Thomas W.P. Slatin

Airway Management
“A Neophytes Guide to Airway Management”

Hinderances To Oxygenation:

• Confined Space Rescue
• Low-Oxygen Enviornment
• Smoke-Filled Room

How To Restore Oxygenation (Step-By-Step):

1. Oxygenate
2. Ventilate via BVM
   • Airway
     • Upper
     • Lower
3. Respiration (Chemical Process)
   • Interfearances
     • Pulminary Edema
     • Carbon Monoxide
4. Circulation
   • Pulminary Embolism (Blood Clot In Lungs)
5. Celluar Respiration
   • Off-Loading of Oxgen
   • On-Loading of Carbon Dioxide
     • Chemical(s):
     • Cyanide (Partially-Burned Plastics)

Simple Diffusion:
(Balance of Gases, Controlled By pH; Carbon Dioxide is responsible for pH levels in the blood.)

Arterial - Off-Load Oxygen
Venous - On-Load Carbon Dioxide

Diffusion is affected by pH and temperature. Extremes of pH and temperature will hinder diffusion and may lead to death.

High CO₂ = High Acidity
Low CO₂ = Low Acidity
Faster and/or Deeper respirations remove excess CO2. Higher acidity makes picking-up oxygen more difficult.  This will eventully lead to hypoxia.

ABG’s - Arterial Blood Gasses

Status Asthmaticus - Severe Asthma; Air goes in, but cannot come out.

Hinderances To Establishing An Airway:

• Confined Space
• Foregn Body Obstruction
• Confined Space
• Crushed Trachea

Secure An Airway Passage:

1. Jaw Thrust
2. Oral Airway
3. Suctioning
4. Intubation
5. Respirations

Primary Objective: AIRWAY

• Major cause of precentable out-of-hospiral death.
• Most often neflected prehospital skill.

Functions of Upper Airway:

• Breathing through nose purifies the air; filtration, humidification, warming to body temperature.
  • Cold can induse asthma.
• Oralpharynx
  • Lips (Upper and Lower)
  • Teeth (32 Usually)
  • Tongue (The Single Biggest Obstruction To Your Success At Intubation)
    • Muscle
    • