Paramedic update part 2
- 1. TOPIC 19 Invasive Airway Management
- 2. Objectives • Discuss the decision-making process when utilizing an advanced airway. • Review blind insertion airway devices. • Understand the current endotracheal intubation dilemma. • Discuss how to help preserve endotracheal intubation in the paramedic scope of practice.
- 3. Introduction • Paramedics can utilize advanced airway skills within their scope of practice. • Paramedics should select the most appropriate intervention for each situation after weighing the costs and benefits.
- 4. Introduction • The responsibility to make good airway management decisions is especially true with the recent controversy surrounding endotracheal intubations.
- 5. Progressing to Invasive Airway Management • Airway management decision should consider: – Assessment findings – Pathophysiology – Other circumstances to create best treatment plan • Invasive procedures should be utilized when their benefits clearly outweigh their risks.
- 6. Progressing to Invasive Airway Management • Consider the following indications for invasive airways: – More basic maneuvers have failed – Invasive airways are indicated by the pathophysiology of the situation – Invasive airways represent the better choice given an analysis of the circumstances – The clinical course of the patient indicates invasive maneuvers.
- 7. Benefits and Risks of Advanced Airway Procedures
- 8. The Endotracheal Intubation Dilemma • Endotracheal intubation is the most secure airway and when performed correctly. • Risks and complications can include hypoxia, increased intracranial pressure, trauma, and death. • Success rates are reported to be low. • Training and ongoing education are challenging.
- 9. Preserving Intubation • Preserving intubation should be a priority for all paramedics and proactive steps must be taken. – Recognize the problem – Select appropriate patients – Improving confirmation is an essential step
- 10. Intubation Confirmation • Confirmation of proper placement is essential. • Positive confirmation recognizes and corrects errors that happen. • The gold standard for confirmation is waveform capnography.
- 11. Intubation Confirmation • Other confirmation devices can be used. • Multiple methods should be used to achieve a definitive confirmation.
- 12. Blind Insertion Airway Devices • Blind airway devices do not require specialized equipment to insert. • They offer an alternative to ETI, but do not definitively protect the airway. • Various types of BIADs exist. – Esophageal obturation devices – Supraglottic devices
- 13. Case Study • You are working a shift at the fire department and you are toned to a house fire. You throw your gear into the ambulance and follow the fire engine to the scene. Upon arrival, you find a crowd standing around a man who is down in the grass. There are flames shooting out of the windows of the house.
- 14. Summary • The paramedic must use good decision making in order to select and utilize the most appropriate interventions for maintaining the airway of a patient. • Controversy surrounds the use of prehospital endotracheal intubation and other advanced airway skills.
- 15. Summary (cont'd) • Paramedics may help preserve endotracheal intubation intervention by recognizing the issues, selecting appropriate situations to use the skill, and improving their ability to confirm proper placement.
- 16. TOPIC 32 Neurology: Stroke
- 17. Objectives • Review the frequency with which strokes occur. • Discuss the common types of occlusive strokes to include pathophysiology and findings. • Review "mini-strokes" such as TIA and RIND. • Discuss strokes caused by hypoperfusion.
- 18. Objectives • Relate the stroke location with cerebral arteries. • Review the stroke scale assessment tools. • Review current treatment standards for patients suffering from a stroke.
- 19. Introduction • Stroke is an acute emergency resulting in disruption of blood flow to a region of the brain. • Can result in temporary or permanent abnormalities of cerebral functioning. • EMS must rapidly identify and transport the potential stroke patient.
- 20. Epidemiology • 700,000 strokes occur per year. – About one every 45 seconds • Strokes are the third leading cause of death in the United States – One stroke-related death every 3 minutes • Higher risk to women, African Americans, and Hispanics/Latinos. • Major cause of permanent disability.
- 21. Pathophysiology • Types of strokes – Ischemic • Thrombotic • Embolic • Transient ischemic attack • Reversible neurologic deficit • Hypoperfusion – Most common • 80 percent to 85 percent
- 22. Pathophysiology • Types of strokes – Hemorrhagic • Intracerebral hemorrhage • Subarachnoid hemorrhage – Etiology • Arteriovenous malformations • Aneurysm – Frequency • 10 percent to 15 percent
- 23. Causes of stroke. Blood is carried from the heart to the brain via the carotid and vertebral arteries, which form a ring and branches within the brain. An ischemic stroke occurs when a thrombus is formed on the wall of an artery or when an embolus travels from another area until it lodges in and blocks an arterial branch. A hemorrhagic stroke occurs when a cerebral artery ruptures and bleeds into the brain (examples shown: subarachnoid bleeding on the surface of the brain and intracerebral bleeding within the brain).
- 24. Pathophysiology • Progression of neurologic dysfunction and damage in stroke – Loss/diminishment of blood flow. – Cells become electrically “silent.” – Na+/K+ pump failure, cells swell and rupture. • “Cytotoxic edema”
- 25. Pathophysiology • Progression of neurologic dysfunction and damage in stroke – Ischemic penumbra receives diminished flow. • It may also become electrically silent.
- 26. Clinical Findings • Assessment of the stroke patient – Time is paramount. – Narrow window for thrombolytic drugs. – Careful assessment for baseline findings and changes is important. • Always try to determine onset time for symptoms.
- 27. Clinical Findings • Signs and symptoms of stroke – Facial droop and/or slurred speech – Dysphasia and aphasia – Unilateral numbness – Headache/dizziness (severe in ICH/SAH)
- 28. Clinical Findings • Signs and symptoms of stroke – Weakness/Paralysis – Mental status changes – Vision changes – Cognitive changes – Incontinence
- 29. (a) The face of a nonstroke patient has normal symmetry. (b) The face of a stroke patient often has an abnormal, drooped appearance on one side. abnormal, drooped appearance on one side. normal symmetry
- 30. A patient who has not suffered a stroke can generally hold the arms in an extended position with eyes closed. (b) A stroke patient will often display “arm drift” or “pronator drift”—one arm will remain extended when held outward with eyes closed, but the other arm will drift or drop downward and pronate (palm turned downward). arms in an extended position with “arm drift” eyes closed
- 31. Cincinnati Prehospital Stroke Scale (CPSS)
- 32. Los Angeles Prehospital Stroke Screen (LAPSS)
- 33. Emergency Medical Care • Consider spinal precautions, determine onset of symptoms. • Support lost function. – Airway, breathing, circulation • Initiate intravenous therapy and titrate as necessary. – Normal saline to keep open rate – Increase if systolic blood pressure drops below 90 mmHg
- 34. Emergency Medical Care • Assess blood glucose level level. – Hypoglycemia may mimic stroke. – Treat hypoglycemia as indicated. • Protect paralyzed limbs. – Be sure to properly secure paralyzed limbs to prevent accidental trauma during patient movement. • Transport.
- 35. Summary • A stroke occurs when there is interruption of blood flow to a region of the brain. • Although symptoms may present as mild initially, it is often not known early on how severely the patient may deteriorate.
- 36. Summary • Prehospital identification and treatment are integral to the successful overall management of stroke patients.
- 37. TOPIC 34 Immunology: Anaphylactic and Anaphylactoid Reactions
- 38. Objectives • Review the frequency with which immunologic emergencies occur. • Understand the pathology of immunologic emergencies. • Discuss chemical mediators and their reactions. • Illustrate the relationship between pathology and symptomatology.
- 39. Objectives • Differentiate between a mild and severe reactions. • Discuss treatment strategies such as epinephrine.
- 40. Introduction • Allergic reactions may present from mild to severe. • Manifestations can be related to the body system failing due to the reaction. • Although an allergic reaction is designed to be beneficial to the body, when the response is severe it can be fatal.
- 41. Epidemiology • Anaphylaxis is not a reportable disease. • An estimated 20,000 to 50,000 persons suffer an anaphylactic reaction each year in the United States • Most common triggers include penicillin, insect stings, radiocontrast media, and food.
- 42. Pathophysiology • Anaphylactic reaction – Patient must be sensitized – Chemical mediators released with subsequent exposure – Effects of mediators causes organ and system failure – Characteristic presentation
- 43. Table 34–1 Common Causes of Anaphylactic Reactions
- 44. Pathophysiology • Anaphylactoid reaction – Not the typical immunologic antigen-antibody reaction – Anaphylactoid trigger “directly” causes the breakdown of mast cells and basophils – Chemical mediators released – Characteristic presentation similar to anaphylactic reaction
- 45. Table 34–2 Common Causes of Anaphylactoid Reactions
- 46. Pathophysiology • Effects of chemical mediator release – Increased capillary permeability – Decreased vascular smooth muscle tone – Increased bronchial smooth muscle tone – Increased mucus secretions in the tracheobronchial tract
- 47. responses in anaphylactic reaction: bronchoconstriction, capillary permeability, vasodilation, and an increase in mucus production.
- 48. Pathophysiology • General considerations – Fatal episodes related to airway occlusion, respiratory failure, severe hypoxia, and circulatory collapse
- 49. Figure 34–2 Localized angioedema to the tongue from an anaphylactic reaction. (© Edward T. Dickinson, MD)
- 50. Table 34–3 Common Signs and Symptoms of Anaphylactic Reactions.
- 51. Table 34–3 (continued) Common Signs and Symptoms of Anaphylactic Reactions.
- 52. Table 34–3 (continued) Common Signs and Symptoms of Anaphylactic Reactions.
- 53. Figure 34–3 Urticaria (hives) from an allergic reaction to a penicillin-derivative drug.
- 54. Assessment Findings • Other notable assessment characteristics – Parenteral injections produce the severest reactions. – The faster the onset, the worse the reaction. – Signs and symptoms peak in 15–30 minutes.
- 55. Assessment Findings • Other notable assessment characteristics – Skin and respiratory reactions are the earliest to present. – Mild reactions could suddenly turn severe. – Most fatalities occur within 30 minutes. – The patient may have a biphasic or multiphasic reaction following treatment.
- 56. Table 34–4 Differentiating Between a Mild and a Moderate to Severe Reaction
- 57. Emergency Medical Care • Keep airway patent. • Suction secretions. • Administer oxygen and ventilate the patient if needed. – Maintain SpO2 above 94 percent • Initiate intravenous infusion – Large bore catheter – Maintain systolic BP of 90 mmHg
- 58. Emergency Medical Care • Administer epinephrine if patient presents with systemic symptoms. – Preferred routes: auto-injector or IM – Adult dose: • 0.2 to 0.5mg of 1:1,000 IM • 0.3 mg auto-injector
- 59. Emergency Medical Care • Administer epinephrine if patient presents with systemic symptoms. – Pediatric dose: • 0.1 mg/kg not to exceed adult dose • 0.15 mg auto-injector • If patient weighs more than 66 lbs. Use adult injector – Repeat every 3 to 5 minutes if severe symptoms persist
- 60. Emergency Medical Care • Administer epinephrine if patient presents with systemic symptoms. – Consider concurrent glucagon with the epinephrine if the patient is taking beta blockers. • Administer diphenhydramine to negate the effects of the histamine.
- 61. Emergency Medical Care • Administer corticosteroids to help stabilize capillary permeability and prevent swelling. • Initiate rapid transport.
- 62. Emergency Medical Care • If an extremity is involved consider application of a loose tourniquet. • Treat wheezing with beta2 agonist. • Treat hypotension with IV fluid bolus. • Treat hypotension secondary to beta blockers with glucagon.
- 63. Summary • An allergic reaction may range from mild to severe. • Anaphylactic and anaphylactoid reactions can rapidly cause death to the patient. • The paramedic must recognize the acute allergic reaction and provide appropriate care based on findings.
- 64. TOPIC 35 Endocrine Emergencies: Hypoglycemia
- 65. Objectives • Review the frequency with which diabetic emergencies occur. • Discuss the etiologies of diabetes mellitus (type 1 and type 2). • Review the roles of insulin and glucagon. • Discuss the causes of hypoglycemia.
- 66. Objectives • Review the symptoms of hypoglycemia and relate to hyperadrenergic or neuroglycopenic pathophysiology. • Review the role of oral glucose in patient management.
