap or flick the soles of the feet or rub the back.

3. Many newborns require some form of stimulation that will encourage them to breathe air and begin circulating blood through the lungs, including:

a. Positioning of the airway

b. Drying

c. Warming

d. Suctioning

e. Tactile stimulation

Resuscitation for a Newborn Who is not Breathing
Assess and support	Temperature (warm and dry) Airway (position and suction) Breathing (stimulate to cry) Circulation (heart rate and skin color)
Basic life support interventions	Dry and warm the newborn Clear the airway with a bulb syringe Stimulate the newborn if unresponsive Ventilate with a BVM, seldom required If pulseless, begin CPR or if HR is <60 bpm following 30 seconds of ventilation and HR is not increasing.

4. To maximize the effects of these measures, follow these tips:

a. Position the newborn on his or her back with the head down and the neck slightly extended.

i. Place a towel or blanket under the shoulders to help maintain the position.

b. If necessary, suction the mouth and then the nose using a bulb syringe or suction device with an 8- or 10-French catheter.

i. Suction both sides of the back of the mouth, but avoid deep suctioning of the mouth and throat.

ii. Aim blow-by oxygen at the newborn’s mouth and nose during resuscitation.

c. In addition to drying the newborn’s head, back, and body vigorously with dry towels, you may rub the newborn’s back and flick or slap the soles of his or her feet.

B. Additional resuscitation efforts

1. Observe the newborn for spontaneous respirations, skin color, and movement of the extremities.

2. Evaluate the heart rate by palpating the pulse at the base of the umbilical cord or at the brachial artery or listening to the newborn’s chest with a stethoscope.

a. The heart rate is the most important measure in determining the need for further resuscitation.

Additional Neonatal Resuscitation Efforts
If the heart is ...	> 100 bpm	60 - 100 bpm	< 60 bpm
Do this:	Keep the newborn warm. Transport the newborn. Assess the newborn continuously.	Begin assisted ventilation with BVM and room air. Reassess the newborn after 90 seconds and if the HR and respirations are not normal, begin to ventilate with 100% oxygen. Continue to reassess the newborn. Call for ALS backup if available. Keep the newborn warm.	Begin assisted ventilation with BVM and 100% oxygen. Reassess the newborn every 90 seconds until HR and respirations are normal. Begin chest compressions. Call for ALS backup if available. If the HR does not increase, medication and ALS will be needed.

3. If chest compressions are required, use the hand-encircling technique for two-person resuscitation.

a. Perform BVM ventilation during a pause after every third compression, using a compression-to-ventilation ratio of 3:1.

b. This will yield a total of 120 “actions” per minute (90 compressions and 30 ventilations).

4. Any newborn who requires more than routine resuscitation requires transport to a hospital with a Level III neonatal intensive care unit.

5. About 12% to 16% of deliveries are complicated by the presence of meconium.

a. If you see meconium in the amniotic fluid or meconium staining and the newborn is not breathing adequately, consider quickly suctioning the newborn’s mouth then nose after delivery before providing rescue ventilations.

C. The Apgar score

1. The Apgar score is the standard scoring system used to assess the status of a newborn.

APGAR Scoring System
Area of Activity	2	1	0
Appearance	Entire newborn is pink	Body is pink, but hands and feet remain blue	Entire newborn is blue or pale
Pulse	> 100 bpm	< 100 bpm	Absent pulse
Grimace or Irritability	Newborn cries and tries to move foot away from finger snapped against the sole of the foot	Newborn gives a weak cry in response to stimulus	Newborn does not cry or react to stimulus
Activity or muscle tone	Newborn resists attempts to straighten hips and knees	Newborn makes weak attempt to resist straightening	Newborn is completely limp with no muscle tone
Respiration	Rapid respirations	Slow respirations	Absent respirations

2. The EMT assigns a number value (0, 1, or 2) to five areas of activity.

a. Appearance

i. The skin of a light-skinned newborn and the mucous membranes of a dark-skinned newborn should turn pink.

ii. Blue skin all over or blue mucous membranes signal a central cyanosis.

b. Pulse

i. If a stethoscope is unavailable, you can measure pulsations with your fingers in the umbilical cord or at the brachial pulse.

ii. A newborn with no pulse requires immediate CPR.

c. Grimace or irritability

i. Grimacing, crying, or withdrawing in response to stimuli is normal in a newborn and indicates that the newborn is doing well.

ii. The way to test this is to snap a finger against the sole of the newborn’s foot.

d. Activity or muscle tone

i. The degree of muscle tone indicates the oxygenation of the tissues.

ii. Normally, the hips and knees are flexed at birth, and, to some degree, the newborn will resist straightening them out.

iii. A newborn should not be floppy or limp.

e. Respirations

i. Normally, a newborn’s respirations are regular and rapid, with a good strong cry.

ii. If the respirations are slow, shallow, or labored, or if the cry is weak, the newborn may have respiration insufficiency and need assistance with ventilation.

iii. Complete absence of respirations or crying is a very serious sign.

3. The total of the five numbers is the Apgar score.

a. A perfect score is 10.

b. Calculate the Apgar score at 1 minute and 5 minutes after birth.

4. Follow these steps in assessing a newborn:

a. Quickly calculate the Apgar score to establish a baseline of the newborn’s status.

b. Stimulation should result in an immediate increase in respiration rate.

i. If not, you must begin ventilations with a BVM.

c. If the newborn is breathing well, you should next check the pulse rate by feeling the brachial pulse or the pulsations at the base of the umbilical cord or auscultating the chest with a stethoscope.

i. The pulse rate should be at least 100 beats/min.

ii. If it is not, begin ventilations with a BVM.

iii. Reassess respirations and heart rate at least every 30 seconds.

d. Assess the newborn’s oxygenation via pulse oximetry and observe for central cyanosis.

i. If present, administer blow-by oxygen by holding oxygen tubing at high-flow close to the newborn newborn’s face.

ii. Set oxygen flow rate to 5 L/min.

e. You should request a second unit as soon as possible if you determine that the newborn is in any distress and will require resuscitation.

5. In situations where assisted ventilation is required, you should use a newborn BVM.

a. Make sure you have a good mask-to-face seal.

b. Using gentle pressure, make the chest rise with each ventilation.

6. If the newborn does not begin breathing on his or her own or does not have an adequate heart rate, continue CPR and rapidly transport.

a. Once CPR has been started, do not stop until the newborn responds or is pronounced dead by a physician.

XII. Complicated Delivery Emergencies

A. Breech delivery

1. The presentation is the position in which an infant is born or the body part that is delivered first.

2. Most infants are born head first, called a vertex presentation.

3. Occasionally, the buttocks are delivered first, called a breech presentation.

a. The fetus is at great risk for trauma from the delivery.

b. Prolapsed cords are more common in a breech delivery.

4. Breech deliveries usually take longer, so you will often have time to transport the pregnant woman to the hospital.

a. However, if the buttocks have already passed through the vagina, the delivery has begun.

b. Provide emergency care and call for ALS backup.

c. If the woman does not deliver within 10 minutes of the buttocks presentation, provide prompt transport.

d. Consult medical control to guide you.

5. Preparing for a breech delivery is the same as for a normal childbirth.

a. Position the pregnant woman.

b. Prepare the OB kit.

c. Place yourself and your partner as you would for a normal delivery.

d. Allow the buttocks and legs to deliver spontaneously, supporting them with your hand to prevent rapid expulsion.

e. Let the legs dangle on either side of your arm while you support the trunk and chest as they are delivered.

f. The head is almost always face down and should be allowed to deliver spontaneously.

g. Make a “V” with your gloved fingers and position them in the vagina to keep the walls of the vagina from compressing the fetus’s airway.

B. Presentation complications

1. On rare occasions, the presenting part of the fetus is neither the head nor the buttocks, but a single arm, leg, or foot.

a. This is called a limb presentation.

2. An infant with a limb presentation cannot be successfully delivered in the field.

a. Usually surgery is needed.

b. You must transport the patient to the hospital immediately.

c. If a limb is protruding, cover it with a sterile towel.

d. Never try to push it back in, and never pull on it.

e. Place the patient on her back, with her head down and pelvis elevated.

f. Remember to give the woman high-flow oxygen.

3. Prolapse of the umbilical cord, where the umbilical cord comes out of the vagina before the fetus, must be treated in the hospital.

a. The fetus’s head will compress the cord during birth and cut off circulation to the fetus, depriving it of oxygenated blood.

b. Do not attempt to push the cord back into the vagina.

c. There is usually time to get the patient to the hospital.

d. Your job is to try to keep the fetus’s head from compressing the cord.

e. Place the pregnant woman supine with the foot of the cot raised 6 to 12 inches higher than the head, with her hips elevated on a pillow or folded sheet.

i. Alternatively, the woman may be placed in the knee-chest position; kneeling and bent forward, facedown.

ii. Either of these positions will help keep the weight of the fetus off the prolapsed cord.

f. Carefully insert your sterile gloved hand into the vagina, and gently push the fetus’s head away from the umbilical cord.

g. Wrap a sterile towel, moistened with saline, around the exposed cord.

h. Give the patient high-flow oxygen and transport rapidly.

C. Spina bifida

1. Spina bifida is a developmental defect in which a portion of the spinal cord or meninges may protrude outside of the vertebrae and possibly outside of the body.

a. When it protrudes outside the body, it is seen on a newborn’s back and usually occurs in the lower third of the back in the lumbar area.

b. Cover the open area of the spinal cord with a sterile, moist dressing immediately after birth to help prevent a potentially fatal infection.

c. Maintenance of the newborn’s body temperature is important when applying moist dressings because the moisture can lower the newborn’s body temperature.

i. Have someone hold the newborn against his or her body.

D. Multiple gestation

1. Twins occur about once in every 30 births.

a. Usually, multiple fetuses are diagnosed early in pregnancy with modern ultrasound techniques.

b. With multiple fetuses, always be prepared for more than one resuscitation, and call for assistance.

2. Twins are usually smaller than single fetuses, and delivery is typically not difficult.

a. Consider the possibility of twins any time the first newborn is small or the woman’s abdomen remains fairly large and firm after birth.

b. If twins are present, the second one will usually be born within 45 minutes of the first.

c. About 10 minutes after the first birth, contractions will begin again, and the birth process will repeat itself.

3. The procedure for delivering twins is the same as that for a single fetus; however, you will need some supplies from an additional OB kit.

a. Clamp and cut the cord of the first newborn as soon as it has been born and before the second newborn is delivered.

b. There may only be one placenta, or there may be two.

4. Record the time of birth of each twin separately.

5. Twins may be so small that they look premature.

a. Handle them carefully and keep them warm.

F. Premature birth

1. A normal, full term, single newborn will weigh approximately seven pounds at birth.

2. Any newborn who delivers before eight months (36 weeks) or weighs less than five pounds at birth is considered premature.

3. A premature newborn is smaller and thinner than a full-term newborn, and the head is proportionately larger in comparison with the rest of the body.

a. The vernix caseosa will be absent or minimal in the premature newborn.

b. There will also be less body hair.

5. Premature newborns require special care to survive.

a. They often require resuscitation efforts, which should be performed unless it is physically impossible.

b. With such care, premature newborns as small as one pound have survived and developed normally.

G. Postterm pregnancy

1. Postterm pregnancy refers to pregnancies lasting longer than 42 weeks.

2. Postterm fetuses can be larger than a typical 40-week fetus, sometimes weighing 10 pounds or more.

3. This condition can lead to problems with the woman and fetus.

a. A more difficult labor and delivery

b. Increased chance of injury to the fetus

c. Increased likelihood of cesarean section being required

d. Woman is at risk for perineal tears and infection

e. Postterm newborns have increased risks of meconium aspiration, infection, and being stillborn.

f. Newborns may not have been able to develop normally because of the restricted size of the uterus.

4. You should be prepared to resuscitate the newborn, as respiratory and neurologic functions may have been affected.

H. Fetal demise

1. You may find yourself delivering a fetus who died in the woman’s uterus before labor.

2. The onset of labor may be premature, but labor will otherwise progress normally in most cases.

3. If an intrauterine infection has caused the demise, you may note an extremely foul odor.

a. The delivered fetus may have skin blisters, skin sloughing, and a dark discoloration.

b. The head will be soft and perhaps grossly deformed.

4. Do not attempt to resuscitate an obviously dead neonate.

I. Delivery without sterile supplies

1. On rare occasions, you may have to deliver a newborn without a sterile OB kit.

2. Even without the OB kit, you should always have eye protection, gloves, and a protective mask with you.

3. Carry out the delivery as if sterile supplies were available.

a. If possible, use freshly laundered sheets and towels.

b. As soon as the newborn is delivered, wipe the inside of the mouth with your finger to clear away blood and mucus.

c. You should not cut or clamp the umbilical cord.

d. Instead, as soon as the placenta delivers, wrap it in a clean towel or put it in a plastic bag and transport it to the hospital.

e. Always keep the placenta and the newborn at the same level, or elevate the placenta slightly if possible.

f. Keep the newborn warm.

XIII. Postpartum Complications

A. Bleeding that exceeds approximately 500 mL is considered excessive.

1. If bleeding continues after delivery of the placenta, you should continue to massage the uterus.

2. Check your technique and hand placement if bleeding continues.

3. Treat the woman if she appears to be in shock, including elevating the feet.

4. Excessive bleeding after birth is usually caused by the muscles of the uterus not fully contracting due to:

a. Delivery of more than one infant

b. A long labor process that causes the uterus to be too “tired” to contract

c. Parts of the placenta still being inside the uterus

5. Cover the vagina with a sterile pad, change the pad as often as possible.

a. Do not discard any blood-soaked pads.

b. Hospital personnel will use them to estimate the amount of blood loss.

c. Save any tissues that may have passed from the vagina.

6. Administer oxygen if necessary, monitor vital signs frequently, and transport the patient immediately to the hospital.

a. Never hold the woman’s legs together or pack the vagina with gauze pads in an attempt to control bleeding.

B. Postpartum patients are also at an increased risk of an embolism—most commonly a pulmonary embolism.

1. A pulmonary embolism results from a clot that travels through the bloodstream and becomes lodged in the pulmonary circulation, blocking blood flow to the lungs, and is potentially life threatening.

3. If you deliver a newborn in the field and the woman begins to report sudden difficulty breathing or shortness of breath, consider pulmonary embolism as a possibility.

4. Also suspect a pulmonary embolism in patients of childbearing age with respiratory complaints who have recently delivered, especially with the sudden onset of difficulty breathing or altered mental status.

a. Provide supportive care of the ABCs with high-flow oxygen and rapid transport to the hospital.

Chapter 34, Pediatric Emergencies

Unit Summary

After completing this chapter and related coursework, you will understand the anatomy and physiology of the child as compared to the adult. You will learn the appropriate assessment and care for the types of illness and injury affecting children of all ages, injury patterns based on size, and special body system injuries. You will also learn the indicators of abuse and neglect, and the medical and legal responsibilities of an EMT.

National EMS Education Standard Competencies

Special Patient Populations

Applies a fundamental knowledge of the growth, development, and aging and assessment findings to provide basic emergency care and transportation for a patient with special needs.

Patients With Special Challenges

• Recognizing and reporting abuse and neglect (Chapter 35, “Geriatric Emergencies”)

Health care implications of:

• Abuse (Chapter 35, “Geriatric Emergencies”)

• Neglect (Chapter 35, “Geriatric Emergencies”)

• Homelessness (Chapter 36, “Patients With Special Challenges”)

• Poverty (Chapter 36, “Patients With Special Challenges”)

• Bariatrics (Chapter 36, “Patients With Special Challenges”)

• Technology dependence (Chapter 36, “Patients With Special Challenges”)

• Hospice/terminally ill (Chapter 36, “Patients With Special Challenges”)

• Tracheostomy care/dysfunction (Chapter 36, “Patients With Special Challenges”)

• Home care (Chapter 36, “Patients With Special Challenges”)

• Sensory deficit/loss (Chapter 36, “Patients With Special Challenges”)

• Developmental disability (Chapter 36, “Patients With Special Challenges”)

Pediatrics

Age-related assessment findings, and age-related assessment and treatment modifications for pediatric-specific major diseases and/or emergencies:

• Upper airway obstruction

• Lower airway reactive disease

• Respiratory distress/failure/arrest

• Shock

• Seizures

• Sudden infant death syndrome

Age-related assessment findings, and developmental stage-related assessment and treatment modifications for pediatric-specific major diseases and/or emergencies:

• Upper airway obstruction

• Lower airway reactive disease

• Respiratory distress/failure/arrest

• Shock

• Seizures

• Sudden infant death syndrome

• Gastrointestinal disease

Trauma

Applies fundamental knowledge to provide basic emergency care and transportation based on assessment findings for an acutely injured patient.

Special Considerations in Trauma

Recognition and management of trauma in:

• Pregnant patient (Chapter 33, “Obstetrics and Neonatal Care”)

• Pediatric patient

• Geriatric patient (Chapter 35, “Geriatric Emergencies”)

Pathophysiology, assessment, and management of trauma in the:

• Pregnant patient (Chapter 33, “Obstetrics and Neonatal Care”)

• Pediatric patient

• Geriatric patient (Chapter 35, “Geriatric Emergencies”)

• Cognitively impaired patient (Chapter 36, “Patients With Special Challenges”)

Knowledge Objectives

1. Explain some of the challenges inherent in providing emergency care to pediatric patients and why effective communication with both the patient and his or her family members is critical to a successful outcome.

2. Discuss the physical and cognitive developmental stages of an infant, including health risks, signs that may indicate illness, and patient assessment.

3. Discuss the physical and cognitive developmental stages of a toddler, including health risks, signs that may indicate illness, and patient assessment.

4. Discuss the physical and cognitive developmental stages of a preschool-age child, including health risks, signs that may indicate illness, and patient assessment.

5. Discuss the physical and cognitive developmental stages of a school-age child, including health risks, signs that may indicate illness, and patient assessment.

6. Discuss the physical and cognitive developmental stages of an adolescent, including health risks, signs that may indicate illness, and privacy issues.

7. Describe differences in the anatomy and physiology of the pediatric patient compared to the adult patient and their implications for EMTs, with a focus on the following body systems: respiratory, circulatory, nervous, gastrointestinal, musculoskeletal, and integumentary.

8. Describe the differences in the pathophysiology of the pediatric patient compared to the adult patient and their implications for EMTs, with a focus on the following body systems: respiratory, circulatory, nervous, gastrointestinal, musculoskeletal, and integumentary.

9. Explain the steps in the primary assessment of a pediatric patient, including the elements of the pediatric assessment triangle (PAT), hands-on ABCs, transport decision considerations, and privacy issues.

10. Explain the steps in the secondary assessment of a pediatric patient, including what EMTs should look for related to different body areas and the method of injury.

11. Describe the emergency care of a pediatric patient in respiratory distress, including the different causes of pediatric respiratory emergencies, the signs and symptoms of increased work of breathing, and the difference between respiratory distress and respiratory failure.

12. List the possible causes of an upper and a lower airway obstruction in a pediatric patient and the steps in the management of foreign body airway obstruction.

13. Describe asthma; its possible causes, signs and symptoms; and steps in the management of a pediatric patient who is experiencing an asthma attack.

14. Explain how to determine the correct size of an airway adjunct intended for a pediatric patient during an emergency.

15. List the different oxygen delivery devices that are available for providing oxygen to a pediatric patient, including the indications for the use of each and precautions EMTs must take to ensure the patient’s safety.

16. Describe the emergency care of a pediatric patient who is in shock (hypoperfusion), including common causes, signs, and symptoms.

17. Describe the emergency care of a pediatric patient with an altered mental status, including common causes, signs, and symptoms.

18. Describe the emergency care of a pediatric patient who has experienced a seizure, including the different types of seizures, common causes, signs, and symptoms.

19. Describe the emergency care of a pediatric patient with meningitis, including common causes, signs, symptoms, and special precautions.

20. Describe the emergency care of a pediatric patient who is experiencing a gastrointestinal emergency, including common causes, signs, and symptoms.

21. Describe the emergency care of a pediatric patient who has been poisoned, including common sources of poison, signs and symptoms.

22. Describe the emergency care of a pediatric patient who is dehydrated, including how to gauge the severity of dehydration based on key signs and symptoms.

23. Describe the emergency care of a pediatric patient who is experiencing a fever emergency, including common causes.

24. Describe the emergency care of a pediatric patient who has experienced a drowning emergency, including common causes, signs, and symptoms.

25. Discuss the common causes of pediatric trauma emergencies; include how to differentiate between injury patterns in adults, infants, and children.

26. Discuss the significance of burns in pediatric patients, their most common causes, and general guidelines EMTs should follow when assessing patients who have sustained burns.

27. Explain the four triage categories used in the JumpSTART system for pediatric patients during disaster management.

28. Describe child abuse and neglect and its possible indicators, including the medical and legal responsibilities of EMTs when caring for a pediatric patient who is a possible victim of child abuse.

29. Discuss sudden infant death syndrome (SIDS), including its risk factors, patient assessment, and special management considerations related to the death of an infant patient.

30. Discuss the responsibilities of EMTs when communicating with a family or loved ones following the death of a child.

31. Discuss some positive ways EMTs may cope with the death of a pediatric patient and why managing posttraumatic stress is important for all health care professionals.

Skills Objectives

1. Demonstrate how to position the airway in a pediatric patient. (Skill Slide 34-1)

2. Demonstrate how to palpate the pulse and estimate the capillary refill time in a pediatric patient.

3. Demonstrate how to use a length-based resuscitation tape to size equipment appropriately for a pediatric patient.

4. Demonstrate how to insert an oropharyngeal airway in a pediatric patient. (Skill Slide 34-2)

5. Demonstrate how to insert a nasopharyngeal airway in a pediatric patient. (Skill Slide 34-3)

6. Demonstrate how to administer blow-by oxygen to a pediatric patient.

7. Demonstrate how to apply a nasal cannula to a pediatric patient.

8. Demonstrate how to apply a nonrebreathing mask to a pediatric patient.

9. Demonstrate how to assist ventilation of an infant or child using a bag-valve mask (BVM).

10. Demonstrate how to perform one-person BVM ventilation on a pediatric patient. (Skill Slide 34-4)

11. Demonstrate how to perform two-person BVM ventilation on a pediatric patient.

12. Demonstrate how to immobilize a pediatric patient who has been involved in a trauma emergency. (Skill Slide 34-5)

13. Demonstrate how to immobilize a pediatric patient in a car seat who has been involved in a trauma emergency. (Skill Slide 34-6)

I. Introduction

A. Children differ anatomically, physically, and emotionally from adults.

1. The illnesses and injuries that children sustain, and their responses to them, vary based on age or developmental level.

2. It is important to remember that children are not small adults.

a. Depending on his or her age, the child may not be able to tell you what is wrong.

3. Fear of EMS providers and pain can make the child difficult to assess.

a. Parents or primary caregivers may be stressed, frightened, or behaving irrationally.

b. For these reasons, pediatrics, the specialized medical practice devoted to the care of young patients, can be challenging.

B. Once you learn how to approach children of different ages and what to expect while caring for them, you will find that treating children also offers some very special rewards.

1. Their innocence and openness can be appealing.

2. Children often respond to treatment much more rapidly than adults do.

II. Communication With the Patient and the Family

A. Caring for an infant or child means that you must care for the parents or caregivers as well.

1. Family members or caregivers often need emotional support.

2. If the caregiver is unable to assist with the patient assessment, ask your partner to speak with them while you continue the assessment.

B. A calm parent usually results in a calm child.

1. The parent can often assist you with the child’s care.

2. An agitated parent means the child will act the same way, which may make the child’s care more difficult.

C. Remain calm, efficient, professional, and sensitive.

D. The primary goal in treating any infant or child patient is the anticipation and recognition of respiratory system problems and support of any compromised or lost function.

III. Growth and Development

A. Many physical and emotional changes occur during childhood.

1. Pediatric patients extend from birth until age 18.

2. The thoughts and behaviors of children as a whole are often grouped into five stages:

a. Infancy: first year of life

b. Toddler: ages 1 to 3 years

c. Preschool-age child: ages 3 to 6 years

d. School-age child: ages 6 to 12 years

e. Adolescents: ages 13 to 18 years

B. The infant

1. Infancy is usually defined as the first year of life.

a. The first month after birth is called the neonatal or newborn period.

2. 0 to 2 months

a. Infants less than 2 months spend most of their time sleeping or eating.

b. They respond mainly to physical stimuli, such as light, warmth, hunger, and sound.

c. Infants sleep for up to 16 hours a day between feeding times and caregiver interactions.

i. Infants should be aroused easily from a sleeping state.

d. Infants cannot tell the difference between parents and strangers.

e. Crying is one of the main modes of expression.

f. Their basic needs consist of food, warmth, and comfort.

g. Soothing includes holding, cuddling, or rocking.

h. Hearing is well developed at birth.

i. Calm, reassuring talk is helpful in soothing.

i. An inconsolable infant, after all obvious needs have been addressed, could be a sign of significant illness.

j. Have a sucking reflex for feeding

k. Head control is limited.

l. Also predisposed to hypothermia

m. It is often necessary to unbundle the infant during your assessment.

3. 2 to 6 months

a. Infants at this stage are more active.

i. Makes them easier to evaluate

b. They spend more time awake, smile and make eye contact, and recognize caregivers.

c. Will often have a strong sucking reflex, active extremity movement, and a vigorous cry.

d. May follow objects with their eyes.

e. Have increased awareness of surroundings

i. Will use both hands to examine objects.

f. About 70% of infants will sleep through the night by 6 months.

g. Will begin to roll over at this stage.

h. Persistent crying, irritability, or lack of eye contact can be an indicator of serious illness, depressed mental status, or a delay in development.

4. 6 to 12 months

a. During this stage, infants begin to babble.

b. By their first year, they say their first word.

c. Learn to sit without support

d. Begin to crawl and finally begin to walk

i. Predisposes this age group to increased exposure to physical danger.

e. Infants in this group also begin teething and explore their world by putting objects in their mouths.

i. Higher risk for choking and poisonings

f. May cry if separated from their parents or caregivers.

i. Called separation anxiety

ii. Assess while keeping the caregiver close by.

g. Persistent crying or irritability can be a symptom of serious illness.

5. Assessment

a. Begin assessment by observing the infant from a distance.

b. Let the caregiver continue to hold the baby during physical assessment.

i. Will avoid separation anxiety and often make the assessment easier.

c. Provide as much sensory comfort as possible.

i. Warm your hands and the end of the stethoscope.

d. Do any painful procedures at the end of the assessment process.

e. Complete each procedure efficiently and avoid interruptions.

f. Explain each procedure to the parent or caregiver before you perform it, because the procedure and the infant’s reaction may be upsetting.

C. The toddler

1. After infancy, until 3 years of age, a child is called a toddler.

a. Toddlers experience rapid changes in growth and development.

2. 12 to 18 months

a. Toddlers begin to walk and explore during this period.

i. They are able to open doors, drawers, boxes, and bottles.

b. The patient will be curious about your equipment.

c. Because they are explorers by nature and not afraid, injuries in this age group increase.

d. Toddlers begin to imitate the behaviors of older children and parents.

e. Know major body parts when you point to them

f. May speak 4 to 6 words

g. Because of a lack of molars, they may not be able to fully chew their food, leading to increased risk of choking.

3. 18 to 24 months

a. The mind of the toddler develops rapidly.

i. Vocabulary will increase from 10–15 words to about 100 words.

ii. They will be able to name a common object that you point to.

b. Toddlers begin to understand cause and effect.

c. Balance and gait improve rapidly at this stage.

i. Running and climbing skills develop.

d. Toddlers at this stage tend to cling to their parents or caregivers and often have an object that comforts them.

i. Use any comforting objects when available to help calm the toddler.

4. Assessment

a. May have stranger anxiety.

b. May resist separation from caregiver.

i. Allow them to hold any special object, such as a toy, for comfort.

c. Demonstrate the assessment on a doll or stuffed animal first if possible.

i. May limit the toddler’s anxiety and make the assessment easier to perform

d. May be unhappy about being restrained or held for procedures

e. Do not like having clothing removed.

f. Toddlers can have a hard time describing or localizing pain.

i. Use visual clues or Wong-Baker FACES pain scale.

g. They may be distracted by a toy.

h. Begin your assessment at the feet or away from the location of pain, if possible.

i. Persistent crying or irritability can be a symptom of serious illness or injury.

j. Previous medical experiences may lead to hesitation toward you.

D. The preschool-age child (ages 3 to 6 years)

1. Able to use simple language effectively

a. The most rapid increase in language occurs during this stage.

2. Children can walk and run well and begin throwing, catching, and kicking during play.

3. Toilet training is mastered at this stage.

4. Have a rich imagination and can be fearful about pain.

a. May believe injury is a result of earlier bad behavior

5. Learn which behaviors are appropriate and which behaviors will lead to a “time out”

a. Tantrums may occur.

6. Foreign body aspiration airway obstruction continues to be a high risk.

7. Assessment

a. Begin the assessment prior to touching the patient, ie: the respiratory rate.

b. Can understand directions and be specific in describing painful areas.

c. Despite increased ability to communicate, much of the history must still be obtained from the caregivers.

d. Communicate simply and directly.

e. Explain what you are about to do in plain language.

f. Appealing to the child’s imagination may facilitate the examination process.

g. Allow the patient to become familiar with tools being used.

h. Do not lie to a patient of this age—it is difficult to regain lost trust.

i. The patient may be easily distracted by games or a toy, or conversation.

j. Begin the assessment at the feet and move toward the head.

k. Use adhesive bandages to cover the site of an injection or other small wound.

l. Modesty is developing, so keep the child covered as much as possible.

E. School-age years (ages 6 to 12 years)

1. Children at this age are beginning to act more like adults.

a. They can think in concrete terms.

b. They can respond sensibly to questions.

c. They can help take care of themselves.

2. School is important at this stage, and concerns about popularity and peer pressure begin.

a. Children with chronic illness or disabilities can become self-conscious about fitting in.

3. At this stage, children begin to understand death is final, but their understanding of what death is and why it occurs is still unrealistic.

a. May increase anxiety about illness and injury.

4. Assessment

a. Assessment begins to be more like an adult assessment.

b. To help gain trust, talk to the child, not just the caregiver.

c. The child is probably familiar with the process of a physical exam.

i. May or may not make the assessment easier depending on the child’s experiences

d. Start with the head and work toward the feet, as in an adult assessment.

e. If possible, give the child choices. For example:

i. Would you like to sit up or lie down?

ii. Would you like to take off your clothes yourself?

f. Ask only the type of questions that let you control the answer. For example:

Would you like this cuff to hug your right or left arm?
Do not bargain or debate with the patient.

g. Allow the child to listen to his or her own heartbeat through the stethoscope.

h. These children can understand the difference between physical and emotional pain.

i. Give them simple explanations about what is causing their pain and what will be done about it.

j. Ask the parent’s or caregiver’s advice about which distraction will work best.

F. Adolescents (ages 13 to 18 years)

1. Most adolescents are able to think abstractly and can participate in decision making.

a. Personal morals begin to develop.

b. Are able to discriminate between what is right and wrong

c. Are able to incorporate their own values and beliefs into their daily decision-making process

2. Physically similar to adults, but they are still children on the emotional level.

a. Gradually shift from relying on family to relying on friends for psychological support, social development, and acceptance from their peers.

b. Interest in romantic relationships begins.

c. This is the stage when puberty begins.

i. Makes the adolescent very concerned about body image and appearance

ii. Injuries or illnesses can be over- or under expressed due to feelings about body image or fear of disfigurement.

iii. May dislike being observed during procedures and have strong feelings about privacy

d. Adolescence is a time of experimentation and risk-taking behaviors.

i. Adolescents often feel “indestructible.”

ii. They struggle with independence, loss of control, body image, sexuality, and peer pressure.

iii. They may have mood swings or depression, or when ill/injured, may act younger than their age.

3. Assessment

a. Adolescents can often understand very complex concepts and treatment options.

i. Provide them with information when they request it.

b. Allow adolescents to be involved in their own care.

i. Provide choices, while lending guidance.

c. An EMT of the same gender should perform the physical examination, if possible, to lessen the stress of the event.

d. Allow the adolescent to speak openly and ask questions.

e. Risk-taking behaviors are common at this age.

i. Some risks can ultimately facilitate development and judgment and shape their identity as an adult.

ii. Risks can also result in unintentional trauma, drug and/or alcohol abuse, unprotected sex, and teen pregnancy.

f. Female patients may be pregnant.

i. Important to report this information to the receiving facility

ii. Adolescents may not want parents to know this information.

(a) Try to interview the adolescent without the caregiver present if you suspect she is withholding information.

g. Adolescents have a clear understanding of the purpose and meaning of pain.

i. Explain necessary procedures in advance.

ii. Assess the level of pain by observing facial and body expression as well as by asking.

iii. To distract them, find out some of their interests and get them talking.

IV. Anatomy and Physiology

A. The body is growing and changing rapidly during childhood.

1. You must understand the physical differences between children and adults and alter your patient care accordingly.

B. The respiratory system

1. Anatomy of the pediatric airway differs from adults.

a. Pediatric airway is smaller in diameter and shorter in length.

b. Lungs are smaller.

c. Heart is higher in a child’s chest.

d. Glottic opening is higher and positioned more anteriorly, and the neck appears to be nonexistent.

e. As children develop, the neck gets proportionally longer as the vocal cords and epiglottis achieve anatomically correct adult position. $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\Ch34\9781284080179_CH34_CP01.jpg$

f. Occiput is larger and rounder, which requires more careful positioning of the airway.

g. Tongue is larger relative to the size of the mouth and in a more anterior location in the mouth. Child’s tongue can easily block the airway.

h. Long, floppy, U-shaped epiglottis in infants and toddlers is larger than in adults.

i. Rings of cartilage in the trachea are less developed and may easily collapse if the neck is flexed or hyperextended.

j. The upper airway has a narrowing funnel shape compared to the cylinder shape of the lower airway.

k. Diameter of the trachea in infants is about the same as a drinking straw.

i. Airway is easily obstructed by secretions, blood, or swelling.

ii. Infants are nose breathers and may require suctioning and airway maintenance.

iii. A respiratory rate of 30 to 60 breaths/min is normal for a newborn to school-age patient.

iv. A respiratory rate of 12 to 20 breaths/min is normal for a teenager.

l. Children have an oxygen demand twice that of an adult.

i. This higher demand combined with a smaller oxygen reserve increases the risk of hypoxia.

m. The muscles of the diaphragm dictate the amount of oxygen a child inspires.

i. Anything that places pressure on the abdomen of a young child can block the movement of the diaphragm and cause respiratory compromise.

ii. Must use caution when applying the straps of a spinal immobilization device because it may hinder the tidal volume.

iii. Place the baby on their backs to sleep until they are one year old. The weight of their bodies can cause them to tire and develop respiratory issues.

n. Gastric distention can interfere with movement of the diaphragm and lead to hypoventilation.

o. Breath sounds are more easily heard because of their thinner chest walls.

p. Less air is exchanged with each breath, so detection of poor air movement or complete absence of breath sounds may be more difficult.

C. The circulatory system

1. Important to know the normal pulse ranges when evaluating children.

a. An infant’s heart can beat 160 times or more per minute.

i. This is the primary method the body uses to compensate for decreased perfusion.

b. Children are able to compensate for decreased perfusion by constricting the vessels in the skin.

i. Blood flow to the extremities can be diminished.

c. Signs of vasoconstriction include pallor (early sign), weak distal pulses in the extremities, delayed capillary refill, and cool hands or feet.

Responsive Pediatric Pulse Rates
Age	Pulse rate (beats per minute)
Newborn to 3 months	85 - 205
3 months to 2 years	100 - 190
2 years to 10 years	60 - 140
> 10 years	60 - 100

D. The nervous system

1. Compared to an adult nervous system, the pediatric nervous system is immature, underdeveloped, and not well protected.

a. Head-to-body ratio of infants and young children is disproportionately larger.

i. More prone to head injuries from falls or motor vehicle crashes

b. Occipital region of the head is larger, which increases the momentum of the head during a fall.

c. The subarachnoid space is relatively smaller, leaving less cushioning for the brain.

d. The brain tissue and cerebral vasculature are fragile and prone to bleeding from shearing forces.

i. Such as during an incidence of shaken baby syndrome

2. Pediatric brain also requires a higher amount of cerebral blood flow, oxygen, and glucose than does adult brain tissue.

a. This means that the pediatric brain is at risk for secondary brain damage from hypotension and hypoxic events.

3. Spinal cord injuries are less common in pediatric patients.

a. If the cervical spine is injured, it is more likely to be an injury to the ligaments because of a fall.

b. For suspected neck injury, perform manual in-line stabilization or follow local protocols.

E. The gastrointestinal system

1. Abdominal muscles are less developed in pediatric patients.

a. Less protection from trauma.

b. Liver, spleen, and kidneys are proportionally larger and situated more anteriorly, so they are prone to bleeding and injury.

i. Because organs are positioned closer to each other, there is a higher risk for multiple organ injury caused by minimal direct impact.

F. The musculoskeletal system

1. Open growth plates allow bones to grow during childhood.

a. As a result of open growth plates, children’s bones are softer and more flexible, making them prone to stress fractures.

b. Bone length discrepancies can occur if there is injury to a growth plate.

i. Important to immobilize extremities with sprains and strains because they may actually be stress fractures.

2. The bones of an infant’s head are flexible and soft.

a. Soft spots are located at the front and back of the head.

i. Referred to as fontanelles

ii. Will close at particular stages of development

iii. Fontanelles of an infant can be a useful assessment tool.

(a) Bulging fontanelles can indicate increased intracranial pressure.

(b) Sunken fontanelles can indicate dehydration.

3. The thoracic cage in children is highly elastic and pliable because it is primarily composed of cartilaginous connective tissue.

a. The ribs and vital organs are less protected by muscle and fat.

G. The integumentary system

1. The integumentary system of the pediatric population differs in a few ways:

a. The skin is thinner with less subcutaneous fat.

b. Composition of skin is thinner and tends to burn more deeply and easily than an adult’s.

c. Higher ratio of body surface area to body mass can lead to larger fluid and heat losses.

V. Patient Assessment

A. Scene size-up

1. Assessment begins at the time of initial dispatch.

a. Prepare mentally for approaching and treating an infant or child.

b. Plan for pediatric scene size-up, pediatric equipment, and age-appropriate physical assessment.

c. If possible, collect the age and gender of the child, location of the scene, NOI or MOI, and chief complaint from dispatch.

2. Scene safety

a. Ensure appropriate safety precautions and standard precautions have been taken.

b. Note the position in which the patient is found.

c. Look for possible safety threats to the child, parents or caregivers, bystanders, or EMS providers.

d. Patients may be a safety threat if they have an infectious disease.

e. Next, do an environmental assessment.

i. Will give important information on the chief complaint, number of patients, MOI or NOI, and ongoing health risks.

ii. Inspect the physical environment and interactions with caregivers/family.

iii. Information from parents or caregivers is important and may provide clues to the patient’s problem.

(a) Document dangerous scene conditions and inappropriate statements from caregivers.

3. Traumatic scene where the child is unresponsive or too young to communicate

a. Assume the injury was significant enough to cause head or neck injuries.

b. Perform cervical spine immobilization if you suspect the MOI to be severe.

i. Remember to pad under the child’s head and/or shoulder to facilitate a neutral position for airway management.

B. Primary assessment

1. The objective of the primary assessment is to identify and treat immediate or potential threats to life.

2. Pediatric Assessment Triangle (PAT) $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\Ch34\9781284080179_CH34_CP02.jpg$

a. Use the pediatric assessment triangle to determine if the patient is sick or not sick.

i. The PAT is a structured assessment tool that allows you to rapidly form a general impression without touching the patient.

(a) Can be performed in less than 30 seconds

ii. PAT consists of three elements and requires no equipment:

(a) Appearance (muscle tone and mental status)

(b) Work of breathing

b. Appearance

i. Note the level of responsiveness or interactiveness and muscle tone.

ii. You can also evaluate the pediatric patient’s level of responsiveness by using the AVPU scale, modified as necessary for the pediatric patient’s age.

iii. An infant or child with a normal level of responsiveness will act appropriately for his or her age, exhibiting good muscle tone and maintaining good eye contact.

iv. Poor muscle tone or poor eye contact can mean an abnormal level of responsiveness.

v. TICLS mnemonic can help determine if the patient is sick:

(a) Tone

(b) Interactiveness

(d) Look or gaze

(e) Speech or cry

c. Work of breathing

i. Increases as the body attempts to compensate for abnormalities in oxygenation and ventilation.

ii. Increased work of breathing often manifests as:

(a) Abnormal airway noise

(b) Accessory muscle use

(d) Head bobbing

(e) Nasal flaring

(f) Tachypnea: Increased respiratory rate

(g) Tripod position: In older children, this position will maximize the effectiveness of the airway.

d. Circulation to the skin

i. When cardiac output fails, the body shunts blood from areas of lesser need (such as skin) to areas of greater need (such as brain, heart, and kidneys).

ii. Pallor of the skin and mucous membranes may be seen in compensated shock.

(a) May also be a sign of anemia or hypoxia

iii. Mottling is another sign of poor perfusion.

iv. Cyanosis reflects a decreased level of oxygen in the blood.

(a) Is a late sign of respiratory failure or shock

(b) Never wait for the development of cyanosis before administering oxygen.

e. From the PAT findings, you will decide if the pediatric patient is stable or requires urgent care.

i. If the patient is unstable, assess the ABCs, treat any life threats, and transport immediately.

(a) With obvious life-threatening external hemorrhage, assess and address the CABs first, including tourniquets for arterial hemorrhage from extremities.

ii. If the patient is stable, continue with the remainder of the patient assessment process, perform necessary interventions, and discuss transport options with the parents or caregivers.

3. Hands-on ABCs

a. Next, you will perform a hands-on ABCs assessment.

b. Assess and treat any life threats as you identify them by following the ABCDE format:

i. Airway

ii. Breathing

iii. Circulation

iv. Disability

v. Exposure

c. Airway

i. If the airway is open and the patient can adequately keep it open, assess respiratory adequacy.

ii. If a patient is unresponsive or has difficulty keeping the airway clear, ensure that it is properly positioned and that it is clear of mucus, vomitus, blood, and foreign bodies.

(a) If trauma has been ruled out, use head tilt–chin lift to open the airway.

(b) If trauma is suspected, use the jaw-thrust maneuver to open the airway.

iii. Always position the airway in a neutral sniffing position.

(a) Keeps the trachea from kinking

(b) Maintains proper alignment should you have to immobilize the spine

iv. Position the airway in a pediatric patient: 78286_CH32_SKDSK01_02

(a) Position the pediatric patient on a firm surface.

(b) Place a folded towel about 1 inch (2.5 cm) thick under the shoulders and back.

v. Establish whether the patient can maintain his or her own airway. 78286_CH32_SKDSK01_03

d. Breathing

i. Look, listen, feel technique

ii. Place both hands on the patient’s chest to feel for the rise and fall of the chest wall.

iii. Belly breathing in infants is considered adequate because of the soft pliable bones of the chest and the strong muscular diaphragm.

iv. Bradypnea (decrease in respiratory rate) is an ominous sign and indicates impending respiratory arrest.

e. Circulation

i. Must determine if the patient has a pulse, is bleeding, or is in shock.

(a) Infants and children can tolerate only a small amount of blood loss before circulatory compromise occurs.

ii. In infants, palpate the brachial pulse or femoral pulse.

iii. In children older than one year, palpate the carotid pulse.

iv. Strong central pulses usually indicate that the child is not hypotensive.

v. Weak or absent peripheral pulses indicate decreased perfusion.

(a) Absence of a central pulse indicates the need for CPR.

vi. Tachycardia may be an early sign of hypoxia or shock or a less serious condition such as fever, anxiety, pain, or excitement.

vii. Interpret the pulse within the context of the overall history, the PAT, and primary assessment.

viii. A trend of an increasing or decreasing pulse rate may suggest worsening hypoxia or shock or improvement after treatment.

(a) When hypoxia or shock becomes critical, bradycardia occurs.

(b) Bradycardia in a pediatric patient often indicates impending cardiopulmonary arrest.

ix. Feel the skin for temperature and moisture.

x. Estimate the capillary refill time.

(a) Color should return within 2 seconds.

f. Disability

i. Use the AVPU scale or the pediatric Glasgow Coma Scale to assess level of responsiveness.

ii. Check the responses of pupils.

(a) A normal pupil constricts after a light stimulus.

(b) Pupillary response may be abnormal in the presence of drugs, ongoing seizures, hypoxia, or brain injury.

iii. Look for symmetric movement of the extremities.

iv. Pain is present with most types of injury.

(a) Inadequate treatment of pain has many adverse effects on the pediatric patient and the family.

v. Assessment of pain must take into consideration the developmental age of the patient.

(a) The ability to recognize pain will improve as the patient becomes older.

(b) The Wong-Baker FACES Scale is helpful in assessing the level of pain.

g. Exposure

i. The hands-on ABCs require that the caregiver remove part of the pediatric patient’s clothing to allow observation of the face, chest wall, and skin.

(a) Be careful to avoid heat loss by covering the patient as soon as possible.

ii. Pediatric population is more prone to hypothermic events due to immature thermoregulatory systems, thinner skin, and a lack of subcutaneous fat.

(a) Infants younger than six months lack the ability to shiver in response to cold.

(b) Newborns and infants less than one month are the most susceptible to hypothermia.

iii. Infants and young children should be kept warm during transport or when the patient is exposed to assess or reassess an injury.

(a) Cover the head: Up to 50% of heat loss can occur with a head that is larger in proportion to the rest of the body.

4. Transport decision

a. Determine whether rapid transport to the hospital is indicated.

i. If the pediatric patient is in stable condition, obtain a patient history, perform a secondary assessment at the scene, transport, and provide additional treatment as needed.

ii. Rapid transport is indicated if any of the following conditions exist:

(a) A significant MOI with the addition of:

(1) Any fall from a height equal to or greater than a pediatric patient’s height, especially with a headfirst landing

(2) Bicycle crash

(b) A history compatible with a serious illness

(d) A potentially serious anatomic abnormality

(e) Significant pain

(f) Abnormal level of responsiveness, AMS, and/or any signs or symptoms of shock

b. Also consider the following when making a transport decision:

i. The type of clinical problem.

ii. The expected benefits of ALS treatment in the field.

iii. Local EMS system treatment and transport protocols.

iv. Your comfort level.

v. Transport time to the hospital.

c. If the pediatric patient’s condition is urgent, then initiate immediate transport to the closest appropriate facility.

d. Specialty facilities such as trauma centers or children’s hospitals have the training, staff, and equipment to provide complete care for all levels of pediatric patients.

e, The most appropriate facility is not always the closest. Ask yourself:

i. Can I deliver the pediatric patient to the most appropriate facility without risk or delay to the pediatric patient?

ii. If the answer is no, transport the pediatric patient to the closest facility.

f. Pediatric patients weighing less than 40 pounds who do not require spinal immobilization should be transported in a car seat.

i. A seat should be chosen to fit the appropriate weight of the pediatric patient.

g. To mount a car seat to a stretcher:

i. Place the head of the stretcher in an upright position.

ii. Place the seat so it is against the back of the stretcher.

iii. Secure one of the stretcher straps from the upper portion of the stretcher through the seatbelt positions on the car seat and strap it tightly to the stretcher.

iv. Repeat on the lower portion of the stretcher.

v. Push the car seat into the stretcher tightly and retighten the straps.

h. Follow the seat manufacturer’s instructions to secure a car seat to a captain’s chair.

i. Patients younger than 2 years must be transported in a rear-facing position because of the lack of mature neck muscles.

i. For pediatric patients who require spinal immobilization, the patient should be immobilized on a longboard or other suitable spinal immobilization device.

j. Pediatric patients in cardiopulmonary arrest should be on a device that can be secured to the stretcher.

k. You should not use the pediatric patient’s own car seat.

l. The goal is to secure and protect the pediatric patient for transport in the ambulance.

C. History taking

1. Your approach to the history will depend on the age of the pediatric patient.

a. Historical information for an infant, toddler, or preschool-age child will have to be obtained from the parent or caregiver.

b. When dealing with an adolescent, most information will be obtained from the patient.

i. Sexual activity, possibility of pregnancy, and drug or alcohol use should be obtained from patients in private.

c. Questioning the parents or child about the immediate illness or injury should be based on the child’s chief complaint.

d. When interviewing the parent/caregiver or older child about the chief complaint, obtain the following:

i. NOI or MOI

ii. How long the pediatric patient has been sick or injured

iii. The key events leading to the injury or illness

iv. Presence of fever

v. Effects of the illness of injury on the pediatric patient’s behavior

vi. Pediatric patient’s activity level

vii. Recent eating, drinking, and urine output

viii. Change in bowel or bladder habits

ix. Presences of vomiting, diarrhea, abdominal pain

x. Presence of rashes

e. Obtain the name and phone number of the caregiver if they are not able to come to the hospital with you.

2. SAMPLE history

a. SAMPLE history for the pediatric patient is the same as an adult’s.

b. The process for obtaining OPQRST is the same for children and adults.

c. Questions should be based on the pediatric patient’s age and developmental stage of life.

D. Secondary assessment

1. Physical examinations

a. A secondary assessment of the entire body should be used when pediatric patients have the potential for hidden illnesses or injuries (unresponsive or have a significant MOI).

b. May help identify problems that were not as obvious during the primary assessment, but over time, the presenting signs and symptoms have become more apparent.

i. Use the DCAP-BTLS mnemonic:

Deformities
Contusions
Abrasions
Punctures/Penetrations
Burns
Tenderness
Lacerations
Swelling.

c. A focused assessment should be performed on pediatric patients without life-threatening illnesses or injuries.

i. Focus your physical examination on the area(s) of the body affected by the illness or injury as well as on the chief complaint, MOI or NOI, and the findings of the primary assessment.

d. Infants, toddlers, and preschool-age children who do not have life-threatening illnesses or injuries should be assessed starting at the feet and ending at the head.

e. School-age children and adolescents can be assessed using the head-to-toe approach.

f. Physical examination may include the following:

i. Head

(a) The younger the patient, the larger the head is in proportion to the rest of the body.

(b) Look for bruising, swelling, and hematomas.

(1) Significant blood loss can occur between the skull and scalp of an infant.

(c) A tense or bulging fontanelle in an upright, non-crying infant suggests elevated intracranial pressure caused by meningitis, encephalitis, or intracranial bleeding.

(d) A sunken fontanelle suggests dehydration.

ii. Nose

(a) Young infants are obligate nose breathers, so nasal congestion with mucus can cause respiratory distress.

(b) Gentle bulb or catheter suction of the nostrils may bring relief.

iii. Ears

(a) Look for drainage from the ear canals.

(1) Leaking blood suggests a skull fracture.

(b) Check for bruises behind the ears or Battle sign.

(1) Late sign of skull fracture

iv. Mouth

(a) In the trauma patient, look for active bleeding and loose teeth.

(b) Note the smell of the breath.

v. Neck

(a) Examine the area near the trachea for swelling or bruising.

(b) Note if a pediatric patient cannot move their neck and has a high fever, as this may indicate bacterial or viral meningitis.

vi. Chest

(a) Examine the chest for penetrating injuries, lacerations, bruises, or rashes.

(b) If the patient is injured, feel the clavicles and every rib for tenderness and/or deformity.

vii. Back

(a) Inspect the back for lacerations, penetrating injuries, bruises, or rashes.

viii. Abdomen

(a) Inspect the abdomen for distention.

(b) Gently palpate the abdomen and watch for guarding or tensing of abdominal muscles, which could suggest infection, obstruction, or intra-abdominal injury.

(d) Look for any seat belt abrasions or bruising.

ix. Extremities

(a) Assess for symmetry.

(b) Compare both sides for color, warmth, size of joints, swelling, and tenderness.

2. Vital signs

a. Some of the guidelines used to assess adult circulatory status have important limitations in pediatric patients.

i. Normal heart rates vary with age in pediatric patients.

ii. Blood pressure is usually not assessed in pediatric patients younger than 3 years.

(a) Offers little information about the patient’s circulatory status and is difficult to obtain.

b. Assessment of the skin is a better indication of a pediatric patient’s circulatory status.

c. It is important to use appropriately sized equipment when assessing a pediatric patient’s vital signs.

i. To obtain accurate blood pressure reading, use a cuff that covers two thirds of the pediatric patient’s upper arm.

(a) Cuffs that are too small will give a falsely high reading.

(b) Cuffs that are too large will give a falsely low reading.

d. The formula 70 + (2 × child’s age in years) = systolic blood pressure is a useful tool to determine blood pressure in children 1 to 10 years of age.

e. Respiratory rates may be difficult to interpret.

i. Count the respirations for at least 30 seconds and then double that number (if counted for 30 seconds).

ii. In infants and children younger than 3 years, evaluate respirations by assessing the rise and fall of the abdomen.

f. Assess the pulse rate by counting at least 1 minute, noting quality and regularity.

g. Normal vital signs in pediatric patients vary with age.

i. Assess respirations and then the pulse, and assess blood pressure last.

(a) Warm stethoscope before placing it on the skin.

h. Evaluate pupils using a small penlight.

i. Compare the size of the pupils against each other.

i. A pulse oximeter is a valuable tool to measure the oxygen saturation in a pediatric patient with respiratory issues.

E. Reassessment

1. Reassess the pediatric patient’s condition as necessary.

a. Obtain vital signs every 15 minutes for a child in stable condition.

b. Obtain vital signs every 5 minutes for a child in an unstable condition.

c. Continually monitor respiratory effort, skin color and condition, and level of responsiveness or interactiveness.

i. Repeat the primary assessment and adjust your treatment accordingly.

2. Interventions

a. Parents or caregivers may be able to assist.

i. Able to calm and reassure child

ii. Often well versed on their child’s medical conditions

iii. Oxygen or nebulizer administration

3. Communication and documentation

a. Communicate and document all relevant information to ED personnel.

VI. Respiratory Emergencies and Management

A. Respiratory emergencies

1. Respiratory problems are the leading cause of cardiopulmonary arrest in the pediatric population.

a. Failure to recognize and treat declining respiratory status will lead to death.

b. During respiratory distress, the pediatric patient is working harder to breathe and will eventually go into respiratory failure if left untreated.

2. In the early stages of respiratory distress, you may note changes in the pediatric patient’s behavior, such as combativeness, restlessness, and anxiety.

3. Signs and symptoms of increased work of breathing:

a. Nasal flaring

b. Abnormal breath sounds

c. Accessory muscle use

d. The tripod position

4. As the pediatric patient progresses to possible respiratory failure:

a. Efforts to breathe decrease.

b. The chest rises less with inspiration.

c. The body has used up all its available energy stores and cannot continue to support the extra work of breathing.

i. Without care, cyanosis may develop.

d. Changes in behavior will also occur until the pediatric patient demonstrates an altered level of responsiveness.

e. Patients may also experience periods of apnea.

f. As the lack of oxygen becomes more serious, the heart muscle becomes hypoxic and slows down.

i. Leads to bradycardia.

(a) Almost always an ominous sign in pediatric patients.

ii. If the heart rate is slow, you must begin CPR immediately.

(a) May quickly progress to cardiopulmonary arrest.

g. Respiratory failure does not always indicate airway obstruction.

i. It may indicate trauma, nervous system problems, dehydration, or metabolic disturbances.

h. A pediatric patient’s condition can progress from respiratory distress to respiratory failure at any time.

i. You must reassess the pediatric patient frequently.

i. A child or infant in respiratory distress needs supplemental oxygen.

j. For infants and children in possible respiratory failure, assist ventilations with a BVM and 100% oxygen.

k. Allow the pediatric patient to remain in a comfortable position, usually on the lap of the caregiver or parent.

B. Airway obstruction

1. Children can obstruct their airway with any object they can fit into their mouth. $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\Ch34\9781284080179_CH34_CP03.jpg$

2. In cases of trauma, teeth may have been dislodged into the airway.

3. Blood, vomitus, or other secretions can also cause mild or severe airway obstruction.

4. Infections, including pneumonia, croup, epiglottitis, and bacterial tracheitis, can also cause airway obstructions.

a. Infection should be considered if a patient has congestion, fever, drooling, and cold symptoms.

b. Croup is an infection in the airway below the level of the vocal cords.

c. Epiglottitis is an infection of the soft tissue in the area above the vocal cords.

5. Obstruction by a foreign object may involve the upper or lower airway.

a. Obstruction may be partial or complete.

b. Signs and symptoms frequently associated with a partial upper airway obstruction include decreased or absent breath sounds and stridor.

i. Stridor is usually caused by swelling of the area surrounding the vocal cords or upper airway obstruction.

ii. Infants or children with a complete airway obstruction will not make any sounds, will have no breath sounds, and will become rapidly cyanotic.

c. Signs and symptoms of a lower airway obstruction include wheezing and/or crackles.

6. The best way to auscultate breath sounds in a pediatric patient is to listen on both sides of the chest at the level of the armpit, or the midaxillary region of the lungs.

7. Immediately begin treatment of a pediatric patient with an airway obstruction.

a. If the patient is conscious and coughing forcefully and someone saw him or her ingest a foreign object, encourage the child to cough to clear the airway.

i. If this does not remove the object, do not intervene, except to provide supplemental oxygen.

ii. Allow the patient to remain in whatever position is most comfortable, and monitor his or her condition.

b. If you see signs of severe airway obstruction, attempt to clear the airway immediately:

i. Ineffective cough (no sound)

ii. Inability to speak or cry

iii. Increasing respiratory difficulty, with stridor

iv. Cyanosis

v. Loss of responsiveness

c. If an infant is conscious with a complete airway obstruction, perform up to five back blows followed by chest thrusts.

i. Position the infant face down on your forearm, supporting the jaw and head with your hand, and slap the back forcefully five times with the heel of your other hand.

ii. If the airway does not clear, flip the child onto his or her back and perform up to five chest thrusts in the same manner you would for CPR.

iii. Repeat the process until the obstruction clears, or until the infant becomes unconscious.

d. If a child is conscious with a complete airway obstruction, perform abdominal thrusts (Heimlich maneuver).

i. Continue until the obstruction is relieved or until the child loses responsiveness.

e. Use head tilt–chin lift and finger sweep to remove a visible foreign body in an unconscious pediatric patient.

f. Chest compressions are recommended to relieve a severe airway obstruction in an unconscious pediatric patient.

i. Increases pressure in the chest, creating an artificial cough that may force a foreign body from the airway.

C. Asthma

1. A condition in which the smaller air passages (bronchioles) become inflamed, swell, and produce excessive mucus, which leads to difficulty breathing.

2. A true emergency if not promptly identified and treated

a. According to the Centers for Disease Control and Prevention (CDC), 10% of children in the United States have asthma and, in 2007 alone, 185 children died of asthma.

b. Common causes for an asthma attack include upper respiratory infection, exercise, exposure to cold air or smoke, and emotional stress.

3. Signs and symptoms of asthma

a. Characteristic wheezing as patients attempt to exhale through partially obstructed lower air passages

b. In other cases, the airways are completely blocked and no air movement is heard.

c. Cyanosis and respiratory arrest may quickly develop.

d. Tripod position allows for easier breathing.

4. Treatment of pediatric patient with asthma

a. If possible, let the pediatric patient assume a position of comfort in a parent’s lap.

b. Administer supplemental oxygen via route that is tolerated by the child.

c. A bronchodilator via a metered-dose inhaler with a spacer mask device may be administered based on local protocols.

i. Often the parents or caregivers have attempted multiple dosages of albuterol.

(a) In this case, meet ALS providers en route for advanced care.

d. If you must assist ventilations, use slow, gentle breaths.

i. Resist the temptation to squeeze the reservoir bag hard and fast.

e. A prolonged, unrelieved asthma attack may progress into status asthmaticus.

i. A true emergency

ii. Administer oxygen and provide rapid transport to the ED.

f. If a patient becomes so exhausted he or she stops struggling to breathe, the patient is not recovering and is likely to stop breathing.

i. Manage airway aggressively, administer oxygen, and transport promptly.

ii. ALS support should be considered.

D. Pneumonia

1. According to the World Health Organization, pneumonia is the leading cause of death for over two million children worldwide annually.

2. Pneumonia is a general term that refers to an infection of the lungs.

a. Often a secondary infection; it occurs after a preexisting infection such as a cold.

b. Can also occur from chemical ingestion or a direct lung injury or a submersion incident

c. Children with diseases causing immunodeficiency are at increased risk for developing pneumonia.

d. Incidence is greatest during fall and winter months.

3. Presentation in the pediatric patient

a. Unusual rapid breathing, or will breathe with grunting or wheezing sounds

b. Nasal flaring

c. Tachypnea

d. Hypothermia or fever

e. Unilateral diminished breath sounds or crackles over the infected lung segments

4. Treatment of pneumonia in the pediatric patient

a. Primary treatment will be supportive.

b. Monitor the patient’s airway and breathing status.

c. Administer supplemental oxygen if required.

d. If the child is wheezing, administer a bronchodilator if permitted in your EMS system.

5. Diagnosis of pneumonia must be confirmed in the hospital.

E. Croup

1. Croup (laryngotracheobronchitis) is an infection of the airway below the level of the vocal cords, usually caused by a virus.

a. Typically seen in children between ages six months and three years

b. Easily passed between children

2. The disease starts with a cold, cough, and a low-grade fever that develops over two days.

a. The hallmark signs of croup are stridor and a seal-bark cough.

3. Croup often responds well to the administration of humidified oxygen.

a. Bronchodilators are not indicated for croup and can make the child worse.

F. Epiglottitis

1. Epiglottitis (supraglottitis) is an infection of the soft tissue in the area above the vocal cords. $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\Ch34\9781284080179_CH34_CP04.jpg$

a. Bacterial infection is the most common cause.

2. Since the development of a vaccine against one organism that causes epiglottitis, the incidence of this disease has dramatically decreased.

3. In preschool- and school-aged children especially, the epiglottis can swell to two to three times its normal size.

4. Children with this infection look ill, report a very sore throat, and have a high fever.

a. They will often be found in the tripod position and drooling.

G. Bronchiolitis

1. Specific viral illness of newborns and toddlers, often caused by respiratory syncytial virus (RSV).

a. Causes inflammation of the bronchioles.

b. RSV is highly contagious and spread through coughing or sneezing.

c. Viruses can survive on surfaces.

d. Viruses tend to spread rapidly through schools and childcare centers.

2. More common in premature infants and results in copious secretion that may require suctioning

a. Occurs during the first 2 years of life and is more common in males

b. Most widespread in winter and early spring

c. Bronchioles become inflamed, swell, and fill with mucus causing wheezing.

d. Airways of infants and young children can easily become blocked.

3. Look for signs of dehydration, shortness of breath, and fever.

4. Treatment of bronchiolitis in the pediatric patient

a. Display a calm demeanor when approaching.

b. Allow patients to remain in a position of comfort.

c. Treat airway and breathing problems as appropriate.

d. Humidified oxygen is helpful if available.

e. Consider ALS backup.

H. Pertussis

1. Pertussis, also known as whooping cough, is a communicable disease caused by a bacterium that is spread through respiratory droplets.

2. As a result of vaccinations, this potentially deadly disease is less common in the United States.

3. The typical signs and symptoms are similar to a common cold: coughing, sneezing, and a runny nose.

a. As the disease progresses, the coughing becomes more severe and is characterized by the distinctive whoop sound heard during inspiration.

b. Infants infected with pertussis may develop pneumonia or respiratory failure.

4. To treat pediatric patients, keep the airway patent (open) and transport.

5. Pertussis is contagious, so follow standard precautions, including wearing a mask and eye protection.

I. Airway adjuncts

1. Devices that help to maintain the airway or assist in providing artificial ventilation, including:

a. Oropharyngeal and nasopharyngeal airways

b. Bite blocks

c. BVMs

2. Oropharyngeal airway

a. Designed to keep the tongue from blocking the airway and makes suctioning easier

b. Should be used for pediatric patients who are unconscious and in possible respiratory failure

i. Should not be used in conscious patients, those who have a gag reflex, or who may have ingested a caustic or petroleum-based product

c. To insert an oropharyngeal airway in a pediatric patient.

i. Determine the appropriately sized airway.

ii. Confirm the correct size visually, by placing it next to the pediatric patient’s face.

iii. Position the pediatric patient’s airway with the appropriate method.

iv. Open the mouth. Insert the airway until the flange rests against the lips.

v. Reassess the airway.

3. Nasopharyngeal airway. 78286_CH32_SKDSK03_02

a. Usually well tolerated and not as likely to cause vomiting

b. Used for responsive pediatric patients

c. Used in association with possible respiratory failure

d. Rarely used in infants younger than 1 year

e. Should not be used in pediatric patients with nasal obstruction or head trauma

f. To insert a nasopharyngeal airway in a pediatric patient. 78286_CH32_SKDSK03_03

i. Determine the correct airway size by comparing its diameter to the opening of the nostril (nare).

ii. Place the airway next to the pediatric patient’s face to confirm correct length.

iii. Position the airway.

iv. Lubricate the airway. Insert the tip into the right naris with the bevel pointing toward the septum.

v. Carefully move the tip forward until the flange rests against the outside of the nostril.

vi. Reassess the airway.

g. Potential problems:

i. An airway with a small diameter may easily become obstructed by mucus, blood, vomitus, or the soft tissues of the pharynx.

ii. If the airway is too long, it may stimulate the vagus nerve and slow the heart rate, or enter the esophagus, causing gastric distention.

May cause a spasm of the larynx and result in vomiting if inserted into a responsive patient.
Nasopharyngeal airways should not be used when pediatric patients have facial trauma because the airway may tear soft tissues and cause bleeding into the airway.

J. Oxygen delivery devices

1. In treating infants and children who require more than the usual 21% oxygen found in room air, you have several options.

a. Blow-by technique at 6 L/min provides more than 21% oxygen concentration.

b. Nasal cannula at 1 to 6 L/min provides 24% to 44% oxygen concentration.

c. Nonrebreathing masks at 10 to 15 L/min provide up to 95% oxygen concentration.

d. BVM (with oxygen reservoir) at 10 to 15 L/min provides nearly 100% oxygen concentration.

2. Use of a nonrebreathing mask, nasal cannula, or a simple face mask is indicated only for pediatric patients who have adequate respirations and/or tidal volumes.

a. Children with respirations of fewer than 12 breaths/min or more than 60 breaths/min, and altered level of responsiveness, and/or an inadequate tidal volume, should receive assisted ventilations with a BVM.

3. Blow-by method

a. The blow-by method is not nearly as effective as a face mask or nasal cannula for delivering oxygen. $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\Ch34\9781284080179_CH34_CP05.jpg$

b. Does not provide high concentration of oxygen, but it is better than no oxygen.

c. Use this technique if the patient does not tolerate a mask or cannula.

d. Administering blow-by oxygen:

i. Place oxygen tubing through a small hole in the bottom of an 8-oz cup.

ii. Connect tubing to an oxygen source set at 6 L/min. $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\Ch34\9781284080179_CH34_CP06.jpg$

iii. Hold the cup approximately one to two inches away from the child’s nose and mouth.

4. Nasal cannula

a. Some pediatric patients prefer the nasal cannula; others find it uncomfortable.

b. Applying a nasal cannula:

i. Choose the appropriately sized pediatric nasal cannula. The prongs should not fill the nares entirely.

ii. Connect the tubing to an oxygen source set at 1 to 6 L/min.

5. Nonrebreathing mask

a. Delivers up to 90% oxygen to the pediatric patient and allows them to exhale all carbon dioxide without rebreathing it $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\Ch34\9781284080179_CH34_CP07.jpg$

b. Applying a nonrebreathing mask:

i. Select the appropriately sized pediatric nonrebreathing mask. The mask should extend from the bridge of the nose to the cleft of the chin.

ii. Connect the tubing to an oxygen source set at 10 to 15 L/min.

iii. Adjust oxygen flow as needed to match the respiratory rate and depth.

6. Bag-valve mask

a. Indicated for pediatric patients who have respirations that are either too slow or too fast, who are unresponsive, or who do not respond in a purposeful way to painful stimuli $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\Ch34\9781284080179_CH34_CP08.jpg$

b. Assisting ventilation using a BVM:

i. Ensure that you have the appropriate equipment in the right size. Masks should extend from the bridge of the nose to the cleft of the chin.

ii. Maintain a good seal with the mask on the face.

iii. Ventilate at the appropriate rate and volume using a slow, gentle squeeze. Stop squeezing and begin to release the bag as soon as the chest wall begins to rise, indicating that the lungs are filled to capacity.

7. One-person BVM ventilation on a pediatric patient

a. Open the airway and insert the appropriate airway adjunct.

b. Hold the mask on the pediatric patient’s face with a one-handed head tilt–chin lift maneuver (EC clamp method).

(d) Squeeze the bag using the correct ventilation rate of 1 breath every 3 to 5 seconds, or 12 to 20 breaths/min.

(e) Allow adequate time for exhalation.

(f) Assess the effectiveness of ventilation by watching bilateral rise and fall of the chest.

8. Two-person BVM ventilation on a pediatric patient

a. This procedure is similar to one-person BVM ventilation except that one rescuer holds the mask to the patient’s face and maintains the head position and the other ventilates.

b. Usually more effective in maintaining a tight seal, as it provides an open airway due to proper body position

K. Cardiopulmonary arrest

1. Cardiac arrest in infants and children is most often associated with respiratory failure and arrest.

a. Children are affected differently than adults when it comes to decreasing oxygen concentration.

i. Adults become hypoxic and the heart develops dysrhythmia that leads to sudden cardiac death.

(a) This is often in the form of ventricular fibrillation.

(b) AED is the treatment of choice.

ii. Children become hypoxic and their hearts slow down, becoming more bradycardic.

(a) The heart will beat slower and more weakly until no pulse is felt.

(b) The overall survival rate from cardiac arrest in the prehospital setting is about 8%.

(d) A child who is breathing very poorly with a slowing heart rate must be ventilated with high concentrations of oxygen early to try to oxygenate the heart before cardiac arrest occurs.

VII. Circulation Emergencies and Management

A. Shock

1. Shock is a condition that develops when the circulatory system is unable to deliver a sufficient amount of blood to the organs of the body.

a. Results in organ failure and eventually cardiopulmonary arrest

i. Compensated shock is the early stage of shock, when the body can still compensate for the blood loss.

ii. Decompensated shock is the later stage of shock, when the blood pressure is falling.

2. In pediatric patients, the most common causes of shock include:

a. Traumatic injury with blood loss

i. Especially abdominal

b. Dehydration from diarrhea or vomiting

c. Severe infection

d. Neurologic injury

i. Such as severe head trauma

e. A severe allergic reaction/anaphylaxis to an allergen

i. Insect bite or food allergy

f. Diseases of the heart

g. A collapsed lung

i. Tension pneumothorax

h. Blood or fluid around the heart

i. Cardiac tamponade

ii. Pericarditis

3. Pediatric patients respond differently than adults to fluid loss.

a. They may respond by increasing their heart rate, increasing their respirations, and showing signs of pale or blue skin.

4. Signs of shock in children are as follows:

a. Tachycardia

b. Poor capillary refill time (>2 seconds)

c. Mental status changes

5. Begin treating shock by assessing the ABCs, intervening as required.

a. If there is an obvious life-threatening external hemorrhage, the order becomes CAB, because bleeding control is the most critical step.

b. If cardiac arrest is suspected, the order also becomes CAB because chest compressions are essential.

c. Pediatric patients in shock often have increased respirations but do not demonstrate a fall in blood pressure until shock is severe.

d. In assessing circulation, pay attention to the following:

i. Pulse

(a) Assess rate and quality of pulses. A weak, “thready” pulse is a sign of a problem. Anything over 160 beats/min suggests shock.

ii. Skin signs

(a) Assess temperature and moisture of hands and feet.

iii. Capillary refill time

(a) A 2-second capillary refill time is normal.

iv. Color

(a) Assess skin color.

v. Changes

(a) Changes in pulse rate, color, skin signs, and capillary refill time are all important clues suggesting shock.

vi. Blood pressure is the most difficult vital sign to measure in pediatric patients.

(a) Blood pressure may be normal with compensated shock.

(b) Low blood pressure is a sign of decompensated shock requiring ALS and rapid transport.

vii. Assessment should also include talking with the parents or caregivers to determine when signs and symptoms first appeared and whether any of the following occurred:

Decreased urine output
Absence of tears
Sunken fontanelle
Changes in level of responsiveness and behavior

e. Limit your management to these simple interventions.

f. Do not waste time performing field procedures.

g. Ensure the airway is open and prepare for artificial ventilation.

h. Control bleeding.

i. Give supplemental oxygen by mask or blow-by method.

j. Continue to monitor the airway and breathing.

k. Position the pediatric patient in a position of comfort.

l. Keep the patient warm with blankets and by turning up the heat in the patient compartment.

m. Provide immediate transport.

n. Contact ALS backup as needed.

6. Anaphylaxis

a. Anaphylaxis, also called anaphylactic shock, is a life-threatening allergic reaction that involves a generalized, multisystem response to an antigen.

i. Characterized by airway swelling and dilation of blood vessels

ii. Common causes are insect stings, medications, or food.

b. Signs and symptoms of anaphylactic shock in the pediatric patient:

i. Hypoperfusion

ii. Stridor and/or wheezing

iii. Increased work of breathing

iv. Altered appearance

v. Restlessness, agitation, and sometimes a sense of impending doom

vi. Hives are usually present.

c. Treatment of pediatric patient with anaphylactic shock:

i. Maintain the airway and administer oxygen via a tolerated route.

ii. In stable patients, allow the parent or caregiver to assist in the positioning of the patient, oxygen delivery, and keeping the patient calm.

iii. Based on protocol, assist with epinephrine auto-injector, if available.

Pediatric epinephrine auto-injector is supplied in a dose of 0.15 mg and is given intramuscularly in the lateral thigh.

iv. Provide rapid transport.

B. Bleeding disorders

1. Hemophilia is a congenital condition in which the patient lacks one or more of the normal clotting factors of blood.

a. Most forms are hereditary and are severe.

b. Predominantly found in male population.

c. Bleeding may occur spontaneously.

d. All injuries become serious because blood does not clot.

i. Transport immediately.

ii. Do not delay applying a tourniquet for life-threatening hemorrhage.

VIII. Neurologic Emergencies and Management

A. Altered mental status (AMS)

1. AMS is an abnormal neurologic state in which the pediatric patient is less alert and interactive than is age appropriate.

a. Understanding normal developmental or age-related changes in behavior and listening carefully to the caregiver’s opinion are key.

b. A pediatric patient not behaving in a developmentally appropriate manner could indicate an altered mental status.

c. The mnemonic AEIOU-TIPPS reflects the major causes of AMS.

i. Alcohol

ii. Epilepsy

iii. Insulin

iv. Overdose

v. Underdose

vi. Trauma

vii. Infection

viii. Psychosis

ix. Stroke

d. Signs and symptoms vary from simple confusion to coma.

e. Management focuses on the ABCs and transport.

i. If the level of responsiveness is low, the pediatric patient may not be able to protect his or her airway.

(a) Ensure a patent airway and adequate breathing through a nonrebreathing mask or a BVM.

ii. Transport to the hospital.

B. Seizures

1. A seizure is the result of disorganized electrical activity in the brain.

a. Common causes of seizures:

i. Child abuse

ii. Electrolyte imbalance

iii. Fever

iv. Hypoglycemia

v. Infection

vi. Ingestion

vii. Lack of oxygen

viii. Medications

ix. Poisoning

x. Seizure disorder

xi. Recreational drug use

xii. Head trauma

xiii. No cause can be found

b. May manifest in a variety of ways, depending on the age of the child.

c. Seizures in infants can be very subtle, consisting only of an abnormal gaze, sucking motions, or “bicycling” motions.

d. In older children, seizures are more obvious and typically consist of repetitive muscle contractions and unresponsiveness.

i. Once a seizure stops, the patient’s muscles relax, becoming almost flaccid or floppy, and the breath becomes labored.

(a) This is the postictal state.

ii. The longer and more intense the seizures are, the longer it will take for this imbalance to correct itself.

(a) Once the pediatric patient regains a normal level of responsiveness, the postictal state is over.

e. Seizures that continue every few minutes without regaining responsiveness in between or last longer than 30 minutes are referred to as status epilepticus.

f. Recurring or prolonged seizures should be considered potentially life threatening.

i. If the patient does not regain responsiveness or continues to seize, protect the patient from harming himself or herself and call for ALS backup.

(a) These patients need advanced airway management and medication to stop the seizure.

2. Management

a. Securing and protecting the airway are your priorities.

i. Position the head to open the airway.

ii. Clear the mouth with suction.

iii. Consider placing the pediatric patient in the recovery position if he or she is vomiting and suction is inadequate.

b. Provide 100% oxygen by nonrebreathing mask or blow-by method.

i. Begin BVM ventilations if there are no signs of improvement.

ii. Some caregivers will have given the child a rectal dose of diazepam (Diastat) prior to your arrival; monitor breathing and level of responsiveness carefully.

iii. Transport to the appropriate facility.

C. Meningitis

1. Inflammation of tissue (meninges) that covers the spinal cord and brain.

a. Caused by an infection by bacteria, viruses, fungi, or parasites.

b. If left untreated, it can lead to brain damage or death.

2. Being able to recognize a pediatric patient with meningitis is an important skill to have.

a. Some individuals are at greater risk:

i. Males

ii. Newborn infants

iii. Children with compromised immune systems from AIDS or cancer

iv. Children who have any history of brain, spinal cord, or back surgery

v. Children who have had head trauma

vi. Children with shunts, pins, or other foreign bodies within their brain or spinal cord

(a) Especially children with ventriculoperitoneal (VP) shunts

3. Signs and symptoms of meningitis vary, depending on the age of the patient.

a. Fever and altered level of responsiveness are common symptoms in all ages.

i. Changes in the level of responsiveness can range from a mild or severe headache to confusion, lethargy, and/or an inability to understand commands or interact appropriately.

b. Children may also experience a seizure, which may be the first sign of meningitis.

c. Infants younger than two to three months can have apnea, cyanosis, fever, a distinct high-pitched cry, or hypothermia.

d. “Meningeal irritation” or “meningeal signs” are terms used by doctors to describe the pain that accompanies movement.

i. Often results in a characteristic stiff neck.

e. One sign of meningitis in an infant is increasing irritability and a bulging fontanelle without crying.

4. Neisseria meningitidis is a bacterium that causes a rapid onset of meningitis symptoms, often leading to shock and death.

a. Children with N. meningitidis typically have small, pinpoint, cherry-red spots or a larger purple/black rash on the face or body. $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\Ch34\9781284080179_CH34_CP09.jpg$

i. These children are at serious risk of sepsis, shock, and death.

5. All pediatric patients with suspected meningitis should be considered contagious.

a. Follow standard precautions when dealing with pediatric patients with possible meningitis and follow up to learn the patient’s diagnosis.

b. If exposed to saliva or respiratory secretions, you should receive antibiotics.

6. Treatment of child with suspected meningitis:

a. Provide supplemental oxygen and assist with ventilation if needed.

b. Reassess vital signs frequently during transport to a higher level of service available.

IX. Gastrointestinal Emergencies and Management

A. Never take a complaint of abdominal pain lightly, because a large amount of bleeding may occur within the abdominal cavity without any outward signs of shock.

1. Monitor for signs and symptoms of shock, including an altered mental status; pale, cool skin; tachypnea; tachycardia; and bradycardia.

B. Complaints of gastrointestinal origin are common in pediatric patients.

1. May be from ingestion of certain foods or unknown substances

2. In most cases, the pediatric patient will be experiencing abdominal discomfort with nausea, vomiting, and/or diarrhea.

a. Vomiting and diarrhea can cause dehydration.

3. Appendicitis is also common.

a. If untreated, can lead to peritonitis or shock

i. Peritonitis is an inflammation of the peritoneum, which lines the abdominal cavity.

b. Will typically present with a fever and pain on palpation of the right lower abdominal quadrant.

c. Rebound tenderness is a common sign associated with appendicitis.

4. If you suspect appendicitis, promptly transport the patient to the hospital for further evaluation.

5. Obtain a thorough history from the primary caregiver. In particular, ask questions such as:

a. How many wet diapers has the child had today?

b. Is your child tolerating liquids, and is he or she able to keep them down?

c. How many times has your child had diarrhea and for how long?

d. When he or she cries, are tears present?

X. Poisoning Emergencies and Management

A. Poisoning is common among children.

1. Can occur by ingesting, inhaling, injecting, or absorbing a toxic substance

2. Common sources of poisoning in children are:

a. Alcohol

b. Aspirin and acetaminophen

c. Cosmetics

d. Household cleaning products such as bleach and furniture polish

e. Houseplants

f. Iron

g. Prescription medications

h. Illicit (street) drugs

i. Vitamins

3. Signs and symptoms of poisoning vary widely, depending on the substance and the age and weight of the child.

a. The patient may appear normal at first, or may be confused, sleepy, or unconscious.

b. Some substances only take one pill to be lethal in a small child.

4. Be alert for signs of abuse.

5. After you have completed your primary assessment, ask the parent or caregiver the following questions:

a. What is the substance(s) involved?

b. Approximately how much of the substance was ingested or involved in the exposure?

c. What time did the incident occur?

d. Are there any changes in behavior or level of responsiveness?

e. Was there any choking or coughing after the exposure?

6. Contact Poison Control for assistance in identifying poisons.

7. Treatment of a poisoned pediatric patient:

a. First perform an external decontamination.

i. Remove tablets or fragments from the patient’s mouth.

ii. Wash or brush poison from the skin.

b. Assess and maintain ABCs and monitor breathing.

i. Provide oxygen and perform ventilations if necessary.

c. If a child demonstrates signs of shock, position supine, keep the child warm, and transport promptly.

d. In some cases, give activated charcoal, according to medical control or local protocol.

i. Not indicated for pediatric patients who have ingested an acid, an alkali, or a petroleum product.

ii. Not recommended for pediatric patients who have a decreased level of responsiveness and cannot protect their own airway, or who are unable to swallow.

iii. Some common trade names for the suspension form are Insta-Char, Actidose, and Liqui-Char.

iv. The usual dose for a child is 1 g of activated charcoal per kilogram of body weight; pediatric dose is 12.5 to 25 g.

XI. Dehydration Emergencies and Management

A. Dehydration occurs when fluid losses are greater than fluid intake.

1. Vomiting and diarrhea are the most common causes of dehydration.

a. If left untreated, dehydration can lead to shock and death.

2. Infants and children are at greater risk than adults for dehydration because their fluid reserves are smaller than those in adults.

a. Life-threatening dehydration can overcome an infant in a matter of hours.

3. Dehydration can be mild, moderate, or severe.

4. Signs of mild dehydration:

a. Dry lips and gums $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\Ch34\9781284080179_CH34_CP10.jpg$

b. Decreased saliva

c. Few wet diapers

5. Signs of moderate dehydration:

a. Sunken eyes

b. Sleepiness

c. Irritability

d. Loose skin

e. Sunken fontanelles

6. Signs of severe dehydration:

a. Mottled, cool, clammy skin

b. Delayed capillary response time

c. Increased respirations

B. Treating dehydration in the pediatric patient:

1. Assess ABCs, obtain baseline vital signs.

a. If dehydration is severe, ALS backup may be necessary for IV access.

2. Transport to the ED if signs are moderate to severe.

XII. Fever Emergencies and Management

A. Simply defined, a fever is an increase in body temperature, usually in response to an infection.

1. Temperatures of 100.4°F (38°C) or higher are considered abnormal.

2. Fever is rarely life threatening, but fever with a rash can be a sign of a serious condition, such as meningitis.

3. Common causes of fever in pediatric patients include:

a. Infection

b. Status epilepticus

c. Cancer

d. Drug ingestion (aspirin)

e. Arthritis

f. Systemic lupus erythematosus (rash across nose)

g. High environmental temperature

4. Fever is the result of an internal body mechanism in which heat generation is increased and heat loss is decreased.

5. An accurate body temperature is an important vital sign for pediatric patients.

a. A rectal temperature is the most accurate for infants to toddlers.

b. Older children will be able to follow directions for placing a thermometer under the tongue or arm.

6. Depending on the source of infection, the pediatric patient may present with signs of respiratory distress; shock; a stiff neck; a rash; skin that is hot to the touch; flushed cheeks; seizures; and, in infants, bulging fontanelles.

a. Assess the patient for other signs and symptoms such as nausea, vomiting, diarrhea, decreased feedings, and headache.

7. Provide rapid transport and manage the patient’s ABCs.

a. Follow standard precautions if you suspect the patient may have a communicable disease.

b. Remove the child's clothes and sponge with tepid water.

B. Febrile seizures

1. Febrile seizures are common in children between the ages of 6 months and 6 years.

a. Most pediatric seizures are the result of fever alone, which is why they are called febrile seizures.

b. Typically occur on the first day of a febrile illness

c. Characterized by generalized tonic-clonic seizure activity

d. Last fewer than 15 minutes with little or no postictal state

e. May be a sign of a more serious problem, such as meningitis

2. Assess ABCs, provide cooling measures with tepid water, and provide prompt transport.

a. All patients with febrile seizures need to be seen in the hospital setting.

XIII. Drowning Emergencies and Management

A. In drowning emergencies, you must always take steps to ensure your own safety.

1. Drowning is the second-most-common cause of unintentional death among children aged 1 to 4 years in the United States.

a. Children often fall into swimming pools and lakes, but many drown in bathtubs and even puddles or buckets of water.

b. Older adolescents drown when swimming or boating; alcohol is frequently a factor.

2. Principal condition that results from drowning is lack of oxygen.

a. Even a few minutes without oxygen affects the heart, lungs, and brain.

i. Causes life-threatening problems such as cardiac arrest, respiratory failure, and coma

b. Submersion in icy water can lead to hypothermia.

i. Most people in this situation die.

c. Diving into water increases the risk of neck and spinal cord injuries.

3. Signs and symptoms will vary based on the type and length of submersion.

a. A pediatric patient may present with:

i. Coughing

ii. Choking

iii. airway obstruction

iv. difficulty breathing

v. AMS

vi. seizure activity

vii. Unresponsiveness

viii. fast, slow, or no pulse

ix. pale, cyanotic skin

x. abdominal distention

B. Management of drowning emergencies

1. Assess and manage ABCs.

2. Contact the ALS crew to intervene if needed.

3. Administer 100% oxygen via nonrebreathing mask or BVM if assisted ventilations are required.

a. Be prepared to suction as these patients often vomit.

4. If trauma is suspected, apply a cervical collar and place the patient on a longboard.

a. Pad all open spaces under the pediatric patient before securing the patient onto the board.

5. Perform CPR on unresponsive patients in cardiopulmonary arrest.

XIV. Pediatric Trauma Emergencies and Management

A. Unintentional injuries are the number one killer of children in the United States.

1. Quality of care in the first few minutes after a child has been injured can have an enormous impact on that child’s chances for complete recovery.

2. The muscles and bones of children continue to grow well into adolescence.

a. For this reason, coupled with their risk-taking approach to activities, adolescents are prone to fractures of the extremities.

3. A fracture of the femur is rare in pediatric patients, but when it does occur, it is a source of major blood loss.

4. Older children and adolescents are prone to long bone fractures (femur and humerus) because they tend to take more risks during physical activities.

B. Physical differences

1. Children are smaller than adults, and therefore the location of their injuries may differ from that of an adult’s for the same type of crash.

2. Children’s bones and soft tissues are less well developed than those of an adult’s, and therefore the force of an injury affects these structures differently.

a. Because a child’s head is proportionally larger than an adult’s, it exerts greater stress on the neck structures during a deceleration injury.

C. Psychological differences

1. Children are often injured because of their underdeveloped judgment and their lack of experience.

2. Always assume the child has serious head and neck injuries.

D. Injury patterns

1. It is important for the EMT to understand the special physical and psychological characteristics of children and what makes them more likely to have certain kinds of injuries.

2. Vehicle collisions

a. Children playing or riding a bicycle can dart out in front of motor vehicles without looking.

i. The area of greatest injury varies, depending on the size of the child and the height of the bumper at the time of impact.

b. Children involved in these types of injuries typically sustain high-energy injuries to the head, spine, abdomen, pelvis, or legs.

3. Sport activities

a. Children, especially those who are older or adolescents, are often injured in organized sports activities.

b. Head and neck injuries can occur after high-speed collisions in contact sports such as football, wrestling, ice hockey, field hockey, soccer, or lacrosse.

c. Remember to immobilize the cervical spine when caring for children with sport-related injuries.

i. Be familiar with your local protocols for helmet removal.

E. Injuries to specific body systems

1. Head injuries

a. Head injuries are common in children because the size of a child’s head in relation to the body is larger than that of an adult.

b. An infant also has a softer, thinner skull, which may result in injury to the brain tissue.

c. The scalp and facial vessels can bleed very easily and may cause a great deal of blood loss if not controlled.

d. Nausea and vomiting are common signs and symptoms of a head injury in children.

i. Easy to mistake for abdominal injury or illness

ii. You should suspect a serious head injury in any child who experiences nausea and vomiting after a traumatic event.

e. Spinal motion restriction (SMR)

i. Spinal motion restriction is necessary for all children who have possible head or spinal injuries after a traumatic event.

ii. SMR in pediatric patients.

(a) Use a towel under the back, from the shoulders to the hips, to maintain the head in a neutral position.

(b) Apply an appropriately sized cervical collar.

(d) Secure the torso first.

(e) Secure the head.

(f) Ensure that the child is strapped in properly.

iii. Immobilization can be difficult because of the child’s body proportions.

(a) Young children require padding under the shoulders to maintain a neutral position.

(b) At around 8 to 10 years of age, children no longer require padding underneath the torso. They can lie supine on the backboard.

(c) Padding will be required along the sides so the child can be properly secured on an adult-sized backboard. 78286_CH32_SKDSK07_02

iv. Steps for SMR a pediatric patient in a car seat.

(a) Stabilize the head in a neutral position.

(b) Place a short backboard or pediatric immobilization device between the patient and the surface he or she is resting on.

(d) Place a towel under the back, from the shoulders to the hips, to ensure neutral head position.

(e) Secure the torso first; pad any voids.

(f) Secure the head to the short backboard or pediatric immobilization device.

2. Chest injuries

a. Usually the result of blunt rather than penetrating trauma $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\Ch34\9781284080179_CH34_CP11.jpg$

b. Chest wall flexibility in children can produce a flail chest.

i. Keep this in mind as you assess a child who has sustained high-energy blunt trauma to the chest.

ii. Even though there may be no external sign of injury, there may be injuries within the chest such as a contusion on the lungs.

iii. Pediatric patients are managed in the same manner as adults.

3. Abdominal injuries

a. Abdominal injuries are common in children.

i. Children can compensate for significant blood loss better than adults without signs or symptoms of shock developing.

ii. Children can have a serious injury without early external evidence of a problem.

b. All children with abdominal injuries should be monitored for signs and symptoms of shock, including a weak, rapid pulse; cold, clammy skin; decreased capillary refill; confusion; and decreased systolic blood pressure.

c. If the patient shows signs and symptoms of shock, prevent hypothermia by keeping the patient warm with blankets.

i. If the patient has bradycardia, ventilate.

d. Monitor during transport.

4. Burns

a. Burns to children are generally considered more serious than burns to adults.

i. Infants and children have more surface area relative to total body mass, which means greater fluid and heat loss.

ii. Children also do not tolerate burns as well as adults do.

iii. Children are also more likely to go into shock, develop hypothermia, and experience airway problems.

b. The most common ways in which children are burned are:

i. Exposure to hot substances, such as scalding water in the bathtub

ii. Hot items on a stove

iii. Exposure to caustic substances such as cleaning solvents or paint thinners

iv. Older children are more likely to be burned by flames from fire.

(a) You should expect possible internal injuries when you see a child with burns around the mouth and face.

c. Infection is a common problem following a burn injury in a child.

i. Burned skin cannot resist infection as effectively as normal skin can.

ii. Sterile techniques should be used in handling the skin of children with burn wounds if possible.

d. You should consider the possibility of child abuse in any burn situation.

i. Make sure you report any information about suspicions to the appropriate authorities.

e. Severity of burns:

i. Minor: Partial-thickness burns involving less than 10% of body surface.

ii. Moderate: Partial-thickness burns involving 10% to 20% of body surface.

iii. Severe: Any full-thickness burn; a partial-thickness burn involving more than 20% of body surface; or any burn involving the hands, feet, face, airway, or genitalia.

f. Pediatric patients are managed in the same manner as adults.

i. If the patient shows signs and symptoms of shock, prevent hypothermia by keeping him or her warm with blankets.

ii. If the patient has bradycardia, ventilate.

iii. Monitor the patient during transport.

5. Injuries of the extremities

a. Children have immature bones with active growth centers.

b. Growth of long bones occurs from the ends at specialized growth plates.

i. Growth plates are potential weak spots.

ii. Incomplete or greenstick fractures can occur.

c. Generally, extremity injuries in children are managed in the same manner as those in adults.

i. Painful deformed limbs with evidence of broken bones should be splinted.

(a) Specialized splinting equipment should only be used if it fits the pediatric patient.

(b) You should not attempt to use adult immobilization devices on a pediatric patient unless the pediatric patient is large enough to properly fit.

6. Pain management

a. The first step in pain management is recognizing that the patient is in pain.

b. Since some pediatric patients will be nonverbal or have a limited vocabulary, look for visual clues and use the Wong-Baker FACES pain scale.

c. You are limited to the following pain interventions:

i. Positioning $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\Ch34\9781284080179_CH34_CP12.jpg$

ii. Ice packs

iii. Extremity elevation

d. These interventions will decrease the pain and swelling to the injury site.

i. Additional ALS interventions may be needed.

e. Another important tool is kindness and providing emotional support.

XV. Disaster Management

A. The JumpSTART triage system was developed for pediatric patients.

1. Intended for patients younger than age 8 years and weighing less than 100 lb.

2. There are four triage categories in the JumpSTART system, designated by colors corresponding to different levels of urgency.

3. Decision points include:

a. Able to walk (except in infants)

i. Green tag: minor, not in need of immediate treatment

b. Presence of spontaneous breathing, with a peripheral pulse, and appropriately responsive to painful stimuli

i. Yellow tag: delayed treatment

c. Apnea responsive to positioning or rescue breathing, respiratory failure, breathing but without a pulse, or inappropriate painful response.

i. Red tag: immediate response

d. Apneic and without pulse, or apneic and unresponsive to rescue breathing

i. Black tag: considered deceased or expectant deceased

XVI. Child Abuse and Neglect

A. Child abuse means any improper or excessive action that injures or otherwise harms a child or infant.

1. Includes physical abuse, sexual abuse, neglect, and emotional abuse

2. Over half a million children are victims of child abuse annually.

a. Many of these children suffer life-threatening injuries and some die.

b. If suspected child abuse is not reported, the abuse is likely to happen again, perhaps causing permanent injury or even death.

i. Must be aware of the signs of child abuse and neglect

ii. It is your responsibility to report it to law enforcement or child protection agencies.

B. Signs of abuse

1. As an EMT you will be called to homes because of reported injury to a child.

2. Child abuse occurs in every socioeconomic status, so you must be aware of the patient’s surroundings and document your findings objectively.

a. You may be called to testify in abuse cases; it is essential to record all findings, including any statements made by caregivers or others on the scene.

3. Ask yourself the following questions:

a. Is the injury typical for the developmental level of the child?

b. Is the MOI reported consistent with the injury?

c. Is the parent or caregiver behaving appropriately?

d. Is there evidence of drinking or drug use at the scene?

e. Was there a delay in seeking care for the child?

f. Is there a good relationship between the caregiver and the child?

g. Does the child have multiple injuries at different stages of healing?

h. Does the child have any unusual marks or bruises that may have been caused by cigarettes, grids, or branding injuries?

i. Does the child have several types of injuries?

j. Does the child have any burns on the hands or feet that involve a glove distribution?

k. Is there an unexplained decreased level of responsiveness?

l. Is the child clean and an appropriate weight for his or her age?

m. Is there any rectal or vaginal bleeding?

n. What does the home look like? Clean or dirty? Is it warm or cold? Is there food?

4. The mnemonic CHILD ABUSE may help you remember the points to look for.

Possible Child Abuse Mnemonic
C	Consistency of the injury with the child’s developmental age
H	History inconsistent with the injury
I	Inappropriate parental concerns
L	Lack of supervision
D	Delay in seeking care

A	Affect
B	Bruises of varying ages
U	Unusual injury patterns
S	Suspicious circumstances
E	Environmental clues

5. Bruises

a. Observe the color and location of any bruises.

i. New bruises are pink or red.

ii. Over time, bruises turn blue, then green, then yellow-brown and faded.

iii. Note the location of bruises.

(a) Bruises to the back, buttocks, or face are suspicious and are usually inflicted by a person.

6. Burns

a. Burns to the penis, testicles, vagina, or buttocks are usually inflicted by someone else.

b. Burns that encircle a hand or foot to look like a glove are usually inflicted by someone else.

i. You should suspect abuse if the child has cigarette burns or grid pattern burns.

7. Fractures

a. Fractures of the humerus or femur do not normally occur without major trauma.

b. Falls from a bed are not usually associated with fractures.

i. You should maintain some index of suspicion if an infant or young child sustains a femur fracture.

ii. A complete fracture of the bone in a pediatric patient indicates that the child was exposed to a great deal of traumatic force.

8. Shaken baby syndrome

a. Infants may sustain life-threatening head trauma by being shaken or struck in the head.

i. This life-threatening condition is called shaken baby syndrome.

ii. There is bleeding within the head and damage to the cervical spine as a result of intentional, forceful shaking.

iii. The infant will be found unconscious, often without evidence of external trauma.

(a) Infant may appear to be in cardiopulmonary arrest.

b. Shaking tears blood vessels in the brain, resulting in bleeding around the brain.

i. The pressure from the blood results in an increased cranial pressure, leading to coma and/or death.

9. Neglect

a. Physical neglect is the refusal or failure on the part of the caregiver to provide life necessities.

i. Examples are water, clothing, shelter, personal hygiene, medicine, comfort, and personal safety.

b. Children who are neglected are often dirty, too thin, or appear developmentally delayed because of lack of stimulation.

i. You may observe such children when you are making calls for unrelated problems.

ii. Report all suspected cases of neglect.

C. Symptoms and other indicators of abuse

1. Abused children may appear withdrawn, fearful, or hostile.

a. You should be concerned if a child does not want to discuss how an injury occurred.

2. Occasionally, the parent or caregiver will reveal a history of “accidents.”

a. Be alert for conflicting stories or a lack of concern from the caregiver.

b. The abuser may be a parent, caregiver, relative, or friend of the family.

3. EMTs in all states must report suspected abuse.

a. Most states have special forms to do so.

b. Supervisors are generally forbidden to interfere with the reporting of suspected abuse.

c. Law enforcement and child protection services will determine whether there is abuse.

i. It is not your job to prove that there is abuse.

ii. If suspected abuse in a residence is reported to you, call law enforcement and wait in the ambulance for their arrival.

D. Sexual abuse

1. Children of any age and of either gender can be victims of sexual abuse.

a. Maintain an index of suspicion regardless of the patient’s social or economic situation.

i. This type of abuse is often the result of longstanding abuse by relatives.

2. Assessment

a. Should be limited to determining the type of dressing any injuries require.

b. Treat any bruises or fractures as well.

c. Do not examine the genitalia of a young child unless there is evidence of bleeding or there is any injury that must be treated.

d. Do not allow the child to wash, urinate, or defecate before a physician completes a physical examination.

i. Difficult step, but important to preserve evidence

e. Ensure that an EMT or police officer of the same gender remains with the child, unless locating one will delay transport.

f. Maintain professional composure the entire time.

i. Assume a concerned, caring approach.

ii. Shield the child from onlookers and curious bystanders.

g. Obtain as much information as possible from the child and any witnesses.

i. Children may be hysterical or unwilling to say anything.

ii. You are in the best position to obtain the most accurate firsthand information.

(a) Record any information carefully and completely on the patient care report.

h. Transport all children who are victims of sexual assault.

i. Sexual abuse is a crime.

i. Cooperate with law enforcement officials in their investigations.

XVII. Sudden Infant Death Syndrome

A. The death of an infant or a young child is called sudden infant death syndrome (SIDS) when, after a complete autopsy, the death remains unexplained.

1. About 3,500 infants die of SIDS annually.

a. The American Academy of Pediatrics recommends that a baby be placed on his or her back on a firm mattress in a crib that is free of bumpers, blankets, and toys.

b. The CDC recommends having the baby sleep in the same room, but not the same bed, chair, or sofa, as an adult.

c. Place the baby on their backs for naps and at night until they are one year old. Once babies can roll back and forth from their back to their tummy on their own, you can leave them in whatever position they like.

2. Although it is impossible to predict SIDS, risk factors include:

a. Mother younger than age 20 years

b. Mother smoked during pregnancy

c. Low birth weight

3. Death as the result of SIDS can occur at any time of day.

4. You will encounter three tasks:

a. Assessment of the scene

b. Assessment and management of the patient

c. Communication and support of the family

B. Create a safe place for baby to sleep

a. Choose a firm mattress and fitted sheet for the baby's crib. Remove toys, blankets, pillows, bumper pads and other accessories from the crib.

b. Share your room, not your bed. Place the baby's crib or bassinet in your bedroom instead of letting the baby sleep in the same bed with you.

c. Practice safe sleep for naps and at night. Even after late-night feedings, return the baby to their own crib or bassinet before you are ready to go to sleep.

C. Patient assessment and management

1. An infant who has been a victim of SIDS will be pale or blue, not breathing, and unresponsive.

2. Other causes for such a condition include the following:

a. Overwhelming infection

b. Child abuse

c. Airway obstruction from a foreign object or as a result of infection

d. Meningitis

e. Accidental or intentional poisoning

f. Hypoglycemia (low blood glucose level)

g. Congenital metabolic defects

3. Begin with assessment of the ABCs.

a. Provide interventions as necessary.

b. Depending on how much time has passed, patient may show signs of postmortem changes, including:

i. Stiffening of the body, called rigor mortis.

ii. Dependent lividity, which is pooling of the blood in the lower parts of the body or those that are in contact with the floor or bed.

c. If a child shows these signs, call medical control.

i. In some EMS systems, a victim of SIDS may be declared dead on the scene.

ii. Deciding whether to start CPR on a child with rigor mortis or dependent lividity can be very difficult.

(a) Family members may consider anything less to be withholding critical care.

iii. Best solution may be to begin CPR and transport the child and family to the nearest ED.

d. If there is no sign of postmortem changes, begin CPR immediately.

4. As you assess the patient, pay special attention to any marks or bruises on the child before performing any procedures.

a. Note any intervention that was done before your arrival.

D. Scene assessment

1. Carefully inspect the environment, noting the condition of the scene where the infant was found.

2. Your assessment of the scene should concentrate on the following:

a. Signs of illness, including medications, humidifiers, or thermometers

b. The general condition of the house

c. Signs of poor hygiene

d. Family interaction

i. Do not allow yourself to be judgmental about family interactions at this time.

ii. Do note and report any behavior that is clearly not within the acceptable range, such as physical and verbal abuse.

e. The site where the infant was discovered

i. Note all items in the infant’s crib or bed, including all pillows, stuffed animals, toys, and small objects.

E. Communication and support of the family after the death of a child

1. The sudden death of an infant is a devastating event for a family.

a. It also tends to evoke strong emotional responses among health care providers.

b. Part of your job at this point is to allow the family to express their grief.

2. In addition to any medical treatment the child may require, you must be prepared to offer the family a high level of empathy and understanding.

3. The family may want you to initiate resuscitation efforts, which may or may not conflict with your EMS protocols.

4. Always introduce yourself to the child’s parents or caregivers, and ask about the child’s date of birth and medical history.

5. Do not, in any case, speculate on the cause of the child’s death.

6. The family will want to see the child and should be asked whether they want to hold the child and say goodbye.

7. The following interventions are helpful in caring for the family at this time:

a. Learn and use the child’s name rather than the impersonal “your child.”

b. Speak to family members at eye level, and maintain good eye contact with them.

c. Use the word “dead” or “died” when informing the family of the child’s death; euphemisms such as “passed away” or “gone” are ineffective.

d. Acknowledge the family’s feelings (“I know this is devastating for you,”), but never say “I know how you feel,” even if you have experienced a similar event; the statement will anger many people.

e. Offer to call other family members or clergy if the family wishes.

f. Keep any instructions short, simple, and basic. Emotional distress may limit their ability to process information.

g. Ask each adult family member individually whether he or she wants to hold the child.

h. Wrap the dead child in a blanket, as you would if he or she were alive, and stay with family members while they hold the child.

i. Ask them not to remove tubes or other equipment that was used in an attempted resuscitation.

8. Each individual and each culture expresses grief in a different way.

a. Some will require intervention.

b. Most caregivers feel directly responsible for the death of a child.

i. This does not mean they are actually responsible.

ii. Although you should keep the possibility of neglect or abuse in mind, your role is not that of investigator.

iii. Further inquiry is the responsibility of law enforcement.

9. Some EMS systems arrange for home visits after a child’s death so that EMS providers and family members can come to some sort of closure.

a. You need special training for such visits.

10. A child’s death can be very stressful.

a. Take time before going back to the job.

b. Talk with other EMS colleagues.

c. Be alert for signs of posttraumatic stress in yourself and others.

i. Nightmares

ii. Restlessness

iii. Difficulty sleeping

iv. Lack of appetite

d. Consider the need for professional help if these signs occur.

F. Apparent life-threatening event

1. Infants who are not breathing and are cyanotic and unresponsive when found sometimes resume breathing and color with stimulation.

a. These children have had what is called an apparent life-threatening event (ALTE).

i. Called “near-miss SIDS” in the past

b. Classic ALTE is characterized by:

i. A distinct change in muscle tone

ii. Choking or gagging

c. After the event, the child may appear healthy and show no signs of illness or distress.

i. You must complete a careful assessment and provide rapid transport to the ED.

d. Pay strict attention to airway management.

e. Assess the infant’s history and environment.

f. Allow caregivers to ride in the back of the ambulance.

g. Physicians will have to determine the cause.

Chapter 35, Geriatric Emergencies

Unit Summary

After completing this chapter and related coursework, you will understand the physiological and psychological changes that occur with the aging process. You will also learn and understand the types of illness and injuries common to the geriatric population. You will understand the GEMS triangle, use of advance directives, and signs and symptoms of elder abuse.

National EMS Education Standard Competencies

Special Patient Populations

Applies a fundamental knowledge of growth, development, and aging and assessment findings to provide basic emergency care and transportation for a patient with special needs.

Geriatrics

• Impact of age-related changes on assessment and care

• Changes associated with aging, psychosocial aspects of aging, and age-related assessment and treatment modifications for the major or common geriatric diseases and/or emergencies

Cardiovascular diseases
Respiratory diseases
Neurologic diseases
Endocrine diseases
Alzheimer’s disease
Dementia

Patients With Special Challenges

• Recognizing and reporting abuse and neglect (Chapter 34, “Pediatric Emergencies”)

Health care implications of:

• Abuse (Chapter 34, “Pediatric Emergencies”)

• Neglect (Chapter 34, “Pediatric Emergencies”)

• Homelessness (Chapter 36, “Patients With Special Challenges”)

• Poverty (Chapter 36, “Patients With Special Challenges”)

• Bariatrics (Chapter 36, “Patients With Special Challenges”)

• Technology dependence (Chapter 36, “Patients With Special Challenges”)

• Hospice/terminally ill (Chapter 36, “Patients With Special Challenges”)

• Tracheostomy care/dysfunction (Chapter 36, “Patients With Special Challenges”)

• Homecare (Chapter 36, “Patients With Special Challenges”)

• Sensory deficit/loss (Chapter 36, “Patients With Special Challenges”)

• Developmental disability (Chapter 36, “Patients With Special Challenges”)

Trauma

Applies fundamental knowledge to provide basic emergency care and transportation based on assessment findings for an acutely injured patient.

Special Considerations in Trauma

• Recognition and management of trauma in the

Pregnant patient (Chapter 33, “Obstetrics and Neonatal Care”)
Pediatric patient (Chapter 34, “Pediatric Emergencies”)
Geriatric patient

• Pathophysiology, assessment, and management of trauma in the

Pregnant patient (Chapter 33, “Obstetrics and Neonatal Care”)
Pediatric patient (Chapter 34, “Pediatric Emergencies”)
Geriatric patient
Cognitively impaired patient (Chapter 36, “Patients With Special Challenges”)

Knowledge Objectives

1. Define the term “geriatrics.”

2. Recognize some of the special aspects of the lives of older people.

3. Discuss generational considerations when communicating with a geriatric patient.

4. Describe the common complaints and the leading causes of death in older people.

5. Discuss the physiologic changes associated with the aging process and the age-related assessment and treatment modifications that result.

6. Explain the GEMS diamond and its role in the assessment and care of the geriatric patient.

7. Explain special considerations when performing the patient assessment process on a geriatric patient with a medical condition.

8. Define polypharmacy and the toxicity issues that can result.

9. Discuss the effect of aging on psychiatric emergencies.

10. Explain special considerations when performing the patient assessment process on a geriatric patient with a traumatic injury.

11. Discuss the effects of aging on environmental emergencies.

12. Explain special considerations when responding to calls to nursing and skilled care facilities.

13. Define an advance directive and explain its use with older patients.

14. Describe the prevalence of elder abuse and neglect; include why the extent of elder abuse is not well known.

15. Explain the assessment and care of a geriatric patient who has potentially been abused or neglected.

16. Recognize acts of commission or omission by a caregiver that result in harm, potential harm, or threat of harm to a geriatric patient.

Skill Objectives

There are no skill objectives for this chapter.

I. Introduction

A. Geriatrics is the assessment and treatment of disease in a person who is 65 years or older.

1. The baby boomer generation, people born between 1946 and 1964, are more active and fit than people their age were in previous generations.

2. 65 years is used as the threshold age to be consistent with the definition used by other medical groups and governmental agencies.

3. How fast one ages is a function of genetics, lifestyle, and, perhaps, attitude.

4. The older population is growing to a larger percentage of the overall population.

B. Geriatric patients present a special challenge for health care providers because the classic presentation of injuries and illness are often altered by the presence of chronic conditions, multiple medications, and the physiology of aging.

1. Many of the elderly have a combination of different diseases in various stages.

2. As the older population increases, communities, companies, and hospitals are encouraging awareness of geriatric issues.

II. Generational Considerations

A. It is important to understand and appreciate how the life of an older person might differ from yours.

1. Older people may have recently lost a spouse, face financial difficulties, or be struggling to stay independent.

B. It takes time and patience to interact with an older person.

1. Have patience and treat the patient with respect.

2. Make every attempt to avoid ageism, the stereotyping of older people that often leads to discrimination.

a. Not all older people have dementia.

b. Not all older people are hard of hearing.

c. Not all older people are sedentary or immobile.

3. Older people can stay fit and be active, even though they are not able to perform at the same level as they did in their youth.

III. Communication and Older Adults

A. Effective verbal communication skills are essential to the successful assessment and treatment of older patients.

1. The aging process brings with it changes in vision, hearing, taste, smell, touch, and pain sensation.

2. Changes in communication abilities accompany aging, such as dementia and other diseases.

B. Communication techniques

1. Your first words to the patient and the attitude behind them can gain or lose a patient’s trust.

a. Speak respectfully when you introduce yourself.

b. Address the patient by using “sir” or “ma’am.”

c. If you know the patient’s last name, use “Mr.,” “Mrs.,” or “Ms.”

d. Never use familiar or casual terms when referring to your patients unless they have invited you to do so.

2. When you interview an older patient, the following techniques should be used:

a. Identify yourself.

b. Be aware of how you present yourself.

c. Look directly at the patient at eye level and ensure good lighting, especially when the patient has diminished sight.

d. Speak slowly and distinctly.

e. Have one person talk to the patient and ask only one question at a time.

f. Do not assume that all older patients are hard of hearing.

g. Give the patient time to respond unless the condition appears urgent.

h. Listen to the answer the patient gives you.

i. Explain what you will do before you do it.

j. Do not talk about the patient in front of him or her as though the patient is not there.

IV. Common Complaints and the Leading Causes of Death in Older People

A. The changing physiology of geriatric patients can predispose this population to a host of problems not seen in youth.

1. A simple rib fracture in an 80- or 90-year-old can result in pneumonia or even death.

2. A hip fracture from a low-mechanism fall is common in older people and may have dire consequences.

a. Hip fractures are more likely to occur when bones are weakened by osteoporosis or infection.

b. Sedentary behavior while healing can predispose the patient to pneumonia and blood clots.

B. The most common conditions in geriatric patients are:

1. Hypertension

2. Arthritis

3. Heart disease

4. Cancer

5. Diabetes mellitus

6. Asthma

7. Chronic bronchitis or emphysema

8. Stroke

C. The leading causes of death in the geriatric population include:

1. Heart disease

2. Cancer

3. Chronic lower respiratory disease

4. Stroke

5. Alzheimer disease

5. Diabetes mellitus

6. Influenza and pneumonia

V. Changes in the Body

A. Human growth and development peaks in the late 20s and early 30s, at which point the aging process begins.

1. The process of aging is gradual and starts much earlier than most people realize.

2. The aging process can vary dramatically from one person to another.

B. The aging process is inevitably accompanied by changes in physiologic function, such as a decline in the function of the liver and kidneys.

1. All tissues in the body undergo aging.

2. The decrease in the functional capacity of various organ systems is normal but can affect the way in which a patient responds to illness.

3. Do not mistake the changes for signs of illness and give treatment when none is necessary.

a. At the other end of the spectrum, do not attribute genuine disease symptoms to “just getting old” and neglect their treatment.

VI. Changes in the Respiratory System

A. Anatomy and physiology

1. Age-related changes can predispose an older adult to respiratory illness.

2. One of the conditions contributing to respiratory infections is weakening of the airway musculature, which can cause decreased breathing capacity.

a. Older patients have less help from muscles in the chest wall when they have trouble breathing.

b. They also have a decreased cough reflex.

3. The alveoli in lung tissue can become enlarged and the elasticity decreases, making it harder to expel used air.

4. The body’s chemoreceptors, which monitor the changes in oxygen and carbon dioxide levels in the blood, slow with age, causing the body to respond more slowly to hypoxia.

B. Pathophysiology

1. Pneumonia

a. Chronic lower respiratory disease, influenza, and pneumonia are in the top five causes of geriatric deaths.

b. Pneumonia is an inflammation/infection of the lung from bacterial, viral, or fungal causes.

c. It is the leading cause of death from infection in Americans older than 65 years.

d. Aging causes some immune suppression and increases the risk of contracting infections like pneumonia.

e. Increased mucus production, pulmonary secretions, and the inflammatory effects of infection all interfere with the ability of the alveoli to oxygenate the blood.

f. Management of pneumonia is the same for any patient; however, maintain a high index of suspicion for any geriatric patient with signs and symptoms of pneumonia.

g. Remember to wear respiratory protection when assessing a patient with a potentially infectious respiratory disease.

2. Pulmonary embolism

a. Pulmonary embolism is a condition that causes a sudden blockage of an artery by a venous clot.

b. A patient with a pulmonary embolism will present with hypoxia or shortness of breath and sometimes chest pain.

i. It can be confused with cardiac, lung, or musculoskeletal conditions.

c. Risk factors include:

i. Living in a nursing home or recent hospitalization for medical illness or surgery

ii. Trauma

iii. Cancer

iv. History of blood clots or heart failure

v. Presence of a pacemaker or central venous catheter

vi Paralyzed extremities

vii. Obesity

viii. Recent long-distance travel

ix. Sedentary behavior

d. Patients present with:

i. Tachycardia

ii. Sudden onset of dyspnea

iii. Shoulder, back, or chest pain

iv. Cough

v. Syncope in patients in whom the clot is larger

vi. Anxiety

vii. Apprehension

viii. Low-grade fever

ix. Hemoptysis

x. Leg pain, redness, and unilateral pedal edema

xi. Fatigue

xii. Cardiac arrest (worst-case scenario)

e. Treatment should focus on airway, ventilatory, and circulatory support.

i. Any blood that is coughed up should be cleared from the airway.

ii. Supplemental oxygen is mandatory.

VII. Changes in the Cardiovascular System

A. Anatomy and physiology

1. A variety of changes occur in the cardiovascular system as a person grows older, with the net effect of a decrease in the efficiency of the system.

a. The heart hypertrophies with age, probably in response to the chronically increased afterload imposed by stiffened blood vessels.

b. Over time, cardiac output declines, mostly as a result of a decreasing stroke volume.

c. Arteriosclerosis (a disease that causes the arteries to thicken, harden, and calcify) contributes to systolic hypertension, which places an extra burden on the heart.

2. Some changes in cardiovascular performance are probably not a direct consequence of aging, but rather reflect the deconditioning effect of a sedentary lifestyle.

a. Many people tend to limit physical activity and exercise as they grow older.

B. Pathophysiology

1. With aging, a person’s ability to speed up contractions, increase contraction strength, and constrict or narrow blood vessels is decreased because of stiffer vessels.

a. As stroke volume is reduced, cardiac output decreases.

b. The heart may lose its ability to raise cardiac output to meet the needs of the body.

2. Geriatric patients are at risk for atherosclerosis, an accumulation of fat and cholesterol in the arteries.

a. Major complications include myocardial infarction and stroke.

b. Affects more than 60% of people older than 65 years

c. Atherosclerosis makes stroke, heart disease, hypertension, and bowel infarction more likely.

3. Older people are also at an increased risk of formation of an aneurysm, an abnormal, blood filled dilation of the wall of a blood vessel.

a. Severe blood loss can occur when an aneurysm ruptures.

4. The blood vessels themselves become stiff, which results in a higher systolic blood pressure.

5. Other anatomic changes include stiffening and degeneration of the heart valves, which may impede normal blood flow in and out of the heart.

a. Aging also alters the heart’s electrical conduction system.

b. This can cause a heart rate that is too fast, too slow, or too erratic to provide effective blood flow to the body.

6. Orthostatic hypotension is a drop in blood pressure with a change in position.

a. The body is less able to adapt to rapid postural changes.

7. Another vessel-related problem is called venous stasis.

a. Refers to the loss of proper function of the veins in the legs that would normally carry blood back to the heart

b. Causes blood clots in the superficial veins (superficial phlebitis) and blood clots in the deep veins (deep venous thrombosis)

c. Deep vein thrombosis can lead to pulmonary embolism.

d. People with this condition usually exhibit edema, or swelling, of the legs and ankles.

e. Eventually causes a reddish-brown discoloration on the skin and, in some cases, skin ulcers

8. Heart attack (myocardial infarction)

a. The classic symptoms of a heart attack are often not present in geriatric patients.

i. “Silent” heart attacks are particularly common in women and people with diabetes.

ii. A silent heart attack is a heart attack that has either no symptoms, minimal symptoms or unrecognized symptoms.

b. Any of the following symptoms may be a manifestation of acute cardiac disease in older patients:

i. Dyspnea

ii. Epigastric and abdominal pain

iii. Loss of bladder and bowel control

iv. Nausea and vomiting

v. Weakness, dizziness, lightheadedness, and syncope

vi. Fatigue

vii. Confusion

c. Other signs and symptoms that can indicate a cardiovascular problem include:

i. Issues with circulation

ii. Diaphoresis (profound sweating)

iii. Pale, cyanotic, or mottled skin

iv. Abnormal or decreased breath sounds

v. Increased peripheral edema

d. Obtain baseline vital signs.

i. This information will provide you with a primary picture of the severity of your patient’s condition.

ii. You can use these findings to measure against in your ongoing assessment of the patient.

f. Treatment mostly consists of airway, ventilatory, and circulatory support.

i. Give oxygen.

ii. Continue to evaluate.

iii. Cardiac problems can be expected to worsen suddenly, so be prepared.

9. Heart failure

a. The signs and symptoms will differ depending on the extent to which the right and/or left side of the heart is not functioning correctly.

b. Right-sided heart failure occurs when the fluid backs up into the body.

i. You will see jugular vein distention, ascites, and peripheral edema.

ii. An enlarged liver may also be present, which is determined by palpation.

iii. Right-sided heart failure is often caused by left-sided heart failure, so it is common to see signs of both.

c. With left-sided heart failure, fluid backs up into the lungs.

i. Causes pulmonary edema

ii. The patient will have severe shortness of breath and hypoxia with crackles in the lungs.

d. Paroxysmal nocturnal dyspnea is a condition that is characterized by a sudden attack of respiratory distress that wakes the person at night when he or she is reclining.

i. Caused by fluid accumulation in the lungs

ii. Patients report coughing, feeling suffocated, and cold sweats; you will notice tachycardia.

iii. If you suspect congestive heart failure, one question you can ask is, “Do you sleep sitting up?”

e. Treatment should consist of airway, ventilatory, and circulatory support.

10. Stroke

a. Stroke is a leading cause of death in older people.

b. Preventable risk factors include smoking, hypertension, diabetes, atrial fibrillation, obesity, and a sedentary lifestyle.

c. Uncontrollable factors include age, race, and gender.

d. Signs and symptoms include:

i. Acute altered level of responsiveness

ii. Numbness, weakness, or paralysis on one side of the body

iii. Slurred speech

iv. Difficulty speaking (aphasia)

v. Visual disturbances

vi. Headache and dizziness

vii. Incontinence

viii. Seizure

e. Hemorrhagic strokes, in which a broken blood vessel causes bleeding into the brain, are less common and more likely to be fatal.

f. Ischemic strokes occur when a blood clot blocks the flow of blood to a portion of the brain.

g. The treatment goal is to salvage as much of the surrounding brain tissue as possible.

h. Determining the onset of the symptoms of stroke is important.

i. If the symptoms occurred within the past few hours, the patient will be a candidate for stroke center therapy.

j. Transient ischemic attack (TIA) can present with the same signs and symptoms as a stroke; always manage the patient as if he or she is having a stroke.

VIII. Changes in the Nervous System

A. Anatomy and physiology

1. Changing in thinking speed, reaction time, memory, and posture stability are the most common normal findings in older people.

2. The brain decreases in terms of weight (10% to 20%) and volume as a person ages.

a. This increases the amount of space in the cranium, thus increasing the change for head injuries.

b. Head injuries with a minimal mechanism are commonly missed in older patients.

3. There is a 5% to 50% loss of neurons in older people.

a. Neurons are responsible for transmission of impulses, so the motor and sensory neural networks slow down with age.

b. This affects the control of the rate and depth of breathing, heart rate, blood pressure, hunger, thirst, and body temperature.

4. The performance of most of the sense organs declines with increasing age.

5. Vision

a. Visual acuity, depth perception, and the ability of the eyes to accommodate light change with age.

b. Cataracts, clouding of the lenses or their surrounding membranes, interfere with vision and make it difficult to distinguish colors and see clearly.

c. Decreased tear production leads to drier eyes.

d. Older people develop an inability to differentiate colors and have decreased night vision.

e. The inability to see up close is called presbyopia and it is caused by a loss of elasticity of the crystalline lens.

f. A number of other disease processes plague the vision of older adults, including:

i. Glaucoma - damage the optic nerve which is vital for good vision. This damage is often caused by an abnormally high pressure in your eye.

ii. Macular degeneration - Macular degeneration causes loss in the center of the field of vision.

iii. Retinal detachment - a thin layer of tissue (the retina) at the back of the eye pulls away from the layer of blood vessels that provides it with oxygen and nutrients. Retinal detachment is often accompanied by flashes and floaters in your vision.

6. Hearing

a. Typical hearing problems cause changes in the inner ear and make hearing high-frequency sounds difficult.

b. Changes in the ear can also cause problems with balance and make falls more likely.

c. Presbycusis is a gradual hearing loss that occurs as we age.

d. Heredity and long-term exposure to loud noises are the main factors that contribute to hearing loss.

e. When assessing your patient, check for the use of hearing aids and that they are functioning.

7. Taste

a. The sense of taste can be diminished because of a decrease in the number of taste buds.

b. The negative result might be lessened interest in eating, which can lead to:

i. Weight loss

ii. Malnutrition

iii. Complaints of fatigue

8. Touch

a. An older person may have a decreased sense of touch and pain perception from the loss of the end nerve fibers.

b. This loss can create situations in which an older person may be injured and not know it.

i. Specifically, there is a decreased sensation of hot and cold.

B. Pathophysiology

1. Dementia

a. Dementia is the slow onset of progressive disorientation, shortened attention span, and loss of cognitive function.

b. It is a chronic, generally irreversible condition that causes a progressive loss of cognitive abilities, psychomotor skills, and social skills.

c. Dementia is the result of many neurologic diseases and may be caused by:

i. Alzheimer disease - diagnosed by evaluation of signs and symptoms and conducting several tests.

ii. Parkinson disease

iii. Cerebrovascular accidents

iv. Genetic factors

d. Determine the patient’s normal mental status by questioning family members or friends; evaluate history, risk factors, and current medications.

e. On assessment, the patient might exhibit loss of cognitive function.

i. Patients may have short- and long-term memory problems and a decreased attention span, or they may be unable to perform their daily routines.

ii. They also may show a decreased ability to communicate and appear confused.

f. Other aspects of dementia can complicate your ability to assess and manage the patient.

i. Sometimes patients are not only confused, but angry as well.

ii. They will have impaired judgment.

iii. They may be unable to vocalize areas of pain and current symptoms.

iv. They may be unable to follow commands.

g. Patients with dementia may express anxiety over movement out of their current residence.

i. You must exercise extreme tolerance and patience.

2. Delirium

a. Delirium is a sudden change in mental status, responsiveness, or cognitive processes.

b. Marked by the inability to focus, think logically, and maintain attention.

i. Short term memory loss may be related to the patient’s inability to focus.

ii. Long term memory usually remains intact.

c. Delirium affects 15% to 50% of hospitalized people aged 70 years or older.

d. Acute anxiety may be present in addition to the other symptoms.

e. This condition is generally the result of a reversible physical ailment, such as tumors or fever, or metabolic causes.

f. Other important things to look for in the history are:

i. Intoxication or withdrawal from alcohol

ii. Withdrawal from sedatives

iii. Medical conditions such as urinary tract infections, bowel obstructions, dehydration, fever, cardiovascular disease, and hyper- or hypoglycemia

iv. Psychiatric disorders such as depression

v. Malnutrition or vitamin deficiencies

vi. Environmental emergencies

g. Assess and manage the patient for:

i. Hypoxia

ii. Hypovolemia

iii. Hypoglycemia

iv. Hypothermia

h. Critical BLS and ALS interventions may include supplemental oxygen, treatment of shock, glucose, and rewarming measures.

i. During the physical examination, you may see changes in circulation, breath sounds, motor function, and pupillary response.

i. Hypotension can indicate hypovolemia.

ii. Dilated pupils could suggest hypoxia.

iii. Wheezing, crackles, and rhonchi

j. Treatment should include airway, ventilatory, and circulatory support and oxygen with airway adjuncts.

3. Syncope (fainting)

a. Always assume that this is a life-threatening problem until proven otherwise.

b. Syncope is often caused by an interruption of blood flow to the brain.

c. An older person who has a period of unresponsiveness should be examined to determine the cause of the syncope.

4. Neuropathy

a. A disorder of the nerves of the peripheral nervous system in which function and structure of the peripheral motor, sensory, and autonomic neurons are impaired

b. Symptoms depend on whether the nerves affected are motor, sensory, or autonomic and where the nerves are located.

c. Motor nerves

i. Muscle weakness

ii. Cramps

iii. Spasms

iv. Loss of balance

v. Loss of coordination

d. Sensory nerves

i. Tingling

ii. Numbness

iii. Itching

iv. Pain

v. Burning, freezing, or extreme sensitivity to touch

e. Autonomic nerves

i. Changes in blood pressure and heart rate

ii. Constipation

iii. Bladder and sexual dysfunction

IX. Changes in the Gastrointestinal System

A. Anatomy and physiology

1. Changes in the mouth include a reduction in the volume of saliva, with a resulting dryness of the mouth.

a. Dental loss is widespread in the older population and contributes to nutritional and digestive problems.

b. These oral changes increase the risk of choking.

2. Like oral secretions, gastric secretions are reduced as a person ages.

a. Enough acid is still present to produce ulcers under certain conditions.

b. Changes in gastric motility also occur, which may lead to slower gastric emptying.

3. Function of the small and large bowel changes little as a consequence of aging.

a. The incidence of certain diseases involving the bowel increases as a person grows older.

b. Nutrients from food are not as readily absorbed.

4. Blood flow to the liver declines.

a. The activity of the enzyme systems involved with the detoxification of drugs declines as a person ages.

B. Pathophysiology

1. Age-related changes in the gastrointestinal (GI) system include:

a. Issues with dental problems

b. Decrease in saliva and sense of taste, leading to poor nutrition

c. Poor muscle tone of the smooth muscle sphincter between the esophagus and stomach that can cause regurgitation and lead to heartburn and acid reflux

d. A decrease in hydrochloric acid in the stomach

e. Alterations in absorption of nutrients and slowing peristalsis

f. Weakening of the rectal sphincter

2. Changes in the liver predispose older patients to a number of problems.

a. The liver, which is responsible for removing toxins and breaking down drugs in the body, shrinks with age.

b. Blood flow to the liver declines, and there is decreased metabolism.

c. This has a direct effect on how medications may affect the patient.

3. GI bleeding issues that affect older people are:

a. GI bleeding caused by

i. Inflammation

ii. Infection

iii. Obstruction of the upper or lower GI tract

b. Usually heralded by hematemesis

c. Bleeding that travels through the lower digestive tract usually manifests as melena (black, tarry stools).

d. Red blood usually means a local source of bleeding, such as hemorrhoids.

e. A patient with GI bleeding may experience weakness, dizziness, or syncope.

f. Bleeding in the GI system can be life threatening.

4. Specific GI problems that are more common in older patients include:

a. Diverticulitis

i. A condition in which the walls of the gut weaken and small pouches protrude from the colon along those weakened segments

ii. Inflammation develops in one of these pouches

iii. A geriatric patient generally presents with left lower quadrant pain and fever.

b. Bleeding in the upper and lower GI system

i. Upper GI bleeding occurs in the esophagus, stomach, or duodenum.

ii. Irritation of the lining of the stomach or ulcers can cause forceful vomiting that tears the esophagus.

iii. Long-term use of nonsteroidal anti-inflammatory drugs, hepatitis, and cancer can contribute to bleeding problems.

iv. Lower GI bleeding occurs in the colon or rectum.

c. Peptic ulcer disease

i. More common in older adults, especially people who use NSAIDs

ii. The patient will complain of a gnawing, burning pain in the upper abdomen that improves after eating but returns later.

iii. Complications include bleeding, anemia, and bowel perforation.

d. Gallbladder disease

i. More common in older adults, and they have a higher risk of complications from gallstones

ii. Patients will present with fever and right upper quadrant pain that may radiate to the shoulder.

iii. Patients may also present with jaundice.

e. Bowel obstruction

i. The ability of the GI tract to move feces through the system slows with aging, and patients can experience problems having bowel movements.

ii. When patients are straining to have a bowel movement, they can stimulate the vagus nerve, which can cause a vasovagal response.

iii. This is a condition in which the heart rate drops dramatically and the patient becomes dizzy or passes out.

5. When assessing patients, ask about NSAID and alcohol use.

a. Presentation can include:

i. Pale or yellow, thin skin

ii. Frail musculoskeletal system

iii. Peripheral, sacral, and periorbital edema

iv. Hypertension

v. Fever

vi. Tachycardia

vii. Dyspnea

6. Orthostatic vital signs can help determine if a patient is hypovolemic.

a. Blood pressures and pulse rates are obtained with the patient lying, sitting, and standing.

b. Note any drop in blood pressure and increase in heart rate that occurs as the patient moves to an upright position.

c. Do not attempt to assess orthostatic vitals on a patient with obvious signs of shock, hypotension, altered level of responsiveness, or possible spinal injury.

7. Treatment consists of airway, ventilatory, and circulatory support; oxygen should be delivered with adjuncts appropriate to the patient’s condition.

8. The acute abdomen—non-gastrointestinal complaints

a. Abdominal complaints in geriatric patients are extremely difficult to assess.

b. In the prehospital setting, the most serious threat from abdominal complaints is blood loss, which can lead to shock and death.

c. Abdominal aortic aneurysm (AAA) is one of the most rapidly fatal conditions.

i. AAA tends to develop in people who have a history of hypertension and atherosclerosis.

ii. The walls of the aorta weaken, and blood begins to leak into the layers of the vessel, causing the aorta to bulge like a bubble on a tire.

iii. If enough blood is lost into the vessel wall itself, shock occurs.

iv. If the vessel wall bursts, it rapidly leads to fatal blood loss.

v. A patient with an AAA most commonly reports abdominal pain radiating through to the back with occasional flank pain.

vi. If you see or palpate a pulsating mass just above and slightly to the left of the navel, do not continue manipulation or allow other providers to palpate the mass.

vii. Treat the patient for shock, including high-flow oxygen and thermal regulation, and provide prompt transport to the hospital.

X. Changes in the Renal System

A. Anatomy and physiology

1. The largest component of the urinary system are the kidneys or renal organs.

2. Age-related changes in the genitourinary system specific to the kidney include:

a. A reduction in renal function

b. A reduction in renal blood flow

c. Tubule degeneration

3. For the genitourinary system in general, there is:

a. Decreased bladder capacity

b. Decline in sphincter muscle control

c. Decline in voiding senses

d. Increase in nocturnal voiding

e. Benign prostatic hypertrophy (enlarged prostate)

4. The kidneys are responsible for maintaining the body’s fluid and electrolyte balance and have important roles in maintaining the body’s long-term acid–base balance and eliminating drugs from the body.

a. The kidneys decline in weight as a person ages.

b. Renal blood flow decreases by as much as 50%.

B. Pathophysiology

1. Acute illness in older patients is often accompanied by derangements in fluid and electrolyte balance.

2. Bowel and bladder continence require anatomically correct GI and genitourinary tracts, functioning and intact sphincters, and properly working cognitive and physical functions.

a. Incontinence is not a normal part of aging and can lead to skin irritation, skin breakdown, and urinary tract infections.

b. As people age, the capacity of the bladder decreases.

c. Two major types of incontinence are distinguished: stress and urge.

i. Stress incontinence occurs during activities such as coughing, laughing, sneezing, lifting, and exercise.

ii. Urge incontinence is triggered by hot or cold fluids, running water, and even thinking about going to the bathroom.

d. Treatment consists of medications, physical therapy, and possibly surgery.

3. The opposite of incontinence is urinary retention or difficulty urinating.

a. In men, enlargement of the prostate can place pressure on the urethra, making voiding difficult.

b. Bladder and urinary tract infections can also cause inflammation.

c. In severe cases of urinary retention, patients may experience renal failure.

XI. Changes in the Endocrine System

A. Anatomy and physiology

1. The endocrine system functions as the control center of the body.

2. A significant change that occurs in an older person is decreased metabolism of thyroxine.

3. Thyroxine affects the body’s metabolism, temperature, growth, and heart rate.

a. A reduction in thyroid hormones can cause a condition called hypothyroidism.

4. Most of the signs and symptoms people experience are attributed to the process of aging and include:

a. Slower heart rate

b. Fatigue

c. Drier skin and hair

d. Cold intolerance

e. Weight gain

5. Other endocrine changes include:

a. An increase in the secretion of antidiuretic hormone, causing fluid imbalance

b. Hyperglycemia

c. Increases in the levels of norepinephrine, possibly having a harmful effect on the cardiovascular system

B. Pathophysiology

1. Hyperosmolar hyperglycemic nonketotic syndrome (HHNS) is a diabetic complication in older people and occurs more often in people with type 2 diabetes.

2. The signs and symptoms of HHNS and diabetic ketoacidosis often overlap.

a. Hyperglycemia

b. Polydipsia (thirst)

c. Polyuria (urination)

d. Polyphagia (hunger)

e. Dizziness

f. Confusion

g. Altered mental status

h. Seizures

3. On assessment, you may see changes in circulation such as:

a. Warm, flushed skin

b. Poor skin turgor

c. Pale, dry, oral mucosa

d. Furrowed tongue

4. The patient may present with signs and symptoms of hypotension and shock, including tachycardia.

5. The blood glucose level will be variable in DKA, whereas in HHNS, the value is typically 600 mg/dL or higher.

6. DKA will present with Kussmaul respirations, while HHNS will not.

7. Assessment of the patient should include:

a. Obtaining blood pressure

b. Distal pulses

c. Auscultation of breath sounds

d. Temperature

e. Assessment of blood glucose level (if permitted by local protocol)

8. Treatment should include airway, ventilatory, and circulatory support; provide oxygen with adjuncts appropriate to the patient’s condition.

XII. Changes in the Immune System

A. Infections are commonly seen in older people because they generally have an increased risk of infection and are less able to fight infections once they occur.

1. Many older patients may be unable to develop a fever, and in fact may be hypothermic as a manifestation of severe systemic infection.

2. Anorexia, fatigue, weight loss, falls, or changes in mental status may be the primary symptoms of infection in these patients.

3. Pneumonia and urinary tract infection are common in patients who are bedridden.

4. When infection occurs, signs and symptoms may be decreased or minimized by the patient because of the:

a. Loss of sensation

b. Lack of awareness

c. Fear of being hospitalized

XIII. Changes in the Musculoskeletal System

A. Anatomy and physiology

1. Aging brings a widespread decrease in bone mass in men and women, but especially among postmenopausal women.

a. Bones become more brittle and tend to break more easily.

b. The disks between the vertebrae of the spine begin to narrow, and a decrease in height of between 2″ and 3″ may occur through the lifespan, along with changes in posture.

c. Joints lose their flexibility and may be further immobilized by arthritic changes.

d. A decrease in the amount of muscle mass often results in less strength.

B. Pathophysiology

1. Changes in physical abilities can affect older adults’ confidence in their mobility.

a. Muscle fibers become smaller and fewer.

b. Motor neurons decrease in number.

c. Strength declines.

d. Ligaments and cartilage of the joints lose their elasticity.

e. Cartilage goes through degenerative change.

2. The stooped posture of older people comes from atrophy of the supporting structures of the body.

a. Two of every three older patients will show some degree of kyphosis.

b. Lost height in older adults generally results from compression in the spinal column.

3. Osteoporosis, a condition that affects men and women, is characterized by a decrease in bone mass leading to reduction in bone strength and greater susceptibility to fracture.

a. The extent of bone loss that a person undergoes is influenced by numerous factors, including:

i. Genetics

ii. Smoking

iii. Level of activity

iv. Diet

v. Alcohol consumption

vi. Hormonal factors

vii. Body weight

b. The most rapid loss of bone occurs in women during the years following menopause.

i. Many postmenopausal women use hormone replacement therapy as a means to reduce the loss of bone.

c. Calcium and vitamin D supplementation is another treatment for the condition, and many other medications are available to improve bone strength.

4. Osteoarthritis is a progressive disease of the joints that destroys cartilage, promotes the formation of bone spurs in joints, and leads to joint stiffness.

a. Results from wear and tear and, in some cases, from repetitive trauma to the joints

b. Affects 35% to 45% of the population older than 65 years

c. Affects several joints of the body, most commonly those in the hands, knees, hips, and spine

d. Patients complain of pain and stiffness that gets worse with exertion.

e. Patients are typically treated with anti-inflammatory medications and physical therapy.

XIV. Changes in Skin

A. The proteins that make the skin pliable decline with age.

1. The layer of fat under the skin also becomes thinner because of the redistribution of fluids and proteins.

2. Bruising becomes more common because the skin can tear more easily.

3. Exocrine (sweat) glands do not respond as readily to heat because of atrophy and changes to the tissues of the dermal layer of the skin.

B. Another problem that affects the skin is pressure ulcers, sometimes referred to as bedsores or decubitus ulcers.

1. The pressure from the weight of the body cuts off the blood flow to the area of skin.

2. With no blood flow to the skin, a sore develops.

3. To help prevent these ulcers, take special care to pad under any bony prominences and in the voids in a patient who may be immobilized for an extended period.

4. You may see these ulcers in the following various stages of development:

a. Stage I: Non-blanching redness with damage under the skin

b. Stage II: Blister or ulcer that can affect the dermis and epidermis

c. Stage III: Invasion of the fat layer through to the fascia

d. Stage IV: Invasion to muscle or bone

5. Decubitus ulcers can be painful and cause complications such as bleeding, sepsis, and bone inflammation called osteomyelitis.

XV. Toxicology

A. Older people are more susceptible to toxicity because of:

1. Decreased kidney function

2. Altered GI absorption

3. Decreased vascular flow in the liver

B. The kidneys undergo many changes with age.

1. Decreased liver function makes it harder for the liver to detoxify the blood and eliminate substances such as medications and alcohol.

2. These metabolic issues can also make it difficult for physicians to find the appropriate dosage for new medications.

C. Typical OTC medicines used by older people include aspirin, antacids, cough syrups, and decongestants.

1. Many people believe OTC medications cannot be dangerous.

2. These medications can have negative effects when mixed with each other and/or with herbal substances, alcohol, and prescription medications.

D. Polypharmacy refers to the use of multiple prescription medications by one patient.

1. Patients may not remember what medications one doctor prescribed or may not want to tell one doctor about seeing another.

2. Negative effects can include overdosing and negative medication interaction.

3. Both overdose and underdose can lead to serious problems.

4. Medication noncompliance in older patients is also an issue and may occur because of:

a. Financial challenges

b. Inability to open containers

c. Impaired cognitive, vision, and hearing ability

XVI. Behavioral Emergencies

A. Depression

1. Depression is not part of normal aging, but rather a medical disease. This common, often debilitating psychiatric disorder affects millions of older Americans.

2. In contrast with the normal emotional experiences of sadness, grief, loss, and temporary bad moods, depression is extreme and persistent and can interfere significantly with an older adult’s ability to function.

3. Depression is treatable with medication and therapy.

4. If depression goes unrecognized or untreated, it is associated with a higher suicide rate in the geriatric population than in any other age group.

5. Risk factors for depression include:

a. History of depression

b. Chronic disease

c. Loss

6. The following conditions contribute to the onset of significant depression:

a. Substance abuse

b. Isolation

c. Prescription medication use

d. Chronic medical conditions

7. Treatment of severe depression in older adults usually consists of behavioral counseling, medication, or a combination of both.

B. Suicide

1. Most older adult suicide victims have recently been diagnosed with depression and have seen their primary care physician within the month before the event.

2. Older men have the highest suicide rate of any age group in the United States.

a. At highest risk are white men age 85 years and older who use firearms as their suicide method of choice.

b. Older persons who attempt suicide choose much more lethal means than younger victims and generally have diminished recuperative capacity to survive an attempt.

c. Unlike younger people, geriatric patients typically do not make suicidal gestures or attempt to get help.

d. Instead, the rate of completed suicide is disproportionately high in the geriatric population.

e. Many geriatric patients see no other way out when they have a terminal illness or debilitating cardiac or neurological condition (such as severe heart disease or stroke).

3. Some common predisposing events and conditions include:

a. Death of a loved one

b. Physical illness

c. Depression and hopelessness

d. Alcohol abuse

e. Alcohol dependence

f. Loss of meaningful life roles

4. When assessing the patient who is displaying signs of depression, it is appropriate to ask if he or she is considering suicide.

a. If the answer is “yes,” the next question should be, “Do you have a plan?”

b. Include this information in your report.

XVII. The GEMS Diamond

A. The GEMS diamond was created to help you remember what is different about older patients.

1. It is not intended to be a format for the approach to geriatric patients, nor is it intended to replace the ABCs of care.

2. Instead, it serves as an acronym for the issues to be considered when assessing every older patient.

B. “G” stands for geriatric patient.

1. Consider that older patients are different from younger patients and may present atypically.

2. Be familiar with the normal changes of aging and treat older patients with compassion and respect.

C. “E” stands for an environmental assessment.

1. Assessing the environment can help give clues to the patient’s condition and the cause of the emergency.

2. Preventive care is very important for a geriatric patient who may not carefully study the environment or may not realize where risks exist.

D. “M” stands for medical assessment.

1. Older patients tend to have a variety of medical problems and may be taking numerous prescriptions, over-the-counter, and herbal medications.

2. Obtaining a thorough medical history is very important.

E. “S” stands for social assessment.

1. Older people may have less of a social network because of the death of a spouse, family members, and friends.

2. Older people may also need assistance with activities of daily living.

3. Consider obtaining information pamphlets about some of the agencies for older people in your area.

XVIII. Special Considerations in Assessing a Geriatric Medical Patient

A. Assessing an older person can be challenging because of:

1. Communication issues

2. Hearing and vision deficits

3. Alteration in responsiveness

4. Complicated medical histories

5. Effects of medication

B. Scene size-up

1. Scene safety

a. Geriatric patients are commonly found in their own homes, retirement homes, or skilled nursing facilities.

i. Many older people live alone.

ii. Access to them may be hampered if their condition prevents them from getting to the door.

iii. Police or fire department assistance may be required.

b. Many older people try to maintain their independence as long as they can.

i. You need to take note of negative or unsafe environmental conditions.

ii. The patient may not be forthcoming about their medical condition, you have to look for clues that might explain the patient’s medical history or current problem.

c. In a nursing home or residential care facility, you will need to locate the patient’s room and find a staff member who can explain why you were called.

d. In any case in which the patient’s mental status is altered, you need to find someone who can tell you the patient’s history and whether the patient’s behavior or level of responsiveness is normal or altered.

2. Mechanism of injury/nature of illness

a. The NOI may be difficult to determine in older people who may have an altered mental status or dementia.

b. You must ask the family member, caregiver, or bystander why he or she called.

c. Multiple and chronic disease processes may also complicate the determination of the NOI.

d. Complaints from an older person may be vague.

e. Chest pain, shortness of breath, and an altered level of responsiveness should always be considered serious.

C. Primary assessment

1. Address life threats.

2. Determine the transport priority of your patient based on his or her condition and maintain a high index of suspicion for serious injuries even with mechanisms of injury that might seem minor in younger patients.

3. As you approach the patient, you should be able to tell if the patient is generally in stable or unstable condition.

a. Use the AVPU scale to determine the patient’s level of responsiveness.

4. Airway and breathing

a. Anatomic changes that occur as a person ages predispose geriatric patients to airway problems.

i. Aging and disease can compromise a patient’s ability to protect his or her airway with loss of a gag reflex and normal swallowing mechanisms.

ii. Changes in level of responsiveness, dementia, and poststroke weakness or paralysis can cause airway obstruction or aspiration.

b. Ensure that the patient’s airway is open and is not obstructed by dentures, vomitus, fluid, or blood.

c. Suction may be necessary.

d. Anatomic changes also affect a person’s ability to breathe effectively, including:

i. Increased chest wall stiffness

ii. Brittle bones

iii. Weakening of the airway musculature

iv. Decreased muscle mass

e. Loss of mechanisms that protect the upper airway, such as cough and gag reflexes, cause a decreased ability to clear secretions.

f. A decrease in the number of cilia that line the bronchial tree results in the inability of the patient to remove material from the lung, which can cause infection.

g. In some patients, the alveoli are damaged, and a lack of elasticity results in a decreased ability to exchange oxygen and carbon dioxide.

h. Airway and breathing issues should be treated with oxygen as soon as possible.

5. Circulation

a. Poor perfusion is a serious issue in an older adult.

b. Physiologic changes may negatively affect circulation.

i. Less-responsive nerve stimulation may lower the rate and strength of the heart’s contractions.

ii. Lower heart rates and weaker and irregular pulses are common in older patients.

c. Vascular changes and circulatory compromise might make it difficult to feel a radial pulse in an older patient.

d. Circulation problems in older adults should be treated with oxygen as soon as possible.

e. Determine if cardiac abnormalities in an older patient indicate an acute emergency or a chronic condition; acute emergencies should be managed rapidly.

6. Transport decision

a. Patient assessment is more complicated in an older adult, and multiple problems can exist.

b. Any complaints that compromise airway, breathing, or circulation should result in transportation of the patient as a priority patient.

c. Your most important task is to determine conditions that are life threatening, treat them to the best of your ability, and provide transport to priority patients.

d. Priority patients include patients who have:

i. Poor general impression

ii. Airway or breathing problems

iii. Acute altered level of responsiveness

iv. Shock

v. Severe pain

vi. Uncontrolled bleeding

e. Older people do not have the reserves that younger people do, and they will easily decompensate.

f. Consider early on if ALS treatment and immediate transport is appropriate and available.

D. History taking

1. Investigate the chief complaint.

a. Find and account for all medications.

b. Communication may be more complicated with an older adult, but it is critical that you obtain a thorough patient history.

c. The determination should be made early on as to whether the altered level of responsiveness is acute or chronic.

i. Chronic mental status impairment is not a normal process of aging but is caused by a pathologic or disease process; you should never accept confusion as normal.

ii. Older people may not show severe symptoms even if they are very ill.

d. Multiple disease processes and multiple and/or vague complaints can make assessment complicated.

i. Ask questions to assess the nature of the problem, and determine whether it may or may not be life threatening.

ii. Take a full set of vital signs; ask what is “normal” for that patient.

2. SAMPLE history

a. You may have to rely on a relative or caregiver to help you in collecting a SAMPLE history.

b. Note the signs you observe and your general impression.

c. Make sure you have a list of the patient’s medications or take the medications with you to the hospital, if possible.

d. The last meal is particularly important in a patient with diabetes, but negative nutrition can have a negative effect on a patient.

e. It is advantageous to provide transport to a facility that knows the patient’s medical history.

E. Secondary assessment

1. The secondary assessment may be performed on scene, en route to the emergency department, or not at all.

2. Physical examinations

a. Your older patient may not be comfortable with being exposed.

b. Protect his or her modesty.

c. Consider the need to keep your patient warm during the exam.

3. Vital signs

a. The heart rate should be in the normal adult range but may be compromised by medications such as beta-blockers.

b. Weak and irregular pulses are common in older patients.

c. Circulatory compromise may make it difficult to feel a radial pulse in an older patient, in that case palpate the carotid artery.

d. Blood pressure tends to be higher in older people.

e. Capillary refill is not a good assessment because of skin changes and reduced circulation to the skin.

f. The respiratory rate should be in the same range as in a younger adult, but remember that chest rise will be compromised by increased chest wall stiffness.

g. Be sure to auscultate breath sounds to listen for:

i. Crackles associated with pulmonary edema

ii. Rhonchi or rattles associated with pneumonia

iii. Wheezes associated with asthma

h. Monitoring devices

i. Careful interpretation of pulse oximetry data is necessary in older adults because the pulse oximetry device requires adequate perfusion to get an accurate reading.

ii. Adhesive probes might help confirm accuracy of the data.

iii. Determine what the patient’s normal blood pressure is; your baseline blood pressure and any change from the patient’s normal baseline can alert you to a potential problem.

F. Reassessment

1. Reassess the geriatric patient often because the condition of an older adult may deteriorate quickly.

2. Reassess the vital signs.

3. Reassess the patient’s complaint.

4. Recheck interventions.

5. Identify and treat changes in the patient’s condition.

6. Interventions

a. Accommodate positioning requests when possible, especially when a patient is experiencing shortness of breath.

b. Allow the patient to maintain a position of comfort, unless contraindicated.

c. Assist ventilation as needed.

d. Administer glucose for a patient with diabetes who has altered mental status and a manageable airway.

e. In specific cases, you may also assist with nitroglycerin, aspirin, or inhalers; pharmacologic interventions require medical direction and are based on local protocol

f. Administration of oxygen may be a useful therapy for many geriatric problems.

i. Be mindful of monitoring the level of responsiveness in a patient with COPD.

g. Be prepared to ventilate if breathing becomes inadequate.

h. Listen to your patient, respond to your patient, and provide reassurance.

7. Communication and documentation

a. Communicate your findings and the interventions you used to emergency department personnel.

b. Document all history, medication, assessment, and intervention information.

XIX. Trauma and Geriatric Patients

A. In general, the risk of serious injury or death is more common in older patients who experience trauma than in younger patients.

1. Conditions that create risk and complicate the assessment of geriatric patients:

a. Slower homeostatic compensatory mechanisms

b. Limited physiologic reserves

c. Normal effects of aging on the body

d. Existing medical issues

2. Physical findings in an older adult may be more subtle and more easily missed.

a. The mechanisms that cause serious injury in older people are usually much more minimal than in younger people.

b. Recuperation from trauma is longer and often less successful in older people.

c. Many injuries in older people are undertriaged and undertreated.

B. Because of changes in the body, older pedestrians are more likely to have life-threatening complications after being struck by a vehicle.

1. Older pedestrians commonly suffer injury to the legs and arms.

2. Other injuries can be caused by a secondary collision onto the street, often involving the head.

C. Older people are more likely to experience burns because of altered mental status, inattention, and a compromised neurologic status.

1. Risk of mortality from burns is increased when:

a. Pre Existing medical conditions exist

b. The immune system is weakened

c. Fluid replacement is complicated by renal compromise

D. There is higher mortality from penetrating trauma in older adults, especially in the case of gunshot wounds.

1. Penetrating trauma can easily cause serious internal bleeding.

E. Falls are the leading cause of fatal and nonfatal injuries in older adults.

1. Nearly half of fatal falls in geriatric patients result in traumatic brain injury.

F. Anatomic changes and trauma

1. Changes in pulmonary, cardiovascular, neurologic, and musculoskeletal systems make older patients more susceptible to trauma.

a. The brain shrinks, leading to higher risks of cerebral bleeding following head trauma.

b. Skeletal changes cause curvature of the upper spine that often requires additional padding during spinal immobilization.

c. Loss of strength, sensory impairment, and medical illness all increase the risk of falls.

2. A geriatric patient’s overall physical condition may lessen the ability of the patient’s body to compensate for the effects of even simple injuries.

a. A geriatric patient’s blood pressure drops sooner than in a younger adult patient during a traumatic emergency.

3. As a result of bone loss from osteoporosis, older patients of both sexes are prone to fractures, especially of the hip.

a. Hip fractures are much more common among women.

b. Contributing factors include:

i. Stresses of ordinary activity

ii. A standing fall

iii. Vitamin D and calcium deficiencies

iv. Metabolic bone diseases

v. Tumors

c. Injuries to the hip tend to be recurring.

d. Older patients with osteoporosis are also at risk for pelvic fractures.

e. Recovering from these kinds of injuries can be complicated for an older person.

4. With age, the spine stiffens as a result of shrinkage of disk spaces, and vertebrae become brittle.

a. Compression fractures of the spine are more likely to occur.

5. Because brain tissue shrinks with age, older patients are more likely to sustain closed head injuries, such as subdural hematomas.

a. Acute subdural hematomas are among the deadliest of all head injuries.

i. Tiny veins between the surface of the brain and its outer covering stretch and tear, allowing blood to collect.

ii. Blood fills the skull very rapidly, compressing brain tissue, which often results in brain injury.

b. Serious head injuries are often missed in older patients because the mechanism may seem relatively minor.

c. Other factors that predispose an older patient to a serious head injury include:

i. Long-term abuse of alcohol

ii. Recurrent falls or repeated head injury

iii. Anticoagulant medication

G. Environmental Injury

1. Internal temperature regulation slows with age owing to:

a. Slowed endocrine system

b. Slowed circulation

c. Decreased sweat production in the skin

d. Chronic disease, medication use, and alcohol use

2. Half of all deaths from hypothermia occur in older people; most indoor hypothermia deaths involve geriatric patients.

a. Living where harsh winters occur is a risk factor.

b. Hypothermia can also develop at temperatures above freezing when an older person is exposed for a prolonged period.

3. Death rates from hyperthermia more than double in older people compared with younger people; people older than 85 years are at highest risk.

XX. Special Considerations in Assessing Geriatric Trauma Patients

A. Trauma is never isolated to a single issue when you are assessing and caring for a geriatric patient.

B. Scene size-up

1. Scene safety

a. Ensure your own safety first.

b. Take standard precautions.

c. Consider the number of patients.

d. Determine if you need additional or specialized resources.

2. Mechanism of injury/nature of illness

a. Look for clues that indicate whether your patient’s traumatic incident may have been preceded by a medical incident.

b. Bystander information may help determine if a loss of responsiveness occurred.

c. MOI is important in establishing whether an injury is considered critical, and it affects treatment and transport considerations.

C. Primary assessment

1. Address life threats.

2. Determine the transport priority of the patient.

a. It is recommended that older trauma patients be transported to a trauma center.

3. Form a general impression.

a. As you approach the patient, you should be able to tell if he or she is generally in stable or unstable condition.

b. Determining neurologic status may be difficult if you do not know the patient’s baseline.

i. Try to get information from someone familiar with the patient, if possible.

c. Use the AVPU and the Glasgow Coma Scale to determine mental status.

i. An important consideration with any patient is the inability to remember the event.

4. Airway and breathing

a. If the patient is talking to you, the airway is patent.

b. Patients who have noisy respirations have airway compromise.

c. Older patients may have a diminished ability to cough, so suctioning is important.

d. Assess for the presence of dentures but do not remove them unless they are creating an airway patency problem.

e. In an unresponsive patient, open the airway with a modified jaw-thrust maneuver.

f. Perform a thorough respiratory assessment and physical assessment of the chest, and treat accordingly.

g. Use pulse oximetry to monitor oxygenation.

5. Circulation

a. Manage any external bleeding immediately.

b. Drinking alcohol and taking anticoagulant medications that can make internal bleeding worse or external bleeding more difficult to control.

c. Physiologic changes secondary to aging can worsen the effects of trauma.

d. Older people do not heal from trauma as easily as younger adults.

e. Older patients can more easily go into shock.

f. Patients who were hypertensive prior to injury may have a normal blood pressure when they are actually in shock.

D. History taking

1. Investigate the chief complaint.

a. Considerations in your assessment of the patient’s condition and stability must include past medical conditions, even if they are not currently acute or symptomatic.

E. Secondary assessment

1. Physical examinations

a. Should be performed on a geriatric trauma patient in the same manner as for any adult but with consideration of the higher likelihood of damage from trauma

b. Any head injury can be life threatening in an older adult.

c. When examining the chest, consider that breathing may be impaired.

d. Check lung sounds, and look to see if there is any evidence of pacemakers or previous cardiac surgery.

e. Decreased muscle size in the abdomen may mask abdominal trauma.

f. Look for bruising and other evidence of trauma.

g. Injury to the liver or spleen may present with diffuse abdominal pain, or pain may refer to the left shoulder.

2. Vital signs

a. Assess the pulse, blood pressure, and skin signs.

b. Capillary refill time is unreliable in older people because of compromised circulation.

c. Remember that some older people take beta-blockers, which will inhibit their heart from becoming tachycardic as you would expect in shock.

F. Reassessment

1. Repeat the primary assessment.

a. Remember that a geriatric patient has a higher likelihood of decompensating after trauma.

2. Interventions

a. Broken bones are common and should be splinted in a manner appropriate to the injury.

b. Effective application of conventional splints and backboards may be difficult or impossible unless a large amount of padding is used.

c. Trying to force a patient into a “normal” anatomic position can harm the patient.

d. In hip and pelvic fractures, avoid log rolling the patient.

e. In general, padding should be done for comfort and to help decrease the likelihood of decubitus ulcers forming.

f. Provide blankets and heat to prevent hypothermia.

3. Communication and documentation

a. Communication with older people can be challenging.

b. Provide psychological support as well as medical treatment.

c. Document assessment, treatment, and reassessment, including any changes in the patient’s status.

XXI. Assessment of Falls

A. Falls can be caused by a medical condition such as fainting, a cardiac rhythm disturbance, or a medication interaction.

1. Whenever you assess a geriatric patient who has fallen, it is important to find out why the fall occurred.

2. Consider that the fall may have been caused by a medical condition.

a. Look carefully for clues from the patient, bystanders, and the environment.

b. Consider that if a medical condition caused the fall, it may be life threatening.

XXII. Response to Nursing and Skilled Care Facilities

A. With many of your geriatric patients with whom you interact, the call will occur at a nursing home or other skilled care facility.

1. The kind of facility will depend on the type of care needed.

2. Nursing homes are facilities that serve patients who need 24-hour care and are sometimes a step down from an acute care hospital.

a. Patients require assistance with daily living and need therapeutic or rehabilitation services.

3. Calls to these types of facilities can sometimes be challenging.

a. Patients often have an altered level of responsiveness and may not be able to give you a nature of illness or mechanism of injury.

b. The staff is usually spread thin.

c. The most important piece of information you need to establish immediately is, “What is wrong with the patient that is new or different today that made you call 9-1-1?”

d. Talk to the staff who directly care for the patient on a daily basis.

e. With potentially limited information, you need to do an assessment to determine if the patient’s problem is life threatening and/or requires ALS-level care.

4. Infection control needs to be a high priority for EMTs when visiting these facilities.

a. Good handwashing and standard precautions can inhibit the spread of infectious pathogens to people who already have compromised immune systems.

b. An infection in an older patient can lead to life-threatening sepsis.

B. There are many risks to the patients and the EMTs.

1. Methicillin-resistant Staphylococcus aureus (MRSA) infections are common among people who are living in close quarters such as nursing homes.

a. The organism can be found in decubitus ulcers, on feeding tubes, and on indwelling urinary catheters.

b. Can cause mild infections on the skin or invade the bloodstream, lungs, or the urinary tract

c. Primarily spread by broken skin-to-skin contact, but is also acquired by touching objects that have the bacteria on them

d. To protect yourself and reduce the spread of MRSA infections, you should wash your hands before and after every patient contact, properly dispose of or disinfect all medical equipment, and take appropriate standard precautions with every patient.

2. Many infections in hospitals are caused by vancomycin-resistant enterococci (VRE).

a. Enterococci are bacteria that are normally present in the human intestines and the female reproductive tract.

b. Some of the enterococci have become resistant to the antibiotic commonly used to treat these infections, which is vancomycin.

3. The respiratory syncytial virus (RSV) causes an infection of the upper and lower respiratory tracts.

a. The symptoms are similar to the common cold but can be more severe and last longer.

b. The virus is highly contagious and is found in discharges from the nose and throat of an infected person.

c. Also transmitted by direct contact with droplets from coughs or sneezes and by touching a contaminated surface

d. MRSA and respiratory syncytial virus infections can be life threatening, especially in an immunocompromised patient.

i. Wear appropriate PPE and decontaminate your ambulance and diagnostic equipment.

ii. Document the infection control issue.

iii. Advise the receiving facility of infectious disease in the patient.

iv. Report an infectious disease to your company or the local health department.

4. Clostridium difficile is a bacterium responsible for the most common cause of hospital-acquired infectious diarrhea.

a. It is a bacterium that normally grows in the intestines.

b. Health care workers may carry this bacterium following contact with contaminated feces.

c. It can also be found on environmental surfaces such as:

i. Furniture

ii. Floors

iii. Toilets

iv. Sinks

v. Bedding

d. Symptoms can range from minor diarrhea to a life-threatening inflammation of the colon.

e. Typical alcohol-based hand sanitizers do not inactivate or kill C. difficile. Contact precautions with gowns and gloves and handwashing with soap and water after each and every patient contact is essential to prevent transmission.

XXIII. Dying Patients

A. As older patients are living longer, more terminally ill patients are choosing to die at home rather than in a hospital.

1. Often the patient comes to terms with his or her impending death before the family does.

2. Dying patients receive what is called palliative, or comfort, care.

a. Palliative care recognizes that death is a normal part of the life cycle.

b. It does not hasten or prolong death, but focuses on relieving pain and providing emotional support and comfort for the patient and his or her loved ones.

3. Your interaction with a dying patient will have a long-term effect on the family.

a. Be understanding, sensitive, and compassionate.

b. Determine if the family wishes for the patient to go to the hospital or stay in the home.

B. Advance directives are specific legal papers that direct relatives and caregivers about what kind of medical treatment may be given to patients who cannot speak for themselves.

1. Dealing with advance directives has become more common for EMS providers because more people are electing to use hospice services and spend their final days at home.

B. Advance directives may take the form of a do not resuscitate (DNR) order.

1. A DNR order gives you permission not to attempt resuscitation for a patient in cardiac arrest.

2. For a DNR order to be valid, the form must be signed by the patient or legal surrogate and by one or more physicians or other licensed health care providers.

3. DNR does not mean “do not treat.”

a. If the patient is still alive, you are obligated to provide supportive measures that may include oxygen delivery, pain relief, and comfort.

b. Basic airway, breathing, and circulatory support should be provided.

c. Cardiopulmonary resuscitation may not be provided.

4. A health care power of attorney is an advance directive that is exercised by a person who has been authorized by the patient to make medical decisions for him or her.

5. When transporting patients from nursing facilities, consider the following general guidelines:

a. Patients have the right to refuse treatment, including resuscitative efforts, provided that they are able to communicate their wishes.

b. A DNR order is valid in a healthcare facility only if it is in the form of a written order by a physician.

c. You should periodically review state and local protocols and legislation regarding advance directives.

d. When you are in doubt or when there are no written orders, you should try to resuscitate the patient.

XXIV. Elder Abuse and Neglect

A. Elder abuse is defined as any action on the part of an older person’s family member, caregiver, or other associated person that takes advantage of the older person’s person, property, or emotional state.

1. Abuse can result from acts of commission (words or actions that cause harm), such as verbal, physical, or sexual assault.

2. Abuse can also result from acts of omission (failure to act), such as denying an older person adequate nutrition or medical care.

3. The exact extent of elder abuse is not known for several reasons, including the following:

a. Elder abuse is a problem that has been largely hidden from society.

b. The definitions of abuse and neglect among the geriatric population vary.

c. Victims of elder abuse are often hesitant to report the problem to law enforcement agencies or human and social welfare personnel.

4. The abused person may feel traumatized by the situation or be afraid that the abuser will punish him or her for reporting the abuse.

a. The abused person may be frail and have multiple chronic medical conditions or dementia.

5. Elder abuse occurs most often in women older than 75 years.

a. The physical and emotional signs of abuse, such as rape, spouse beating, and nutritional deprivation, are often overlooked or not accurately identified.

b. Older women in particular are not likely to report incidents of sexual assault to law enforcement agencies.

c. Patients with sensory deficits, dementia, and other forms of altered mental status may not be able to report abuse.

6. Abusers of older people are sometimes products of child abuse themselves, and the abuse that is inflicted on the older person may be retaliatory.

a. Most of these abusers are not trained in the particular care that older people require and have little relief time.

b. Their lives are now significantly complicated by the constant, demanding needs of the older person they have to care for.

c. The abuser may also have marked fatigue, be unemployed with financial difficulties, or abuse one or more substances.

7. Environments such as nursing, convalescent, and continuing care centers are also sites where older people sustain physical, psychological, financial, or pharmacologic harm.

a. Often, care providers in these environments consider older people to be management problems or categorize them as obstinate and undesirable patients.

b. Consult local authorities, but in general you should assume that you have the same obligation to report suspected elder abuse as you do suspected child abuse.

i. Notify the receiving hospital personnel of your concerns.

ii. Report to the proper authorities based on local protocols.

iii. Factually document your findings.

B. Assessment of elder abuse

1. Take note of the environment and conditions a patient lives in, and of soft-tissue injuries that cannot be explained by the person’s lifestyle and physical condition.

2. You should suspect abuse when answers to questions about what caused the injury are concealed or avoided.

3. Suspect abuse when you are given unbelievable answers.

4. Information that may be important in assessing possible abuse includes the following:

a. Caregiver apathy about the patient’s condition

b. Overly defensive reaction by caregiver to your questions

c. Caregiver does not allow patient to answer questions

d. Repeated visits to the emergency department or clinic

e. A history of being accident-prone

f. Soft-tissue injuries

g. Unbelievable, vague, or inconsistent explanations of injuries

h. Psychosomatic complaints

i. Chronic pain without medical explanation

j. Self-destructive behavior

k. Eating and sleep disorders

l. Depression or a lack of energy

m. Substance and/or sexual abuse history

5. Many patients who are being abused are so afraid of retribution that they make false statements.

6. Repeated abuse can lead to a high risk of death.

a. A preventive measure in reducing additional maltreatment of the patient is identification of the abuse.

C. Signs of physical abuse

1. Injuries may be the result of acute or chronic abuse or neglect.

2. Inflicted bruises are usually found on the:

a. Buttocks and lower back, genitals, and inner thighs

b. Cheeks or earlobes

c. Neck

d. Upper lip

e. Inside the mouth

3. Pressure bruises caused by the human hand may be identified by oval grab marks, pinch marks, or handprints.

4. Human bites are typically inflicted on the upper extremities and can cause lacerations and infection.

5. Inspect the patient’s ears for indications of twisting, pulling, or pinching, and evidence of frequent blows to the outer ears.

6. Investigate multiple bruises in various states of healing.

7. Typical abuse from burns is caused by contact with:

a. Cigarettes

b. Matches

c. Heated metal

d. Forced immersion in hot liquids

e. Chemicals

f. Electrical power sources

8. Observe the patient’s weight and try to determine whether he or she appears undernourished or has been unable to gain weight in the current environment.

9. Check for signs of neglect, such as evidence of:

a. Lack of hygiene

b. Poor dental hygiene

c. Poor temperature regulation

d. Lack of reasonable amenities in the home

10. Regard injuries to the genitals or rectum with no reported trauma as evidence of sexual abuse in any patient.

a. Geriatric patients with altered mental status may never be able to report sexual abuse.

b. Many women do not report cases of sexual abuse because of shame and the pressure to remain silent.

Chapter 36, Patients With Special Challenges

Unit Summary

After completing this chapter and related coursework, you will understand the special needs of patients with developmental, sensory, and physical disabilities. You will understand the unique anatomy and physiology of and assessment and treatment needed for these patients. The special care considerations for patients who rely on medical technological assistance are discussed, as are considerations for the management of obese patients.

National EMS Education Standard Competencies

Special Patient Populations

Applies a fundamental knowledge of growth, development, and aging and assessment findings to provide basic emergency care and transportation for a patient with special needs.

Patients With Special Challenges

Recognizing and reporting abuse and neglect (covered in Chapter 34, “Pediatric Emergencies,” and Chapter 35, “Geriatric Emergencies”).

Health care implications of:

• Abuse (Chapter 34, “Pediatric Emergencies,” and Chapter 35, “Geriatric Emergencies”)

• Neglect (Chapter 34, “Pediatric Emergencies,” and Chapter 35, “Geriatric Emergencies”)

• Homelessness

• Poverty

• Bariatrics

• Technology dependent

• Hospice/terminally ill

• Tracheostomy care/dysfunction

• Home care

• Sensory deficit/loss

• Developmental disability

Trauma

Applies fundamental knowledge to provide basic emergency care and transportation based on assessment findings for an acutely injured patient.

Special Considerations in Trauma

Recognition and management of trauma in the:

• Pregnant patient (Chapter 33, “Obstetrics and Neonatal Care”)

• Pediatric patient (Chapter 34, “Pediatric Emergencies”)

• Geriatric patient (Chapter 35, “Geriatric Emergencies”)

Pathophysiology, assessment, and management of trauma in the:

• Pregnant patient (Chapter 33, “Obstetrics and Neonatal Care”)

• Pediatric patient (Chapter 34, “Pediatric Emergencies”)

• Geriatric patient (Chapter 35, “Geriatric Emergencies”)

• Cognitively impaired patient

Knowledge Objectives

1. Give examples of patients with special challenges EMTs may encounter during a medical emergency.

2. Explain the special patient care considerations required when providing emergency medical care to patients with intellectual disabilities, including patients with autism spectrum disorder (ASD), Down syndrome, or prior brain injuries.

3. Describe the different types of visual impairments and the special patient care considerations required when providing emergency medical care for visually impaired patients, depending on the level of their disability.

4. Describe the various types of hearing impairments and the special patient care considerations required when providing emergency medical care for hard-of-hearing patients, including tips on effective communication.

5. Describe the various types of hearing aids worn by patients; include strategies to troubleshoot a hearing aid that is not working.

6. Explain the special patient care considerations required when providing emergency medical care to patients who have cerebral palsy, spina bifida, or paralysis.

7. Define obesity.

8. Explain the special patient care considerations required when providing emergency medical care to bariatric patients; include the best way to move bariatric patients.

9. Explain the special patient care considerations required when providing emergency medical care to patients who rely on a form of medical technological assistance, including the following:

Tracheostomy tube
Mechanical ventilator
Apnea monitor
Internal cardiac pacemaker
Left ventricular assist device (LVAD)
External defibrillator vest
Central venous catheter
Gastrostomy tube
Ventricular peritoneal shunt
Vagus nerve stimulator
Colostomy bag, ileostomy bag, or urostomy bag

10. Describe home care, the types of patients it serves, and the services it encompasses.

11. Contrast hospice and palliative care with curative care.

12. Explain the responsibilities of EMTs when responding to calls for terminally ill patients who have DNR orders.

13. Discuss the issues of poverty and homelessness in the United States, their negative effects on a person’s health, and the role of the EMTs as patient advocates.

Skill Objectives

1. Demonstrate different strategies to communicate effectively with a patient who has a hearing impairment.

I. Introduction

A. Today, more people with chronic diseases live at home or outside of a hospital setting.

1. It is important to treat both the patient and the caregiver with respect

2. Focus on decreasing the length of hospitalization

3. The caregiver and / or the family can be a resource regarding the patient’s medical condition

B. Examples of patients with special challenges:

1. Children who were born prematurely and have associated respiratory problems

2. Patients with a congenital disease, disease which is present at birth, ie cystic fibrosis

3. Patients with an acquired disease, disease which occurs after birth

4. Patients with neurologic disorder, a disorder of the nervous system. Structural, biochemical or electrical abnormalities in the brain, spinal cord or other nerves can result in a range of symptoms.

5. Patients with congenital or acquired diseases resulting in altered body function that requires medical assistance for breathing, eating, urination, or bowel function

6. Infants or small children with congenital heart disease

7. Patients with sensory deficits such as hearing or visual impairments

8. Geriatric patients with chronic diseases requiring visitation from a home health care service

C. Some people living at home depend upon:

1. Mechanical ventilation

2. Intravenous pumps

3. Other devices

D. Do not allow yourself to be distracted by the noise and mechanics of the medical equipment—your focus needs to remain on the patient.

1. Focus on the ABCs.

2. If the emergency is the result of mechanical failure, use equipment on the ambulance or the family’s “go bag.”

II. Intellectual Disability

A. Developmental disability

1. Refers to insufficient development of the brain, resulting in some level of dysfunction or impairment which occurs before 22 years of age

2. Can include intellectual, hearing, or vision impairments that surface during infanthood or childhood

a. Intellectual disability results in the inability to learn and socially adapt at a normal developmental rate.

b. Possible causes

i. Genetic factors

ii. Congenital infections

iii. Complications at birth

iv. Malnutrition

v. Environmental factors

vi. Prenatal drug or alcohol use

vii. Traumatic brain injury

viii. Poisoning (eg, with lead or other toxins)

3. Characteristics of a patient with slight intellectual impairment:

a. May appear slow to understand or have a limited vocabulary

b. May behave immaturely compared to their peers

c. If severely disabled, may not have the ability to care for themselves, communicate, understand, or respond to surroundings

4. Rely on patients and family members for information to:

a. Understand how well the patient can understand you

b. Understand how the patient will interact with you

c. Gain additional medical information regarding the patient

5. Patient anxiety

a. Patients may have difficulty adjusting to change or a break in routine.

b. Patients may become more difficult to interact with as anxiety increases.

c. Make every effort to respect the patient’s wishes and concerns.

d. Take as much time as necessary to explain in a calming, understandable way the treatment the patient is about to receive.

6. Patients with intellectual disabilities are susceptible to the same diseases as other patients.

B. Autism Spectrum Disorder

1. General term used to describe a group of complex disorders of brain development that vary greatly in signs and symptoms

2. Pervasive developmental disorder characterized by impairment of social interaction

3. Other characteristics

a. Severe behavioral problems

b. Repetitive motor activities

c. Impairment in verbal and nonverbal skills

d. May be hyper- or hyposensitive to sensory stimuli

e. May show their pain in unusual ways, such as humming, singing, and removing clothing

4. Wide spectrum of disability—some patients are independent; others are unable to care for themselves

5. Patients have difficulty using or understanding nonverbal means of communicating

a. Frequently have difficulty making eye-to-eye contact

b. Do best with simple, one-step directions

c. Tend to have trouble answering open-ended questions

d. May talk in robotic or monotone speech patterns

e. May repeat phrases over and over again

f. May confuse pronouns (eg, say “you” when they really mean “I”)

g. May not speak at all

6. Approximately 1 in every 68 American children is diagnosed.

7. It affects males five times more than females.

8. Typically diagnosed by 3 years of age

9. Children with autism receive special instruction and care in school-based settings.

10. It is likely that some older adults with autism have never been diagnosed nor received any assistance.

11. Patients with autism generally do not have other medical disorders and will have medical needs similar to their peers without autism.

12. Rely on parents or caregivers for information, and keep them involved in the patient’s treatment.

13. Explain what you are going to do before you do it.

14. Move slowly, stay calm, and perform physical examinations from distal to proximal.

15. Demonstrate the examination on a parent or caregiver first to show the patient what he or she can expect.

C. Down syndrome

1. Characterized by a genetic chromosomal defect that can occur during fetal development, resulting in mild to severe intellectual impairment

2. Increased maternal age and a family history are known risk factors for this condition.

3. Associated physical abnormalities and conditions

a. Round head with a flat occiput

b. Enlarged, protruding tongue

c. Slanted, wide-set eyes and folded skin on either side of the nose, covering the inner corners of the eye

d. Short, wide hands

e. Small face and features

f. Congenital heart defects

g. Thyroid problems

h. Hearing and vision problems

i. Misalignment of teeth and other dental anomalies

j. Speech abnormalities

k. Epilepsy

4. Increased risk for medical complications

a. As many as 40% may have heart conditions and hearing and vision problems.

5. Intubation may be difficult due to large tongues and small oral and nasal cavities.

6. Mask ventilation can be challenging—jaw-thrust maneuver or a nasopharyngeal airway may be necessary.

7. Management of seizures is the same as for any other patient with seizures, as discussed in Chapter 17, “Neurologic Emergencies.”

8. In approximately 15% of people with Down syndrome, the atlantoaxial joint, where the first two vertebrae meet, is unstable.

a. Atlantoaxial instability (AAI)

b. Most patients do not show symptoms.

c. Increased risk of complications when they experience trauma

D. Patient interaction

1. It is normal to feel somewhat uncomfortable when initiating contact with a developmentally disabled patient.

2. Treat the patient as you would any other patient.

3. Approach the patient in a calm, friendly manner, watching for signs of increased anxiety or fear.

4. Have the members of your team hold back slightly until you can establish a rapport with the patient.

5. Introduce the team members and explain what they are going to do.

6. Move slowly but deliberately, explaining beforehand what you are going to do, just like you would with any other patient.

7. Watch carefully for signs of fear or reluctance from the patient.

8. Make sure you are at eye level with the patient.

9. Do your best to soothe the patient’s anxiety and discomfort as you work through your assessment and provide treatment.

10. By initially establishing trust and communication, you will have a much better chance for a successful outcome.

E. Brain injury

1. Patients with a prior brain injury may be difficult to assess and treat.

2. Take the time to speak with the patient and family to establish what is considered normal for the patient.

3. Talk in a calm, soothing tone, and watch the patient closely for signs of anxiety or aggression.

4. Do not expect the patient to walk to the ambulance or stretcher.

5. Treat the patient with respect, use his or her name, explain procedures, and reassure the patient throughout the process.

III. Sensory Disabilities

A. Visual Impairment

1. Possible causes

a. Congenital defect

b. Disease

c. Injury

d. Degeneration of the eyeball optic nerve or nerve pathway

2. Degree of visual impairment may range from partial to total.

a. Some patients lose peripheral or central vision.

b. Some can distinguish light from dark or discern general shapes.

3. Visual impairments may be difficult to recognize.

a. Look for signs that the patient is visually impaired (glasses, cane, service animal).

4. Patient interaction

a. Make yourself known when you enter the room.

b. Introduce yourself and your team or have them introduce themselves so that the patient can identify their voices and locations.

c. Retrieve any visual aids and give them to your patient to make the interaction more comfortable.

d. A visually impaired patient may feel vulnerable, especially during the chaos of a crash scene.

e. The patient may have learned to use other senses such as hearing, touch, and smell to compensate for the loss of sight, and the sounds and smells of the scene may be disorienting.

f. Tell the patient what is happening, identify noises, and describe the situation and surroundings, especially if you must move the patient.

5. Transport considerations

a. Patients may use a cane or walker (be sure to take it with you).

b. A service animal can remain with the patient and will provide reassurance for the patient and prevent delays in transport; however, in some cases you may need to make arrangements for the care or accompaniment of the animal.

c. An ambulatory patient may be led by a light touch on the arm or elbow or the patient may rest his or her hand on your shoulder.

i. You may ask patients which method they prefer to use.

ii. Patients should be gently guided but never pulled or pushed.

iii. Obstacles need to be communicated in advance.

B. Hearing Impairment

1. Impairment can range from a slight hearing loss to total deafness.

a. Patients may have difficulty with pitch, volume, and speaking distinctly.

b. Patients may learn to speak even though they have never heard sounds.

c. Patients may have since sustained partial or total hearing loss, leading them to speak too loudly.

d. Many older people will have some degree of hearing loss.

2. Most common forms of hearing loss

a. Sensorineural deafness

i. Nerve damage

ii. Results from a lesion or damage to the inner ear

b. Conductive hearing loss

i. Caused by a faulty transmission of sound waves

ii. Can be caused by an accumulation of wax within the ear canal or a perforated eardrum

c. Clues that a person could be hearing impaired

i. Presence of hearing aids

ii. Poor pronunciation of words

iii. Failure to respond to your presence or questions

d. Communication

i. Assist the patient with finding and inserting any hearing aids.

ii. Face the patient while you communicate.

iii. Do not exaggerate your lip movements or look away.

iv. Position yourself approximately 18″ directly in front of the patient.

v. Do not speak louder, and try lowering the pitch of your voice.

vi. Most people who are hearing impaired have learned to use body language (eg, hand gestures and lip reading).

vii. Ask the patient, “How would you like to communicate with me?”

viii. American sign language

(a) May use an interpreter, family member, or friend

(b) If an interpreter is not readily available, call your receiving facility early on to request one.

ix. Helpful hints for communication

(a) Speak slowly and distinctly into a less-impaired ear, or position yourself on that side.

(b) Change speakers to someone with a low-pitched voice.

(d) Only one person should ask interview questions, to avoid confusing the patient.

(e) Try the “reverse stethoscope” technique: put the earpieces of your stethoscope in the patient’s ear and speak softly into the diaphragm of the stethoscope.

C. Hearing aids

1. Device that makes sound louder

2. May be either external or internal

3. Several types are available.

a. Behind-the-ear type

i. Contained in plastic case that rests behind the ear

b. Conventional body type

i. Older style used for profound hearing loss

c. In-the-canal and completely in-the-canal type

i. Contained in plastic case that fits partly or completely inside of ear canal

d. In-the-ear type

i. Contained in shell that fits in outer part of ear

e. Implantable options are also available.

4. The device should fit snugly.

5. If you hear whistling, the hearing aid may not be inserted far enough.

6. If the hearing aid is not working, troubleshoot the problem, it may not be functioning.

IV. Physical Disabilities

A. Cerebral palsy

1. Group of disorders characterized by poorly controlled body movement

2. Possible causes

a. Result of damage to the developing fetal brain while in utero

b. Oxygen deprivation at birth

c. Traumatic brain injury at birth

d. Infection such as meningitis during early childhood

3. Range of mild to severe symptoms

a. Poor posture

b. Uncontrolled, spastic movements of the limbs

c. Visual and hearing impairments

d. Difficulty communicating

e. Epilepsy (seizures)

f. Intellectual disabilities

g. Unsteady gait (ataxia), which may necessitate wheelchair or walker

4. Observe airway closely

a. Patients may have increased secretion production and difficulty swallowing (dysphagia).

b. May require aggressive suctioning to clear the airway

5. Important considerations

a. Do not assume that patients have an intellectual disability.

b. Limbs are often underdeveloped and are prone to injury.

c. Patients who have the ability to walk may have an ataxic or unsteady gait and are prone to falls.

d. If the patient has a specially made pillow or chair, the patient may prefer to use it during transport.

e. Pad the patient to ensure his or her comfort.

f. Never force a patient’s extremities into any position.

g. Whenever possible, take walkers or wheelchairs along during transport.

h. Be prepared for a seizure and keep suctioning available.

B. Spina bifida

1. Birth defect caused by incomplete closure of spinal column during embryonic or fetal development

2. Spinal cord is exposed.

3. Opening can be closed surgically, but often leaves spinal and neurologic damage.

4. Associated conditions

a. Hydrocephalus

i. Requires the placement of a shunt to drain excessive amounts of cerebrospinal fluid from the brain

b. Partial or full paralysis of the lower extremities

c. Loss of bowel and bladder control

d. Extreme latex allergy

5. Ask patients or caregivers how to best move them before you transport them.

C. Paralysis

1. Inability to voluntarily move one or more body parts

2. Possible causes

a. Stroke

b. Trauma

c. Birth defects

3. Patients may have normal sensation or hyperesthesia (increased sensitivity).

4. Facial paralysis may also cause communication challenges

5. Diaphragm may not function correctly, requiring the use of a ventilator.

6. Patients may have specialized equipment

a. Urinary catheters

b. Tracheostomy tubes

c. Colostomy bags

d. Feeding tubes

7. Patients may have difficulty swallowing, creating the need for suctioning.

8. Each type of spinal cord paralysis requires its own equipment and may have its own complications.

9. Always take great care when lifting or moving a paralyzed patient.

10. Ask patients or caregivers how to best move them before you transport them.

V. Bariatric Patients

A. Obesity is a condition in which a person has an excessive amount of body fat.

1. The result of an imbalance between calories consumed and calories used

2. Causes of obesity are not fully understood.

3. May be attributed to a low metabolic rate or genetic predisposition

4. Term obese used when someone is 30% or more over his or her ideal body weight

5. Severe obesity is when a person is 2–3 times over the ideal weight.

6. Quality of life may be negatively affected.

7. Associated health problems

a. Mobility difficulties

b. Diabetes

c. Hypertension

d. Heart disease

e. Stroke

B. Interaction with patients with obesity

1. Patients may be embarrassed by their condition or be fearful of scorn as a result of past experiences.

2. If transport is necessary, plan early for extra help and/or specialized equipment.

a. Send a member of your team to find the easiest and safest exit.

b. Do not risk dropping the patient or injuring a team member by trying to lift too much weight.

C. Interaction with patients with morbid obesity

1. Treat the patient with dignity and respect.

2. Ask your patient how it is best to move him or her before attempting to do so.

3. Avoid lifting the patient by only one limb, which would risk injury to overtaxed joints.

4. Coordinate and communicate all moves to all team members prior to starting to lift.

5. If the move becomes uncontrolled at any point, stop, reposition, and resume.

6. Look for pinch or pressure points from equipment because this could cause significant soft tissue injury or deep venous thrombosis.

7. Large patients may have difficulty breathing if you lay them in a supine position.

8. There are many types of specialized equipment for morbidly obese patients, and some areas have specially equipped bariatric ambulances for such patients.

9. Become familiar with the resources available in your area.

10. Plan egress routes to accommodate large patients, equipment, and the lifting crew members.

11. Notify the receiving facility early.

VI. Patients With Medical Technology Assistance

A. Tracheostomy tubes

1. Tracheal stoma provides a path between the surface of the neck and the trachea

2. Stoma is kept open by a plastic tracheostomy tube

3. Can be temporary or permanent

4. Passes from the neck directly into the major airways

5. For patients who:

a. Depend on home automatic ventilators

b. Have chronic pulmonary medical conditions

6. Tubes bypass the nose and mouth.

7. Tubes are prone to becoming obstructed by mucous plugs or foreign bodies.

a. Obstructions of the tracheostomy tube are emergency events.

b. DOPE mnemonic helps to recognize cause of obstruction

i. Displacement, dislodged, or damaged tube

ii. Obstruction of the tube (secretions, blood, mucus, vomitus)

iii. Pneumothorax

iv. Equipment failure (kinked tubing, ventilator malfunction, empty oxygen supply)

8. Common problems

a. May be bleeding or air leaking around the tube

b. Tube can become loose or dislodged

c. Opening around the tube may become infected

9. Management

a. Maintain an open airway.

b. Suction tube if necessary to clear a mucus plug.

i. Measure the suction catheter to the patient's obturator before placing the suction device into the stoma.

c. Maintain the patient in a position of comfort.

d. Administer supplemental oxygen.

e. Provide transport to the hospital.

B. Mechanical ventilators

1. Used when patients cannot breathe without assistance

2. Possible causes

a. Congenital defect

b. Chronic lung disease

c. Traumatic brain injury

d. Muscular dystrophy

e. Disease process that weakens the ability to breathe and requires a permanent tracheostomy and mechanical ventilator

3. If the ventilator malfunctions:

a. Remove the patient from the ventilator.

b. Apply a tracheostomy collar.

i. Designed to cover the tracheostomy hole and has a strap that goes around the neck.

ii. May not be available in a prehospital setting

iii. Can improvise by placing a face mask over the stoma

c. Patients require assisted ventilation throughout transport.

4. The patient’s caregivers will know how the mechanical ventilator works.

Caregivers can help you attach the bag and valve from a BVM to the tracheostomy tube.

C. Apnea monitors

1. Used for infants who:

a. Are premature and have severe gastroesophageal reflux that causes choking episodes

b. Have a family history of sudden infant death syndrome

c. Have experienced an apparent life-threatening event

2. Used for 2 weeks to 2 months after birth to monitor the respiratory system

3. Monitor sounds an alarm if the infant experiences bradycardia or apnea.

4. Attached with electrodes or belt around the infant’s chest or stomach

5. Will provide a pulse oximetry reading that will assist you in assessing the patient’s respiratory status

6. If possible, bring the apnea monitor to the receiving hospital with the patient.

D. Internal cardiac pacemakers

1. Device implanted under the patient’s skin to regulate the heart rate

2. Typically placed on the nondominant side of the patient’s chest (or, for small or extremely thin patients, in the abdomen)

3. Pacemakers may also include an automated implanted cardioverter defibrillator to monitor heart rhythm.

4. Never place defibrillator paddles or pacing patches directly over the implanted device.

5. Gather information about the cardiac pacemaker while you obtain the patient’s history.

a. Some patients will have a pacemaker identification card in their wallets containing information about the device.

E. Left ventricular assist devices

1. Special piece of medical equipment that takes over the function of one or both heart ventricles

2. Typically used as a bridge to heart transplantation while a donor heart is being located

3. May be a permanent solution for patients who do not qualify for a transplant.

4. Multiple devices available for adult patients

5. One device approved for use in patients aged 5–16 years

6. May be difficult to palpate a pulse in patients who use an LVAD.

a. Assess perfusion by noting:

i. Level of responsiveness

ii. Skin color, temperature, and moisture

iii. Blood pressure

7. Care

a. Provide support measures and basic care.

d. Use the caregiver as a resource during the transport.

c. The patient should have a “go bag” that must be transported with him or her.

d. Be prepared to provide CPR.

e. Contact medical control or follow local protocols.

f. Notify ALS personnel as soon as possible so that other supportive measures may be initiated.

F. External defibrillator vest

1. A vest with built-in monitoring electrodes and defibrillation pads, which is worn by the patient under his or her clothing

2. Attached to a monitor that provides alerts and voice prompts when it recognizes a dangerous rhythm and before it delivers a shock

3. Uses high-energy shocks similar to an AED.

a. Avoid contact with the patient if the device warns it is about to deliver a shock.

4. If the patient is in cardiac arrest, the vest should remain in place while you perform CPR unless it interferes with compressions.

5. Any patient who is wearing a device that has already delivered a shock should be transported to the hospital for further evaluation.

G. Central venous catheter

1. A catheter that has its tip placed in the vena cava to provide venous access

2. Used for many types of home care patients receiving:

a. Chemotherapy

b. Long-term antibiotic drug therapy or pain management

c. Total parenteral nutrition (TPN)

d. Hemodialysis

3. Common locations

a. Chest

b. Upper arm

c. Subclavicular area

4. Common problems

a. Broken lines

b. Infections around the lines

c. Clotted lines

d. Bleeding around the line or from the tubing attached to the line

H. Gastrostomy tubes

1. Sometimes referred to as gastric tubes or G-tubes

2. Placed into the stomach for patients who cannot ingest fluids, food, or medication by mouth

a. May be inserted through the nose or mouth into the stomach (using a nasogastric or orogastric tube)

b. May be placed surgically directly into the stomach through the abdominal wall

3. May become dislodged during the patient’s normal daily activity

a. Immediately stop the flow of any fluids.

b. Assess for signs or symptoms of bleeding into the stomach.

i. Vague abdominal discomfort

ii. Nausea

iii. Vomiting (especially “coffee ground” emesis)

iv. Blood in emesis

4. Patients may be at increased risk of aspiration.

a. Always have suction readily available.

b. Patients with difficulty breathing should be transported while sitting or lying on their right side with the head elevated 30°.

5. Diabetic patients who receive insulin and gastric tube feedings may become hypoglycemic quickly.

b. Unless the tube is dysfunctional, dislodged, or partially dislodged, continue the tube feeding and transport the pump with you.

I. Shunts

1. For patients with chronic neurologic conditions

2. Tubes that drain excess cerebrospinal fluid

3. During assessment, you will likely feel a device beneath the skin on the side of the head, behind the ear.

a. Fluid reservoir

b. Should alert you to the possibility that the patient has an underlying shunt

4. Types

a. Ventricular peritoneum shunt—drains excess fluid from the ventricles of the brain into the peritoneum of the abdomen

b. Ventricular atrium shunt—drains excess fluid from the ventricles of the brain into the right atrium of the heart

5. Blocked or infected shunt

a. Changes in mental status and respiratory arrest may occur.

b. Infections may occur within the first 2 months after insertion.

6. Signs of distress

a. High-pitched cry or bulging fontanelles (in infants)

b. Headache

c. Projectile vomiting

d. Altered mental status

e. Irritability

f. Fever

g. Nausea

h. Difficulty with coordination (walking)

i. Blurred vision

j. Seizures

k. Redness along the shunt track

l. Bradycardia

m. Heart dysrhythmias

J. Vagus nerve stimulators

1. Treatment used for seizures that are not controlled with medication

2. Stimulate the vagus nerve at predetermined intervals to prevent seizure activity

3. Used in children older than 12 years

4. Located under the patient’s skin

5. About the size of a silver dollar

6. If you encounter a patient with this device, contact medical control or follow your local protocols.

K. Colostomies, ileostomies, and urostomies

1. Colostomy or ileostomy is a surgical procedure that creates an opening between the small or large intestine and the surface of the body.

a. Allows for elimination of waste products into a clear, external bag or pouch, which is emptied or changed frequently

b. Assess for signs and symptoms of dehydration if the patient has been complaining of diarrhea or vomiting.

c. Area around the stoma is prone to infection.

d. Signs of infection:

i. Redness

ii. Warm skin around the stoma

iii. Tenderness with palpation over the colostomy or ileostomy site

2. Urostomy is a surgical procedure that connects the urinary system to the surface of the skin.

a. Allows urine to drain through a stoma in the abdominal wall instead of through the urethra into a clear plastic bag.

b. If the urine is cloudy and the patient complains of abdominal and lower back pain, it may be an indication of a urinary tract infection.

3. Contact medical control or follow local protocols for care of a patient with a colostomy, ileostomy, or urostomy bag.

VII. Patient Assessment Guidelines

A. Interaction with the caregiver of an adult or child with special needs is an important part of the patient assessment process.

1. They have become experts on caring for the patient.

B. Determine the patient’s normal baseline status before assessment.

1. Ask, “What is different today?”

VIII. Home Care

A. Home care occurs within a patient’s home environment.

B. Represents a spectrum of special health care populations

1. Infants

2. Older adults

3. Patients with chronic illnesses

4. Patients with developmental disabilities

5. Services

a. Delivering meals

b. House cleaning

c. Laundry

d. Yard maintenance

e. Physical therapy

f. Personal care (eg, bathing and wound care)

C. EMS may be called to a residence by the home care provider.

D. Obtain baseline health status and history from the home care provider.

IX. Hospice Care and Terminally Ill Patients

A. Terminally ill patients may receive hospice care at a hospice facility or at home with diseases such as:

1. Cancer

2. Heart and lung failure

3. End-stage Alzheimer’s disease

4. AIDS

B. Most patients have completed a do not resuscitate (DNR) order.

1. May have medical orders for scope of treatment

C. Comfort care

1. Palliative care (pain medications)

2. Improves the patient’s quality of life before the patient dies and allows the patient to be with family and friends

D. Follow your local protocols, the patient’s wishes, or legal documents such as a DNR order.

1. All necessary documentation must be brought to the hospital if the patient is to be transported.

E. If the patient is at home, the care you give will have a lasting impact on family; show compassion, understanding, and sensitivity.

F. Ascertain the family’s wishes about having the patient remain in the home or having the patient transported to the hospital.

1. If a family member requests to accompany the patient, he or she should be allowed to do so.

G. Follow local protocols for handling the death of a patient.

X. Poverty and Homelessness

A. People who live in poverty are unable to provide for all of their basic needs:

1. Housing

2. Food

3. Child care

4. Health insurance

5. Medication

B. Disease prevention strategies (dental care, nutrition, and exercise) are likely absent, which leads to increased probability of disease.

C. Homeless population includes:

1. People with mental illness or prior brain trauma

2. Victims of domestic violence

3. Persons with addiction disorders

4. Impoverished families

D. You are an advocate for all patients.

E. Your job is to provide emergency care and transport to the appropriate facility.

F. All healthcare facilities must provide assessment and treatment regardless of the patient’s ability to pay.

G. You can be an advocate by becoming familiar with the social services resources within your community.

Chapter 37, Transport Operations

Unit Summary

After completing this chapter and related coursework, you will be able to describe and apply effective preparation for transport, safe emergency vehicle operations, appropriate transport decisions, safe patient transfer techniques, and a responsible approach to patient care during transport. You will be able to identify the nine phases of a call and describe the EMT’s role in each phase. You will be able to discuss the differences between ground and air medical transport. Furthermore, you will understand the steps necessary to properly clean and disinfect the emergency vehicle and equipment following a call.

National EMS Education Standard Competencies

EMS Operations

Knowledge of operational roles and responsibilities to ensure patient, public, and personnel safety.

Principles of Safely Operating a Ground Ambulance

• Risks and responsibilities of emergency response

• Risks and responsibilities of transport

Air Medical

• Safe air medical operations

• Criteria for utilizing air medical response

Medicine

Applies fundamental knowledge to provide basic emergency care and transportation based on assessment findings for an acutely ill patient.

Infectious Diseases

Awareness of:

• How to decontaminate equipment after treating a patient

• How to decontaminate the ambulance and equipment after treating a patient

Knowledge Objectives

1. List the nine phases of an ambulance call; include examples of key tasks EMTs perform during each phase.

2. Name the medical equipment carried on an ambulance; include examples of supplies that are included in each main category of the ambulance equipment checklist.

3. Name the safety and operations equipment carried on an ambulance; include examples of how each item might be used by EMTs in an emergency.

4. Discuss the importance of performing regular vehicle inspections; include the specific parts of an ambulance that should be inspected daily.

5. List the minimum dispatch information required by EMS to respond to an emergency call.

6. Describe some high-risk situations and hazards during both pre-transport and transport that may affect the safety of the ambulance and its passengers.

7. Discuss the specific considerations that are required to ensure scene safety; include personal safety, patient safety, and traffic control.

8. Describe the key elements that must be included in the written patient report upon patient delivery to the hospital.

9. Summarize the tasks EMTs must complete in the postrun phase.

10. Define the terms cleaning, disinfection, high-level disinfection, and sterilization.

11. Discuss the guidelines for safely and defensively driving an ambulance.

12. Identify key steps EMTs should take to improve safety while en route to the scene, the hospital, and the station.

13. List the three factors that dictate the use of lights and siren to the scene and to the hospital; include the risk-versus-benefit analysis regarding their use.

14. Describe the specific, limited privileges that are provided to emergency vehicle drivers by most state laws and regulations.

15. Explain the additional risks and special considerations posed by the use of police escorts, and the hazards and special considerations posed by crossing intersections.

16. Describe the capabilities, protocols, and methods for accessing air ambulances.

17. Describe key scene safety considerations when preparing for a helicopter medevac, including establishing a landing zone, securing loose objects, mitigating onsite hazards, and approaching the aircraft.

Skill Objectives

1. Demonstrate how to perform a daily inspection of an ambulance.

2. Demonstrate how to present a verbal report that would be given to receiving personnel at the hospital upon patient transfer.

3. Demonstrate how to write a written report that includes all pertinent patient information following patient transfer to the hospital.

4. Demonstrate how to clean and disinfect the ambulance and equipment during the postrun phase.

I. Introduction

A. Horse-drawn ambulances were used in major US cities in the late 1700s.

B. US hospitals started their own ambulance services in the 1860s.

1. Ambulance attendants traveled with limited medical supplies.

C. Today’s ambulances are stocked with standard medical supplies, and many are equipped with state-of-the-art technology that can transmit data directly to the emergency department.

D. Today’s emphasis on rapid response places the EMT in greater danger while driving to calls.

1. Although technology can aid in directing the route and mode of response of the ambulance, it is also distracting and potentially places the crew at higher risk for crashes.

2. An underlying principle to operating an emergency vehicle is that you must drive with due regard for the safety of others.

II. Emergency Vehicle Design

A. An ambulance is a vehicle that is used for treating and transporting patients who need emergency medical care to a hospital.

1. The first use of motor-powered ambulances occurred in the late 1800s.

B. Today’s ambulance designs are based on NFPA 1917, Standard for Automotive Ambulances, and on suggestions from the ambulance industry and from EMS personnel.

1. An enlarged patient compartment is one of the most significant developments.

2. First-responder vehicles respond initially to a scene with personnel and equipment to treat the sick and injured until an ambulance can arrive.

C. Components of the modern ambulance:

1. A driver’s compartment

2. A patient compartment big enough for two EMTs and two supine patients

3. Equipment and supplies to provide emergency medical care at the scene and during transport

4. Two-way radio communication

5. Design and construction that ensure maximum safety and comfort

D. Each state establishes its own standards for ambulance licensing or certification.

1. Many states use federal specifications.

E. The Star of Life® emblem identifies vehicles as ambulances, and is often affixed to the sides, rear, and roof of the ambulance.

1. Local or state regulatory authorities determine which emblems may be displayed on the side of a prehospital care ambulance.

III. Phases of an Ambulance Call

A. An ambulance call has nine phases:

1. Preparation

2. Dispatch

3. En route

4. Arrival at scene

5. Transfer of patient to ambulance

6. En route to receiving facility (transport)

7. At receiving facility (delivery)

8. En route to station

9. Post-run

B. The preparation phase

1. Make sure equipment and supplies are in their proper places and ready for use at the start of the shift and after each run

a. If items are missing or do not work, they are of no use to you or the patient.

b. Maintaining working order includes cleaning, lubricating, and periodic inspecting equipment.

2. New equipment should be placed on an ambulance only after proper instruction on its use and consulting with the medical director.

3. Equipment and supplies should be durable and standardized.

4. Store equipment and supplies in the ambulance according to how urgently and how often they are used.

a. Place items needed for life-threatening conditions within easy reach, at the head of the primary stretcher.

b. Place items for cardiac care, external bleeding control, and monitoring blood pressure at the side of the stretcher.

c. Make sure batteries are fresh and equipment is functioning properly.

5. Cabinets and drawers should have transparent fronts or be labeled, and should open easily and close securely.

6. Medical equipment

a. Basic supplies

i. Disposable gloves and sharps

ii. Airway and ventilation equipment

iii. Basic wound care supplies

iv. Splinting supplies

v. Childbirth supplies

vi. Automated external defibrillator

vii. Patient transfer equipment

viii. Medications

ix. Communication equipment

x. Other regionally appropriate supplies

b. Airway and ventilation equipment

i. Oropharyngeal airways for adults, children, and infants

ii. Nasopharyngeal airways for adults and children

iii. Equipment for advanced airway procedures (if authorized by state regulations and the medical director)

iv. Two portable artificial ventilation devices that operate independently of an oxygen supply

(a) Pocket masks

(b) Bag-valve masks

v. One portable and one mounted suctioning unit

(a) Large-bore, nonkinking suction tubing, with semirigid tips available

(b) Suction yoke

(d) Suction catheter

(e) Water for rinsing suction tips

(f) Suction tubing

(g) All parts must be disposable or made of material that is easily cleaned or decontaminated.

vi. One portable oxygen supply unit

(a) Located near a door or in the jump kit

(b) Minimum capacity of least 500 L of oxygen

(d) Should be able to deliver oxygen at a variable rate of 1–15 L/min

(e) At least one extra portable 500-L cylinder on the ambulance

vii. One mounted oxygen unit

(a) Capacity of 3,000 L of oxygen

(b) Equipped with visible flowmeters, capable of delivering 1–15 L/min

(d) Transparent, disposable oxygen masks (with and without nonrebreathing bags) in sizes for adults, children, and infants

(e) Ambulance services that undertake runs lasting longer than 1 hour should consider a disposable, single-use humidifier.

c. CPR equipment

i. A CPR board provides a firm surface under the patient’s torso and establishes an appropriate degree of head tilt.

(a) If unavailable, use a long or short backboard.

(b) Use a tightly rolled sheet or towel to raise the patient’s shoulder 3 to 4 inches.

ii. Mechanical devices that deliver chest compressions and ventilations are also available.

d. Basic wound care supplies

i. Trauma shears

ii. Sterile sheets and sterile burn sheets

iii. Adhesive tape in several widths

iv. Self-adhering, soft roller bandages

v. Sterile dressings

vi. Gauze

vii. Abdominal or laparotomy pads

viii. Sterile universal trauma dressings

ix. Sterile, occlusive, non-adherent dressings

x. Adhesive bandages

xi. Tourniquets

e. Splinting supplies

i. Adult- and child-size traction splints

ii. Arm and leg splints (eg, inflatable, vacuum, cardboard, plastic, foam wire-ladder, or padded board)

iii. Triangular and roller bandages

iv. Short backboard

v. Long backboard

vi. Head immobilization devices

vii. Cervical collars in an adjustable size or a variety of sizes

f. Childbirth supplies

i. At least one sterile emergency obstetrics kit:

(a) Surgical scissors

(b) Hemostats or special cord clamps

(d) Small rubber bulb syringe

(e) Towels

(f) Gauze sponges

(g) Pairs of sterile gloves

(h) Plastic wrap

(i) Sanitary napkins

(j) Plastic bag

(k) Baby stocking cap

(l) Baby blanket

g. Automated external defibrillator (AED)

i. Semi Automated defibrillation equipment

ii. Manual monitor/defibrillators that have automated external defibrillation capacity

iii. Consult local protocols and the local medical director.

h. Patient transfer equipment

i. Primary wheeled ambulance stretcher

(a) Fasteners to secure the stretcher firmly to the floor or side of the ambulance during transport

(b) At least three restraining devices for the patient

(1) Scoop stretcher - reduce the chance of undesirable movement of injured areas during transfer of a trauma patient, as they maintain the patient in a supine alignment during transfer to a stretcher, vacuum mattress or long spine board.

(2) Portable/folding stretcher - auxiliary uses such as secondary stretcher.

(3) Flexible stretcher - often supported longitudinally by wooden or plastic planks. It is a tarpaulin with handles. It is primarily used to move a patient through confined spaces, e.g., a narrow hallway, or to lift obese patients.

(4) Basket stretcher - used where there are obstacles to movement or other hazards: for example, in confined spaces, on slopes, in wooded terrain.

ii. Wheeled stair chair

iii. Long backboard

iv. Short backboard or short immobilization device

i. Medications

i. Appropriate medications that have not expired

ii. Telephone number and radio frequency of online medical control or local poison control center on the ambulance

j. Jump kit

i. Portable, durable, and waterproof

ii. “5-minute kit”: anything needed in the first 5 minutes with the patient, except for the AED

iii. Easy to open and secure

iv. Typical contents:

Disposable gloves
Face shield or mask with goggles
Triangular bandages
Trauma shears
Adhesive tape
Universal trauma dressings
Self-adhering soft roller bandages
Oropharyngeal airways
Bag-valve masks, with masks for adults, children, and infants
Blood pressure cuff
Stethoscope
Penlight
Sterile gauze dressings
Sterile dressings (abdominal pads)
Adhesive strips
Oral glucose
Activated charcoal
Other medications

7. Safety and operations equipment

a. Includes several kinds of equipment for responder safety, rescue operations, and locating emergency scenes

b. Personal safety equipment

i. Personal protective equipment for exposure to blood or other bodily fluids:

(a) Face shields

(b) Gowns, shoe covers, and caps

(d) Helmets with face shields or safety goggles

(e) Safety shoes or boots

ii. No hazardous materials (HazMat) gear; reserved for HazMat technicians and response teams

c. Equipment for work areas

i. Located in a waterproof compartment outside the patient compartment

ii. Warning devices that flash or have reflectors

iii. Two high-intensity, recharging battery-powered, stand-up, halogen, 20,000-candlepower flashlights

iv. Type ABC fire extinguishers, dry chemical, 5-lb minimum

v. Hard hats or helmets with face shields or safety goggles

vi. Portable floodlights

d. Preplanning/navigation guides

i. GPS devices and MDTs are standard equipment in modern ambulances.

ii. Store directions to key locations (eg, local hospitals) in the GPS.

iii. Keep detailed street and area maps in the driver’s compartment.

iv. Familiarize yourself with the roads and traffic patterns in your town or city.

v. Plan alternative routes to frequent destinations.

vi. Be familiar with special facilities and locations within your regional operating area.

e. Extrication equipment

i. Located in a weatherproof compartment outside the patient compartment

ii. Contains equipment that is needed for simple, light extrication, even if an extrication and rescue unit is readily available

8. Personnel

a. At least one EMT in the patient compartment during transport

i. Two EMTs are strongly recommended.

ii. Some services allow non-EMT drivers with two EMTs in the patient compartment.

9. Daily inspections

a. Items included in the ambulance inspection:

i. Fuel, oil, and transmission fluid levels

ii. Engine cooling

iii. Batteries, inspected when the engine is off

iv. Brake fluid

v. Engine belts

vi. Inflation pressure of wheels and tires (including the spare) and any signs of unusual or uneven wear

vii. All interior and exterior lights

viii. Windshield wipers and fluid

ix. Horn and siren

x. Air conditioners, heaters, and ventilating system

xi. Ability of doors to open, close, latch, and lock properly

xii. Communication systems, vehicle and portable

xiii. Cleanliness and positions of all windows and mirrors

b. Inspect the cleanliness, quantity, and function of medical equipment and supplies.

i. Oxygen supplies

ii. Jump kit

iii. Splints

iv. Dressings and bandages

v. Backboards and other immobilization equipment

vi. Emergency obstetrics kit

vii. All battery-operated equipment (eg, AED)

10. Safety precautions

a. Review standard traffic safety rules and regulations.

b. Make sure safety devices (eg, seat belts) are in proper working order.

c. Oxygen tanks must be secured by fixed clasps or housings.

d. All equipment in the cab, rear, and compartments must be secured appropriately.

C. The dispatch phase

1. Dispatch must be easy to access and in service 24 hours a day.

a. May be operated by the local EMS or by a shared service with law enforcement and the fire department

b. The dispatch center might serve only one jurisdiction, or it might be an area or regional center.

2. The Emergency Medical Dispatcher (EMD) should gather and record:

a. The nature of the call

b. The caller’s name, present location, and call-back number

c. The exact location of the patient(s) (most important)

d. The number of patients and the severity of their conditions

e. Other pertinent information

D. En route to the scene

1. In many ways, the en route to the scene phase is the most dangerous phase for EMTs.

2. Crashes cause many serious injuries.

a. Fasten seat belts and shoulder harnesses before moving the ambulance.

3. Review dispatch information.

4. Prepare to assess and care for the patient.

a. Assign specific duties and scene management tasks.

b. Decide which equipment should be taken initially.

E. Arrival at the scene

1. If you are the first to arrive, you will perform a scene size-up and give a brief report of your findings to dispatch.

2. Use the following guidelines:

a. Look for safety hazards to yourself, your partner, bystanders, and the patient.

b. Evaluate the need for additional units.

c. Determine the mechanism of injury or nature of illness.

d. Evaluate the need for spinal immobilization.

e. Follow standard precautions which include donning reflective vests as required by state EMS agencies.

3. For mass-casualty incidents, estimate and communicate the number of patients to the incident commander.

a. Request additional units through dispatch.

b. The incident command system will be established, defining each responder’s role in the response.

4. Safe parking

a. Pick a position that will allow for efficient traffic control and flow around an emergency scene.

b. The first vehicle to arrive should park 100 feet before a crash scene to create a barrier between the EMTs and traffic.

c. If the collision is just over the crest of a small hill, set traffic cones starting at the back of the ambulance over the crest to warn oncoming traffic.

d. Do not park alongside a scene; you may block the movement of other emergency vehicles.

e. Park uphill and/or upwind of a scene with smoke or hazardous materials.

f. Leave your warning lights or devices on.

g. Keep a safe distance between your vehicle and operations at the scene.

h. Stay away from fires, explosive hazards, downed wires, and unstable structures.

i. Set the parking brake.

j. Park as close to the scene as possible to facilitate emergency medical care and rapid transport from the scene.

k. If it is necessary to block traffic to unload equipment or load patients, do so quickly and safely.

5. Traffic control

a. Only when all patients have been treated and the emergency situation is under control should you be concerned with restoring the flow of traffic.

b. Traffic control is intended to ensure an orderly traffic flow, warn other drivers, and prevent another crash.

c. As soon as possible, place warning devices (eg, reflectors) on both sides of the crash.

F. The transfer phase

1. In most cases excessive speed is unnecessary and dangerous and may prevent the provider in the back of the ambulance from rendering appropriate care, as well as alarming the patient.

a. Use common sense and defensive driving techniques.

2. The patient must be packaged for transport.

Secure the patient to a backboard, scoop stretcher, or wheeled ambulance stretcher.

b. Properly lift the patient into the patient compartment.

3. Secure the patient with at least three straps across the body.

a. Use deceleration or stopping straps over the patient’s shoulders, especially if the patient is lying flat or secured to a backboard.

G. The transport phase

1. Provide dispatch with the following information when you are ready to transport the patient:

a. Number of patients

b. Name of receiving hospital

c. Beginning mileage of the ambulance (in some jurisdictions)

2. Monitor the patient’s condition en route.

a. Recheck a stable patient’s vital signs every 15 minutes.

b. Recheck an unstable patient’s vital signs every five minutes.

3. Contact the receiving hospital.

4. Do not abandon the patient emotionally.

a. Be aware of the patient’s level of need.

H. The delivery phase

1. Inform dispatch as soon as you arrive at the hospital.

2. Report your arrival to the triage nurse or other arrival personnel.

3. Physically transfer the patient.

4. Present a complete verbal report.

5. Complete a detailed patient care report as soon as you are free from patient care duties.

a. History of the current illness or injury

b. Pertinent positives and negatives

c. Nature of illness or mechanism of injury

d. Relevant past medical or surgical history

e. Medications and allergies

f. Prehospital treatment and its effect

6. After transferring the patient, it may be possible to restock items used during the call (eg, oxygen masks, dressings, bandages).

I. En route to the station

1. Inform dispatch whether you are in service and where you are going.

2. As soon as you are back at the station:

a. Clean and disinfect ambulance and equipment, if not already done at the hospital.

b. Restock supplies, if not already done at the hospital.

J. The postrun phase

1. Complete and file any additional reports and again inform dispatch of your status, location, and availability.

2. Perform routine ambulance inspections and refuel the vehicle.

3. Key terms:

a. Cleaning: the process of removing dirt, dust, blood, or other visible contaminants from a surface or equipment

b. Disinfection: the killing of pathogenic agents by directly applying a chemical made for that purpose to a surface or equipment

c. High-level disinfection: the killing of pathogenic agents by the use of potent means of disinfection

d. Sterilization: a process, such as the use of heat, that removes all microbial contamination

4. After each call, while wearing at a minimum disposable gloves perform the following regimen:

a. Strip used linens from the stretcher and place them in a plastic bag or designated receptacle.

b. Discard medical waste (eg, disposable equipment used for patient care during the call) in an appropriate receptacle.

c. Wash contaminated areas with soap and water.

d. Disinfect all non-disposable equipment used for patient care during the call.

e. Clean the stretcher with an EPA-registered germicidal/virucidal solution or bleach and water at 1:100 dilution.

f. Clean spillage or other contamination with the same germicidal/virucidal solution or bleach/water solution.

5. Create a schedule for the routine full cleaning of the emergency vehicle.

6. Refer to the manufacturer’s recommendations to create a written policy/procedure for cleaning each piece of equipment.

IV. Defensive Ambulance Driving Techniques

A. According to the National Highway Traffic Safety Administration, between 1992 and 2011, there were approximately 4,500 motor vehicle traffic crashes involving an ambulance each year.

1. Some of these accidents were fatal.

2. An ambulance involved in a crash delays patient care, at a minimum, and, at worst, may take the lives of the EMTs, other motorists, or pedestrians.

3. You are strongly encouraged to participate in a certified defensive driving program before attempting to operate an emergency vehicle.

B. Driver characteristics

1. Some states require drivers to successfully complete an approved emergency vehicle operations course.

2. Physical fitness and alertness are necessary to properly operate an emergency vehicle. You should not be driving if:

a. You take medications that can cause drowsiness or slow your reaction time.

b. You have been drinking alcohol.

c. You have been working long shifts or multiple consecutive shifts.

i. Notify your employer or dispatch if you have worked a shift previously and feel unable to safely operate an emergency vehicle.

3. Emotional maturity and stability are necessary to operate under stress.

4. You cannot drive in any manner that pleases you simply because you have lights and sirens on.

5. You must operate the vehicle with due regard for the safety of others and preservation of property.

C. Safe driving practices

1. Speed does not save lives; good care does.

2. All drivers and passengers must wear seat belts and shoulder restraints at all times.

a. If you remove your seat belt to provide care, fasten it again as soon as possible.

b. Unrestrained or improperly restrained patients and equipment may become airborne during a collision.

3. Become familiar with how your emergency vehicle accelerates, corners, sways, and stops under various conditions.

a. Make sure you understand the vehicle’s braking characteristics and the best downshifting techniques.

4. In a multilane highway, stay in the extreme left-hand (fast) lane, allowing other motorists to move over to the right lane when they see or hear you approach.

5. Siren risk–benefit analysis

a. The decision to activate the emergency lighting and sirens will depend on several factors:

i. Local protocols

ii. Patient condition

iii. Anticipated clinical outcome of the patient

6. Driver anticipation

a. Always assume that motorists around your vehicle have not heard your siren/public address system or seen you until proven otherwise by their actions.

b. If a motorist yields the right-of-way, the emergency vehicle operator should attempt to establish eye contact with the other driver.

c. Look at the direction of the other vehicle’s front tires to get an early indication of which way it will turn.

d. Always drive defensively.

7. Cushion of safety

a. Maintain a safe following distance from the vehicles in front of you and try to avoid being tailgated from behind.

b. Ensure that the blind spots in your vehicle’s mirrors do not prevent you from seeing vehicles or pedestrians on either side of the ambulance.

c. To distance yourself from a tailgater, slow down or contact the local police.

d. Never get out of the ambulance to confront a driver.

e. Three blind spots around the ambulance:

i. Rearview mirror creates a blind spot in front of driver

ii. Rear of vehicle cannot be seen fully through the mirror

iii. Side of the vehicle

f. Scan your mirrors frequently for any new hazards, and use a spotter and predetermined hand signals when backing up an ambulance.

8. Excessive speed

a. Excessive speed is unnecessary, is dangerous, and does not increase the patient’s chance of survival.

b. Makes it difficult for EMTs to provide care in the patient compartment

c. Hinders the driver’s reaction time

d. Increases the time and distance needed to stop the ambulance

9. Siren syndrome

a. Causes drivers to drive faster in the presence of sirens, due to increased anxiety

b. Although a siren signifies a request for drivers to yield the right-of-way, drivers do not always do so.

10. Vehicle size and distance judgment

a. Awareness of emergency vehicle size and weight improve the driver’s ability to maneuver and judge distance.

b. Crashes often occur when the vehicle is backing up.

i. Always use someone outside the ambulance as a ground guide when you are backing up to avoid any incidents.

c. Vehicle size and weight greatly influence braking and stopping distances.

11. Road positioning and cornering

a. Road position means the position of the vehicle on the roadway relative to the inside or outside edge of the paved surface.

b. To keep the ambulance in the proper lane when turning a corner, enter high in the lane (to the outside) and exit low (to the inside).

12. Weather and road conditions

a. Ambulances have a longer braking time and stopping distance and require increased following distances in inclement weather.

b. The weight of the ambulance is unevenly distributed, which makes it more prone to roll over.

c. Be alert to changing weather, road, and driving conditions.

d. Hydroplaning

i. At speeds of greater than 30 mph, a tire may lift off the road as water “piles up” under it; the vehicle may then feel as if it is floating.

ii. If hydroplaning occurs, you should gradually slow down without jamming on the brakes.

e. Water on the roadway

i. Wet brakes will not slow the vehicle as efficiently as dry brakes, and the vehicle may pull to one side or the other.

ii. Avoid driving through large pools of standing water.

iii. Avoid driving through moving water.

f. Decreased visibility

i. In areas where there is fog, smog, snow, or heavy rain, slow down after warning cars behind you.

ii. Always use headlights during the day.

iii. Watch carefully for stopped or slow-moving vehicles.

g. Ice and slippery surfaces

i. Good all-weather tires and an appropriate speed will reduce traction problems significantly.

ii. Consider using studded snow tires or tire chains, if they are permitted by law.

13. Laws and regulations

a. Although emergency vehicle drivers are exempt from normal vehicle operations during a call, certain laws and regulations must be followed.

i. Motor vehicle crashes account for a large number of lawsuits against EMS personnel and services.

b. If you are on an emergency call and are using your warning lights and siren, you may be allowed to do the following:

i. Park or stand in an otherwise illegal location

ii. Proceed through a red traffic light or stop sign, but never without stopping first

iii. Drive faster than the posted speed limit if life and property are not endangered

iv. Drive against the flow of traffic on a one-way street or make a turn that is normally illegal

v. Travel left of center to make an otherwise illegal pass

c. An emergency vehicle is never allowed to pass a school bus that has stopped to load or unload children and is displaying its flashing red lights or extended “stop arm.”

d. Use of warning lights and siren is governed by three basic principles:

i. The unit must be on a true emergency call to the best of your knowledge.

ii. Both audible and visual warning devices must be used simultaneously.

iii. The unit must be operated with due regard for the safety of all others.

e. Right-of-way privileges

i. State motor vehicle statutes or codes often grant an emergency vehicle the right to disregard the rules of the road when responding to an emergency.

ii. In doing so, the operator of an emergency vehicle must not endanger people or property under any circumstances.

iii. Get to know your local right-of-way privileges and exercise them only when it is absolutely necessary for the patient’s well-being.

f. Use of escorts

i. Use police escorts as a guide only when you are in unfamiliar territory.

ii. Neither vehicle should use its warning lights or siren.

iii. If you are being guided, follow at a safe distance.

iv. Using escorts can be hazardous because a gap can open between the vehicles, which can confuse drivers and cause a collision.

g. Intersection hazards

i. Intersection crashes are the most common and usually the most serious type of collision in which ambulances are involved.

ii. Always be alert and careful when approaching intersections.

iii. If you are on an urgent call and cannot wait for traffic lights to change, come to a brief stop at the light and check for other motorists and pedestrians before proceeding.

h. Highways

i. Shut down emergency lights and sirens until you have reached the far left lane.

i. Unpaved roadways

i. Take special care.

ii. Operate the vehicle at a lower speed and maintain a firm grip on the steering wheel.

j. School zones

i. It is unlawful for an emergency vehicle to exceed the speed limit in school zones regardless of the condition of the patient.

14. Distractions

a. While the ambulance is in motion, focus on driving and anticipating roadway hazards.

b. Minimize distractions from:

i. Mobile dispatch terminals and GPS

ii. Mounted mobile radio

iii. Stereo

iv. Cell phone

v. Eating/drinking

15. Driving alone

a. When driving alone, it is your responsibility to focus on figuring out the safest route while mentally preparing for the call.

b. Such situations demand your complete attention and focus.

16. Fatigue

a. Recognize when you are fatigued, and alert your partner or supervisor.

b. If you are feeling fatigued, you should be placed out of service for the remainder of the shift or until the fatigue has passed and you feel capable of operating the vehicle safely.

V. Air Medical Operations

A. Air ambulances are used to evacuate medical and trauma patients.

1. Fixed-wing units are used for interhospital patient transfers over distances greater than 100 to 150 miles.

2. Rotary-wing units (helicopters) are more efficient for shorter distances.

B. Specially trained crews accompany air ambulance flights.

1. The EMT’s duties are limited to providing ground support.

2. Familiarize yourself with the capabilities, protocols, and methods for accessing helicopters in your area.

C. Helicopter medical evacuation operations

1. Medical evacuation (medevac) is performed exclusively by helicopters.

2. Medevac capabilities, protocols, and procedures vary between EMS systems.

3. Calling for a medivac

a. Why call for a medivac?

i. The transport time to the hospital by ground is too long considering the patient’s condition.

ii. Road, traffic, or environmental conditions prohibit the use of a ground ambulance.

iii. The patient requires advanced care beyond EMT capabilities (eg, pain medication administration, airway insertion).

iv. There are multiple patients who will overwhelm the resources at the hospital reachable by ground transport.

b. Who receives a medevac?

i. Patients with time-dependent injuries or illnesses

ii. Patients suspected of having a stroke, heart attack, or serious spinal cord injury

iii. Patients who are found in remote areas and have experienced SCUBA diving accidents, near-drownings, or skiing and wilderness accidents

iv. Trauma patients

v. Candidates for limb replantation, a burn center, a hyperbaric chamber, or a venomous bite center

c. Whom do you call?

i. Generally, the dispatcher should be notified first.

ii. In some regions, EMS may be able to communicate with the flight crew after initiating the medevac request.

D. Establishing a landing zone

1. The safest and most effective way to land and take off is similar to that used by fixed-wing aircraft.

a. Landing at a slight angle allows for safer operations.

2. Establishing a landing zone is the responsibility of the ground EMS crew.

3. An appropriate site for a landing zone should be:

a. A hard or grassy level surface 100 × 100 feet (recommended) and no less than 60 × 60 feet

b. Cleared of loose debris (eg, branches, trash bins, flares, accident tape, medical equipment and supplies)

c. Clear of overhead or tall hazards (eg, power lines, telephone cables, antennas, trees)

4. Mark the landing site using weighted cones or emergency vehicles positioned at the corners of the landing zone with headlights facing inward to form an X.

a. Never use caution tape or ask people to mark the site.

b. Do not use flares.

5. Move nonessential persons and vehicles to a safe distance outside the landing zone.

6. Communicate the direction of strong wind to the flight crew.

a. They may request that you create some form of wind directional device to aid their approach.

E. Landing zone safety and patient transfer

1. Stay away from the helicopter and go only where the pilot or crew member directs you.

2. Keep a safe distance from the aircraft whenever it is on the ground and “hot,” which means the helicopter blades are spinning.

3. Stay outside the landing zone perimeter unless directed to come to the aircraft by a member of the flight crew.

4. If you are asked to enter the landing zone, stay away from the tail rotor; the tips of its blades move so rapidly that they are invisible.

5. Always approach the helicopter from the front, even if it is not running.

6. When you approach the aircraft, walk in a crouched position.

7. Keep the following guidelines in mind when operating at a landing zone:

a. Become familiar with your jurisdiction’s helicopter hand signals.

b. Do not approach the helicopter unless instructed and accompanied by flight crew.

c. Make certain that all patient care equipment and the patient are properly secured to the stretcher.

d. Some helicopters may load patients from the side, whereas others have rear-loading doors.

e. Smoking, open flames, and flares are prohibited within 50 feet of the aircraft at all times.

f. Wear eye protection during approach and take-off.

8. Communication issues

a. In your medevac request, to prevent communication issues, include a ground contact radio channel and call sign of the unit the medivac should make contact with.

F. Special considerations

1. Night landings

a. Do not shine spotlights, flashlights, or any other lights in the air to help the pilot; they may temporarily blind the pilot.

b. Direct low-intensity headlights or lanterns toward the ground at the landing site.

c. Illuminate overhead hazards or obstructions if possible.

2. Landing on uneven ground

a. If a helicopter must land on uneven ground, use extra caution.

b. The main rotor blade will be closer to the ground on the uphill side.

c. Approach the aircraft from the downhill side only or as directed by the flight crew.

3. Medevacs at HazMat incidents

a. Immediately notify the flight crew of the presence of HazMat at the scene.

b. Consult the flight crew and incident commander about the best approach and distance from the scene for a medivac.

c. The landing zone should be uphill and upwind from the HazMat scene.

d. Properly decontaminate patients before loading them into the helicopter.

G. Medevac issues

1. Factors that influence the decision to request a medevac:

a. Assess the severity of the weather or environment/terrain.

i. Helicopters are typically unable to operate in severe weather conditions such as thunderstorms, blizzards, and heavy rain.

b. Most helicopter services are limited to flying at 10,000 feet above sea level.

c. Medivac helicopters fly between 130 and 150 mph.

d. Because of the cabin’s confined space, assess the number and size of the patients who can be safely transported in a medivac helicopter.

e. Typical medevac flights are extremely expensive compared to ambulance transports.

i. The decision to request a medevac should not be based on the perceived ability of the patient to pay the bill, but rather on the medical necessity.

Chapter 38, Vehicle Extrication and Special Rescue

Unit Summary

After completing this chapter and related coursework, you will be able to describe and apply, in context, EMS rescue operations to include vehicle extrication and its 10 phases. Additionally, you will be able to describe various specialized components of EMS operations to include tactical EMS, trench rescue, high-angle rescue, and the EMT’s role in these operations. The safety aspects of these operations and are also discussed.

National EMS Education Standards Competencies

EMS Operations

Knowledge of operational roles and responsibilities to ensure patient, public, and personnel safety.

Vehicle Extrication

• Safe vehicle extrication

• Use of simple hand tools

Knowledge Objectives

1. Explain the responsibilities of an EMT in patient rescue and vehicle extrication.

2. Discuss how to ensure safety at the scene of a rescue incident, including scene size-up and the selection of the proper personal protective equipment and additional necessary gear.

3. Describe examples of vehicle safety components that may be hazardous to both EMTs and patients following a collision and how to mitigate their dangers.

4. Define the terms extrication and entrapment.

5. Describe the ten phases of vehicle extrication and the role of the EMT during each one.

6. Discuss the various factors related to ensuring situational safety at the site of a vehicle extrication, including controlling traffic flow, performing a 360-degree assessment, stabilizing the vehicle, dealing with unique hazards, and evaluating the need for additional resources.

7. Describe the special precautions the EMT should follow to protect the patient during a vehicle extrication.

8. Explain the different factors that must be considered before attempting to gain access to the patient during an incident that requires extrication.

9. Discuss patient care considerations related to assisting with rapid extrication, providing emergency care to a trapped patient, and removing and transferring a patient.

10. Explain the difference between simple access and complex access in vehicle extrication.

11. Describe examples of situations that would require special technical rescue teams and the EMT’s role in these situations.

Skill Objectives

There are no skill objectives for this chapter.

I. Introduction

A. You will usually not be responsible for rescue; you may assist with extrication.

1. Rescue involves many different processes and environments.

2. Rescue requires training beyond the EMT level.

3. This chapter covers the basic concepts of extrication so that you can function effectively as part of a team during a rescue incident.

II. Safety

A. Extrication requires mental and physical preparation.

1. Priority is to provide patient care

2. Personal safety and that of your team must be addressed before patient care is initiated.

a. Safety begins with the proper mind-set and the proper personal protective gear.

3. The equipment that you use and the gear that you wear will depend on the hazards you expect to encounter, as well as what you observe during your scene size-up.

a. Protective gear may include:

i. Turnout gear

ii. Helmets

iii. Hearing protection

iv. Fire extinguisher

v. Blood- and fluid-impermeable gloves

vi. Leather gloves over disposable gloves

III. Vehicle Safety Systems

A. Vehicle safety systems can become hazards after a collision.

1. Shock-absorbing bumpers may be compressed or “loaded” following a front- or rear-end collision.

a. Approach vehicles from the side.

b. They can release and injure your knees and legs.

2. Manufacturers are required to install supplemental restraints or airbags in all new cars.

a. airbags fill with a non-harmful gas on impact and quickly deflate after the crash.

b. airbags are located in the steering wheel and the dash in front of the passenger.

i. Side-impact airbags may be located in the doors or seats.

c. airbags should be deployed and deflated before you arrive.

i. Undeployed airbags may spontaneously inflate while you provide patient care.

ii. Maintain at least a 5-inch clearance around side-impact airbags that have not deployed.

iii. Maintain at least a 10-inch clearance around driver-side airbags that have not deployed.

iv. Maintain at least a 20-inch clearance around passenger-side airbags that have not deployed.

d. Haze inside vehicles in which the airbags have deployed is caused by cornstarch or talc.

i. Used to prevent minor skin irritations by reducing the friction between the occupant’s skin and the airbag.

e. Appropriate protective gear, including eye protection, will reduce the risk of eye or lung irritation from this substance.

IV. Fundamentals of Extrication

A. Your primary concern is safety.

1. Your primary roles are to:

a. Provide emergency medical care.

b. Prevent further injury to the patient.

2. You may provide care as extrication goes on around you.

a. Extrication: the removal from entrapment or from a dangerous situation or position

b. Entrapment: a condition in which a person is caught within a closed area with no way out or has a limb or other body part trapped

c. In the context of this chapter, extrication means the removal of the patient from a wrecked vehicle.

B. Roles and responsibilities

1. EMS providers are responsible for:

a. Assessing and providing medical care

b. Triaging and packaging patients

c. Providing additional assessment and care as needed once patients are removed

d. Providing transport to the emergency department

2. The rescue team is responsible for:

a. Securing and stabilizing the vehicle

b. Providing safe entrance and access to the patients

c. Extricating any patients

3. Law enforcement officers are responsible for:

a. Controlling traffic

b. Maintaining order at the scene

c. Establishing and maintaining a perimeter

4. Firefighters are responsible for:

a. Extinguishing fire

b. Preventing additional ignition

c. Ensuring that the scene is safe

d. Removing spilled fuel

5. Roles and responsibilities often vary based on jurisdiction and available agencies.

6. Good communication among team members and clear leadership are essential to safe, efficient provision of proper emergency care.

C. Preparation

1. Preparing for an incident requiring extrication involves preincident training with rescue personnel for the various types of rescue situations to which you might respond.

2. Rescue personnel must routinely check the extrication tools and their response vehicles.

a. Such preparations reduce the possibility of equipment failure at an emergency scene.

D. En route to the scene

1. Procedures and safety precautions similar to those in the phases of an ambulance call are used when responding to a rescue incident.

E. Arrival and scene size-up

1. Position the ambulance to block the scene from oncoming traffic.

a. Use only essential warning lights.

i. Too many lights tend to distract or confuse motorists.

ii. Many emergency responders have been injured on-scene when they were struck by passing vehicles.

b. Choose a location to park that allows safe access to the scene while leaving a way out.

c. Do not park where you will be blocked in.

d. Position so that the back of the ambulance is pointing toward the scene to facilitate patient transport.

e. At a hazardous materials incident, park uphill and upwind from the hazard.

2. Put on PPE and look for passing cars before exiting your vehicle.

a. Do not assume motorists will heed warning lights.

3. Make sure the scene is properly marked and protected.

a. Request assistance from law enforcement; they should ensure the road is closed or traffic flow is diverted using cones, flares, or tape.

b. Your job is to provide patient care, but you might be forced to direct traffic until other units arrive.

4. Size-up is the ongoing process of information gathering and scene evaluation to determine appropriate strategies and tactics to manage an emergency.

a. Pay attention to downed electrical lines, leaking fluids, fire, and broken glass.

b. It is important to identify any additional resources that will be needed.

i. May include additional EMS units and other public safety personnel.

5. Situational awareness is the ability to recognize any possible issues and act proactively to avoid a negative impact.

6. You can evaluate the hazards and determine the number of patients by doing a 360-degree walk around of the scene.

a. Look for the following:

i. Mechanism of injury

ii. Downed electrical lines

iii. Leaking fuels or fluids

iv. Smoke or fire

v. Broken glass

vi. Trapped or ejected patients

vii. The number of patients and vehicles involved

b. While looking at the vehicle(s) involved in a motor vehicle collision, note the damage to the vehicle(s).

i. Bent steering wheel may indicate significant face and/or thoracic trauma.

ii. Imprints in the dashboard may indicate lower extremity injuries such as fractures and possible hip dislocations and fractures.

iii. Lift deployed airbags to see if there is deformity to the steering wheel or dashboard, which indicates the patient struck the structure after the airbag deflated.

iv. Unrestrained patients may have contact injuries as well as secondary injuries; check windshield for a spider-web pattern of shattered glass indicating possible head, face, or neck injuries.

v. Include findings in your documentation; use the information to maintain a high index of suspicion.

c. Evaluate the need for additional resources such as:

i. Extrication equipment

ii. Fire department

iii. Law enforcement

iv. HazMat unit

v. Utility company

vi. Advanced life support units

vii. Air transport

d. Look for spilled fuel and other flammable substances.

i. Sometimes postcrash fires are started when sparks ignite spilled fuel.

e. An electrical short or a damaged battery may also cause a post-crash fire.

f. Rain, sleet, or snow can present an added hazard for rescue.

g. Crashes that occur on hills are harder to handle than those that occur on level ground.

i. Increases potential for vehicle rollover.

ii. Requires stabilization prior to gaining access.

iii. Conditions for the crash may cause other motorists to also lose control of their vehicles and injure you.

h. Some crash scenes may present threats of violence.

i. Intoxicated people or people who are upset may pose a threat to you or others.

ii. Be alert for weapons.

7. Coordinate your efforts with rescue teams and law enforcement.

a. Communicate with members of the rescue team throughout extrication.

i. Start talking to the incident commander as soon as you arrive.

ii. You become a member of the rescue team and will enter the vehicle and provide care for the patient(s) when approved by the incident commander.

F. Hazard control

1. Downed electrical lines are a common hazard at vehicle crash scenes.

a. Never attempt to move downed electrical lines.

b. Always assume electrical lines are charged until you receive confirmation from the incident commander or the electric company.

c. If power lines are close to a vehicle involved in a crash, instruct the patient to remain in the vehicle until power is shut off.

d. Remain in the safe zone, outside of the danger zone (hot zone).

i. A hot zone is an area where individuals can be exposed to sharp metal edges, broken glass, toxic substances, radiation, or explosion of hazardous materials.

2. Family members and bystanders can also create hazards.

a. The danger zone is off-limits to bystanders.

i. You should help set up and enforce this zone.

3. The vehicle also can be a hazard.

a. An unstable automobile on its side or roof can be a danger to you.

i. Stabilize the vehicle before gaining access.

ii. Rescue personnel can stabilize the car with a variety of jacks or cribbing.

b. Ensure that the car is in “park” with the parking brake set and the ignition turned off.

i. Both battery cables should be disconnected, negative side first, to minimize the possibility of sparks or fire.

4. Alternative fuel vehicles

a. Vehicles may be powered by electricity and electricity/gasoline hybrids, or fuels such as propane, natural gas, methanol, or hydrogen.

i. One common feature is the need for responders to disconnect the battery to prevent further fire or explosion.

ii. In more than 40% of today’s alternative fuel vehicles, the batteries are located in the truck or under the seats, not in the engine compartment.

iii. There may be more than one battery present.

b. Hybrid vehicle systems

i. Hybrid batteries have a higher voltage than traditional automotive batteries.

ii. It may take up to 10 minutes for a high voltage system to de-energize after the main battery is turned off.

iii. Avoid high-voltage cables (typically orange) and components.

iii. Damaged high-voltage batteries may give off toxic fumes.

iv. Do not approach the vehicle if an unusual odor is detected, and retreat if you experience burning in your eyes or throat.

G. Support operations

1. Support operations include:

a. Lighting the scene

b. Establishing tool and equipment staging areas

c. Marking helicopter landing zones

2. Fire and rescue personnel will work together on these functions.

H. Gaining access

1. Gaining access to the patient is a critical phase of extrication.

a. Make sure that the vehicle is stable and hazards are eliminated or controlled.

b. Check with the incident commander and enter the scene only after these conditions are met.

2. The exact way to gain access to a patient depends on the situation.

a. It is up to you to identify the safest, most efficient way to gain access.

b. If there are multiple patients, you should locate and rapidly triage each patient to determine who needs urgent care.

3. To determine the exact location and position of the patient, consider the following questions:

a. Is the patient in a vehicle or in some other structure?

b. Is the vehicle or structure severely damaged?

c. What hazards exist that pose a risk to the patient and rescuers?

d. In what position is the vehicle? On what type of surface? Is the vehicle stable or is it apt to roll or tip?

4. As patients’ conditions change, you may have to change your course of action.

5. Rapid vehicle extrication may be needed to quickly remove a patient if the environment is threatening or if the patient needs cardiopulmonary resuscitation.

a. Cardiopulmonary resuscitation is not effective if the patient is sitting upright.

b. In rapid vehicle extrication, you and your team may have to move a patient from inside of a vehicle to a supine position on a long backboard.

c. A team of experienced EMTs should be able to perform rapid extrication in 1 minute or less.

6. During the access and extrication phases, make sure the patient remains safe.

a. A heavy, fire-resistant blanket can be used to protect the patient from breaking glass, flying particles, tools, or other hazards.

i. A firefighter turnout coat can be used in lieu of a heavy fire resistant blanket.

ii. A long backboard may be used as a shield.

iii. A tarp can be placed over the patient to provide further protection.

b. Maintain good communication with the patient.

i. Always describe what you are going to do before you do it and as you are doing it, even if you think the patient is unresponsive.

c. Try to keep heat, noise, and force to a minimum.

7. Simple access

a. Your first step is simple access, trying to get to the patient as quickly and simply as possible without using any tools or breaking any glass.

i. If the car door is locked and there is no indication of other hazards, you can instruct the patient to unlock the door without moving her head or neck.

b. Automobiles are built for easy entry and exit.

i. It may be necessary to use forcible entry methods.

c. The rescue team should provide the entrance you need to gain access to the patient.

d. If the rescue team has not yet arrived, use tools like hammers, center punches, pry bars, and hacksaws.

i. Available on the ambulance

e. Gain access by trying to use all door handles or by rolling down the windows before breaking any windows or using other methods of forced entry.

8. Complex access

a. Complex access requires special tools, such as pneumatic and hydraulic devices.

i. Requires special training

ii. Includes breaking windows or removing roof

iii. When breaking a window in a structure, break a window in a room away from where the patient is located.

b. These advanced skills are typically performed by a specialized team.

I. Emergency care

1. Providing medical care to a patient who is trapped in a vehicle is essentially the same as for any other patient.

2. Once entrance and access to the patient have been provided and the scene is safe, perform a primary assessment and provide care before further extrication begins.

a. Provide manual stabilization to protect the cervical spine, as needed.

b. Open the airway.

c. Provide high-flow oxygen.

d. Assist or provide for adequate ventilation.

e. Control any significant external bleeding.

f. Treat all critical injuries.

g. Address life-threatening external hemorrhage before airway and breathing.

J. Removal of the patient

1. Rescue personnel should coordinate with you to determine the best removal route.

a. Removal of a patient from a motor vehicle is a multistep process that is intensive in terms of the number of rescue personnel involved, the equipment used, and the effort required to prevent further injury or harm.

2. You should participate in the preparation for patient removal.

a. Determine how urgently the patient must be extricated.

i. If the situation does not require using the rapid extrication technique, the removal can be done slower and the EMT may use a vest-type extrication device or short-board.

b. Determine where you should be positioned to best protect the patient.

c. After the patient has been extricated, determine how you will move the patient to the backboard and then to the stretcher.

d. Carefully examine trapped patients or limbs to determine the extent of injury.

i. If possible, evaluate sensation in the trapped area.

e. Your input is essential so that the rescue team plans an extrication that protects the patient from further harm.

i. Reevaluate whether the patient needs rapid extrication.

f. In most cases, it is impractical to apply extremity splints within the vehicle.

i. Extremity injuries can generally be supported and immobilized while the patient is being removed.

ii. Secure a fractured arm to the patient’s side.

iii. Secure a fractured leg to the other leg.

g. Once the plan has been devised, you should determine how best to protect the patient.

3. Often you will be placed in the vehicle alongside the patient.

a. Be sure to wear proper protective equipment.

b. Your safety and the patient’s safety are paramount.

i. Appropriate hearing protection should be worn.

K. Transfer of the patient

1. Perform a complete primary assessment once the patient has been freed and any other previously inaccessible patients have been freed.

a. Make certain that the spine is manually stabilized.

b. Apply a cervical collar if this has not already been done.

2. Move the patient in a series of smooth, slow, controlled steps, with designated stops to allow for repositioning and adjustments.

a. Position each EMT for a smooth, controlled transfer.

b. One person should be in charge of the move.

i. Choose a path that requires the least manipulation of the patient and equipment.

ii. Ensure that everyone understands the steps and is ready.

iii. Move only on the team leader’s command

iv. Move the patient as a unit.

v. Continue to protect the patient from any hazards.

3. Once the patient has been placed on the stretcher, continue with any additional assessment and treatment that was deferred.

L. Termination

1. Termination involves returning emergency units to service.

a. All equipment used on the scene must be checked before reloading them on the apparatus.

b. Check and clean the ambulance thoroughly, replacing used supplies.

c. Rescue and medical units are required to complete all necessary reports.

V. Specialized Rescue Situations

A. Sometimes a patient can be reached only by teams trained in special technical rescues.

1. Specialized skills of these teams include the following:

a. Cave rescue

b. Confined space rescue

c. Cross-field and trail rescue (park rangers)

d. Dive rescue

e. Missing person search and rescue

f. Mine rescue

g. Mountain-, rock-, and ice-climbing rescue

h. Ski slope and cross-country or trail snow rescue (ski patrol)

i. Structural collapse rescue

j. Special weapons and tactics (SWAT) team

k. Technical rope rescue (low- and high-angle rescue)

l. Trench rescue

m. Water and small craft rescue

n. White-water rescue

B. Technical rescue situations

1. A technical rescue situation requires specialized skills and equipment to safely enter and move around.

a. Situations may contain hidden dangers.

b. It is not safe to include personnel who have not been trained.

2. A technical rescue group is trained and on call for certain types of technical rescues.

a. Made up of individuals from one or more departments

b. Many members of technical rescue groups are also trained as emergency medical responders (EMRs) or EMTs.

3. Check with the incident commander to make sure the technical rescue group has been summoned and is en route.

a. The incident commander is the individual who has overall command of the scene in the field.

b. One member must be clearly in charge.

c. A lack of identifiable leadership at the scene hinders the rescue effort and patient care.

i. The incident commander’s assessment will dictate how medical care, packaging, and transport will proceed.

ii. Customarily, the senior medical person takes this role.

iii. If no incident commander is present, follow local guidelines.

4. When you arrive at a technical rescue scene, you will be directed or led to the staging area.

a. If the staging area is some distance from the ambulance, take a long backboard and/or a basket stretcher.

b. Be sure to take all of the jump kits and other equipment you may need to treat and immobilize the patient.

c. Set up your equipment at the staging area, a stable location where you will be able to treat the patient.

d. Perform a primary assessment as soon as the rescue team brings the patient to you.

e. Packaging and carrying the patient back to the ambulance requires a joint effort between EMTs and the technical rescue team.

i. Consider using an air medical unit if the patient will need to be carried or transported an extensive distance.

C. Search and rescue

1. An ambulance is usually summoned to the incident command post when a person is lost outdoors and a search effort is initiated.

a. Your role is to stand by at the command post until the missing person or persons have been found.

2. As soon as you are briefed on the situation, isolate and prepare the equipment you may need to carry to the patient’s location.

a. Leave the prepared equipment in the back of the ambulance to protect it from the weather.

3. You may be asked to stay with family members of the lost individual.

a. Gather any medical history and communicate to those in charge.

b. Only the incident commander should communicate any news or progress of the search to the family.

i. Set your radio at a discreet volume.

4. Once the missing person is found, you will be guided by search personnel to the location where you can begin treatment.

a. Time and effort can sometimes be decreased by relocating the ambulance or by using an all-terrain vehicle.

b. Ensure that equipment is evenly distributed among providers.

c. Ensure that a pace is maintained such that all can stay together easily.

D. Trench rescue

1. Many cave-ins and trench collapses have poor outcomes for victims.

a. Collapses usually involve large areas of falling dirt that weigh approximately 100 lb per cubic foot.

b. Victims with thousands of pounds of dirt on their chests cannot fully expand their lungs and may become hypoxic.

2. The risk of a secondary collapse is a concern to rescue personnel and EMTs.

a. Safety measures can reduce the potential for injury.

b. Response vehicles should be parked at least 500 feet from the scene.

c. All vehicles should be turned off to avoid a secondary collapse caused by vibration.

d. All road traffic should be diverted from the 500-foot safety area.

3. Other hazards include downed electrical wires and broken glass or water lines.

a. Construction equipment at the collapse site may be unstable and could fall into the cave-in or trench site.

4. Witnesses to the incident should be identified.

a. May be valuable in providing information on the number of victims and their locations

5. Assist untrapped individuals from the area.

6. At no time should medical or rescue personnel enter a trench deeper than four (4) feet without proper shoring in place.

7. During the extrication of any survivors, medical personnel trained in cave-in and trench collapse rescue will provide most medical care.

a. You should be prepared to receive patients once they have been extricated from the site.

E. Tactical emergency medical support

1. A steady increase in violence throughout the country has resulted in EMTs taking precautions to ensure personal safety.

2. Normally, when the potential for violence exists, responding units should wait until the scene is secured by law enforcement officers.

a. Sometimes a special weapons and tactics (SWAT) team is needed to secure an area.

i. Hostage incidents

ii. Barricaded subjects

iii. Snipers

b. Many communities have incorporated specially trained EMTs, paramedics, nurses, and even physicians into police SWAT units.

i. Provide a special level of care to the sick and injured

ii. Their training goes well beyond the practices seen in standard emergency medical care.

3. When called to the scene of a law enforcement tactical situation, determine the location of the command post and report to the incident commander for instructions.

a. Lights and siren should be turned off, and outside radio speakers should not be used when nearing the scene.

b. The command post is usually located in an area that cannot be seen by the suspect and is out of range of possible gunfire.

i. Remain in this area.

c. Planning measures are key in these situations.

i. Have the incident commander identify the specific location of the incident.

ii. The incident commander should determine a safe location to meet up with SWAT members if an injury occurs and determine a safe route to this point.

iii. Designate primary and secondary helicopter landing zones if your region uses aeromedical evacuation.

iv. The quickest route to the closest hospital, burn center, and trauma center should be identified.

F. Structure fires

1. In most areas, an ambulance is dispatched with the fire department to any structure fire.

a. A fire in a house or other building is considered a structure fire.

b. Determine whether any special route is needed because of the fire.

c. Ask the incident commander where the ambulance should be staged.

i. The ambulance should be far enough away from the fire to be safe.

ii. It cannot block or hinder other arriving equipment.

iii. It cannot be blocked in.

iv. It should be close enough to be visible so patients can be brought to it easily.

d. Determine if there are any injured patients or whether you have been called to stand by.

i. A number of ambulances may be dispatched to the scene.

2. Search and rescue in a burning building requires special training and equipment.

a. Operations are performed by teams of firefighters wearing full turnout gear and self-contained breathing apparatus (SCBA).

i. They carry tools and hose lines.

ii. These teams will bring patients out of the burning building to the area where the ambulance is staged.

iii. Stay with the ambulance unless otherwise instructed.

iv. After the fire is out, do not leave the scene because you may have to treat an injured firefighter.

v. The ambulance should leave only if transporting a patient or if the incident commander has released it.

3. Sometimes a scene may be further complicated by the presence of hazardous materials.

a. Hazardous materials pose a threat to you and to others at the scene, as well as a much larger area and population.

b. Follow additional procedures outlined in Chapter 39, “Incident Management.”

Chapter 39, Incident Management

Unit Summary

After completing this chapter and related coursework, you will be able to describe and apply, in context, the National Incident Management System (NIMS) to include describing command and general staff roles. Additionally, you will be able to describe various specialized components of establishing incident command and its inherent responsibilities. This chapter also describes the importance of using the incident command system (ICS) in HazMat incidents and setting up EMS branch operations. Control zones, personal protective equipment, and triage methods are also discussed.

National EMS Education Standard Competencies

EMS Operations

Knowledge of operational roles and responsibilities to ensure patient, public, and personnel safety.

Incident Management

• Establish and work within the incident management system.

Multiple Casualty Incidents

• Triage principles

• Resource management

• Triage

• Performing

• Retriage

• Destination decisions

• Posttraumatic and cumulative stress

Hazardous Materials Awareness

• Risks and responsibilities of operating in a cold zone at a hazardous material or other special incident.

Knowledge Objectives

1. Describe the purpose of the National Incident Management System (NIMS) and its major components.

2. Describe the purpose of the incident command system (ICS) and its organizational structure.

3. Explain the role of EMS response within the ICS.

4. Describe how the ICS assists EMS in ensuring both personal safety and the safety of bystanders, health care professionals, and patients during an emergency.

5. Describe the role of the EMT in establishing command under the ICS.

6. Describe the purpose of the medical branch of the ICS and its organizational structure.

7. Describe the specific conditions that would define a situation as a mass-casualty incident (MCI); include examples.

8. Describe what occurs during primary and secondary triage, how the four triage categories are assigned to patients on the scene, and how destination decisions regarding triaged patients are made.

9. Explain how to perform the START and JumpSTART triage methods.

10. Contrast a disaster with a mass-casualty incident.

11. Describe the role of EMTs during a disaster operation.

12. Recognize the entry-level training or experience requirements identified by the HAZWOPER regulation for EMTs to respond to a HazMat incident.

13. Define hazardous material; include the classification system used by the NFPA.

14. Discuss the specific reference materials that EMTs use to recognize a HazMat incident.

15. Explain the role of EMTs during a HazMat incident both before and after the HazMat team arrives; include the precautions required to ensure the safety of civilians and responders.

16. Describe how the three control zones are established at a HazMat incident and discuss the characteristics of each zone, and the responders who work within each one.

17. Describe the four levels of personal protective equipment (PPE) required at a HazMat incident to protect responders from injury by or contamination from a particular substance.

18. Explain patient care at a HazMat incident; include the special requirements that are necessary for those patients who require immediate treatment and transport prior to full decontamination.

Skills Objectives

1. Demonstrate how to perform triage based on a fictional scenario that involves a mass-casualty incident.

2. Using a reference, correctly identify DOT labels, placards, and markings that are used to designate hazardous materials.

3. Demonstrate the ability to use a variety of reference materials to identify a hazardous material.

I. Introduction

A. The most challenging situations you can be called to are disasters and mass-casualty incidents (MCIs).

1. A mass-casualty incident refers to any call that involves three or more patients, or any situation that places such a great demand on available equipment or personnel that the system would require a mutual aid response.

a. An agreement between neighboring EMS systems to respond when local resources are insufficient to handle the response

B. These incidents can be overwhelming, because you will find a large number of patients and not enough resources.

C. Use of the incident command system (ICS) makes it possible to do the greatest good for the greatest number of people.

D. As an EMT, you will typically be assigned to work within the EMS/medical branch under an ICS.

E. The National Incident Management System (NIMS) was developed to promote efficient coordination of emergency incidents at the regional, state, and national levels.

II. National Incident Management System

A. The Secretary of Homeland Security implemented the NIMS in 2004.

1. It provides a framework to enable federal, state, and local governments, as well as private-sector and nongovernmental organizations, to work together effectively.

2. The organizational structure must be flexible enough to be rapidly adapted for use in any situation.

3. The NIMS provides standardization in:

a. Terminology

b. Resource classification

c. Personnel training

d. Certification

4. Another important feature is the concept of interoperability, which refers to the ability of agencies of different types or from different jurisdictions to communicate with each other.

B. The ICS is one component of the NIMS.

1. The major NIMS components are as follows:

a. Preparedness

i. The NIMS establishes measures for all responders to incorporate into their systems to prepare for their response to all incidents at any time.

b. Communications and information management

i. The NIMS communications and information systems enable the essential functions needed to provide interoperability.

c. Resource management

i. The NIMS sets up mechanisms to describe, inventory, track, and dispatch resources before, during, and after an incident.

d. Command and management

i. The NIMS standardizes incident management for all hazards and across all levels of government.

ii. Based on three key constructs: ICS, multiagency coordination systems, and public information systems

e. Ongoing management and maintenance

i. The NIMS Integration Center (NIC) provides strategic direction for and oversight of the NIMS, supporting routine maintenance and continuous improvement of the system in the long term.

III. Incident Command System

A. The ICS is sometimes referred to as the incident management system.

B. The purpose of the ICS is:

1. Ensure responder and public safety

2. Achieve incident management goals

3. Ensure the efficient use of resources

C. Communication is the building block of good patient care.

1. Common terminology and the use of “clear text” communications help responders from multiple agencies work efficiently together.

D. The goal of the ICS is to make the best use of your resources to manage the environment around the incident and to treat patients during an emergency.

1. The ICS is designed to control duplication of effort and freelancing.

a. Freelancing is when individual units or different organizations make independent and often inefficient decisions about the next appropriate action.

2. One of the organizing principles of the ICS is limiting the span of control of any one individual.

a. Refers to keeping the supervisor/worker ratio at one supervisor for three to seven workers

3. Organizational levels may include sections, branches, divisions, and groups.

a. Sections are responsible for a major functional area such as finance, logistics, planning, or operations.

b. Branches tend to be established when span of control is a problem and are in charge of activity directly related to the section (ie, fire, law enforcement, EMS, etc)

c. Divisions usually refer to crews working in the same geographic area.

i. The larger the incident, the more divisions there will be.

d. Groups usually refer to crews working in the same functional area, but possibly in different locations.

E. The ICS roles and responsibilities

1. The general staff includes command, finance, logistics, operations, and planning.

2. Command staff includes the public information officer (PIO), safety officer, and liaison officer.

3. Command

a. The incident commander (IC) is in charge of the overall incident.

i. Assesses the incident

ii. Establishes the strategic objectives and priorities

iii. Develops a plan to manage the incident

b. Large incidents require a multiagency or multijurisdiction response and need to use a unified command system.

c. A single command system is one in which one person is in charge, even if multiple agencies respond.

i. Ideally, it is used for short-duration, limited incidents that require the services of a single agency.

d. It is important that EMTs know who the IC is, how to communicate with the IC, and where the command post is located.

i. If the incident is very large, EMTs will report to a supervisor working under the IC.

e. An IC may turn over command to someone with more experience in a critical area.

i. This change, or transfer of command, must take place in an orderly manner and, if possible, face to face.

f. When an incident draws to a close, there should be a termination of command.

i. Your agency should have demobilization procedures to implement as the situation deescalates or comes to an end.

4. Finance

a. Responsible for documenting all expenditures at an incident for reimbursement

i. Not usually needed at smaller incidents

b. Various functions within the finance section:

i. Time unit

ii. Procurement unit

iii. Compensation/claims unit

iv. Cost unit

5. Logistics

a. The logistics section or section chief has responsibility for:

i. Communications equipment

ii. Facilities

iii. Food and water

iv. Fuel

v. Lighting

vi. Medical equipment and supplies for patients and emergency responders

6. Operations

a. At a very large or complex incident, the operations section is responsible for managing the tactical operations usually handled by the IC.

b. The operation section chief will supervise the people working at the scene of an incident, who will be assigned to branches, divisions, and groups.

7. Planning

a. This section solves problems as they arise.

i. Obtains data about the problem

ii. Analyzes the previous incident plan

iii. Predicts what or who is needed to make the new plan work

iv. Works closely with the operations, finance, and logistics sections

b. Another function is to develop an incident action plan, which is the central tool for planning during a response to a disaster emergency.

i. Should be written at the outset of the response and revised continually throughout the response

ii. The level of detail required will vary according to the size and complexity of the response.

8. Command staff

a. The safety officer monitors the scene for conditions or operations that may present a hazard to responders and patients.

i. He or she has the authority to stop an emergency operation whenever a rescuer is in danger.

ii. A safety officer should remove hazards to EMS personnel and patients before the hazards cause injury.

b. The public information officer (PIO) provides the public and media with clear and understandable information.

i. The designated PIO may cooperate with PIOs from other agencies in a joint information center.

c. The liaison officer relays information and concerns among command, the general staff, and other agencies.

F. Communications and information management

1. Communication has historically been the weak point at most major incidents.

2. It is recommended that communications be integrated.

a. All agencies should be able to communicate quickly and effortlessly via radios.

b. Communications allow for accountability throughout the incident, as well as instant communication between recipients.

G. Mobilization and deployment

1. When an incident has been declared and the need for additional resources has been identified, a request is made for additional resources.

2. Check-in at the incident

a. On arrival at an incident, you should check in with the incident commander.

b. Checking in accomplishes different functions:

i. Allows you to be assigned to a supervisor for job tasking

ii. Allows for personnel tracking throughout the incident

iii. Ensures that costs, pay, and reimbursement can be calculated accurately

3. Initial incident briefing

a. Report to your supervisor for an initial briefing that will allow you to get information regarding the incident, as well as specific job functions and responsibilities.

4. Incident record keeping

a. If a large piece of equipment becomes inoperable, it may be possible for replacement costs to come from the incident.

b. Record keeping allows for tracking of time spent on the actual incident for reimbursement purposes.

5. Accountability

a. Accountability means keeping your supervisor advised of your location, actions, and completed tasks.

b. Includes advising your supervisor of the tasks that you have been unable to complete and what tools you need to complete them

6. Incident demobilization

a. Once the incident has been stabilized and all of the hazards mitigated, the IC will determine which resources are needed or not needed and when to begin demobilization.

b. This process allows for a prompt return of resources to their parent organizations to be placed back in service.

IV. EMS Response Within the Incident Command System

A. Preparedness

1. Preparedness involves the decisions made and basic planning done before an incident occurs.

2. Preparedness in a given area involves decisions and planning about the most likely natural disasters for the area, among other disasters.

3. Your EMS agency should have written disaster plans that you are regularly trained to carry out.

a. A copy of the disaster plan should be kept in each EMS vehicle.

b. Your local EMS organizations should develop an assistance program for the families of EMS responders.

B. Scene size-up

1. Sizing up a scene starts with dispatch.

2. When you arrive first on the scene, you will make an initial assessment and some preliminary decisions.

3. The size-up will be driven by three basic questions:

a. What do I have?

i. Assess the scene for hazards.

ii. Confirm the incident location.

iii. Establish whether the incident is open or closed.

An open incident is not yet contained and is producing more patients
A closed incident is contained and all casualties are accounted for

iv. Estimate the number of casualties.

v. Report immediately to dispatch.

b. What do I need?

i. Decide what resources are needed.

ii. You may need more EMS responders, ambulances, or other forms of transportation.

c. What do I need to do?

i. Consider the safety of yourself, your partner, other rescuers, the patient, and any bystanders.

ii. You may have to initially work to isolate or stabilize the incident before providing care for injured persons.

iii. Remember, you cannot help the injured if the scene is unstable.

C. Establishing command

1. Command should be established by the most senior official, notification to other responders should go out, and necessary resources should be requested.

2. A command system ensures that resources are effectively and efficiently coordinated.

3. Command must be established early, preferably by the first-arriving, most experienced public safety official.

D. Communications

1. If possible, use face-to-face communications to limit radio traffic.

a. If you communicate via radio, do not use 10-codes or signals.

2. Most communications problems should be worked out before a disaster happens by designating channels strictly for command during a disaster.

3. Communications equipment must be reliable, durable, and field-tested.

4. Be sure there are backups in place.

5. Your plan should include a “plan B” in case of communications failure.

V. The Medical Branch of Incident Command

A. Medical incident command is more commonly known as the medical (or EMS) branch of the ICS.

1. The medical branch director will supervise the primary roles of the medical branch—triage, treatment, and transport of injured people.

2. The medical branch director will help ensure that:

a. EMS units responding to the scene are working within the ICS

b. Each medical division or group receives a clear assignment before beginning work at the scene

c. Personnel remain with their vehicle in the staging area until they are assigned their duties

B. Triage supervisor

1. Ultimately in charge of counting and prioritizing patients

2. The primary duty of the triage division or group is to ensure that every patient receives initial assessment of his or her condition.

3. One of the most difficult parts of being a triage supervisor is that you must not begin treatment until all patients are triaged, or you will compromise your triage efforts.

C. Treatment supervisor

1. The treatment supervisor will locate and set up the treatment area with a tier for each priority of the patient.

2. Treatment supervisors ensure that secondary triage of patients is performed and that adequate patient care is given as resources allow.

3. Treatment supervisors also assist with moving patients to the transportation area.

D. Transportation supervisor

1. The transportation supervisor coordinates the transportation and distribution of patients to appropriate receiving hospitals and helps to ensure that hospitals do not become overwhelmed by a patient surge.

2. The transportation supervisor documents and tracks the number of transport vehicles, patients transported, and the facility destination of each vehicle and patient.

E. Staging supervisor

1. A staging supervisor is assigned when an MCI or disaster requires a multi-vehicle or multi-agency response.

2. Emergency vehicles must have permission from the staging supervisor to enter an MCI scene and should only drive in the directed area.

3. The staging area should be established away from the scene so that the parked vehicles are not in the way.

F. Physicians on scene

1. Emergency physicians will have the ability to make difficult triage decisions.

2. They also provide secondary triage decisions in the treatment area, deciding which priority patients are to be transported first.

3. Physicians can provide on-scene medical direction for EMTs, and they can provide care in the treatment sector as appropriate.

G. Rehabilitation supervisor

1. The rehabilitation supervisor establishes an area that provides protection for responders from the elements and the situation.

2. The rehabilitation area should be located away from exhaust fumes and crowds and out of view of the scene itself.

3. Rehabilitation is where a responder’s needs for rest, fluids, food, and protection from the elements are met.

4. The rehabilitation supervisor must also monitor responders for signs of stress, including:

a. Fatigue

b. Altered thinking patterns

c. Complete collapse

H. Extrication and special rescue

1. An extrication supervisor or rescue supervisor determines the type of equipment and resources needed for the situation.

2. Because extrication and rescue are medically complex, the supervisors will usually function under the EMS branch of the ICS.

I. Morgue supervisor

1. The morgue supervisor will work with area medical examiners, coroners, disaster mortuary assistance teams, and law enforcement agencies to coordinate removal of the bodies and body parts.

2. The morgue supervisor should attempt to leave the dead victims in the location found, if possible, until a removal and storage plan can be determined.

3. The morgue area should be out of view of the living patients and other responders, and it should be secured from the public.

VI. Mass-Casualty Incidents

A. An MCI is:

1. An emergency situation that involves three or more patients, places great demand on the EMS system and/or has the potential to produce multiple casualties.

B. All systems have different protocols for when to declare an MCI and initiate the ICS.

1. As the EMT, ask yourself the following questions when considering whether the call is an MCI:

a. How many seriously injured or ill patients can you care for effectively and transport in your ambulance?

b. What happens when you have three patients to deal with?

c. How long will it take for additional help to arrive?

d. What happens if the number of patients exceeds the number of available ambulances?

2. You and your team cannot treat and transport all injured patients at the same time.

a. At an MCI, you will often experience an increased demand for equipment and personnel.

b. You should never leave the scene with patients if there are still other patients present who are sick or wounded.

c. This would leave patients at the scene without medical care and can be considered abandonment.

3. If there are multiple patients and not enough resources to handle them without abandoning victims, you should:

a. Declare an MCI.

b. Request additional resources.

c. Initiate the ICS and triage procedures.

VII. Triage

A. “Triage” simply means “to sort” patients based on the severity of their injuries.

1. The goal of doing the greatest good for the greatest number means that the triage assessment is brief and the patient condition categories are basic.

a. Primary triage is the initial triage done in the field.

b. Secondary triage is done as patients are brought to the treatment area.

2. During primary triage, patients are briefly assessed and then identified in some way, such as by attaching a triage tag or triage tape.

3. After the primary triage, the triage supervisor should communicate the following information to the medical branch director:

a. The total number of patients

b. The number of patients in each of the triage categories

c. Recommendations for extrication and movement of patients to the treatment area

d. Resources needed to complete triage and begin movement of patients

4. When the initial triage has been completed, secondary triage (or retriage) can occur, allowing for the EMT to reassess all remaining patients and to upgrade the triage category, if necessary.

B. Triage categories

1. There are four common triage categories.

a. Immediate (red)

i. First-priority patients

ii. Need immediate care and transport

iii. Usually have problems with the ABCs, head trauma, or signs and symptoms of shock

b. Delayed (yellow)

i. Second-priority patients

ii. Need treatment and transport, but it can be delayed

iii. Usually have multiple injuries to bones or joints, including back injuries with or without spinal cord injury

c. Minor or minimal (green; hold)

i. Third-priority patients

ii. May require no field or only “minimal” treatment

iii. If they have any apparent injuries, they are usually soft-tissue injuries such as contusions, abrasions, and lacerations.

d. Expectant (black; likely to die or dead)

i. Last-priority patients

ii. Patients who are dead or whose injuries are so severe that they have, at best, a minimal chance of survival

iii. May include patients who are in cardiac arrest or who have an open head injury

iv. Patients in this category receive treatment and transport only after patients in the other three categories have received care.

C. Triage tags

1. Tagging patients early assists in tracking them and can help keep an accurate record of their condition.

2. Triage tags should be weatherproof and easily read.

3. The patient tags or tape should be color-coded and should clearly show the category of the patient.

4. The tags will become part of the patient’s medical record.

5. Whatever labeling system is used, it is imperative for the transportation officer to be able to identify which patient was transported by which unit and to which destination, and the priority of the patient’s condition.

D. START triage

1. One of the easiest methods of triage

a. Stands for Simple Triage And Rapid Treatment

b. Uses a limited assessment of the patient’s ability to walk, respiratory status, hemodynamic status (pulse), and neurologic status

2. The first step is performed on arrival at the scene by calling out to patients at the disaster site and then directing them to an easily identifiable landmark.

a. The injured persons in this group are the walking wounded and are considered minimal (green) priority, or third-priority, patients.

3. The second step is directed toward non-walking patients.

a. You move to the first non-ambulatory patient and assess the respiratory status.

b. If the patient is not breathing, open the airway by using a simple manual maneuver.

c. A patient who still does not begin to breathe is triaged as expectant (black).

d. If the patient begins to breathe, tag him or her as immediate (red), place the patient in the recovery position, and move on to the next patient.

4. If the patient is breathing, make a quick estimation of the respiratory rate.

5. The next step is to assess the hemodynamic status of the patient by checking for bilateral radial pulses.

6. The final assessment is to assess the patient’s neurologic status by assessing the patient’s ability to follow simple commands.

E. JumpSTART triage for pediatric patients

1. Intended for use in children younger than 8 years or who appear to weigh less than 100 lb

2. Begins by identifying the walking wounded

a. Infants or children not developed enough to walk or follow commands (including children with special needs) should be taken as soon as possible to the treatment sector for immediate secondary triage.

3. There are several differences within the respiratory status assessment compared with that in START.

a. If you find that a pediatric patient is not breathing, immediately check the pulse.

b. If there is no pulse, label the patient as expectant (black).

c. If the patient is not breathing but has a pulse, open the airway with a manual maneuver.

d. If the patient does not begin to breathe, give five rescue breaths and check respirations again.

e. A child who does not begin to breathe should be labeled expectant.

f. The most common cause of cardiac arrest in children is respiratory arrest.

4. The next step is to assess the approximate rate of respirations.

5. The next assessment is the hemodynamic status of the patient.

a. Assess the pulse that you feel the most competent and comfortable checking.

b. If there is an absence of a distal pulse, label the child as an immediate priority and move to the next patient.

6. The final assessment is for neurologic status.

a. A modified AVPU score is used.

F. Triage special considerations

1. Patients who are hysterical and disruptive to rescue efforts may need to be handled as an immediate priority and transported off the site, even if they are not seriously injured.

2. A responder who becomes sick or injured during the rescue effort should be handled as an immediate priority and be transported off the site as soon as possible.

3. Hazardous materials (HazMat) and weapons of mass destruction incidents force the HazMat team to identify patients as contaminated or decontaminated before the regular triage process.

G. Destination decisions

1. All patients triaged as immediate (red) or delayed (yellow) should preferably be transported by ground ambulance or air ambulance, if available.

2. In extremely large situations, a bus may transport the walking wounded.

3. Immediate-priority patients should be transported two at a time until all are transported from the site.

a. Then patients in the delayed category can be transported two or three at a time until all are at a hospital.

b. Finally, the walking wounded are transported.

c. Expectant patients who are still alive would receive treatment and transport at this time.

d. Dead victims are handled or transported according to the standard operating procedure for the area.

4. Early notification to receiving facilities will allow for the hospitals to increase staffing and move patients within their facility as required.

VIII. Disaster Management

A. A disaster is a widespread event that disrupts functions and resources of a community and threatens lives and property.

1. Many disasters may not involve personal injuries.

2. On the other hand, many disasters such as floods, fires, and hurricanes will result in widespread injuries.

a. Unlike an MCI, which generally lasts no longer than a few hours, emergency responders will generally be on the scene of a disaster for days to weeks and sometimes months.

b. Only an elected official can declare a disaster.

B. Your role in a disaster is to respond when requested and to report to the IC for assigned tasks.

1. In a disaster with an overwhelming number of casualties, area hospitals may decide that they cannot treat all patients in their facility.

2. They may mobilize medical and nursing teams with equipment.

3. Using a facility such as a warehouse near the disaster scene, they will set up a casualty collection area to:

a. Perform triage

b. Provide medical care

c. Transport patients to the hospital on a priority basis

4. If a casualty collection area is established, it will be coordinated through the ICS in the same way as all other branches and areas of the operation.

IX. Introduction to Hazardous Materials

A. When you arrive at a possible HazMat incident, you must first step back and assess the situation.

1. Rushing into such unsafe scenes can have catastrophic results.

a. If overcome, you will be unable to assist patients.

b. Requiring emergency care yourself, you will then further strain the EMS system.

B. Because of the unique aspects of responding to and working at a HazMat incident, OSHA has published a set of guidelines known as Hazardous Waste Operations and Emergency Response Standard (or HAZWOPER).

1. EMTs are required to have training at the First Responder Awareness Level.

2. First responders at the awareness level should have sufficient training or experience to demonstrate the following competencies:

a. An understanding of what hazardous substances are and the risks associated with them

b. An understanding of the potential outcomes of an incident

c. The ability to recognize the presence of hazardous substances

d. The ability to identify the hazardous substances, if possible

e. An understanding of the role of the first responder awareness individual in the emergency response plan

f. The ability to determine the need for additional resources and to notify the communication center

X. Recognizing a Hazardous Material

A. A hazardous material is any material that poses an unreasonable risk of damage or injury to persons, property, or the environment if it is not properly controlled during:

1. Handling

2. Storage

3. Manufacture

4. Processing

5. Packing

6. Use and disposal

7. Transportation

B. Train yourself to take the time to look at the whole scene so that you can identify the critical visual indicators and fit them into what is known about the problem.

C. Hazardous materials may be involved in any of the following situations:

1. A truck or train crash in which a substance is leaking from a tank truck or railroad tank car

2. A leak, fire, or other emergency at an industrial plant, refinery, or other complex where chemicals or explosives are produced, used, or stored

3. A leak or rupture of an underground natural gas pipe

4. Deterioration of underground fuel tanks and seepage of oil or gasoline into the surrounding ground

5. Buildup of methane or other by-products of waste decomposition in sewers or sewage-processing plants

6. A motor vehicle crash resulting in a ruptured gas tank

D. It is important to approach the scene from a safe location and direction.

1. The traditional rules of staying uphill and upwind are a good place to start.

2. It may be wise to use binoculars and view the scene from a safe distance.

3. Be sure to question anyone involved in the incident.

E. Occupancy and location

1. A wide variety of chemicals are stored in:

a. Warehouses

b. Hospitals

c. Laboratories

d. Industrial complexes

e. Residential garages

f. Bowling alleys

g. Home improvement centers

h. Garden supply stores

i. Restaurants

2. The location and type of building are two good indicators of the possible presence of a hazardous material.

F. Senses

1. The senses that can be safely used are those of sight and sound.

2. Using any of your senses that bring you in proximity to the chemical should be done with caution or avoided.

3. Clues that are seen or heard from a distance may enable you to take precautionary steps.

G. Containers

1. In basic terms, a container is any vessel or receptacle that holds a material.

2. Often the container type, size, and material of construction provide important clues about the nature of the substance inside.

a. Do not rely solely on the type of container when making a determination about hazardous materials.

3. One way to distinguish containers is to divide them into two categories based on their capacity: bulk and non bulk storage containers.

4. Container volume

a. Bulk storage containers include:

i. Fixed tanks

ii. Highway cargo tanks

iii. Rail tank cars

iv. Totes

v. Intermodal tanks

b. In general, bulk storage containers are found in buildings that rely on and need to store large quantities of a particular chemical.

c. Often these bulk storage containers are surrounded by a secondary containment system to help control an accidental release.

d. Large-volume horizontal tanks are also common.

i. These tanks can hold a few hundred gallons to several million gallons of product and are usually made of aluminum, steel, or plastic.

e. Totes have capacities ranging from 119 gallons to 703 gallons.

i. They can contain any type of chemical, including flammable liquids, corrosives, food-grade liquids, or oxidizers.

ii. Shipping and storing totes can be hazardous because they have no secondary containment system.

f. Intermodal tanks are both shipping and storage vessels.

i. Hold between 5,000 and 6,000 gallons of product

ii. Can be pressurized or nonpressurized

5. Non Bulk storage vessels

a. All types of containers other than bulk containers

b. Hold commonly used commercial and industrial chemicals such as solvents, industrial cleaners, and compounds

c. Drums

i. Easily recognizable, barrel-like containers

ii. Used to store a wide variety of substances, including food-grade materials, corrosives, flammable liquids, and grease

iii. Generally, the nature of the chemical dictates the construction of the storage drum.

d. Bags

i. Commonly used to store solids and powders such as cement powder, sand, pesticides, soda ash, and slaked lime

ii. May be constructed of plastic, paper, or plastic-lined paper

iii. Pesticide bags must be labeled with specific information:

(a) Name of the product

(b) Active ingredients

(d) The total amount of product in the container

(e) The manufacturer’s name and address

(f) The EPA registration number

(g) The EPA establishment number

(h) Signal words to indicate the relative toxicity of the material

(i) Practical first aid treatment description

(j) Directions for use

(k) Agricultural use requirements

(l) Precautionary statements

(m) Storage and disposal information

(n) Classification statement on who may use the product

(o) “Keep out of reach of children” statement

e. Carboys

i. Transport and store corrosives and other types of chemicals

ii. Glass, plastic, or steel container that holds 5 to 15 gallons of product

iii. Glass carboys are often placed in a protective wood, foam, fiberglass, or steel box to help prevent breakage.

f. Cylinders

i. Uninsulated compressed gas cylinders are used to store substances such as nitrogen, argon, helium, and oxygen.

H. The Department of Transportation (DOT) marking system

1. Labels, placards, and other markings are used on buildings, packages, boxes, and containers.

2. Marking systems indicate the presence of a hazardous material from a safe distance and provide clues about the substance.

a. Placards are diamond-shaped indicators that are placed on all four sides of highway transport vehicles, railroad tank cars, and other forms of transportation carrying hazardous materials.

b. Labels are smaller versions of placards, placed on the four sides of individual boxes and smaller packages being transported.

I. Other considerations

1. The DOT system does not require that all chemical shipments be marked with placards or labels.

2. In most cases, the package or cargo tank must contain a certain amount of hazardous material before a placard is required.

a. Commercial package delivery services often carry small amounts of hazardous materials that fall below that weight limit.

b. The vehicle exterior will not display placards to warn of the danger.

3. Conversely, some chemicals are so hazardous that shipping any amount of them requires the use of labels or placards, such as:

a. Explosives

b. Poison gases

c. Water-reactive solids

d. High-level radioactive substances

J. References

1. The Emergency Response Guidebook

a. Offers a certain amount of guidance for responders operating at a HazMat incident

b. Updated every three to four years

c. Provides information on approximately 4,000 chemicals

2. Material safety data sheets (MSDS)

a. A common source of information about a particular chemical

b. Provides basic information about:

i. The chemical makeup of a substance

ii. The potential hazards it presents

iii. Appropriate first aid in the event of an exposure

iv. Other pertinent data for safe handling of the material

c. An MSDS will typically include the following details:

i. The name of the chemical, including any synonyms for it

ii. Physical and chemical characteristics of the material

iii. Physical hazards of the material

iv. Health hazards of the material

v. Signs and symptoms of exposure

vi. Routes of entry

vii. Permissible exposure limits

viii. Responsible-party contact

ix. Precautions for safe handling

x. Applicable control measures, including PPE

xi. Emergency and first aid procedures

xii. Appropriate waste disposal

d. All facilities that use or store chemicals are required by law to have an MSDS on file for each chemical used or stored in the facility.

3. Shipping papers

a. Required whenever materials are transported from one place to another

b. They include the names and addresses of the shipper and the receiver, identify the material being shipped, and specify the quantity and weight of each part of the shipment.

c. Shipping papers for road and highway transportation are called bills of lading or freight bills and are located in the cab of the vehicle.

4. Chemical Transportation Emergency Center (CHEMTREC)

a. CHEMTREC is operated by the American Chemistry Council.

b. Provides invaluable technical information for first responders of all disciplines who are called upon to respond to chemical incidents

c. When you call CHEMTREC, be sure to have the following basic information ready:

i. The name of the chemical(s) involved in the incident

ii. Name of the caller and callback telephone number

iii. Location of the actual incident or problem

iv. Shipper or manufacturer of the chemical (if known)

v. Container type

vi. Railcar or vehicle markings or numbers

vii. The shipping carrier’s name

viii. Recipient of material

ix. Local conditions and exact description of the situation

K. Identification

1. Despite the availability of resources, identification may still be difficult.

a. Little consistency is used on labels and placards, and dishonest transporters sometimes will not label containers or vessels appropriately.

b. Always maintain a high index of suspicion when approaching the scene of a truck or train tanker accident.

2. In the event of a leak or spill, a HazMat incident is often indicated by the presence of the following:

a. Visible cloud or strange-looking smoke from the escaping substance

b. Leak or spill from a tank, container, truck, or railroad car with or without HazMat placards or labels

c. Unusual, strong, noxious (harmful), harsh odor in the area

3. A large number of hazardous gases and fluids are essentially odorless even when a substantial leak or spill has occurred.

a. If you approach a scene where more than one person has collapsed or is unconscious or in respiratory distress, you should assume that there has been a HazMat leak or spill and that it is unsafe to enter the area.

4. The safety of you and your team, the other responders, and the public must be your most important concern.

5. If, as you approach, any signs suggest that a HazMat incident has occurred, you should stop at a safe distance and park upwind or uphill from the incident.

a. After rapidly sizing up the scene, call for the HazMat team.

b. If you do not recognize the danger until you are too close, immediately leave the danger zone.

c. Try to rapidly assess the situation and provide as much information as possible when calling for the HazMat team.

d. Do not reenter the scene and do not leave the area until you have been cleared by the HazMat team.

e. Do not allow civilians to enter the scene, if possible.

f. Avoid all contact with the material.

L. HazMat scene operations

1. Focus your efforts on activities that will ensure the safety and survival of the greatest number of people.

2. Use the ambulance’s public address system to alert individuals near the scene and direct them to move to a safer area.

3. Establishing control zones

a. Control zones are established at a HazMat incident based on the:

i. Chemical and physical properties of the released material

ii. Environmental factors at the time of the release

iii. General layout of the scene

b. Securing access to the incident helps ensure that no one will accidentally enter a contaminated area.

c. If the incident takes place inside a structure, the best place to control access is at the normal points of ingress and egress—doors.

d. If the incident occurs outside, control intersections, on and off ramps, service roads, and other access routes to the scene.

e. Control zones may be expanded or contracted as needed.

f. The hot zone is the area immediately surrounding the release, which is also the most contaminated area.

i. The physical characteristics of the released substance will significantly affect the size and layout of the hot zone.

ii. All specially trained responders entering the hot zone should avoid contact with the product to the greatest extent possible.

iii. All personnel and equipment must be decontaminated when they leave the hot zone.

g. The warm zone is where personnel and equipment transition into and out of the hot zone.

i. It contains control points for access to the hot zone as well as the decontamination area.

ii. Decontamination is the process of removing or neutralizing and properly disposing of hazardous materials from equipment, patients, and rescue personnel.

h. The cold zone is a safe area where personnel do not need to wear any special protective clothing for safe operation; it includes:

i. Personnel staging

ii. The command post

iii. EMS providers

iv. The area for medical monitoring, support, and/or treatment after decontamination

4. Role of the EMT

a. Your job is to report to a designated area outside of the hot and warm zones and provide:

i. Triage

ii. Treatment

iii. Transport

iv. Rehabilitation

M. Classification of hazardous materials

1. The National Fire Protection Association (NFPA) 704, Hazardous Materials Classification standard classifies hazardous materials according to:

a. Health hazard or toxicity levels

b. Fire hazard

c. Chemical reactive hazard

d. Special hazards

2. Toxicity levels

a. Measures the health risk that a substance poses to someone who comes into contact with it

b. The higher the number, the greater the toxicity, as follows:

i. Level 0 includes materials that would cause little, if any, health hazard if you came into contact with them.

ii. Level 1 includes materials that would cause irritation on contact but only mild residual injury, even without treatment.

iii. Level 2 includes materials that could cause temporary damage or residual injury unless prompt medical treatment is provided.

iv. Level 3 includes materials that are extremely hazardous to health.

v. Level 4 includes materials that are so hazardous that minimal contact will cause death.

c. All health hazard levels, with the exception of 0, require specialized training and respiratory and chemical protective gear that is not standard on most ambulances.

N. Personal protective equipment level

1. Personal protective equipment levels indicate the amount and type of protective gear that you need to prevent injury from a particular substance.

2. Level A

a. The most hazardous

b. Requires fully encapsulated, chemical-resistant protective clothing that provides full body protection, as well as SCBA and special, sealed equipment.

3. Level B

a. Requires nonencapsulated protective clothing or clothing that is designed to protect against a particular hazard

b. Also requires eye protection and breathing devices that contain their own air supply, such as SCBA

4. Level C

a. Like Level B, requires the use of nonpermeable clothing and eye protection

b. In addition, face masks that filter all inhaled outside air must be used

5. Level D

a. Requires a work uniform, such as coveralls, that affords minimal protection

6. All levels of protection require the use of gloves.

a. Two pairs of rubber gloves are needed for protection in case one pair must be removed because of heavy contamination.

O. Caring for patients at a HazMat incident

1. It is practical only to provide the simplest assessment and essential care in the hazard zone and the decontamination area because of the:

a. Dangers

b. Time constraints

c. Bulky protective gear that team members wear

2. To avoid entrapment and spread of contaminants, no bandages or splints are applied (except pressure dressings that are needed to control bleeding).

3. The EMTs providing care in the treatment area should assess and treat the patient in the same way as they would a patient who has not been previously assessed or treated.

4. Your care of patients at a HazMat incident must address the following two issues:

a. Any trauma that has resulted from other related mechanisms, such as vehicle collision, fire, or explosion

b. The injury and harm that have resulted from exposure to the toxic hazardous substance

5. Most serious injuries and deaths from hazardous materials result from airway and breathing problems.

a. Maintain the airway and, if the patient appears to be in distress, give oxygen at 12 to 15 L/min with a nonrebreathing mask.

b. Monitor the patient’s breathing at all times.

c. If there are signs that indicate that respiratory distress is increasing, you may need to provide assisted ventilation with a bag-valve mask (BVM) and high-flow oxygen.

6. Treat the patient’s injuries in the same way that you would treat any injury.

7. Your treatment for the patient’s exposure to the toxic substance should focus mainly on supportive care and initiating treatment to the hospital with a minimum of additional delay.

8. Special care

a. In some cases, before the decontamination area has been completely set up, the HazMat team will find one or two patients who need immediate treatment and transport without further delay if they are to survive.

b. It may be necessary to simply cut away all of the patient’s clothing and do a rapid rinse to remove the majority of the contaminating matter before transport.

c. You will need to increase the amount of protective clothing you wear, including:

i. SCBA

ii. Two pairs of gloves

iii. Goggles or a face shield

iv. A protective coat

v. Respiratory protection

vi. A disposable fluid-impervious apron or similar outfit

d. To make decontaminating the ambulance easier, tape the cabinet doors shut.

i. Any equipment kits, monitors, and other items that will not be used en route should be removed from the patient compartment and placed in the front of the ambulance or in outside compartments.

ii. Before loading the patient, turn on the power vent ceiling fan and patient compartment air-conditioning unit fan.

e. When you leave the scene, inform the hospital that you are transporting a critically injured patient who has not been fully decontaminated at the scene.

Chapter 40, Terrorism Response and Disaster Management

Unit Summary

After completing this chapter and related coursework, you will be able to describe what constitutes terrorism and the EMT’s response to terrorism, and be able to apply this knowledge. Additionally, you will demonstrate an understanding of weapons of mass destruction (WMD) agents and countermeasures, as well as a fundamental knowledge of disaster management safety.

National EMS Education Standard Competencies

EMS Operations

Knowledge of operational roles and responsibilities to ensure patient, public, and personnel safety.

Mass-Casualty Incidents Due to Terrorism and Disaster

• Risks and responsibilities of operating on the scene of a natural or man-made disaster.

Knowledge Objectives

1. Define international terrorism and domestic terrorism; include examples of incidents that have been caused by each one.

2. Name four different types of goals that commonly motivate terrorist groups to carry out terrorist attacks.

3. Define weapon of mass destruction (WMD) and weapon of mass casualty (WMC); include examples of weapons considered WMDs.

4. Explain how the Department of Homeland Security (DHS) National Terrorism Advisory System (NTAS) relates to the actions and precautions EMTs must take while performing their daily activities.

5. Name the key observations EMTs must make on every call to determine the potential of a terrorist attack.

6. Explain the critical response actions related to establishing and reassessing scene safety, personnel protection, notification procedures, and establishing command EMTs must perform at a suspected terrorist event.

7. Discuss the history of chemical agents, their four main classifications, routes of exposure, effects on the patient, and patient care.

8. List three categories of biological agents, their routes of exposure, effects on the patient, and patient care.

9. Explain the role of EMS in relation to syndromic surveillance and points of distribution (PODS) during a biologic event.

10. Discuss the history of nuclear/radiological devices, sources of radiological materials and dispersal devices, medical management of patients, and protective measures EMTs must take during a nuclear/radiological incident.

11. Describe the mechanisms of injury caused by incendiary and explosive devices; include the types and severity of wounds.

Skill Objectives

1. Demonstrate the steps EMTs can take to establish and reassess scene safety based on a scenario of a terrorist event.

2. Demonstrate the steps EMTs can take for the management of a patient exposed to a chemical agent.

3. Demonstrate the use of the DuoDote Auto-Injector and/or the Antidote Treatment Nerve Agent Auto-Injector.

I. Introduction

A. It is possible that you may be called on to respond to a terrorist event during your career.

1. The question is not will terrorists strike again, but rather when and where they will strike.

2. You must be mentally and physically prepared for the possibility of a terrorist event.

B. It is difficult to plan and anticipate a response to many terrorist events, yet there are several key principles that apply to every response.

II. What is Terrorism?

A. Terrorist forces have been at work since early civilizations.

1. The US Department of Justice defines both international terrorism and domestic terrorism with these points:

a. Involves violent acts or acts dangerous to human life that violate federal or state law

b. Appears to be intended (i) to intimidate or coerce a civilian population; (ii) to influence the policy of a government by intimidation or coercion; or (iii) to affect the conduct of a government by mass destruction, assassination, or kidnapping

2. One difference between the two is location.

a. International terrorism occurs primarily outside the territorial jurisdiction of the United States.

b. Domestic terrorism occurs primarily within the territorial jurisdiction of the United States.

3. Modern-day terrorism is common in the Middle East where terrorist groups have frequently attacked civilian populations.

4. In the United States, domestic terrorists have struck multiple times in previous years.

B. Only a small percentage of groups actually turn toward terrorism as a means to achieve their goals.

1. Religious extremist groups/doomsday cults

a. Include groups such as Aum Shinrikyo

b. Some of these groups may participate in apocalyptic violence.

2. Extremist political groups

a. Include violent separatist groups and those who seek political, religious, economic, and social freedom

3. Cyber terrorists

a. They attack a population’s technological infrastructure as a means to draw attention to their cause.

4. Single-issue groups

a. Include anti-abortion groups, animal rights groups, anarchists, racists, and even ecoterrorists

III. Weapons of Mass Destruction

A. A weapon of mass destruction (WMD), or weapon of mass casualty (WMC), is any agent designed to bring about:

1. Mass death

2. Casualties

3. Massive damage to property and infrastructure (bridges, tunnels, airports, and seaports)

B. B-NICE and CBRNE are mnemonics to remember the kinds of weapons of mass destruction.

1. B-NICE

a. Biologic

b. Nuclear

c. Incendiary

d. Chemical

e. Explosive

2. CBRNE

a. Chemical

b. Biologic

c. Radiologic

d. Nuclear

e. Explosive

C. To date, the preferred WMD for terrorists has been explosive devices.

1. WMDs are relatively easy to obtain or create and are specifically geared toward killing large numbers of people.

D. Chemical terrorism/warfare

1. Chemical agents are manufactured substances that can have devastating effects on living organisms.

2. They can be produced in liquid, powder, or vapor form, depending on the desired route of exposure and dissemination technique.

3. These agents consist of the following types:

a. Vesicants (blister agents)

b. Respiratory agents (choking agents)

c. Nerve agents

d. Metabolic agents (cyanides)

E. Biologic terrorism/warfare

1. Biologic agents are organisms that cause disease.

2. They are generally found in nature; for terrorist use, however, they are cultivated, synthesized, and mutated in a laboratory.

3. The weaponization of biologic agents is performed to artificially maximize the target population’s exposure to the germ.

4. The primary types are:

a. Viruses

b. Bacteria

c. Toxins

F. Nuclear/radiological terrorism

1. There have been only two publicly known incidents involving the use of a nuclear device.

a. Hiroshima and Nagasaki

2. It is possible for a terrorist to secure radioactive materials or waste to perpetrate an act of terror.

a. These materials are far easier for a determined terrorist to acquire and require less expertise to use.

b. “Dirty bombs” can cause widespread panic and civil disturbances.

IV. EMT Response to Terrorism

A. When you respond to a terrorist event, the basic foundations of patient care remain the same.

1. However, the treatment can and will vary.

2. Always remember situational awareness.

B. Recognizing a terrorist event (indicators)

1. The planning of most acts of terror is covert, which means that the public safety community generally has no prior knowledge of the time, location, or nature of the attack.

a. You must constantly be aware of your surroundings and understand the possible risks for terrorism.

b. You must know the current threat level issued by the federal government through the Department of Homeland Security (DHS).

2. In April 2011, the color-coded Homeland Security Advisory System was replaced by the National Terrorism Advisory System (NTAS).

a. Alerts from the NTAS contain a summary of the threat and the actions that first responders, government agencies, and the public can take to maintain safety.

3. Make sure you are aware of information sent out by the advisory system at the start of your workday.

4. On every call, make the following observations:

a. Type of location

i. Is the location a monument, infrastructure, government building, or religious building?

ii. Is there a large gathering or special event?

b. Type of call

i. Is there a report of an explosion or suspicious device?

ii. Are there reports of people fleeing the scene?

c. Number of patients

i. Are there multiple victims with similar signs and symptoms?

ii. This is probably the single most important clue that a terrorist attack or an incident involving a WMD has occurred.

d. Victims’ statements

i. The second-best indication of a terrorist or WMD event

e. Preincident indicators

i. Has there been a recent increase in violent political activism?

ii. Are you aware of any credible threats made against the location, gathering, or occasion?