- 67. Introduction • Diabetes mellitus (DM) is a condition in which the body no longer metabolizes glucose correctly. • This inability can lead to seriously high or low levels of blood sugar. • The paramedic must quickly identify the problem and support lost function to reduce morbidity and mortality.
- 68. Epidemiology • Most common endocrine disorder. • 6 percent of the population is afflicted with the disease. • Whites are more likely to have the disease than non whites. • Type 1 DM accounts for 5 percent to 10 percent • Type 2 DM accounts for 90 percent to 95 pecent
- 69. Epidemiology • Type 1 diabetes mellitus – Autoimmune disease process – Characteristic to younger patients – Requires supplemental insulin – Prone to hypoglycemia and diabetic ketoacidosis
- 70. Epidemiology • Type 2 diabetes mellitus – Impaired insulin production – Impaired insulin effects – Commonly an adult onset – Associated with a higher body mass index – Controlled through diet and oral pills – Prone to HHNS
- 71. Pathophysiology • Role of hormones in glucose regulation – Insulin and glucagon – Cellular metabolism of glucose
- 72. Glucose movement into the cell with insulin and the inability of glucose to get into the cell without insulin.
- 74. Pathophysiology • Hypoglycemia – Precipitating causes – Patients become symptomatic when the blood glucose level falls to 40–50 mg/dL – Brain most sensitive to low levels of glucose – Body then releases additional hormones aimed at trying to raise glucose back up
- 75. Assessment Findings • General considerations – Findings can be broadly categorized • Hyperadrenergic—increases sympathetic tone • Neuroglucopenic—brain dysfunction from lack of glucose
- 76. Signs and Symptoms of Hypoglycemia
- 77. Assessment Findings • Other notable assessment characteristics – Hypoglycemia may occur suddenly. – Hypoglycemia may present like a stroke. – Once referred to as “insulin shock” as many presentation findings mirrored hypovolemic shock.
- 78. Emergency Medical Care • Keep airway patent; be alert for vomiting. • Place patient in lateral recumbent position. • Administer oxygen based on ventilatory needs. – Keep SpO2 >95 percent.
- 79. Emergency Medical Care • Deliver glucose to the cells. – Administer oral glucose if criteria is met – Administer 50% dextrose if criteria is met via IV or IO – Administer glucagon IM if criteria is met
- 80. Emergency Medical Care • Reassess the patient after medication administration. • Use good clinical judgment when considering refusal requests.
- 81. Summary • Diabetic patients are a fairly common type of patient seen by the paramedic. • Based on the type of diabetes they have, the resulting emergency may cause high or low levels of glucose to develop.
- 82. Summary • The paramedic's goal is to recognize the type of diabetic reaction and provide appropriate care.
- 83. TOPIC 36 Endocrine Emergencies: Hyperglycemic Disorders
- 84. Objectives • Review the frequency and demographic of hyperglycemic emergencies. • Discuss the pathophysiologic changes associated with hyperglycemia. • Review the symptomatology of diabetic ketoacidosis (DKA). • Discuss pathophysiology in hyperglycemic patients.
- 85. Objectives • Diabetic ketoacidosis and hyperglycemic hyperosmolar nonketotic syndrome • Review appropriate emergency care steps.
- 86. Introduction • Hyperglycemic episodes are at the opposite end of diabetic emergencies. • DKA or HHNS must be considered in all patients with altered consciousness. • History of onset and monitored BGL levels are the best way to differentiate hyperglycemic episodes from other problems.
- 87. Epidemiology • DKA is more common in type 1 DM. • HHNS is more common in type 2 DM. • HHNS occurs with higher frequency than DKA does, and is more prevalent in females. • Mortality rates can be 10 percent to 20 percent in hyperglycemic emergencies. • 20 percent to 33 percent of patients with HHNS have no history of DM.
- 88. Pathophysiology • Diabetic ketoacidosis (DKA) – Relative or absolute insulin deficiency. – BGL rises greater than 300 mg/dL. – The brain has plenty of glucose, but the body cannot use it without insulin. – Progression produces: • Metabolic acidosis • Osmotic diuresis • Electrolyte disturbance
- 89. Assessment Findings • Diabetic ketoacidosis – Slow change in mental status – Signs of severe dehydration – Polyuria and polydipsia – Nausea and vomiting, abdominal pain – Fatigue, weakness, lethargy, confusion – Kussmaul respirations – Fruity or acetone odor on breath – ECG changes, dysrhythmias
- 91. Pathophysiology • Hyperglycemic hyperosmolar nonketotic syndrome (HHNS) – Severe elevations in BGL (>600 mg/dL) – Some insulin still present • Not enough or not effective – Changes in physiology • Osmotic diuresis • Electrolyte disturbance – No ketogenesis
- 92. Assessment Findings • HHNS – Slow progression of symptoms – Dehydration findings – Polyuria early, oliguria late – Changes in mental status – Possible seizure activity – Findings of volume depletion
- 93. Signs and Symptoms of Diabetic Emergency Conditions
- 94. Treatment Considerations • General considerations for the prehospital emergency care – Focus of hypoglycemia is the administration of glucose. – Focus of DKA and HHNS is rehydration of the patient.
- 95. Emergency Medical Care • Establish and maintain a patent airway. • Establish and maintain adequate ventilation. • Establish and maintain oxygenation – Titrate oxygen to keep SpO2 >95 percent.
- 96. Emergency Medical Care • Assess blood glucose level. • Initiate intravenous therapy. – Fluid administration based on patient presentation
- 97. Case Study • You are called one afternoon to evaluate an elderly female patient at home. Upon arrival PD is on scene and has forced entry into the home based on the neighbor saying that the elderly occupant has not been seen for days. You find the patient lying on the couch, dried vomit on the face, with loud sonorous respirations.
- 98. Case Study (cont'd) • Scene Size-Up – Standard Precautions taken. – Scene is safe, no entry or egress problems. – One patient, elderly female, looks unresponsive on the couch. – Nature of illness is unknown mental status change. – No signs of struggle or trauma.
- 99. Case Study (cont'd) • What are some concerns you have based on the scene size-up? • What are possible conditions you suspect at this time?
- 100. Case Study (cont'd) • Primary Assessment Findings – Patient does not respond to painful stimuli. – Sonorous respirations. – Breathing is tachypneic with alveolar breath sounds. – Peripheral perfusion absent; skin dry, carotid pulse present. – No indication of significant trauma.
- 101. Case Study (cont'd) • Is this patient a high or low priority? Why? • What are the life threats to this patient? • What emergency care should you provide based on the primary assessment findings?
- 102. Case Study (cont'd) • Medical History – Unknown • Medications – Unknown • Allergies – Unknown
- 103. Case Study (cont'd) • Pertinent Secondary Assessment Findings – Pupils midsize and midposition. – Airway now maintained with OPA. – Breathing still adequate, regular and the rate is fast. – No abnormal odors noted on the patient’s breath.
- 104. Case Study (cont'd) • Pertinent Secondary Assessment Findings – Carotid pulse present, peripheral perfusion absent. – Skin cool and dry, tongue furrowed, membranes pale.
- 105. Case Study (cont'd) • Pertinent Secondary Assessment Findings – B/P 84/64, heart rate 128, respirations 30/min. – Finger prick test of BGL reveals 860 mg/dL. – Pulse oximeter intermittently reading 94 percent.
- 106. Case Study (cont'd) • Pertinent Secondary Assessment Findings – Dried urine stains on patient's clothing and couch. – No other findings contributory to presentation.
- 107. Case Study (cont'd) • With this information, has your field impression changed at all? • What do you suspect is the underlying pathophysiology? • What would be the next steps in management you would provide to the patient?
- 108. Case Study (cont'd) • Care provided: – Patient placed in lateral recumbent position. – Oxygen applied to maintain SpO2 of 95 percent – OPA kept in place, airway remained patent.
- 109. Case Study (cont'd) • Care provided: – Intravenous therapy and fluid resuscitation. – Patient packaged and prepared for transport to hospital.
- 110. Case Study (cont'd) • In a patient with this field impression, discuss why the following findings were present: – Decrease in mental status – Tachycardia – Dry skin and furrowed tongue – Low blood pressure – High glucose level
- 111. Summary • Hyperglycemia can be recognized by its onset and elements of dehydration and confirmed by BGL. • Although the patient needs insulin, immediate initiation of intravenous therapy by the paramedic can allow for rehydration to begin during transport to the hospital.
- 112. TOPIC 59 Patients with Special Challenges
- 113. Objectives • Discuss the complexity of problems when people are living at home with medical technology or are victims of abuse. • Review the pathophysiology of certain special challenges. • Review current treatment strategies for the special challenged or technology-assisted patient.
- 114. Introduction • Advances in medical care and technology allow people with certain deficits to live at home. • When the patients special challenges worsen or their medical devices fail, EMS is the first called to intervene. • Paramedics must be able to assess, intervene, treat, and transport these individuals.
- 115. Epidemiology • Determining the number of “specially challenged” patients is next to impossible. • More than 3 million children are victims of abuse annually. • More than 560,000 cases of elder abuse are reported each year in the United States
- 116. Epidemiology • 3 to 4 million people are victims of spousal or partner abuse. • More than 8 million disabled patients receive health care from professional providers.
- 117. Pathophysiology • A person may be receiving care at home for any of multiple reasons. • When the patient deteriorates or the technology being used fails, EMS is usually called to assist the primary care provider.
- 118. Pathophysiology • Abuse – Child abuse • Physical abuse (which can include neglect) • Emotional abuse • Sexual abuse
- 119. Pathophysiology • Abuse – Elder abuse • Neglect (active and passive) • Physical abuse • Sexual abuse • Financial abuse • Emotional/mental abuse
- 120. Pathophysiology • Mental or emotional illness – May range from mild to severe – Can make assessment challenging – Mental retardation encompasses disabilities that affect the nervous system and have a negative impact on intelligence and learning.
- 121. Physical abuse of an elderly person can have dire consequences because of the patient’s frailty.
- 122. Pathophysiology • Disabilities – Can be caused by disease, trauma, inheritance, or other factors that necessitate sustained medical care for the individual. – Commonly disabilities encountered by EMS include paralysis, obesity, neuromuscular diseases, those susceptible to multiple organ problems.
- 123. Effects of Excess Weight on Organ Systems
- 124. Pathophysiology • Traumatized patients – Head or brain trauma can present with a multitude of residual disabilities. – Can occur at any age. – May result in permanent damage, as evidenced by changes in cognition, learning abilities, emotional abilities, and/or muscle weakness or paralysis.
- 125. Pathophysiology • Technology assistance/dependency – Apnea monitors – CPAP/BiPAP – Tracheosotmy – Ventilators – Vascular access devices – Dialysis – Feeding tubes – Intraventricular shunts
- 126. CPAP and BiPAP • Continuous positive airway pressure (CPAP) and bi-level positive airway pressure (BiPAP) machines – Keep airways open during exhalation; improves both oxygenation and ventilation
- 127. CPAP and BiPAP • CPAP provides a constant positive pressure during the entire ventilatory cycle • BiPAP provides higher pressure during inhalation and lower pressure during exhalation. • Some CPAP and BiPAP machines also allow the administration of oxygen during use.
- 128. A tracheostomy tube for older children and adults has an outer cannula and an inner cannula.
- 129. Ventilators • Home mechanical ventilators are designed to assist a patient who cannot breathe adequately on his own. • Two types of ventilators – Negative pressure ventilators – Positive pressure ventilators.
- 130. Ventilators • Negative pressure ventilators encircle the patient’s chest and generate a negative pressure around the thoracic cage. • Positive pressure ventilators push air into the airway. Exhalation ensues when the positive pressure stops, and the chest wall and lungs recoil.
- 131. Ventilators • Controls on a ventilator – Ventilatory rate – Adjust size of each breath – Adjusts amount of oxygen provided during ventilation
- 132. Ventilators • Alarms: – High-pressure alarm – Low-pressure alarm – Apnea alarm – Low FiO2 alarm
- 133. Vascular access devices include central IV catheters such as a PICC line, central venous lines such as the Broviac catheter, and implants ports such as the MediPort system.
- 134. Pathophysiology • Dialysis – Hemodialysis – Peritoneal dialysis • Feeding tubes • Intraventricular shunts
- 135. Assessment • Consider the challenge. • Relate it to the pathophysiology. • You may need to rely on the care provider to obtain the patient’s medical history and information about any care that has been provided thus far relative to the current emergency.
- 136. Emergency Medical Care • Ensure scene safety. • Consider spinal immobilization. • Assess the airway and maintain a patent airway. • Assess the breathing adequacy. – Ventilate with O2 if inadequate. – Provide oxygen therapy based on patient need.
- 137. Emergency Medical Care • Assess central and peripheral circulation. – Treat hemorrhage as you normal would – Treat for shock if necessary • Complete the secondary assessment. • Transport to appropriate facility.
- 138. Emergency Medical Care • The care you render for specially challenged patients will depend on the condition(s) for which you were summoned.
- 139. Case Study • You are called to a local residence for a 2-year-old male patient for uncontrollable crying and vomiting. Upon your arrival, the mother meets you at the door and states that her son has been crying for the past half hour and has vomited twice.
- 140. Case Study (cont'd) • What possible differentials are you considering at this time? • What Standard Precautions would you take based on what you have been told?
- 141. Case Study (cont'd) • Scene Size-up – One patient – 2-year-old boy, approximately 25 lbs. – Patient lying on bathroom floor crying and holding his bald head. – He runs to his mother when she enters the room. – No entry or egress problems – No signs of trauma or external bleeding
- 142. Case Study (cont'd) • Primary assessment – Patient is alert and anxious. – Airway is patent and maintained by the patient. – Breathing is fast and, patient is crying vigorously.
- 143. Case Study (cont'd) • Primary assessment – Circulation is intact. Peripheral and central pulses are a little slow and bounding. – No obvious signs of trauma noted.
- 144. Case Study (cont'd) • The mother begins to tell you that her son has “water on his brain” and had surgery three weeks ago. She says they implanted a shunt in his head. She asks you if that could be the problem. – How would respond?
- 145. Case Study (cont'd) • What would be your first priority? • What condition do you suspect his mother is referring to? • Explain what an intraventricular shunt does.
- 146. Case Study (cont'd) • If the problem is the shunt, what signs and symptoms would you expect to find? • What challenges will you face in assessing this patient?
- 147. Case Study (cont'd) • Medical History – Hydrocephalus, heart murmur • Medications – None at this time • Allergies – None
- 148. Case Study (cont'd) • Secondary assessment findings – Pupils are slightly dilated – Projectile vomiting – Respirations are still masked by the crying – Slight murmur heard on auscultation
- 149. Case Study (cont'd) • Secondary assessment findings – Systolic blood pressure 96 mmHg, HR 78 bpm, RR 35 – SpO2 96 percent on room air – No other significant pertinent findings
- 150. Case Study (cont'd) • What effects could hypoxia and hypercapnia have on this patient? • Why is this patient bradycardic? • What emergency care would you provide to this patient? • What transport considerations might you have?
- 151. Case Study (cont'd) • Care provided: – Maintain an open airway. Suction if needed. – Administer oxygen and provide ventilations if necessary. – Transport to appropriate facility.
- 152. Case Study (cont'd) • Care provided: – Initiate IV en route and reassess. Limit fluid administration. – Provide supportive care to both patient and family.
- 153. Summary • Paramedics should be familiar with a wide variety of conditions that require special needs such as technology to sustain their vital functioning. • Ultimately, the care rendered will be based on the condition; however, the paramedic must always maintain the airway, breathing, and perfusion first.
- 154. TOPIC 58 Geriatrics
- 155. Objectives • Discuss statistics relating to the aging geriatric imperative. • Discuss pathophysiologic changes that occur to the body due to aging. • Integrate assessment findings with related pathophysiology in geriatric patients. • Review current treatment strategies for geriatric patients.
- 156. Introduction • People over the age of 65 make up the fastest-growing segment of the population. • Changes in physiology due to aging and lifestyle have an effect on pathophysiology as compared to younger adults.
- 157. Epidemiology • Almost 40 million in 2008, or 12.8 of the population. • Cardiovascular disease is the leading cause of death, followed by cancer, strokes, and COPD. • They use one-third of all prescriptions. • The average geriatric patient takes 4.5 medications per day.
- 158. Pathophysiology • Human body changes with age: cellular, organ, and system functions. • Changes in normal physiology start around age 30. • Process can be slowed with diet and exercise, but it cannot be stopped entirely.
- 159. Pathophysiology • Cardiovascular system – Degenerative process to the myocardium – Damage to valves – Thickening of the walls – Loss of artery elasticity – Decrease in baroreceptor activity
- 160. Pathophysiology • Respiratory system – Size and strength of respiratory muscles decrease. – Alveolar surfaces degrade, impairing gas exchange. – Chemoreceptors begin to fail. – More turbulent airflow through the bronchioles.
- 161. Pathophysiology • Nervous system – Nerve cells degenerate and die as early as in the mid-20s. – Reflexes slow, proprioception falters. – Brain atrophies with a resultant increase in cerebrospinal fluid. – Regulation of basal bodily functions becomes less sensitive.
- 162. Pathophysiology • Gastrointestinal system – Sense of taste and smell is diminished. – Cardiac sphincter becomes weaker. – Hepatic function decreases. – Lining of GI system degenerates, resulting in lesser absorption of nutrients.
- 163. Pathophysiology • Endocrine system – Hormones that elevate blood pressure and those that regulate fluid balance become deranged. – Stimulation of adrenergic sites diminishes due to failure of sensitivity of receptor cells.
- 164. Pathophysiology • Musculoskeletal system – Loss of minerals from the bones. – Vertebral disks narrow. – Joints lose flexibility. – Synovial fluid thickens.
- 165. Pathophysiology • Renal system – Decrease in nephrons, kidneys shrink – Diminished ability to filter blood – Fluid and electrolyte disturbances
- 166. Pathophysiology • Integumentary system – Skin becomes thinner from a loss of subcutaneous layer. – Replacement cells generate more slowly. – Sense of touch is dulled, less perspiration. – Less effectiveness as an external barrier.
- 167. Changes in the body systems of the elderly.
- 168. Clues to Illness Found in the Scene Size-Up
- 169. Special Considerations in the Primary Assessment of the Geriatric Patient
- 170. Special Considerations in the Primary Assessment of the Geriatric Patient
- 171. Special Considerations in the Primary Assessment of the Geriatric Patient
- 172. Potential Differential Diagnoses Based on Clinical Findings in Geriatric Patients
- 173. Potential Differential Diagnoses Based on Clinical Findings in Geriatric Patients
- 174. Potential Differential Diagnoses Based on Clinical Findings in Geriatric Patients
- 175. Potential Differential Diagnoses Based on Clinical Findings in Geriatric Patients
- 176. Potential Differential Diagnoses Based on Clinical Findings in Geriatric Patients
- 177. Emergency Medical Care • Manual cervical spine considerations • Assess and maintain the airway. • Determine breathing adequacy. – Provide positive pressure ventilations with supplemental oxygen if breathing is inadequate. – Titrate to maintain saturation >95 percent of breathing adequately.
- 178. Emergency Medical Care • Assess circulatory components. – Check pulse, skin characteristics. – Control major bleeds.
- 179. Emergency Medical Care • Position the patient appropriately. • Obtain intravenous access. • Consider history and medications before initiating any treatment. • Transport and reassess.
- 180. Case Study • Your EMS unit is dispatched for a “possible cardiac arrest” in the low-income housing district. Upon arrival, police escort you into a single-bedroom dwelling where an unresponsive elderly male is found in bed. The report is that the neighbor has not seen him in a few days so he asked the building manager to gain access.
- 181. Case Study (cont'd) • Scene Size-Up – Standard Precautions taken. – Scene is safe, no entry or egress problems. – 70–75-year-old male, about 200 pounds.
- 182. Case Study (cont'd) • Scene Size-Up – Patient dressed in pajamas, time is 1430 hrs. – Nature of illness, is unknown/unresponsive, possible arrest. – Friend is on scene, but is not much help regarding history.
- 183. Case Study (cont'd) • Describe possible ways to learn about the patient's medical history. • For each body system, name at least one differential that could cause unresponsiveness. – Nervous – Respiratory – Cardiac – Endocrine
- 184. Case Study (cont'd) • Primary Assessment Findings – Patient unresponsive. – Pupils reactive, membranes dry, tongue furrowed. – Some vomitus in airway, gurgling with breathing.
- 185. Case Study (cont'd) • Primary Assessment Findings – Respirations rapid and deep. – Carotid pulse 120/min, peripheral pulse absent. – Peripheral skin warm and dry. – No major bleeding noted.
- 186. Case Study (cont'd) • How would you prioritize this patient? • What are the patient's life threats, if any? • What care should be administered immediately?
- 187. Case Study (cont'd) • Medical History – Unknown • Medications – Glucophage found in bathroom – Aspirin and other over-the-counter medications found in cabinet • Allergies – Unknown
- 188. Case Study (cont'd) • Pertinent Secondary Assessment Findings – Pupils reactive to light, membranes dry. – Airway patent, patient breathing fast and deep. – Central pulse present, peripheral absent. – Skin is dry, delayed capillary refill.
- 189. Case Study (cont'd) • Pertinent Secondary Assessment Findings – No bruising, guarding, nor rigidity to abdomen. – Blood glucose level 710 mg/dL, SpO2 96 percent on high flow. – BP 82/62, HR 112, RR 28 and deep. – No other findings contributory to this report.
- 190. Case Study (cont'd) • Is this a structural or metabolic cause of unresponsiveness? • What is the likely underlying cause for the emergency? • Explain the pathology for the following: – Unresponsiveness – Rapid heart rate, dehydration findings
- 191. Case Study (cont'd) • Care provided: – Patient immobilized as a precaution. – High-flow oxygen via nonrebreather mask. – Patient loaded on wheeled cot and taken to ambulance.
- 192. Case Study (cont'd) • Care provided: – Initiated intravenous access. • Fluid administration to rehydrate and maintain systolic blood pressure of 90 mmHg. – Emergent transport to the hospital.
- 193. Summary • Geriatric patients, like pediatric patients, have an altered physiology that needs to be considered given illness and injuries. • The normal decline in the body systems renders the geriatric patient susceptible to a multitude of emergencies.
- 194. Summary • Carefully manage and closely watch elderly patients, as they may deteriorate suddenly.
- 195. TOPIC 57 Pediatrics
- 196. Objectives • Identify personal, EMS, and health care system resources for managing pediatric patients. • Discuss how to approach the pediatric patient. • Review the Pediatric Assessment Triangle and how to implement it with pediatrics.
- 197. Objectives • Discuss common pediatric pathologies and their corresponding management. • Discuss current treatment standards for a patient with a pediatric emergency.
- 198. Introduction • Managing pediatrics requires: – Personal preparation – EMS system preparation – Hospital network system preparation
- 199. Approach: First Impression • First impressions matter more to children. – They do not have the experiences to make correct judgments. – Get down to their level with the caregiver present. – Assessment starts as soon as you arrive.
- 200. Approach a young child on the child’s level, with the caregiver present.
- 201. Parents and Caretakers • Parents and caretakers know you are there to help. – It does not mean they trust you. – Gaining parent's trust will help in gaining the child's trust. – Take time to listen and address the parent’s fears and concerns honestly.
- 202. Assessment • Assessment of the pediatric patient differs from that of the adult patient. • Rapid changes in anatomy, physiology, and cognitive ability. • Vitals change during development. • Pediatric Assessment Triangle – Allows for objective and reproducible evaluation of sick pediatrics patients.
- 203. The Pediatric Assessment Triangle (PAT).
- 204. Assessment • Appearance – Often the first clues to a problem are found in the appearance. – TICLS mnemonic can help. • Tone • Interactiveness • Consolability • Look/Gaze • Speech/Cry
- 205. Assessment • Breathing – Ventilation needed for respiration. – Respiration needed for energy and cellular activity. – Pediatric respiratory is system ill-equipped to handle significant disturbances.
- 206. Assessment • Circulation – Relationship of pump, pipes, and fluid. – When one fails, the other two have to cover. – Causes • Volume loss • Pump failure • Low vascular tone – IV versus IO access.