C. Response actions

1. Scene safety

a. Remember to stage your vehicle a safe distance from the incident.

b. Wait for law enforcement personnel to advise you that the scene has been made secure.

c. If you have any doubt that it may not be safe, do not enter.

d. The best location for staging is upwind and uphill from the incident.

e. Remember the following rules:

i. Failure to park your vehicle at a safe location can place you and your partner in danger.

ii. If your vehicle is blocked in by other emergency vehicles or damaged by a secondary device (or event), you will be unable to provide victims with transportation or escape yourself.

f. Secondary device

i. Terrorists have been known to plant additional explosives that are set to explode after the initial bomb.

ii. This type of secondary device is intended primarily to injure responders and to secure media coverage.

iii. Secondary devices may include various types of electronic equipment such as cell phones or pagers.

2. Responder safety (personnel protection)

a. The best form of protection from a WMD agent is preventing yourself from coming into contact with the agent.

b. The greatest threats facing you in a WMD attack are contamination and cross-contamination.

i. Contamination with an agent occurs when you have direct contact with the WMD or are exposed to it.

ii. Cross-contamination occurs when you come into contact with a contaminated person who has not yet been decontaminated.

3. Notification procedures

a. Notify the dispatcher when you suspect a terrorist or WMD.

b. Inform dispatch of:

i. The nature of the event

ii. Any additional resources that may be required

iii. The estimated number of patients

iv. The upwind route of approach or optimal route of approach

c. It is extremely important to establish a staging area, where other units will converge.

i. Be mindful of access and exit routes when you direct units to respond to a location.

d. Trained responders in the proper protective equipment are the only persons equipped to handle the WMD incident.

e. Keep in mind that there may be more than one type of device or agent present.

4. Establishing command

a. As the first provider on scene, the EMT may need to establish command until additional personnel arrive.

b. You and other EMTs may function as:

i. Medical branch directors

ii. Triage supervisors

iii. Treatment supervisors

iv. Transportation supervisors

v. Logistic officers

vi. Command and general staff

c. If the initial incident command system (ICS) is already in place, immediately seek out the medical staging officer to receive your assignment.

5. Reassessing scene safety

a. It is every EMT’s responsibility to constantly assess and reassess the scene for safety.

b. This is an important component of situational awareness.

V. Chemical Agents

A. Chemical agents are liquids or gases that are dispersed to kill or injure.

1. The characteristics of an agent can be described as liquid, gas, or solid material.

2. Persistent or nonvolatile agents can remain on a surface for long periods, usually longer than 24 hours.

3. Non-persistent or volatile agents evaporate rapidly when left on a surface in the optimal temperature range.

4. Route of exposure is a term used to describe how the agent most effectively enters the body.

a. Agents with a vapor hazard enter the body through the respiratory tract in the form of vapors.

b. Agents with a contact hazard (or skin hazard) give off very little vapor or no vapors and enter the body through the skin.

B. Vesicants (blister agents)

1. The primary route of exposure of blister agents, or vesicants, is the skin (contact).

2. However, if vesicants are left on the skin or clothing long enough, they produce vapors that can enter the respiratory tract.

3. Vesicants cause burn-like blisters to form on the victim’s skin and in the respiratory tract.

4. The vesicant agents consist of:

a. Sulfur mustard (H)

b. Lewisite (L)

c. Phosgene oxime (CX)

5. The vesicants usually cause the most damage to damp or moist areas of the body, such as the armpits, groin, and respiratory tract.

6. Signs of vesicant exposure on the skin include the following:

a. Skin irritation, burning, and reddening

b. Immediate, intense skin pain

c. Formation of large blisters

d. Gray discoloration of skin

e. Swollen and closed or irritated eyes

f. Permanent eye injury (including blindness)

7. If vapors were inhaled, the patient may experience these signs/symptoms:

a. Hoarseness and stridor

b. Severe cough

c. Hemoptysis (coughing up blood)

d. Severe dyspnea

8. Sulfur mustard is a brownish-yellowish oily substance that is generally considered very persistent.

a. As the agent is absorbed into the skin, it begins an irreversible process of damage to the cells.

b. Mustard is considered a mutagen, which means that it mutates, damages, and changes the structures of cells.

c. The patient will experience a progressive reddening of the affected area, which will gradually develop into large blisters.

d. Mustard also attacks vulnerable cells within the bone marrow and depletes the body’s ability to reproduce white blood cells.

e. Sulfur mustard vapors can be inhaled, creating upper and lower airway compromise.

9. Lewisite and phosgene oxime produce blister wounds very similar to those caused by mustard.

a. These agents produce immediate intense pain and discomfort when contact is made.

b. The patient may have a grayish discoloration at the contaminated site.

10. Vesicant agent treatment

a. There are no antidotes for mustard or CX exposure.

b. British anti-lewisite is the antidote for agent L; however, it is not carried by civilian EMS.

c. Ensure that the patient has been decontaminated before you initiate any treatment.

d. If an agent has been inhaled, the patient may require prompt airway support as soon as decontamination is complete.

e. Transport should be initiated as soon as possible.

f. Generally, burn centers are best equipped to handle the wounds and subsequent infections produced by vesicants.

C. Pulmonary agents (choking agents)

1. The pulmonary agents are gases that cause immediate harm to persons exposed to them.

a. Includes chlorine (Cl) and phosgene

b. They produce respiratory-related symptoms such as dyspnea and tachypnea.

2. The primary route of exposure is through the respiratory tract, which makes them an inhalation or vapor hazard.

3. Once inside the lungs, they damage the lung tissue and fluid leaks into the lungs.

4. Pulmonary edema develops, resulting in difficulty breathing because of severely impaired gas exchange.

5. Chlorine (Cl) was the first chemical agent ever used in warfare.

a. Initially it produces upper airway irritation and a choking sensation.

b. The patient may later experience these signs/symptoms:

i. Shortness of breath

ii. Chest tightness

iii. Hoarseness and stridor

iv. Gasping and coughing

c. With serious exposures, patients may experience pulmonary edema, complete airway constriction, and death.

6. Phosgene has been produced for chemical warfare and is a product of combustion such as might be produced in a fire.

a. Phosgene is a very potent agent that has a delayed onset of symptoms, usually hours.

b. The odor produced by the chemical is similar to that of freshly mown grass or hay.

i. The result is that much more of the gas may enter the body unnoticed.

c. Initially, a mild exposure may include these signs/symptoms:

i. Nausea

ii. Chest tightness

iii. Severe cough

iv. Dyspnea on exertion

d. Pulmonary edema may be so severe that the patient continually coughs up white or pink-tinged fluid.

e. A severe exposure produces such large amounts of fluid in the lungs that the patient may actually become hypovolemic and subsequently hypotensive.

7. Pulmonary agent treatment

a. The best initial treatment is to remove the patient from the contaminated atmosphere.

i. This should be done by trained personnel in the proper PPE.

b. Aggressive management of the ABCs should be initiated, paying particular attention to oxygenation, ventilation, and suctioning if required.

c. Do not allow the patient to be active.

d. There are no antidotes to counteract the pulmonary agents.

e. The primary goals are to perform the ABCs, allow the patient to rest in a position of comfort with the head elevated, and initiate rapid transport.

f. If the patient’s condition does not improve with basic airway support, consider requesting ALS intercept.

g. Continuous positive airway pressure (CPAP) may benefit some patients; others will require advanced airway management.

D. Nerve agents

1. The nerve agents are among the most deadly chemicals developed.

a. Classified as WMDs

b. Not readily available to the general public

c. Extremely toxic and rapidly fatal with any route of exposure

2. Nerve agents can cause cardiac arrest within seconds to minutes of exposure.

3. Nerve agents are a class of chemical called organophosphates, which are found in household bug sprays, agricultural pesticides, and some industrial chemicals at much lower strengths then in the weaponized form.

a. Organophosphates block an essential enzyme in the nervous system, causing the body’s organs to become overstimulated and burn out.

4. G agents came from the early nerve agents, the G series.

a. Sarin (GB) is a highly volatile colorless and odorless liquid.

i. LD50 (the standard measurement that represents the amount that will kill 50% of a population exposed to this level) of about 1 drop

ii. Especially dangerous in enclosed environments

iii. When it comes in contact with the skin, it is quickly absorbed and evaporates.

iv. When it is on clothing, it has the effect of off-gassing.

b. Soman (GD) is twice as persistent as sarin and five times as lethal.

i. This agent is a contact and an inhalation hazard.

ii. A unique additive in GD causes it to bind to the cells that it attacks faster than any other agent.

c. Tabun (GA) is approximately half as lethal as sarin and 36 times more persistent.

i. It is a contact and an inhalation hazard.

d. V agent (VX) is a clear oily agent that has no odor and looks like baby oil.

i. It is more than 100 times more lethal than sarin and is extremely persistent.

ii. It is easily absorbed into the skin, and the oily residue that remains is extremely difficult to decontaminate.

5. Nerve agents all produce similar symptoms but have varying routes of entry.

a. The symptoms are described using the military mnemonic SLUDGEM.

i. Salivation, sweating

ii. Lacrimation (excessive tearing) (also rhinorrhea)

iii. Urination

iv. Defecation, drooling, diarrhea

v. Gastric upset and cramps

vi. Emesis (vomiting)

vii. Muscle twitching/miosis (pinpoint pupils)

b. The medical mnemonic DUMBELS is also used:

i. Diarrhea

ii. Urination

iii. Miosis, muscle weakness

iv. Bradycardia, bronchospasm, bronchorrhea

v. Emesis

vi. Lacrimation

vii. Seizures, salivation, sweating

6. Miosis is the most common symptom of nerve agent exposure and can remain for days to weeks.

a. Seen quickly in vapor exposure; may occur later after isolated skin exposure

b. The patient may have been exposed to both.

7. Nerve agent treatment

a. Fatalities from severe nerve agent exposure occur as a result of respiratory complications, which lead to respiratory arrest.

b. You can greatly increase the patient’s chances of survival simply by providing airway and ventilatory support.

c. Often in patients exposed to these agents, seizures will begin and will not stop.

i. These patients will require administration of nerve agent antidote kits.

d. Medical treatment may include:

i. DuoDote Auto-Injector: contains 2.1 mg of atropine and 600 mg of pralidoxime chloride (2-PAM) and is delivered as a single dose through one needle. (The military form is the Antidote Treatment Nerve Agent Auto-Injector [ATNAA].)

ii. If your service carries a nerve agent antidote, refer to your local protocols for dosage and usage information.

E. Metabolic agents (cyanides)

1. Hydrogen cyanide (AC) and cyanogen chloride (CK) are both agents that affect the body’s ability to use oxygen.

a. Cyanide is a colorless gas with an odor similar to almonds.

2. Effects of cyanides begin on the cellular level and are very rapidly seen at the organ and system levels.

a. These deadly gases are commonly found in many industrial settings such as gold and silver mining, photography, and plastics processing.

b. They are often present in fires associated with textile and plastic factories.

3. In low doses, these chemicals are associated with dizziness, light-headedness, headache, and vomiting.

4. High doses will produce symptoms that include the following:

a. Shortness of breath and gasping respirations

b. Respiratory distress or arrest

c. Tachypnea

d. Flushed skin

e. Tachycardia

f. Altered mental status

g. Seizures

h. Coma

i. Apnea

j. Cardiac arrest

5. Cyanide agent treatment

a. Cyanide binds with the body’s cells, preventing oxygen from being used.

b. Once trained personnel wearing the proper PPE have removed the patient from the source of exposure, all of the patient’s clothes must be removed to prevent off-gassing in the ambulance.

c. Patients must be decontaminated by trained personnel before initiating treatment.

d. Support the patient’s ABCs.

i. Mild effects will generally resolve by removing the victim from the source of contamination and administering supplemental oxygen.

ii. Severe exposure will require aggressive oxygenation and perhaps ventilation with supplemental oxygen.

iii. Always use a bag-valve mask (BVM) or oxygen-powered ventilator device.

e. Initiate transport immediately if antidote by ALS is not available.

VI. Biologic Agents

A. Biologic agents pose many difficult issues when used as a WMD.

1. Biologic agents can be almost completely undetectable.

2. Most of the diseases caused by these agents will be similar to other minor illnesses.

B. Biologic agents are grouped as viruses, bacteria, and neurotoxins and may be spread in various ways.

1. Dissemination is the means by which a terrorist will spread the agent.

2. A disease vector is an animal that, once infected, spreads disease to another animal.

3. How easily the disease is able to spread from one human to another human is called communicability.

a. In instances when communicability is high, such as with smallpox, the person is considered contagious.

4. Incubation is the period of time between the person becoming exposed to the agent and the appearance of the first symptoms.

C. Viruses

1. Viruses are germs that require a living host to multiply and survive.

2. Once in the body, the virus invades healthy cells and replicates itself to spread through the host.

3. Viruses move from host to host by direct methods, such as respiratory droplets, or through vectors.

4. Smallpox

a. Smallpox is a highly contagious disease.

b. All forms of standard precautions must be used to prevent cross-contamination.

c. Wear examination gloves, a HEPA-filtered respirator, and eye protection.

d. Before the rash and blisters show, the illness will start with a high fever and body aches and headaches.

e. An easy, quick way to differentiate the smallpox rash from other skin disorders is to observe the size, shape, and location of the lesions.

i. In smallpox, all the lesions are identical in their development.

ii. Smallpox blisters begin on the face and extremities and eventually move toward the chest and abdomen.

iii. The disease is in its most contagious phase when the blisters begin to form.

5. Viral hemorrhagic fevers (VHFs)

a. VHFs consist of a group of diseases caused by viruses that include the Ebola, Rift Valley, Marburg, and yellow fever viruses, among others.

b. This group of viruses causes the blood in the body to seep out from the tissues and blood vessels.

c. Initially, the patient will have flu-like symptoms, progressing to more serious symptoms such as internal and external hemorrhaging.

d. All standard precautions must be taken when treating these illnesses.

D. Bacteria

1. Unlike viruses, bacteria do not require a host to multiply and live.

2. Bacteria are much more complex and larger and can grow up to 100 times larger than the largest virus.

3. Most bacterial infections can be fought with antibiotics.

4. Most bacterial infections will generally begin with flulike symptoms.

5. Inhalation and cutaneous anthrax (Bacillus anthracis)

a. Anthrax is caused by a deadly bacterium that lays dormant in a spore.

b. When exposed to the optimal temperature and moisture, the germ will be released from the spore.

c. The routes of entry are inhalation, cutaneous, and gastrointestinal.

i. The inhalation form, or pulmonary anthrax, is the most deadly and often presents as a severe cold.

ii. Pulmonary anthrax is associated with a 90% death rate if untreated.

d. Antibiotics can be used to treat anthrax successfully.

6. Plague (bubonic/pneumonic)

a. The plague’s natural vectors are infected rodents and fleas.

b. Bubonic plague infects the lymphatic system.

i. When this occurs, the patient’s lymph nodes become infected and grow.

ii. The glands of the nodes will grow large and round, forming buboes.

iii. If left untreated, the infection may spread through the body, leading to sepsis and possibly death.

c. Pneumonic plague is a lung infection, also known as plague pneumonia, that results from inhalation of plague bacteria.

i. This form of the disease is contagious and has a much higher death rate than the bubonic form.

E. Neurotoxins

1. Neurotoxins are the most deadly substances known to humans.

2. These toxins are produced from plants, marine animals, molds, and bacteria.

3. The route of entry is through ingestion, inhalation from aerosols, or injection.

4. Unlike viruses and bacteria, they are not contagious and have a faster onset of symptoms.

5. Botulinum toxin

a. The most potent neurotoxin is botulinum, which is produced by bacteria.

b. When introduced into the body, the neurotoxin affects the nervous system’s ability to function.

i. Voluntary muscle control diminishes as the toxin spreads.

ii. Eventually the toxin causes muscle paralysis, leading to respiratory arrest.

6. Ricin

a. Ricin is derived from mash that is left from the castor bean.

b. When introduced into the body, ricin causes pulmonary edema and respiratory and circulatory failure leading to death.

c. The toxin is quite stable and extremely toxic by many routes of exposure, including inhalation.

d. Signs and symptoms of ricin ingestion are as follows:

i. Fever

ii. Chills

iii. Headache

iv. Muscle aches

v. Nausea

vi. Vomiting

vii. Diarrhea

viii. Severe abdominal cramping

ix. Dehydration

x. Gastrointestinal bleeding

xi. Necrosis of the liver, spleen, kidneys, and GI tract

e. Signs and symptoms of ricin inhalation are as follows:

i. Fever

ii. Chills

iii. Nausea

iv. Local irritation of eyes, nose, and throat

v. Profuse sweating

vi. Headache

vii. Muscle aches

viii. Nonproductive cough

ix. Chest pain

x. Dyspnea

xi. Pulmonary edema

xii. Severe lung inflammation

xiii. Cyanosis

xiv. Seizures

xv. Respiratory failure

f. Treatment is supportive and includes both respiratory support and cardiovascular support as needed.

F. Other EMT roles during a biologic event

1. Syndromic surveillance

a. Syndromic surveillance is the:

i. Monitoring of patients presenting to emergency departments and alternative care facilities

ii. Recording of EMS call volume

iii. Monitoring of the use of over-the-counter medications

b. Patients with signs and symptoms that resemble influenza are particularly important.

c. Quality assurance and dispatch operations need to be aware of an unusual number of calls from patients with unexplainable symptom clusters coming from a particular region or community.

2. Points of distribution (Strategic National Stockpile)

a. PODs are existing facilities that are established in a time of need for the mass distribution of antibiotics, antidotes, vaccinations, and other medications and supplies.

b. These medications may be released in deliveries called “push packs” by the Centers for Disease Control and Prevention Strategic National Stockpile.

i. These push packages have a delivery time of 12 hours anywhere in the country.

c. EMTs, AEMTs, and paramedics may be called on to assist in the delivery of the medications to the public.

i. Your role may include triage, treatment, and transport.

VII. Radiologic/Nuclear Devices

A. What is radiation?

1. Ionizing radiation is emitted in the form of rays, or particles.

2. This energy can be found in radioactive material, such as rocks and metals.

a. Radioactive material is any material that emits radiation.

b. This material is unstable, and it attempts to stabilize itself by changing its structure in a natural process called decay.

3. The energy that is emitted from a strong radiologic source is alpha, beta, gamma (x-ray), or neutron radiation.

a. Alpha is the least harmful penetrating type and cannot move through most objects.

b. Beta radiation is slightly more penetrating than alpha and requires a layer of clothing to stop it.

c. Gamma rays are far faster and stronger than alpha and beta rays.

i. These rays easily penetrate through the human body and require lead or several inches of concrete to prevent penetration.

d. Neutron particles are among the most powerful forms of radiation.

i. Neutrons easily penetrate through lead and require several feet of concrete to stop them.

B. Sources of radiologic material

1. Radiologic materials are generally used for purposes that benefit humankind, such as:

a. Medicine

b. Killing germs in food (irradiating)

c. Construction

2. Once radiologic material has been used for its purpose, the material remaining is called radiologic waste; these materials can be found at:

a. Hospitals and health care facilities with radiology departments

b. Colleges and universities

c. Nuclear power plants

d. Chemical and industrial sites

C. Radiological dispersal devices (RDDs)

1. An RDD is any container that is designed to disperse radioactive material.

2. A dirty bomb carries the potential to injure victims with not only the radioactive material, but also the explosive material used to deliver it.

3. The destructive capability of a dirty bomb is limited to the explosives that are attached to it.

4. The dirty bomb is an ineffective WMD.

D. Nuclear energy

1. Nuclear energy is artificially made by altering (splitting) radioactive atoms.

2. The result is an immense amount of energy that usually takes the form of heat.

3. Nuclear material is used in:

a. Medicine

b. Weapons

c. Naval vessels

d. Power plants

4. Nuclear material gives off all forms of radiation, including neutrons.

E. Nuclear weapons

1. Nuclear weapons are kept only in secure facilities throughout the world.

2. The likelihood of a nuclear attack is extremely remote.

3. Since the collapse of the former Soviet Union, the whereabouts of many small nuclear devices are unknown.

a. These small suitcase-sized nuclear weapons are called Special Atomic Demolition Munitions (SADMs).

b. Some of these are believed to be missing.

F. Symptomatology

1. Patients exposed to a known or suspected source of excessive radiation are considered victims of acute radiation toxicity.

2. The effects of radiation exposure will vary depending on the amount of radiation that a person receives and the route of entry.

3. Radiation can be introduced into the body by all routes of entry as well as through the body (irradiation).

4. Some common signs of acute radiation toxicity are listed in Table 40-11.

G. Medical management

1. Being exposed to a radiation source does not make a patient contaminated or radioactive.

2. However, when patients have a radioactive source on their body, they are contaminated and must be initially cared for by a HazMat responder.

3. Once the patient is decontaminated, you may begin treatment with the ABCs and treat the patient for any burns or trauma.

4. Wear appropriate PPE.

a. Secure in plastic bags any bodily fluids obtained from the patient.

b. Place all body fluids in containers and properly dispose of them with other potentially radioactive waste.

H. Protective measures

1. There are no suits or protective gear designed to completely shield you from radiation.

2. The best ways to protect yourself from the effects of radiation:

a. Time

i. The less time that you are exposed to the source, the less the effects will be.

ii. If you realize that the patient is near a radiation source, leave the area immediately.

b. Distance

i. Radiation is limited in how far it can travel.

ii. Depending on the type of radiation, often moving only a few feet is enough to remove you from immediate danger.

iii. Make certain that responders are stationed far enough from the incident.

c. Shielding

i. Always assume that you are dealing with the strongest form of radiation and use concrete shielding between yourself and the incident.

VIII. Incendiary and Explosive Devices

A. Incendiary and explosive devices come in various shapes and sizes.

1. Incendiary devices are weapons used to start fires; terrorists use

a. Flamethrowers

b. Chemicals

c. Molotov cocktails

d. Other explosive devices

2. It is important for you to be able to identify an object you believe is a potential device, notify the proper authorities, and safely evacuate the area.

3. Remember that there is the possibility of a secondary device when you are responding to the scene.

B. Mechanisms of injury

1. The type and severity of wounds primarily depend on the patient’s distance from the epicenter of the explosion.

2. Blast injuries occur in a number of ways.

a. Primary blast injury

i. Due solely to the direct effects of the pressure wave on the body

ii. The injury is seen almost exclusively in the hollow organs of the body.

iii. An injury to the lungs causes the greatest morbidity and mortality.

b. Secondary blast injury

i. Penetrating or nonpenetrating injury that results from being struck by flying debris

ii. Objects are propelled by the force of the blast and strike the victim, causing injury.

c. Tertiary blast injury

i. Results from whole body displacement and subsequent traumatic impact with environmental objects

ii. Other indirect effects include crush injury from the collapse of structures.

d. Quaternary blast injury

i. Any other injury caused by a blast, including toxic inhalation of combustion gases, burns, a medical emergency (like a myocardial infarction) sustained while fleeing the scene of an explosion, and even a mental health disorder that develops immediately after or days to weeks after detonation of an explosive device.

3. The physics of an explosion

a. When a substance is detonated, a solid or liquid is chemically converted into large volumes of gas under high pressure with resultant explosive energy release.

b. This generates a pressure pulse in the shape of a spherical blast wave that expands in all directions from the point of explosion.

c. Flying debris and high winds commonly cause conventional blunt and penetrating trauma.

4. Tissues at risk

a. Hollow organs such as the middle ear, lungs, and GI tract are most susceptible to pressure changes.

b. The junction between tissues of different densities and exposed tissues such as the head and neck are prone to injury as well.

c. The ear is the organ system most sensitive to blast injuries.

i. The patient may report ringing or pain in the ears or some loss of hearing, and blood may be visible in the ear canal.

d. Primary pulmonary blast injuries occur as contusions and hemorrhages.

i. Patients may report tightness or pain in the chest and may cough up blood and have tachypnea or other signs of respiratory distress.

ii. Subcutaneous emphysema over the chest may be palpated, indicating the presence of a pneumothorax.

iii. Pneumothorax is common and may require emergency decompression.

e. Solid organs are relatively protected from shockwave injury but may be injured by secondary missiles or a hurled body.

f. Hollow organs may be injured by similar mechanisms as lung tissue.

i. Petechiae to large hematomas are the most visible sign.

g. According to the CDC, blast lung is the most common cause of death from blast injury.

h. Neurologic injuries and head trauma are also common causes of fatality from blast injury.

i. Subarachnoid and subdural hematomas are often seen.

ii. Permanent or transient neurologic deficits may be secondary to concussion, intracerebral bleeding, or air embolism.

iii. Instant but transient unresponsiveness, with or without retrograde amnesia, may be initiated.

iv. Bradycardia and hypotension are common after an intense pressure wave from an explosion.

i. Extremity injuries, including traumatic amputations, are common, and patients may die of massive hemorrhage without the rapid application of a tourniquet.

Chapter 41, A Team Approach to Health Care

Unit Summary

After completing this chapter and related coursework, you will understand the significance and characteristics of a team approach to health care and the impact of this approach on positive patient outcomes. You will also be able to list and describe the steps an EMT should follow to assist with ALS skills, including placement of advanced airways and vascular access.

National EMS Education Standard Competencies

There are no National EMS Education Standard Competencies for this chapter.

Knowledge Objectives

Define continuum of care.
List the five essential elements of a group.
Explain the advantages of a team over a group; include the advantages of regularly training and practicing together.
List the five essential elements of a team.
Explain how crew resource management (CRM) can be useful in the prehospital environment.
List the five critical elements necessary to ensure effective transfer of patient care from one provider to another.
List the five steps a receiving health care provider should perform when taking a patient care report (PCR).
Describe the four-step process of assisting with advanced life support (ALS) skills.
Discuss the importance of preoxygenation when performing endotracheal (ET) intubation.
Describe the six steps of the BE MAGIC intubation procedure.
Describe the signs that indicate a complication with an intubated patient.
Explain the importance of ensuring patient comfort during a vascular access procedure.
Describe the steps EMTs can take to troubleshoot interpersonal conflicts.

Skill Objectives

There are no skill objectives for this chapter.

I. Introduction

A. As an EMT, you are a critical member of the emergency health care team that includes not only first responders, paramedics, and other EMTs, but also physicians, nurses, and other personnel who will help care for your patient throughout the duration of his or her injury or illness.

B. You must learn to be an effective team member.

C. By working as a team, emergency health care providers can improve patient and provider safety and deliver better emergency care.

II. An Era of Team Health Care

Previous models of emergency care often consisted of providers who worked separately, passing the patient from one individual or group to the next.

1. In time, emergency health care providers recognized that by working as a unified team from first patient contact to patient discharge, it was possible to improve individual and team performance, patient and provider safety, and patient outcomes.

2. This concept is the continuum of care.

B. Community paramedicine and mobile integrated healthcare (MIH) teams may be the best example of the team concept of continuum of care.

C. The structure and effectiveness of emergency health care teams differ from system to system.

III. Types of Teams

A. Regular teams

1. EMTs consistently interact with the same partner or team.

2. Team members who frequently train and work together are more likely to move smoothly from one step in the procedure to the next.

B. Temporary teams

1. EMTs work with providers with whom they do not regularly interact or may not even know.

a. Providers must work within an environment that supports and promotes collaboration rather than competition.

b. It is crucial to have a clear understanding of the roles, responsibilities, and capabilities of each team member.

i. The best way to accomplish this is to train together.

C. Special teams

1. Fire Team

2. Rescue Team

3. Hazardous materials (HazMat) Team

4. Tactical EMS Team

5. Special event EMS Team

6. EMS bike Team

7. In-hospital patient care technicians

8. MIH technicians

IV. Groups Versus Teams

A. The National Incident Management System (NIMS) defines a group as “[t]he organization level that divides the incident according to functional levels of operation. Groups perform special functions, often across geographic boundaries.”

1. EMS providers may often work as a group in this sense.

2. You must be able to distinguish between a group of providers gathered together on an emergency call and a true team.

3. A group consists of individual health care providers working independently to help the patient.

a. Triage

b. Treatment

c. Transport

4. A team consists of a group of health care providers who are assigned specific roles and are working interdependently in a coordinated manner under a designated leader.

5. The five essential elements of a group include:

a. A common goal

b. An image of themselves as a “group”

c. A sense of continuity of the group

d. A set of shared values

e. Different roles within the group

V. Dependent, Independent, and Interdependent Groups

A. In dependent groups, each individual is told what to do, and often how to do it, by his or her supervisor or group leader.

B. In independent groups, each individual is responsible for his or her own area (either a physical space or set of tasks).

1. May receive support and guidance from a supervisor or group leader but do not have to wait for an assignment before taking action

C. EMTs and other health care providers who work interdependently are functioning as a true team.

1. Each provider may be assigned to a particular area or task, but everyone works together with shared responsibilities, accountability, and a common goal, as opposed to focusing on the goals of their own individual areas.

VI. Effective Team Performance

A. A shared goal

1. Every health care provider on the team must be committed to a common goal— typically, the best possible patient outcome.

B. Clear roles and responsibilities

1. Each provider must know what needs to be done and what is expected of him or her.

C. Diverse and competent skill sets

1. Practice with one another and become familiar with each other’s tools, techniques, capabilities, and preferences so that each team member is competent before the call comes in.

D. Effective collaboration and communication

1. Four important elements of team communication include:

a. A clear message: Speak calmly, confidently, and concisely.

b. Closed loop communication: Repeat the message back to the speaker.

c. Courtesy: Speak politely.

d. Constructive intervention: If it is necessary, respectfully question or correct team members or the team leader if a mistake has been or is about to be made.

E. Supportive and coordinated leadership

1. The team leader provides role assignments, coordination, oversight, centralized decision making, and support for the team to accomplish their goals and achieve desired results.

a. Often defined by policy, procedure, or statute

b. May be the most senior provider in the group

c. May be the person with the highest-level certification

2. Team leaders foster communication and team dynamics using concepts such as crew resource management and team situational awareness.

a. Situational awareness is the knowledge and understanding of one’s surroundings and the ability to recognize potential threats to safety.

3. Crew resource management (CRM) is a way for team members to work together with the team leader to develop and maintain a shared understanding of the emergency situation.

a. CRM recommends use of the PACE mnemonic:

i. Probe: Look or ask to confirm the problem.

ii. Alert: Communicate the problem to the team leader.

iii. Challenge: If the issue is not corrected, then clearly challenge the team’s present course of action that is leading to the problem.

iv. Emergency: If the problem is clear and critical, then immediately communicate the emergency to the entire team.

VII. Transfer of Patient Care

A. At several points along the continuum, the patient’s care will be transferred, or “handed off,” from one unit of providers on the team to another.

1. These transfers introduce the possibility of critical patient care errors, especially when they occur several times and in different settings along the continuum of care.

2. Effective teams minimize the number of transfers during patient care and adhere to strict and careful guidelines when such transfers are unavoidable.

3. Whenever the verbal transfer of care occurs, all team members should do their best to ensure the following:

a. Uninterrupted critical care: Whenever possible, the team member giving the report and the team member taking the report should hand off lifesaving care to another team member, allowing them to focus on the transfer of care.

b. Minimal interference: The transfer of patient care should occur in a location with the least interference possible.

c. Respectful interaction: Each team member involved in the transfer must be respectful of members’ different roles and recognize the importance of each role.

d. Common priorities: Both the team member giving the report and the team member taking the report must focus on their common priorities (critical assessment findings and patient care) vital for the best possible patient outcome.

e. Common language or system: Whenever possible, a mutually agreed-upon and standardized patient handoff format should be used.

B. See Chapter 4, “Communications and Documentation,” for information on PCRs.

VIII. BLS and ALS Providers Working Together

A. BLS and ALS care cannot exist without each other.

B. BLS efforts must continue throughout the continuum of care.

1. You must carefully coordinate your efforts with the advanced tools and techniques used by ALS providers.

C. What may be a “paramedic-only” skill in your EMS system may be common for an EMT to perform in another.

1. It is your responsibility to understand what is allowed by the scope of practice, standard of care, and local protocols where you work.

a. If you work outside these bounds, then you risk legal liability.

2. There are many ways in which you can assist paramedics and other ALS providers with advanced procedures.

IX. Assisting with ALS Skills

A. Assisting follows a four-step process:

1. Patient preparation

2. Equipment setup

3. Performing the procedure

4. Continuing care

B. Assisting with placement of advanced airways

1. Endotracheal (ET) intubation is the insertion of a tube into the trachea to maintain and protect the airway.

a. The ET tube can be inserted through the mouth or through the nose.

2. Patient preparation

a. The more oxygen that is available in the alveoli, the longer the patient can maintain adequate gas exchange in the lungs while the intubation procedure is being performed.

i. Preoxygenation

b. Maintain a high-flow nasal cannula on the patient during the preoxygenation phase and leave the nasal cannula in place during the intubation attempt.

i. Apneic oxygenation

3. Equipment Setup

a. Typically includes:

i. Personal protective equipment (PPE)

ii. Suction unit with rigid, tonsil-tip and nonrigid, whistle-tip (French) catheters

iii. Laryngoscope handle and blade (sized for the patient)

iv. Magill forceps

v. ET tube (sized for the patient)

vi. Stylette or tube introducer (gum elastic bougie)

vii. Water-soluble lubricant

viii. 10-mL syringe

ix. Confirmation device(s), including waveform end-tidal CO2 monitors and/or colorimetric device

x. Commercial ET tube securing device

xi. Alternate airway management devices, such as a supraglottic airway and/or cricothyrotomy kit

4. Performing the procedure

a. BE MAGIC

i. B—Perform BVM preoxygenation.

ii. E—Evaluate for airway difficulties

iii. M—Manipulate the patient

iv. A—Attempt first-pass intubation

v. GI—Use a supraGlottic or Intermediate airway if unable to intubate

vi. C—Confirm successful intubation

b. BVM preoxygenation

i. It is crucial that you adequately preoxygenate the patient before the intubation procedure.

ii. Do not hyperventilate the patient.

iii. Focus on maintaining a good seal, achieving chest rise and fall, and delivering breaths at a rate appropriate for the patient’s age.

c. Evaluate for airway difficulties.

i. Assist the ALS provider with evaluating the patient to identify any factors that will present difficulties during the procedure.

(a) For example, trauma or anatomic deformities to the airway

d. Manipulate the patient

i. Position the patient so that the ALS provider can visualize the vocal cords.

e. Attempt intubation

i. Remove the oral airway and disconnect the mask from the bag in preparation for connecting the bag to the ET tube.

ii. Keep suction equipment at hand.

iii. The ALS provider may ask you for assistance in manipulating the patient’s larynx or otherwise positioning the patient for a better view.

f. Should the intubation attempts fail, it may be your responsibility to prepare and hand over the supraglottic or intermediate airway device.

g. Confirm intubation/correct issues

i. You may attach the end-tidal waveform CO2 detector in line between the ET tube and the bag.

ii. You may also either ventilate the patient while another provider checks for positive breath sounds in the absence of gastric sounds, or you may listen while another team member ventilates.

iii. If intubation is confirmed, you may assist in securing the ET tube.

iv. If intubation cannot be confirmed, you may assist other team members in correcting issues.

h. Continuing care

i. You must continue to observe all of the patient’s monitor readings, as well as monitor for signs of potential complications, including:

(a) Absence of an end-tidal CO2 level

(b) Decreasing SpO2 level

(d) Other physical signs of poor ventilation and perfusion

(e) Improper positioning or dislodgement of the ET tube

C. Vascular access

1. A procedure that gains access to a patient’s circulatory system in order to inject or remove fluids, medicines, or blood products.

2. Patient preparation

a. May involve positioning the patient and equipment

b. May involve explaining the procedure and the reason for it

c. Ensuring the patient is comfortable and calm

3. Equipment setup

a. While vascular access may involve either IV or intraosseous (IO) access, the procedure and equipment list will be generally the same:

i. PPE, including properly-sized gloves

ii. A properly-sized bag or syringe of the IV solution (selected by the ALS provider)

iii. IV tubing and drip set (selected by the ALS provider)

iv. Skin preparation pads, typically alcohol prep pads and/or betadine solution

v. Adhesive tape, torn into several pieces about 1 inch (2.5 cm) in length

vi. Gauze, 2 x 2 inches (50 x 50 mm) or 4 x 4 inches (101 x 101 mm)

vii. Commercial IV securing system

viii. IV “pigtail” catheter

ix. If there is IV access:

(a) Venous constricting band (sometimes referred to as a venous tourniquet)

(b) IV catheter (selected by the ALS provider)

x. If IO access:

(a) IO needle (size selected by the ALS provider)

(b) Mechanical IO driver or insertion device (depending on IO system)

4. Spiking the bag

a. Remove the rubber pigtail found on the end of the IV bag by pulling on it.

i. Remove the protective cover from the sterile piercing spike.

b. Slide the spike into the IV bag port until you see fluid enter the drip chamber. Invert the bag.

c. Squeeze and release the drip chamber until about half full.

d. Unclamp the tubing.

e. Let the fluid flow until air bubbles are removed from the line before turning the roller clamp wheel to stop the flow.

f. Check the drip chamber; it should be only half filled.

i. If the fluid level is too low, then squeeze the IV bag until it fills.

ii. If the chamber is too full, then invert the IV bag and squeeze the chamber to empty the fluid back into the bag.

g. Hang the bag in the appropriate location with the end of the IV tubing easily accessible.

h. Choose the drip set indicated by the ALS provider, and attach it to the fluid bag indicated by the ALS provider.

i. Fill the drip chamber halfway by squeezing it.

j. Flush or “bleed” the tubing to remove any air bubbles by opening the roller clamp.

i. Make sure no bubbles are floating in the tubing.

k. Saline locks (buff caps)

i. Access devices used to maintain an active IV site without running the fluids through the vein

ii. Used primarily for patients who do not need additional fluids but may need rapid medication delivery

iii. Procedures will vary based on local protocol.

5. Performing the procedure

a. While the ALS provider is establishing IV or IO access, you may help to stabilize the patient’s limbs or provide him or her comfort.

6. Continuing care

a. Once vascular access is established, continue patient care by observing the access site for swelling, bleeding, discoloration, or leaking.

b. Observe the IV tubing to see if it is improperly blocked, clamped, or kinked, or if the bag of IV solution is empty.

X. Troubleshooting Team Conflicts

A. When conflict occurs, keep in the mind the following five techniques:

1. The patient comes first.

a. Regardless of interpersonal conflicts that may arise, the patient’s needs must always come first.

2. Do not engage.

a. If the problem causing the conflict does not directly and immediately impact patient care, then do not engage. Have the discussion after the call, when more positive communication may be possible.

3. Keep your cool.

a. Maintain your composure. If you feel that the conflict is over a critical component of patient care, then follow the PACE mnemonic discussed previously. If it is not, then begin by taking a deep breath and slowly counting to 10.

4. Separate the person from the issue.

a. If the conflict arises from the behavior of another team member and the conflict cannot be delayed or avoided, then focus on the behavior itself rather than the individual.

5. Choose your battles.

a. Remember, there is strength in the diversity of team members. Not everyone will work in exactly the same way, and that is a good thing. Avoid engaging in conflict over minor issues in patient care that center around one provider “style” over another.

Table of Contents

Chapter 23, Gynecologic Emergencies

I. Introduction

II. Anatomy and Physiology

III. Pathophysiology

IV. Patient Assessment

V. Emergency Medical Care

VI. Assessment and Management of Specific Conditions

Chapter 24, Trauma Overview

I. Introduction

II. Energy and Trauma

III. Mechanism of Injury Profiles

IV. Blunt and Penetrating Trauma

V. Blunt Trauma

VI. Penetrating Trauma

VII. Blast Injuries

VIII. Multisystem Trauma

IX. Patient Assessment

X. Management: Transport and Destination

Chapter 25, Bleeding

I. Introduction

II. Anatomy and Physiology of the Cardiovascular System

III. Pathophysiology and Perfusion

IV. External Bleeding

V. Internal Bleeding

VI. Patient Assessment for External and Internal Bleeding

VII. Emergency Medical Care for External Bleeding

VIII. Emergency Medical Care for Internal Bleeding

Chapter 26, Soft-Tissue Injuries

I. Introduction

II. The Anatomy and Physiology of the Skin

III. Pathophysiology of Closed and Open Injuries

IV. Patient Assessment of Closed and Open Injuries

V. Emergency Medical Care for Closed Injuries

VI. Emergency Medical Care for Open Injuries

VII. Burns

VIII. Patient Assessment of Burns

XI. Emergency Medical Care for Burns

X. Dressing and Bandaging

Chapter 27, Face and Neck Injuries

I. Introduction

II. Anatomy and Physiology

III. Injuries of the Face and Neck

IV. Patient Assessment

V. Emergency Medical Care

VI. Emergency Medical Care for Specific Injuries

Chapter 28, Head and Spine Injuries

I. Introduction

II. Anatomy and Physiology

III. Head Injuries

IV. Spine Injuries

V. Patient Assessment

VI. Emergency Medical Care for Head Injuries

VII. Emergency Medical Care for Suspected Spinal Injuries

VIII. Preparation for Transport

IX. Helmet Removal

Chapter 29, Chest Injuries

National EMS Education Standard Competencies

I. Introduction

II. Anatomy and Physiology

III. Mechanics of Ventilation

IV. Injuries of the Chest

V. Patient Assessment

VI. Complications and Management of Chest Injuries

VII. Other Chest Injuries

Chapter 30, Abdominal and Genitourinary Injuries

I. Introduction

II. Anatomy and Physiology of the Abdomen

III. Injuries to the Abdomen

IV. Patient Assessment of Abdominal Injuries

V. Emergency Medical Care of Abdominal Injuries

VI. Anatomy of the Genitourinary System

VII. Genitourinary System Injuries

VIII. Patient Assessment of the Genitourinary System

IX. Emergency Medical Care of Genitourinary Injuries

X. Sexual Assault

Chapter 31, Orthopaedic Injuries

I. Introduction

II. Anatomy and Physiology of the Musculoskeletal System

III. Musculoskeletal Injuries

X. Dressing and Bandaging $\\172.16.33.26\Art\OUTPUT\JB LEARNING\EMT_11E_ITK_PPT WORK\JPEG\Ch26\9781284080179_CH26_FIG12A.jpg$