- 207. Treatment Guidelines • Have the appropriate tools • Provide the appropriate care • If needed, fluid challenges are based on age – 20 mL/kg in children – 10 mL/kg is infants • Education, quality improvement, and cooperation can help improve care.
- 208. Case Study • You are called to the home of a 5- year-old child who reportedly fell off a trampoline in his backyard, and now has left leg pain. The parents are gone and the child is in the care of the babysitter.
- 209. Case Study (cont'd) • Scene Size-Up – Standard Precautions taken. – Scene is safe, no entry or egress problems. – 5-year-old male, about 35 pounds.
- 210. Case Study (cont'd) • Scene Size-Up – Patient found sitting under tree in back yard. – Mechanism of injury is fall from a jungle gym (fall <5 feet). – Parents on way home, per babysitter.
- 211. Case Study (cont'd) • Primary Assessment Findings – Patient is responsive. – Airway is clear. – Breathing adequate, patient crying, calms with babysitter.
- 212. Case Study (cont'd) • Primary Assessment Findings – Carotid pulse 120/min, peripheral pulse present. – Peripheral skin warm and slightly diaphoretic. – Good muscle tone.
- 213. Case Study (cont'd) • How would you characterize this patient according to PAT? • What are the patient's life threats, if any? • What care should be administered immediately?
- 214. Case Study (cont'd) • Medical History – None per babysitter • Medications – None per babysitter • Allergies – None per babysitter • Parents arrive home and consent to treatment and tansport.
- 215. Case Study (cont'd) • Pertinent Secondary Assessment Findings – Pupils reactive to light, membranes hydrated. – Airway patent, patient breathing at 24/min. – Central and peripheral pulses present, 90/minute. – Skin is still warm, not as diaphoretic.
- 216. Case Study (cont'd) • Pertinent Secondary Assessment Findings – Pulse oximeter reads 100 percent with low-flow oxygen. – Patient markedly calmer, interacting appropriately.
- 217. Case Study (cont'd) • Pertinent Secondary Assessment Findings – Abdomen is non-tender, no bruising, guarding, nor rigidity. – Left lower leg is painful, tender to touch, contusions, swelling, deformity noted with good distal circulation, motor, and sensory findings.
- 218. Case Study (cont'd) • Is the child improving or deteriorating? • What is the likely underlying cause for the emergency? • Is there any additional treatment or change in treatment required?
- 219. Case Study (cont'd) • Care provided: – Patient immobilized supine, secured for transport. – Low-flow oxygen. – Fracture immobilized and splinted.
- 220. Case Study (cont'd) • Care provided: – Transported with parent in front of ambulance. – IV initiated en route. – Consider medication for pain based on protocol.
- 221. Summary • Pediatric emergencies can be stressful for the provider, the parent, and the child. • Approach to treatment of the pediatric patient should follow the PAT assessment triangle. • Interventions should be provided based upon need, and in concert with the patient and/or parents if possible.
Editor's Notes
- #3: Discuss the objectives.
- #4: Discuss how skills such as endotracheal intubation and surgical airways represent definitive management and are used to secure the most difficult and threatened airways. Explain that the decision to move to invasive procedures should be made after careful consideration of the costs and benefits of the intervention. Discuss how the use of prehospital ETI has been a point of controversy in recent years. Explain that paramedics should be familiar with the ongoing debate and incorporate these valid concerns into their airway management decision-making process.
- #5: Discuss how skills such as endotracheal intubation and surgical airways represent definitive management and are used to secure the most difficult and threatened airways. Explain that the decision to move to invasive procedures should be made after careful consideration of the costs and benefits of the intervention. Discuss how the use of prehospital ETI has been a point of controversy in recent years. Explain that paramedics should be familiar with the ongoing debate and incorporate these valid concerns into their airway management decision-making process.
- #6: The primary assessment is used to identify airway and breathing issues and typically will be the point at which airway interventions take place. Explain how pathophysiology should be used to determine the most appropriate method to resolve the issue. Consider other circumstances to create the best treatment plan for the patient: costs and benefits of the procedure risks crew capabilities equipment on hand other situational data
- #7: Discuss he following indications for invasive airways: More basic maneuvers have failed. Invasive airways are indicated by the pathophysiology of the situation. Invasive airways represent the better choice given an analysis of the circumstances. The clinical course of the patient indicates invasive maneuvers. Discuss how no airway should be approached in a predetermined manner. Stress that each circumstance must be evaluated individually and a plan tailor-made to suit its own particulars.
- #8: Discuss the table. Stress that all invasive airway interventions should take place only after a careful cost–benefit analysis. Invasive procedures may represent the highest level of airway management, but in most cases they also represent the highest level of risk. Definitive airway management can be critically important. In many cases, the benefits of invasive procedures will outweigh the risks. Providers must recognize those circumstances but at the same time resist temptation to apply invasive procedures to situations for which basic maneuvers would be equally effective.
- #9: When performed correctly, ETI represents the highest level of prehospital airway management. Discuss the many risks of failed or unrecognized esophageal intubation. Explain why any success rate less than 100 percent is too low. Discuss some of the causes for low success rates including: Poor initial training Infrequent use of the procedure Nonexistent continuing education Difficulty to improve these circumstances Explain how operating rooms are more frequently using blind insertion devices instead of ETI for short-term anesthesia and how liability questions and competition from other professions have also limited the OR experience. Discuss how intubation is a technical skill and just as with any other technique, lack of use decreases skill. When one considers the educational challenges in context with the difficult situations in which paramedics are charged with performing the skill, it is no wonder that success rates are as low as they are.
- #10: Intubation can be preserved by undertaking three major philosophical shifts: First, we need to recognize and admit that we have a problem. Second, we need to better select the situations in which intubation is used. Third, we must concentrate on improving endotracheal confirmation. Discuss other steps, such as selecting who intubates and providing higher quality initial education that should be considered.
- #11: Discuss the importance of intubation confirmation. Explain that the worst outcomes result from unrecognized incorrect placements. Discuss the importance of waveform capnography. Review the limitations of capnography. Discuss other confirmation devices. Explain why multiple methods should be used to achieve a definitive confirmation.
- #12: Discuss the importance of intubation confirmation. Explain that the worst outcomes result from unrecognized incorrect placements. Discuss the importance of waveform capnography. Review the limitations of capnography. Discuss other confirmation devices. Explain why multiple methods should be used to achieve a definitive confirmation.
- #13: Blind insertion airway devices (BIADs) are a general category of airway adjuncts so named because they do not require specialized equipment, such as a laryngoscope, to insert. Discuss how they are designed to offer a simple alternative to ETI and provide a level of protection from aspiration by (at least in theory) isolating the glottic opening. Discuss the benefits and limitations of BIADs. Stress that these devices should not be substituted for endotracheal intubation when definitive airway management is necessary. Identify complications associated with their use such as eliciting a gag reflex, stimulating the vagus nerve, and causing bradycardia. Discuss the two main categories of BIADs: Esophageal obturation devices Suprglottic devices
- #15: Discuss as needed.
- #18: Discuss the objectives.
- #19: Discuss the objectives.
- #20: Stroke, or acute cerebrovascular syndrome, is an emergency involving the disruption of blood flow through a cerebral vessel within the brain. It may result in: Significant motor (movement) abnormality Sensory abnormality Cognitive (thought or perception) dysfunction Death It is also commonly referred to as a “brain attack,” as immediate recognition and management can reduce the amount of disability or death associated with stroke. Most recently, stroke is being referred to as an acute cerebrovascular syndrome.
- #21: Discuss the epidemiological findings relating to strokes.
- #22: Ischemic strokes occur most frequently, and are caused by an obstruction of blood flow to a region of the brain. Often caused by atherosclerosis. Thrombotic stroke—stationary clot that develops in a cerebral blood vessel. Symptoms are often progressive over time from continued occlusion of blood flow. Embolic stroke—a clot or piece of intravascular material breaks off and travels through blood vessels until it lodges in a cerebral hemisphere. Typically symptoms present very suddenly as blockage is a sudden event. TIA—transient ischemic attack occurs when there is a temporary disruption of blood flow from either an embolism or disruption of an atherosclerotic blood vessel in the brain. Symptoms last commonly for minutes or hours—usually resolves in 24 hours. RIND—reversible ischemic neurologic deficit is similar to a TIA in etiology. RIND resolves in 24–72 hours after onset. Hypoperfusion—occurs when there is low perfusion to the brain due to some failure of the effectiveness of the heart. Findings are global rather than focal since the entire brain is affected by the hypoperfusive state.
- #23: A hemorrhagic stroke is caused by a rupture of a cerebral vessel with resultant bleeding into brain tissue or areas surrounding the brain. Approximately 10 percent to 15 percent of all strokes are hemorrhagic in nature. Hemorrhagic strokes cause a “structural” problem in the brain. The space occupying accumulation of blood shifts and compresses surrounding brain tissue that then causes elevations in the intracranial pressure. Hemorrhagic strokes are fatal more often than ischemic strokes. Etiology: Arteriovenous malformation (AVM) is a weakened area in a blood vessel that balloons out. It may continue to weaken and eventually rupture and bleed into the brain or its surrounding tissue. An aneurysm is a weakened area in a blood vessel that balloons out. It may continue to weaken and eventually rupture and bleed into the brain or its surrounding tissue. Often causes SAH. Types: Intracerebral hemorrhage (ICH) is a rupture of a cerebral blood vessel and blood spills directly onto the brain tissue. ICH is the most common type of hemorrhagic stroke. Subarachnoid hemorrhage (SAH) is when the vessel ruptures into the subarachnoid space.
- #24: Blood is carried from the heart to the brain via the carotid and vertebral arteries, which form a ring and branches within the brain. An ischemic stroke occurs when a thrombus is formed on the wall of an artery or when an embolus travels from another area until it lodges in and blocks an arterial branch. Discuss the pathophysiology of thrombus formation in an ischemic stroke. A hemorrhagic stroke occurs when a cerebral artery ruptures and bleeds into the brain (examples shown: subarachnoid bleeding on the surface of the brain and intracerebral bleeding within the brain).
- #25: Discuss the progression of neurologic dysfunction and damage in stroke. Explain how if the bloodflow is restored to the ischemic “electrically silent” cells, they will become electrically active and function. Explain how cytoxic edema occurs as a result of the sodium potassium pump failure.
- #26: Stress that the brain cells are particularly vulnerable to the diminished blood flow owing to the fact that they do not store glucose and rely completely on glucose delivered via the bloodstream. The area of the brain surrounding the primary stroke site that continues to receive cerebral blood flow from collateral circulation is termed the ischemic penumbra or ischemic shadow. Remind student that a patient must have at a minimum the reticular activating system and one hemisphere intact in order to be conscious. If a patient is unconscious, than either BOTH hemispheres or the RAS is no longer intact.
- #27: Stress the importance of determining onset time, baseline findings, and ongoing changes during prehospital treatment and transport. Decisions regarding if the patient is a candidate for medications depends upon many of these answers. It is imperative that EMS personnel be able to recognize even the most subtle signs and symptoms of stroke so rapid and aggressive stroke treatment can be provided.
- #28: Discuss common findings of a stroke, and that a TIA or RIND may also present with symptoms of a full stroke. Discuss the importance of recognizing subtle symptoms. Prehospital determination of stroke type is not more important than maintaining vital body functions and providing rapid transport to the receiving facility.
- #29: Discuss common findings of a stroke, and that a TIA or RIND may also present with symptoms of a full stroke. Prehospital determination of stroke type is not more important than maintaining vital body functions and providing rapid transport to the receiving facility. Explain that patients with ICH and SAH will typically present with more severe depressed mental status and headache as compared with ischemic stroke patients.
- #30: Review how to assess for a facial droop. Review how to assess for slurred speech. Explain that not every patient will present with these findings.
- #31: Discuss how to assess for an arm drift. Explain that A patient who has not suffered a stroke can generally hold the arms in an extended position with eyes closed. Explain that a stroke patient may display “arm drift” or “pronator drift”—one arm will remain extended when held outward with eyes closed, but the other arm will drift or drop downward and pronate.
- #32: Review and discuss the Cincinnati Prehospital Stroke Scale.
- #33: Review and discuss the Los Angeles Prehospital Stroke Screen. Explain that these stroke assessment scales have a high predictive value.
- #34: The emergency care provided to a stroke patient is primarily supportive and is geared to reverse hypoxemia and hypoperfusion. Ensure that an adequate airway is: Established Maintained Ensure the breathing is adequate: Titrate oxygen therapy to maintain SpO2 above 94 percent if breathing adequately. If the patient is breathing inadequately, begin ventilation at a rate of 10 to 12 per minute. Apply a pulse oximeter to monitor the oxygen saturation levels. Turn the vomiting patient left lateral recumbent. Be sure to respond immediately to: Declines in oxygen saturation by reassessing the adequacy of the airway or ventilation. Managing the airway or ventilating if necessary Increasing the oxygen concentration. Advanced airway to protect from aspiration as needed. Initiate intravenous therapy with normal saline at a keep-open-rate. Titrate fluids if the systolic blood pressure falls below 90 mmHg. Use caution, though, not to administer too much fluid.
- #35: Obtain a blood glucose level, as hypoglycemia can mimic stroke. Administer 50% dextrose or glucagon as indicated for a BGL less than 50 mg/dL. Stress that the administration of dextrose or dextrose-containing solutions if the patient has a normal or high BGL reading is dangerous to the patient. Protect and rapidly transport an acute stroke patient to the most appropriate medical facility for proper medical management.
- #36: Discuss as needed.
- #37: Discuss as needed.
- #39: Discuss the objectives.
- #40: Discuss the objectives.
- #41: An allergic reaction is an immunologic or nonimmunologic response to an allergen or antigen resulting in the release of chemical mediators from specific cells within the body. Explain that an allergic reaction may range from mild to severe. Differentiate between anaphylactic and anaphylactoid reactions. The paramedic must be able to recognize the acute allergic reaction and provide appropriate care based on findings.
- #42: Anaphylaxis is not a reportable disease; therefore, the morbidity and mortality rates are not well established. Studies suggest that the lifetime risk of an individual experiencing an anaphylactic reaction is between 1 percent and 3 percent, with a mortality rate of 1 percent. It is estimated that 20,000 to 50,000 persons suffer an anaphylactic reaction in the United States each year. Explain that the incidence rate has been reported to be increasing, especially in individuals under 20 years of age. Review some of the most common triggers for an anaphylactic reaction.
- #43: Review the traditional “antigen–antibody” reaction to include: the process of sensitization reexposure chemical mediator release subsequent organ and system dysfunction that leads to characteristic findings Explain that the IgE antibodies can remain attached to the mast cells and basophils for seconds, minutes, days, weeks, months, or years. Explain that for the patient to experience the systemic and multiple organ pathologic response and exhibit the typical signs and symptoms, a large enough quantity of mediators must be released from the mast cells and basophils.
- #44: Discuss some of the common causes of anaphylactic reactions.
- #45: Compare and differentiate between the anaphylactoid reaction and the anaphylactic reaction. Explain that during anaphylactoid reaction, the patient would not be sensitized, and no antibodies would be attached to the mast cells and basophils to initiate a reaction. Discuss how the anaphylactoid substance that the patient ingests, injects, absorbs, or inhales causes the mast cells and basophils to break down and release chemical mediators. Stress that the goal is to recognize the misguided immune response, rather than get worried about it being an anaphylactic or anaphylactoid reaction. Treatment between the two is the same.
- #46: Identify some of the common causes of anaphylactoid reactions. Discuss how the anaphylactoid substances are “direct” chemical mediator-releasing agents. Stress that the first-time exposure may cause a direct release of a mass of chemical mediators and create a life-threatening condition, with signs and symptoms that appear to be a full-blown anaphylactic reaction.
- #47: Histamine, the primary chemical mediator, along with leukotriene, prostaglandin, and tryptase, is released when the mast cell or basophil membrane breaks down. Discuss how it is the chemical mediators which circulate and produce the abnormal cell, tissue, organ, and organ system response (not the actual antigen).
- #48: Discuss/review the progression of the reaction. Discuss the life-threatening responses in anaphylactic reaction: Increased capillary permeability •Decreased vascular smooth muscle tone (vasodilation) •Increased bronchial smooth muscle tone (bronchoconstriction) •Increased mucus secretion in the tracheobronchial tract Integrate symptomatology and management considerations.
- #49: The most acute cases, which can rapidly cause death, have the following features: Rapid onset Airway swelling Stridorous airway sounds Low blood pressure Bilateral wheezing
- #50: An increase in capillary permeability allows fluid to leak from the capillary bed and collect in the interstitial space around the cells. Often the edema is noted around the face, tongue, and neck, because of the large number of vessels in that area of the body, and in the hands, feet, and ankles, caused by gravity pulling the fluid downward. Discuss how the increased capillary permeability in the mucous membranes can lead to edema in the airway structures, including the oropharynx, hypopharynx, larynx, and tracheobronchial tract and result in airway closure.
- #54: Review the skin signs associated with an allergic reaction. Warm, flushed skin is an indication of vasodilation, whereas edema and urticaria (hives) indicate an increase in capillary permeability. Discus how both vasodilation and fluid loss from an increase in capillary permeability can produce severe hypotension and extremely poor tissue and organ perfusion.
- #55: These are not characteristics per se, but common themes in the presentation of an acute allergic reaction. Discuss how the paramedic may find evidence of the actual antigen or direct chemical mediator-releasing substance or route of introduction into the body. Obtain a good history. Collect information such as: Are the signs and symptoms getting worse? •Does the patient have a history of allergic reaction or anaphylaxis? If so, how severe was the reaction? Was the patient hospitalized? •Has the patient ever been exposed to the suspected triggering substance previously? •Has the patient taken any medications in an attempt to relieve the signs and symptoms? •How quick was the onset of the signs and symptoms?
- #56: Stress that it is imperative to pay particular attention to the airway, ventilation, oxygenation, and circulatory status during the primary assessment. Explain the importance of assessing the vital signs, because changes can occur very quickly. Explain how the faster the onset of signs and symptoms, the more severe the reaction. Discuss how a biphasic or multiphasic reaction may occur. The patient may respond effectively to the emergency care and appear to be recovering when the signs and symptoms of the reaction recurs.
- #57: Discuss differentiation and how it pertains to management. Differentiate between a mild and a moderate to severe reaction. Stress that one of the initial keys to emergency care is to recognize whether the reaction is mild, moderate, or severe. A mild reaction typically requires only minimal care and close reassessment for deterioration. Patients experiencing a moderate to severe reaction require much more aggressive emergency medical care.
- #58: Relate the management provided with the intended outcomes. Stress again the effects of epinephrine on the pathology of the medical emergency. Stress that fatal episodes of anaphylaxis are associated with airway occlusion, respiratory failure, severe hypoxia, and circulatory collapse. Thus, it is imperative to pay particular attention to the airway, ventilation, oxygenation, and circulatory status during the primary assessment. Discuss signs that the patient might require aggressive airway management, including insertion of an advanced endotracheal tube, are hoarseness, edema to the oropharynx, stridor, and lingual edema. Discuss the need for IV therapy. Explain why an infusion of large amounts of fluid maybe necessary; therefore, a second intravenous line may be required. •
- #59: Epinephrine should be administered to patients with an anaphylactic reaction who present with systemic signs and symptoms, especially those with hypotension, poor perfusion, airway swelling, or difficulty in breathing. Review that the severe signs of an anaphylactic or anaphylactoid reaction are related to an increase in capillary permeability, bronchoconstriction, vasodilation, and an increase in mucus production. Explain why epinephrine becomes the drug of choice because of its ability to stimulate alpha and beta receptors. Alpha stimulation causes vascular smooth muscle contraction, leading to vasoconstriction. Vasoconstriction decreases the vessel diameter and increases resistance to blood flow, leading to an increase in blood pressure and perfusion. The vasoconstriction also tightens the capillaries. This will also reverse hypotension by reducing the leakage of plasma volume to the interstitial space. The beta2 stimulation dilates the bronchiole smooth muscle and reverses the bronchoconstriction. Thus, epinephrine administration eliminates the capillary permeability, vasodilation, and bronchoconstriction associated with anaphylaxis. Discuss the possible routes epinephrine may be administered, but why the IM route is preferred. Review the recommended dosages based on age and weight. Repeat doses should only be administered if the patient continues to exhibit evidence of hypotension, airway swelling, and severe respiratory distress or failure.
- #60: Epinephrine should be administered to patients with an anaphylactic reaction who present with systemic signs and symptoms, especially those with hypotension, poor perfusion, airway swelling, or difficulty in breathing. Review that the severe signs of an anaphylactic or anaphylactoid reaction are related to an increase in capillary permeability, bronchoconstriction, vasodilation, and an increase in mucus production. Explain why epinephrine becomes the drug of choice because of its ability to stimulate alpha and beta receptors. Alpha stimulation causes vascular smooth muscle contraction, leading to vasoconstriction. Vasoconstriction decreases the vessel diameter and increases resistance to blood flow, leading to an increase in blood pressure and perfusion. The vasoconstriction also tightens the capillaries. This will also reverse hypotension by reducing the leakage of plasma volume to the interstitial space. The beta2 stimulation dilates the bronchiole smooth muscle and reverses the bronchoconstriction. Thus, epinephrine administration eliminates the capillary permeability, vasodilation, and bronchoconstriction associated with anaphylaxis. Discuss the possible routes epinephrine may be administered, but why the intramuscular route is preferred. Review the recommended dosages based on age and weight. Repeat doses should only be administered if the patient continues to exhibit evidence of hypotension, airway swelling, and severe respiratory distress or failure.
- #61: Discuss other medications that may be administered based on patient presentation. Discuss why patients on beta blockers may pose a challenge and might require glucagon or higher levels of epinephrine based on protocol. Diphenhydramine—negates the ongoing effects of circulating histamine to help control long-term effects. A typical dose is 25 to 50 mg IV or IM. Administer corticosteroids—help stabilize capillary membrane permeability and prevent subsequent swelling or recurrence.
- #62: Discuss other medications that may be administered based on patient presentation. Discuss why patients on beta blockers may pose a challenge and might require glucagon or higher levels of epinephrine based on protocol. Diphenhydramine- negates the ongoing effects of circulating histamine to help control long term effects. A typical dose is 25 to 50 mg IV or IM. Administer corticosteroids- help stabilize capillary membrane permeability and prevent subsequent swelling or recurrence.
- #63: Discuss other medications that may be administered based on patient presentation. Review the common doses and routes for administering the medications. Relate the management provided with the intended outcomes. Stress again the effects of epinephrine , beta2 agonist, and glucagon on the pathology of the medical emergency.
- #64: Discuss as needed.
- #66: Discuss the objectives.
- #67: Discuss the objectives.
- #68: Diabetes mellitus (DM) is a condition in which the patient experiences a chronically elevated blood glucose level. Discuss how the occasional acute hypoglycemic event carries a high risk of morbidity and mortality. Discuss why it is imperative that the paramedic quickly recognize the signs and symptoms of hypoglycemia and manage the patient accordingly to prevent any long-term effects from the episode.
- #69: Review the statistics.
- #70: Review the traditional description of Type 1 DM. Type 1 DM results from a chronic autoimmune process that destroys the insulin-producing cells (beta cells) in the pancreas. Identify Characteristics of type 1 diabetes patients are: •Typically younger than 40 years of age •Lean body mass •May have rapid weight loss •Polyuria •Polydipsia •Polyphagia Review and discuss why type 1 patients require supplemental insulin to manage their blood glucose levels.
- #71: Review the traditional description of Type 2 DM. Review how the pancreas continues to secrete insulin; however, the blood glucose level is elevated despite the insulin. impaired insulin function an inadequate amount of insulin being released by the pancreas inability of the insulin to reach the receptor sites on the cells failure of the organ to respond to the circulating insulin Review the characteristics of type 2 diabetes patients: •Onset usually in middle-age or older adults (however, more children and adolescents are being diagnosed with type 2) •Obese body mass (however, 20 percent are not obese) •More gradual onset of signs and symptoms Explain why type 2 diabetes is usually controlled through diet, exercise, and oral hypoglycemic medications. In some severe cases, the patient may require insulin supplementation. Discuss why these patients are more prone to developing hyperglycemic hyperosmolar nonketotic syndrome (HHNS).
- #72: Review the role of insulin in transporting glucose into the cell for energy production. Review the role of glucagon in stimulating glycogenolysis (breaking down glycogen stores); also, it stimulates gluconeogenesis. Explain that once in the cell, glucose is metabolized and produces energy in the form of adenosine triphosphate (ATP). Stress that without an adequate blood glucose level, alternative energy sources must be used by the cells. As a result, ATP production and cellular function may be altered.
- #73: Review how the primary function of insulin is to move glucose from the blood and into the cells, where it can be used for energy. Explain that insulin does not directly carry glucose into the cell; however, it triggers a receptor on the plasma membrane to open a channel allowing a protein helper, through the process of facilitated diffusion, to carry the glucose molecule into the cell. Explain that as long as insulin is available it will continue to move glucose into cell. Discuss how this decrease can affect the supply of glucose to the brain.
- #74: Discuss the process of normal glucose regulation.
- #75: Identify the common causes for a patient to have low blood sugar (too much insulin, not enough food, changes in physical exertion, etc.). Discuss how the onset and severity of signs and symptoms also depend on how quickly the glucose level falls, how low it falls, and the typical level for the patient. Discuss the negative feedback system attempt to raise blood sugar by releasing: Glucagon Epinephrine Cortisol Vasopressin
- #76: Review and discuss the basic differences in symptoms based on body pathology.
- #77: Review and discuss the signs and symptoms based on cause.
- #78: These are characteristic findings, not specific, nor always present. Explain that epinephrine is released in both hypovolemic and hypoglycemic shock, hence the reference to “insulin shock”. Discuss how severe episodes of hypoglycemia may cause hemiplegia, making the patient present as if having a potential stroke. Stress that a paramedic should never administer glucose without a confirmed low blood glucose level (BGL), typically less than 60 mg/dL.
- #79: Stress safety first. Review how hypoglycemia can cause airway compromise, but is easily reversible and advanced airway measures should choose airway management measures with that in mind. Discuss how in these patients, basic life support, airway measures are usually the best choice.
- #80: Beyond managing the airway, remaining alert for vomiting, providing oxygen, and positioning the patient, the paramedic must deliver glucose to the cells. Administration of oral glucose should only be done if the patient: Has an intact airway Can swallow Shows symptoms of hypoglycemia Has a monitored BGL less than 60 mg/dl Review the indications for IV or IO dextrose -If the patient has a BGL less than 60 mg/dL in addition to an altered mental status and inability to swallow and is at risk for aspiration. Review the indications for administering IM glucagon- If IV for glucose administration is necessary and can't be established Review the typical adult and pediatric doses for the medications. Discuss the possible complications for each medication.
- #81: Discuss how many patients will regain a normal mental status following administration of medications and may refuse transport. Discuss the criteria for obtaining a refusal. Stress that good clinical judgment should be used when evaluating the ability of the patient to sign off, but in a few situations, even greater concern should be expressed and transport should be initiated if possible: Patients who are alone or unable to take care of themselves. Patients taking oral antidiabetics Patients with infections or other underlying illnesses New-onset diabetics Patients who have had multiple episodes of hypoglycemia in recent history
- #82: Discuss as needed.
- #83: Discuss as needed.
- #85: Discuss the objectives.
- #86: Discuss the objectives.
- #87: Hyperglycemia refers to conditions in which the blood glucose is excessively elevated beyond a normal level. Two acute hyperglycemic conditions that paramedics will encounter in the prehospital environment are: Diabetic ketoacidosis (DKA) Hyperglycemic hyperosmolar nonketotic syndrome (HHNS) or is sometimes called hyperglycemic hyperosmolar nonketotic coma (HHNC) (Note that less than 10 percent of patients truly become comatose) Discuss why both DKA and HHNS should be considered and a BGL should be obtained when assessing and managing a patient with an altered mental status. Explain that the hyperglycemic emergency may be the first sign of diabetes mellitus onset of in a patient with no known history.
- #88: Review statistics. Discuss how elderly patients in nursing homes are at high risk for hyperglycemic episodes.
- #89: Discuss the pathology of DKA. Relate it to type 1 diabetic patients. Explain how even though the blood has an extremely elevated amount of circulating glucose, the cells are starving, but the brain continues to get glucose. Also discuss the pathophysiologic changes due to the excessive glucose and the body's attempt to remedy the situation: Acidosis from body's attempt to convert nonglucose structures into glucose (even though the body does not need it). Osmotic diuresis from glucose spilling over into the kidneys and drawing large amounts of water with it. Electrolyte disturbance from large amounts of urine leaving the body.
- #90: Discuss how the onset of DKA is slow and is related to the gradual accumulating effect of the dehydration from osmotic diuresis and buildup of acid from ketone production. Review the signs and symptoms of DKA. Osmotic diuresis typically produces the classic signs and symptoms of hyperglycemia: • Polyuria • Polydipsia • Constant thirst • Frequent urination at night Osmotic diuresis leads to dehydration and a potential hypovolemic state from fluid loss, producing the following signs: • Dry and warm skin • Poor skin turgor • Dry mucous membranes • Tachycardia • Hypotension • Decreased sweating • Orthostatic vital signs Explain how fruity or acetone odor on the breath is a direct result of small amounts of acetone being disposed of through respiration. Discuss how the ECG changes and dysrhythmias may also result from the electrolyte disturbance.
- #91: Discuss how Kussmaul respirations are deep and rapid respirations that are an attempt to compensate for the increasing ketoacidosis. The deep and rapid respiratory rate blows off carbon dioxide which is necessary for the production of carbonic acid. With the decreased availability of carbon dioxide, less carbonic acid is produced, thereby increasing the pH value and allowing more ketoacids to accumulate.
- #92: Discuss the progression of HHNS: Some insulin still present, just not effective. Glucose levels raise very high levels. Patient sill has osmotic diuresis and electrolyte disturbance. Stress that patients with HHNS do not have ketogenesis due to some insulin still being circulated (enough to prevent gluconeogenesis, but not enough to prevent osmosis or electrolyte disturbances). Explain why these patients will not have Kussmaul respirations or fruity or acetone odor on breath. Discuss how circulatory collapse is a common cause of death.
- #93: Review some of the common precipitating factors and underlying causes of HHNS. Review and discuss the clinical presentation of HHNS. In the early phase of HHNS, the signs and symptoms may be vague, such as leg cramps, weakness, and visual disturbances. Review other signs and symptoms include the following: • Thirst •Fever •Polyuria (early), oliguria (late) •Drowsiness, confusion, lethargy, or coma •Seizures •Hemiparesis or sensory deficits •Tachycardia •Orthostatic hypotension •Hypotension (late signs of profound dehydration) •Poor skin turgor (not a reliable sign in the elderly) •Dry skin and mucous membranes •Sunken eyes •Excessively elevated blood glucose level
- #94: Review and discuss. Differentiate between DKA, HHNS, and hypoglycemia. Stress the differences in presentation between the hyperglycemic disorders and the hypoglycemia. Review and discuss the difference in care. Discuss what the patients in each category need.
- #95: Discuss goals for management.
- #96: Beyond managing the airway, remaining alert for vomiting, providing oxygen, treating seizures if present, and positioning the patient, the paramedic will also need to initiate intravenous access for fluid therapy. If the patient is hypotensive, administer fluid to maintain the systolic blood pressure above 100 mmHg. Otherwise, infuse fluid at a rate of 1 to 2 liters over 1 to 3 hours. In pediatric patients, administer a 20 mL/kg fluid bolus over 1 hour. Monitor the patient’s breath sounds for an indication of fluid overload, and adjust if necessary.
- #97: Beyond managing the airway, remaining alert for vomiting, providing oxygen, treating seizures if present, and positioning the patient, the paramedic will also need to initiate intravenous access for fluid therapy. If the patient is hypotensive, administer fluid to maintain the systolic blood pressure above 100 mmHg. Otherwise, infuse fluid at a rate of 1 to 2 liters over 1 to 3 hours. In pediatric patients, administer a 20 mL/kg fluid bolus over 1 hour. Monitor the patient’s breath sounds for an indication of fluid overload, and adjust if necessary.
- #98: Discuss the case presentation.
- #99: Discuss the case presentation.
- #100: Since the patient did not recognize or respond to your arrival in their living room, the logical conclusion is an altered mental status. For this reason, the paramedic should be concerned for: Airway maintenance Breathing adequacy Whether a pulse is present The possibilities for the patient's unresponsiveness are almost endless. As of yet, the paramedic cannot rule out: Metabolic causes for unresponsiveness (e.g., hypoxia, electrolyte disorder, hypercapnia, low perfusion state, glucose levels) Structural causes (e.g., stroke, cerebral abscess)
- #101: Discuss as needed.
- #102: The person presents as a high priority due to: The change in mental status The partial airway occlusion Life threats include a potential deterioration of the airway or breathing mechanics if the patient's mental status diminishes any further. The sonorous breathing requires immediate attention. If the patient does not have a gag reflex, an oropharyngeal airway can be inserted in conjunction with a manual airway technique. Also be sure to visualize the airway for any remaining vomit or fluid that needs to be suctioned out. Airway management decision making should be utilized by the paramedic.
- #103: Discuss the case. Tell the participants that a quick “run through” of the apartment did not lead to any medications in the typical places or other indications as to the patient's problem.
- #104: Discuss the case progression.
- #106: Discuss the case progression.
- #107: Discuss the case progression.
- #108: Given the presentation, the paramedic should lean towards a hyperglycemic episode. Based on the presenting signs and symptoms, the paramedic should note the absence of ketone odor to the breath and regular respirations. The paramedic should recognize that the patient's likely problem is HHNS. Next steps of management would be to: Ensure good oxygenation Reassess airway and breathing to make sure both components are intact Initiate intravenous therapy aimed at rehydrating the patient. If the patient is hypotensive, administer normal saline to maintain the systolic blood pressure above 100 mmHg; otherwise, infuse fluid at a rate of 1 to 2 liters over one to two hours.
- #109: Discuss the case.
- #110: Discuss the case.
- #111: The change in mental status is likely due to a combination of electrolyte disturbance and volume depletion. A patient with HHNS has plenty of glucose for the brain to metabolize, so a change in mental status was not due to low glucose. Instead it was probably gradual. The brain cannot store glucose, so if the level of circulating glucose drops, the brain will be the first organ to dysfunction. This dysfunction usually turns into a drop in mental status. With the subsequent sympathetic discharge, the patient may also become aggressive. The tachycardia is secondary to the sympathetic discharge that causes the release of epinephrine (beta1 effects) due to volume depletion for diuresis. Along with this is the drop in blood pressure for the same reason (volume depletion). The dry skin and furrowed tongue occurs as the body attempts to shift fluid from interstitial spaces back inside the vascular space for perfusion needs. Over time the skin will become dry, the tongue becomes furrowed, mucous membranes become dry, and urine production will cease. The high sugar level is due to a relative inability of insulin to work in this patient. Because the cells of the body are starving for glucose, the body responds by releasing more glycogen stores and producing glucose from non-carbohydrate sources. The problem is, that the cells need more insulin, not more glucose.
- #112: Discuss as needed.
- #114: Review the objectives.
- #115: In your EMS career thus far, you have almost certainly encountered patients who have special medical challenges or whose lives are dependent on medical technologies. When their pre-existing special challenges worsen, their medical devices fail, or they experience some other emergency independent of the chronic condition, EMS is the first one called to intervene.
- #116: Review the statistics. Explain why getting precise numbers is difficult. It is estimated that millions of other patients receive care from family members or volunteers.
- #117: Review the statistics. Explain why getting precise numbers is difficult. It is estimated that millions of other patients receive care from family members or volunteers.
- #118: Discuss some of the reasons a person may be receiving care at home. Although the patient’s primary care providers are usually knowledgeable about the equipment or technology being used, they may not be as well versed in what to do if that equipment fails or the patient’s status begins to deteriorate. Tertiary care hospitals that care for such patients often maintain an on-call person for specialized conditions and/or equipment.
- #119: Discuss the different types of abuse for each group. Explain how the effects of abuse can impact the patient on various levels. Child abuse occurs when a child falls victim to abuse or neglect. Physical abuse occurs when improper or excessive action is taken that injures or causes harm. Neglect is the provision of inadequate attention or respect to someone who has a claim to that attention. Emotional abuse occurs when a child is regularly threatened, yelled at, humiliated, ignored, blamed, or otherwise emotionally mistreated. Sexual abuse occurs when a child is subject to an older child’s or adult’s advances of a sexual nature and can include both contact and noncontact events. Elder abuse may occur in care centers and other medical institutions, but it can also occur at home. In situations of active neglect, the care provider intentionally fails to meet the obligations to the elderly victim. In passive neglect, the failure is said to occur unintentionally and is often the result of the care provider’s feeling overwhelmed by the needed tasks. Physical abuse can involve the hitting, restraining, shaking, or shoving of an elderly patient. Sexual abuse is said to occur when unwanted or unwarranted advances of a sexual nature are made to which the older person does not or cannot consent. Financial abuse consists of the care provider exploiting the material possessions, property, credit, or monetary assets of the elderly patient for his own personal gain. With emotional/mental abuse, psychological distress or mental harm is inflicted on the elderly patient through verbal assaults, verbal insults, threats of physical harm, or simply ignoring the patient.
- #120: Discuss the different types of abuse for each group. Explain how the effects of abuse can impact the patient on various levels. Child abuse occurs when a child falls victim to abuse or neglect. Physical abuse occurs when improper or excessive action is taken that injures or causes harm. Neglect is the provision of inadequate attention or respect to someone who has a claim to that attention. Emotional abuse occurs when a child is regularly threatened, yelled at, humiliated, ignored, blamed, or otherwise emotionally mistreated. Sexual abuse occurs when a child is subject to an older child’s or adult’s advances of a sexual nature and can include both contact and noncontact events. Elder abuse may occur in care centers and other medical institutions, but it can also occur at home. In situations of active neglect, the care provider intentionally fails to meet the obligations to the elderly victim. In passive neglect, the failure is said to occur unintentionally and is often the result of the care provider’s feeling overwhelmed by the needed tasks. Physical abuse can involve the hitting, restraining, shaking, or shoving of an elderly patient. Sexual abuse is said to occur when unwanted or unwarranted advances of a sexual nature are made to which the older person does not or cannot consent. Financial abuse consists of the care provider exploiting the material possessions, property, credit, or monetary assets of the elderly patient for his own personal gain. With emotional/mental abuse, psychological distress or mental harm is inflicted on the elderly patient through verbal assaults, verbal insults, threats of physical harm, or simply ignoring the patient.
- #121: Mental (or emotional) illnesses can present as unique challenges to the paramedic. Generally, though, the term mental retardation encompasses disabilities that affect the nervous system and typically have a negative impact on intelligence level and how the person learns. Discuss how these disabilities may also cause problems such as speech impediments, behavioral disorders, language difficulties, and some movement disorders.
- #122: Review and discuss some of the causes of mental retardation.
- #123: The term disabilities is often used as an encompassing label that includes impairments, activity limitations, and participation restrictions. The medical model for “disabilities” views it as a problem of the patient that was caused by disease, trauma, inheritance, or other factors that necessitate sustained medical care for the individual. Identify some of the commonly encountered disabilities. Discuss how each pose a different type of challenge to the paramedic.
- #124: It is estimated that more than 40 percent of people in the United States are obese. Obesity is the second leading cause of preventable death today, after smoking. Long-term body deterioration from obesity can result in coronary heart disease, type 2 diabetes, immobility, sleep apnea, and hypertension, to name a few problems—all of which can reduce the life span of the patient should no corrective measures be taken. Discuss some of the causes for obesity.
- #125: Traumatized patients are another type of specially challenged patient for whom the paramedic may be called on to care. Head trauma (or more specifically, brain trauma) in patients can easily result in a multitude of residual disabilities. Discuss challenges that can be faced when providing care to a patient with these disabilities. Most previous head injury patients, though, fall somewhere between those two extremes. Trauma to the brain can occur at any age and may result in permanent damage, as evidenced by changes in cognition, learning abilities, emotional abilities, and/or muscle weakness or paralysis.
- #126: Discuss some of the different types of medical equipment found in the home setting. Stress why you must remain abreast of current home medical care and equipment. Apnea monitors are designed to constantly monitor the patient’s breathing status and then emit a warning signal should breathing cease. Some apnea monitors are also designed to monitor the heart rate. This type of equipment is commonly found in a home with an infant, especially a newborn who was born prematurely. These devices will emit a loud piercing sound to signal a problem and often will emit a series of beeps indicating how long the machine has been alerting.
- #127: Continuous positive airway pressure (CPAP) and bi-level positive airway pressure (BiPAP) machines keep the small bronchiole airways open during exhalation, which in turn improves both oxygenation and ventilation; it also lowers the work of breathing. Explain that the CPAP device provides a constant positive pressure during the entire ventilatory cycle, and the BiPAP machine provides a higher pressure during inhalation and a lower pressure during exhalation. These devices are commonly used on patients with sleep apnea or certain chronic lung diseases. Some CPAP and BiPAP machines also allow the administration of oxygen during use.
- #128: Continuous positive airway pressure (CPAP) and bi-level positive airway pressure (BiPAP) machines keep the small bronchiole airways open during exhalation, which in turn improves both oxygenation and ventilation; it also lowers the work of breathing. Explain that the CPAP device provides a constant positive pressure during the entire ventilatory cycle, and the BiPAP machine provides a higher pressure during inhalation and a lower pressure during exhalation. These devices are commonly used on patients with sleep apnea or certain chronic lung diseases. Some CPAP and BiPAP machines also allow the administration of oxygen during use.
- #129: Tracheostomy tubes are used when it becomes necessary to provide a new surgical opening for the airway in patients with certain medical and/or traumatic conditions. A tracheostomy is a surgical opening through the anterior neck and into the trachea that serves as an alternative site for air entry and exit from the body. A tracheostomy may be used as a permanent opening and is then referred to as a stoma. This technique is commonly performed for patients who have either long-term upper airway problems or medical conditions that result in long-term dependence on mechanical ventilation.
- #130: Home mechanical ventilators are designed to assist a patient who cannot breathe adequately on his own. Discuss reasons that a patient may be dependent on a ventilator. The two types of ventilators are negative pressure ventilators and positive pressure ventilators.
- #131: Negative pressure ventilators, such as the “iron lung,” encircle the patient’s chest and generate a negative pressure around the thoracic cage. The negative pressure created by the devices draws out the rib cage, which, in turn, creates a negative intrathoracic pressure, thereby causing air to be drawn into the lungs. Positive pressure ventilators push air into the airway, much like the EMS provider who squeezes a bag-valve mask. Exhalation then ensues when the positive pressure stops, and the chest wall and lungs recoil.
- #132: Discuss some of the types of controls on a ventilator: one is for the ventilatory rate, one is for adjusting the size of each breath one control that adjusts the amount of oxygen that is provided during ventilation
- #133: Because of variances in the device, the particular ventilator your patient uses may or may not have the following alarms: • High-pressure alarm. •Low-pressure alarm. •Apnea alarm. •Low FiO2 alarm. Discuss situations that may cause these alarms to activate.
- #134: Vascular access devices include central IV catheters such as a PICC line, central venous lines such as the Broviac catheter, and implants ports such as the MediPort system. Vascular access devices (VADs) are devices that are used when a patient is in need of ongoing intravenous medications. The type and duration of use of the device is largely dependent on the medical needs and disease process for which the patient is being treated. Discuss some of the reasons patient may have a VAD. As a paramedic, your system may allow you to administer medications and fluid via vascular access devices. Know that these devices require specific training that is beyond the scope of this topic. Do not initiate an IV in an arm that contains a vascular device.
- #135: Dialysis removes the buildup of toxins that occurs when the kidneys can no longer filter out these toxins. Differentiate between Hemodialysis and peritoneal dialysis. Feeding tubes are medical devices that provide nutrition to patients who cannot chew and/or swallow because of medical conditions or trauma resulting in paralysis or unconsciousness. Review the different types of feeding tubes. enteral feeding or tube feeding nasogastric tube, or NG-tube orogastric tube, or OG-tube. Some feeding tubes are inserted through the skin into the stomach (G-tubes) or jejunum (J-tubes). Intraventricular shunts are used mainly in pediatric patients who have hydrocephalus. Explain how a shunt can keep the intracranial pressure within an acceptable level. In some patients, responding paramedics may also find a reservoir on the side of the skull, placed beneath the scalp, which collects the excess CSF for laboratory testing purposes.
- #136: It is important for the paramedic to remember that it is impossible to cover all types and makes of medical technology used in the home; therefore, the paramedic should always approach the patient or caregiver and ask the following questions to help determine the best course of action for ongoing assessment and care: •Where would I get the best information regarding this piece of equipment? •What does this device do for the patient? •Can I replicate its function should the device fail? Remember that the most important support is to the airway or ventilation. •Will this equipment have an effect on how I assess the patient, or on the findings I may discover? •Has this problem ever occurred previously, and if so, what fixed it? •Has anyone attempted already to remediate the problem? •Are there specific considerations I need to make when deciding how to best prepare the patient for movement and transport him?
- #137: If the patient has a stoma, use a French catheter to suction it out should it be occluded with mucus or secretions. Discuss when it may be necessary to use a bag-valve-mask device to replace the ventilator. Exercise extreme caution to ensure that you are ventilating at an appropriate rate and depth. If the patient has a stoma, use a pediatric mask attached to the BVM and ventilate over the stoma. If a tracheostomy tube is placed in the stoma hole, attach the BVM directly to this. You may need to seal the mouth and nose should the glottic opening still be patent.
- #138: During the secondary assessment, note any signs of abuse and learn as much as you can about any medical technology on which the patient is reliant. Be careful when preparing the patient for movement to the ambulance, and make allowances for proper handling of the patient’s medical equipment. Typically, your on-scene time with specially challenged patients is longer than for nonchallenged patients because of the additional time needed for assessment and proper packaging for transport.
- #139: During the secondary assessment, note any signs of abuse and learn as much as you can about any medical technology on which the patient is reliant. Be careful when preparing the patient for movement to the ambulance, and make allowances for proper handling of the patient’s medical equipment. Typically, your on-scene time with specially challenged patients is longer than for nonchallenged patients because of the additional time needed for assessment and proper packaging for transport.
- #141: The paramedic should be open to all possibilities at this time. Knowing that the patient has already vomited, additional precautions may need to be taken.
- #142: Discuss the case
- #143: Discuss the case
- #144: Discuss the case
- #145: The shunt may or may not be the cause of the particular problem at this time; however, the paramedic must be empathetic when explaining this to the parent. Given the short time period that has lapsed, the mother may not be familiar with complications associated with possible failure of this type of device.
- #146: It is necessary for the paramedic to treat any life threats. The paramedic should then gather more information and complete a secondary assessment. An intraventricular shunt is placed to alleviate the rising ICP. It originates within a ventricle of the brain and extends to a blood vessel in the neck, heart, or abdomen to drain extra CSF and keep the ICP within an acceptable level. Signs and symptoms should be that associated with an ICP. In addition to the special needs of the patient, the patient is a pediatric patient and will have communication challenges and will require an understanding of developmental milestones and norms.
- #147: It is necessary for the paramedic to treat any life threats. The paramedic should then gather more information and complete a secondary assessment. An intraventricular shunt is placed to alleviate the rising ICP. It originates within a ventricle of the brain and extends to a blood vessel in the neck, heart, or abdomen to drain extra CSF and keep the ICP within an acceptable level. Signs and symptoms should be that associated with an ICP. In addition to the special needs of the patient, the patient is a pediatric patient and will have communication challenges and will require an understanding of developmental milestones and norms.
- #148: Discuss the case progression.
- #149: Discuss the case progression.
- #150: Discuss the case progression.
- #151: Hypoxia and hypercapnia could cause the ICP to rise. An increase in ICP could lead to even more complications and patient deterioration. The bradycardia is an attempt to lower ICP. The emergency care will be aimed at maintaining adequate oxygenation, ventilation, and perfusion.
- #154: Discuss as needed.
- #156: Discuss the objectives.
- #157: Explain that people over the age of 65 constitute the fastest-growing segment of the population, and the largest users of health care, in the United States today. Geriatric patients differ from their younger counterparts in many ways, largely owing to changes in physiology from lifestyle and aging. Discuss how geriatric patients often have one or more coexisting long-term condition(s) that require multiple medications which can affect their respond to medical and traumatic emergencies..
- #158: Review the statistics. Discuss as needed. Explain that by 2030, the number of geriatrics will almost double, to more than 71 million. Explain that the death rate is three times higher for elderly victims of trauma than that for young adults.
- #159: Review how the human body changes with age. As a person ages, cellular, organ, and system functioning changes. The cellular, organ, and system change in physiology is a normal part of aging. Discuss how most elderly patients have a combination of different disease processes in varying stages of development. Unfortunately, the aging body has fewer reserves with which to combat disease, and this ultimately contributes to the incidence of acute medical and traumatic emergencies.
- #160: Discuss the pathophysiology of aging on the cardiovascular system. Explain how calcium is progressively deposited in areas of deterioration, especially around the valves of the heart. Damage to the valves of the heart caused by this degeneration can result in different problems such as stenosis or regurgitation. Discuss how hypertrophy decreases the stroke volume and cardiac output. Explain that the arteries harden and lose their elasticity, which creates greater resistance against which the heart must pump. Discuss how the drop in baroreceptor sensitivity makes it harder to regulate blood pressure under normal circumstances as well as during emergencies.
- #161: Discuss the pathophysiology of aging on the respiratory system. Explain that many of the changes in the aging respiratory system occur as a result of alterations in the respiratory muscles and in the elasticity and recoil of the thorax. Diffusion of oxygen and carbon dioxide across the alveolar membrane decreases progressively as more and more alveolar surfaces degenerate. Chemoreceptors become less sensitive over time which results in a relative inability to detect hypoxia or hypercapnia in the blood and tissues. Airflow in and out of the lungs becomes turbulent, which diminishes air delivery to the terminal alveoli during inspiration and can result in air trapping during exhalation. Discuss how a number of pathologic diseases aggravate this pulmonary decline. Review how the ability of the lungs to inhibit or resist disease and infection diminishes with age.
- #162: Discuss the pathophysiology of aging on the nervous system. Explain that reflexes slow, proprioception falters, sight diminishes, and although hearing loss is not inevitable, the ability to discern higher-frequency sounds may slowly be lost. The brain atrophies, resulting in an increase in the amount of cerebrospinal fluid to occupy the extra space in the skull. Explain that as brain neurons degenerate, waste products can collect in tissues, causing abnormal structures called plaques and tangles to form. Discuss how the ability of the brain to monitor and regulate vital functions such as the rate and depth of breathing, heart rate, blood pressure, and core body temperature can become impaired and not operate with the same efficiency during stressful times as in the younger patient.
- #163: Discuss the pathophysiology of aging on the gastrointestinal system. Explain that structures in the mouth deteriorate. Discuss why the elderly can have chronic heart burn. Explain how the changes in the liver can affect digestion and the ability to metabolize certain drugs. Discuss how slowed peristalsis can contribute to fecal impaction and constipation. The lining of the small intestine degenerates, so nutrients are not as readily absorbed which can contribute to malnutrition.
- #164: Discuss the pathophysiology of aging on the endocrine system. Levels of certain hormones that elevate blood pressure can increase and contribute to hypertension, whereas other hormones that help regulate the body’s fluid balance become deranged and contribute to fluid imbalance. Target organ response to beta adrenergic stimulation in the heart and vascular smooth muscle decreases. Aging produces mild carbohydrate intolerance and a minimal increase in fasting blood glucose levels from a drop in receptor cell responsiveness to insulin. Discuss the role of atrial natriuretic hormone on the regulation of water, sodium, potassium, and fat in the elderly. Aging also decreases the metabolism of thyroxine.
- #165: Discuss the pathophysiology of aging on the musculoskeletal system. Explain how osteoporosis can make the bones more brittle and susceptible to fractures and slows the healing process. Two out of every three elderly patients has kyphosis. Discuss how joints begin to lose their flexibility, and become stiff and weak.
- #166: Discuss the pathophysiology of aging on the renal system. The kidneys become smaller in size and weight because of a loss of the nephrons. Discuss how kidney malfunction or injury typically leads to a secondary disturbance in fluid balance and electrolyte distribution. Explain that it is common for elderly patients to suffer from drug toxicity if they take too much medication or take it too frequently.
- #167: Discuss the pathophysiology of aging on the integumentary system. The skin becomes thinner and is much more prone to injury. Explain why wounds heal more slowly. Less perspiration is produced, and the sense of touch is dulled. Discuss how the loss of subcutaneous fat can increase the incidence of hypothermia in the elderly.
- #168: Review the changes in the body systems of the elderly. Explain that because of the general decline in body systems, the elderly are prone to certain traumatic and medical emergencies that can cause rapid deterioration. Discuss how an understanding of what is occurring physiologically in these emergencies will help the paramedic recognize and provide prompt, appropriate care.
- #169: Review as needed.
- #170: Review as needed.
- #171: Review as needed.
- #172: Review as needed.
- #173: Review as needed.
- #174: Review as needed.
- #175: Review as needed.
- #176: Review as needed.
- #177: Review as needed.
- #178: Manage the geriatric patient carefully. Be alert for acute deterioration. Immobilization needs may also be problematic if warranted. Discuss the challenges of dentures and decreased range of motion on the airway and ventilation. Discuss how the elderly are vulnerable to barotrauma from overly aggressive ventilation.
- #179: Manage the geriatric patient carefully. Be alert for acute deterioration. Immobilization needs may also be problematic if warranted. Discuss the challenges of dentures and decreased range of motion on the airway and ventilation. Discuss how the elderly are vulnerable to barotrauma from overly aggressive ventilation.
- #180: Ongoing assessment should focus on maintaining the airway, breathing, and circulatory components, as well as monitoring the mental status. Discuss how to position the patient. Sitting up if able to maintain own airway. Lateral recumbent with altered mentation. Immobilize if necessary. Use padding. Discuss how normal doses of some medications can be rapidly toxic to the geriatric patient. Explain that in some cases, half doses or longer administration times may be indicated. Follow local protocol. Finally, ensure a rapid transport to an appropriate facility.
- #181: Discuss the case study.
- #182: Discuss the case study.
- #183: Discuss the case study.
- #184: When the patient is unresponsive, the paramedic will have to use other sources to try and gain information about their problems. These include: Talking to neighbors, friends, family. Looking in the fridge for meds. Looking in bathroom or on night stand beside bed for meds. Looking in wallet or purse for listing of medications. For each body system, at least one differential: Nervous—stroke, post seizure. Respiratory—COPD, pulmonary emboli, pulmonary edema. Cardiac—myocardial infarction, dysrhythmia, cardiogenic shock. Endocrine—diabetes, hypertensive crisis, electrolyte disturbance.
- #185: Discuss the case progression.
- #186: Discuss the case progression.
- #187: This patient would be considered unstable. The patient has life threats due to: The change in mental status The partial airway occlusion The evidence of poor peripheral perfusion Care that is warranted immediately includes: Suctioning the airway Positioning the patient Applying high-flow oxygen if the breathing is adequate
- #188: Discuss the case progression.
- #189: Discuss the case progression.
- #190: Discuss the case progression.
- #191: This is a metabolic cause for unresponsiveness (findings of symmetry). The likely underlying cause is diabetes. The patient is hyperglycemic, most likely HHNS. The patient is unresponsive from acidosis and poor perfusion due to fluid loss. The tachycardia and dehydration findings are secondary to the osmotic diuresis that occurred from the elevating glucose levels in the blood stream.
- #192: Discuss the care provided.
- #193: Discuss the care provided.
- #194: Review as appropriate.
- #195: Review as appropriate.
- #197: Discuss the objectives.
- #198: Discuss the objectives.
- #199: This topic will discuss these three views that need to be examined to best care for our most precious resource, our children. Before responding to any pediatric calls, one needs to look into three mirrors: One reflects yourself, your attitudes and beliefs. The second reflects your EMS service's unique abilities and weaknesses (whether from an educational, resource, or equipment standpoint) for handling pediatric patients during an emergency. The third requires looking at your capabilities from a regional prehospital and hospital-based systems perspective.
- #200: The first step in caring for children is to be able to get down to their level, both figuratively and quite literally. First impressions matter more to children because they cannot make the assumptions about you, based on your appearance, that adults can. Discuss the importance of getting to know the child who has an “attitude”. Explain how the critically ill or injured child, for whom you need to intervene right away, will not care about your approach and interventions or will have little energy to spare to fight or disagree with you.
- #201: Review the importance of earning the child’s trust. Be careful not to try to trick the child or lie to him—if you are caught, you will lose his trust. For example, do not tell the child that something will not hurt when it will, do not tell him medicine tastes good when it will not, and do not distract him with a toy and check a finger stick glucose without offering a warning.
- #202: As professionals, it is our first responsibility to the patient and family members to make them feel safe and cared for, and to always communicate with respect. Remember that “difficult parents” are stressed by having a sick or injured child and are having trouble coping. Have compassion. Stress the need to take the time to listen to them and to address their fears and concerns honestly.
- #203: Discuss the art of assessing a child and how it requires a high degree of personal investment, professionalism, expert communication skills, and an understanding of the developmental and physical differences among infants and children of different ages. Review the different developmental stages and vital signs for each age group.
- #204: Discuss how the Pediatric Assessment Triangle has allowed for a more objective and reproducible set of criteria for assessing the ill or injured child than any other system to date. Discuss how the PAT modifies traditional ABCs of airway-breathing-circulation to “appearance-breathing-circulation.”
- #205: Discuss the initial assessment of the pediatric patient from across the room as EMS arrives on scene. Stress that an abnormal appearance is never good and can be caused by shock from inadequate perfusion, hypoglycemia, respiratory distress leading to respiratory failure and hypoxemia, hypercarbia and acidosis, neurologic compromise from a closed head injury, or poisoning. Discuss how quickly the clinical condition of a pediatric patient can change.
- #206: After appearance, focus assessment on the mechanics of breathing to ascertain if the patient is sufficiently ventilating for normal respiration. Explain how the respiratory systems of the infant and child are poorly designed to handle an increased workload and thus are at a unique disadvantage when it comes to the mechanics of breathing when the lungs are sick. Discuss the importance of early recognition and management of pediatric respiratory distress and failure. Intervene as appropriate to ensure good oxygenation. Review and discuss the case study in the text.
- #207: Review how disturbances to the pump, pipes, and fluid can change the quality of perfusion—and review how to assess for these changes. Review the determinants of blood pressure and relate them to the pediatric patient. Stress that the rapid transport and resuscitation of pediatric patients are critical to their outcome. Access may be obtained through IV catheters or intraosseous (IO) insertion. The IO route is used in the critical patient when IV access cannot be obtained or would cause delay in care in the critically ill or injured pediatric patient. Fluid challenges are used in shock and are recommended at 20 mL/kg (10 mL/kg in infants). Follow local protocols for vascular access and fluid challenges.
- #208: Discuss the importance of having the appropriate equipment and tools for various ages and sizes for both medical and traumatic emergencies. Discuss why it is important not to overload a pediatric patient with fluid. Stress the need for education about pediatric patients.
- #209: Discuss the case study.
- #210: Discuss the case study.
- #211: Discuss the case study.
- #212: Discuss the case study.
- #213: Discuss the case study.
- #214: At this time, the patient would be categorized as stable. No life threats at this time. One of the most important things is to help the child to feel better by gaining their trust. Beyond this, some oxygen could be administered and the cervical spine should be manually immobilized.
- #215: Discuss the case progression.
- #216: Discuss the case progression.
- #217: Discuss the case progression.
- #218: Discuss the case progression.
- #219: The child is still stable and improving. He is relating better to the care providers. Patient may have a fracture to the left lower leg. Immobilization, splinting, ice, and elevation. IV administration and medication may be considered based on protocol.
- #220: Discuss the care provided.
- #221: Discuss the care provided.
- #222: Review as appropriate.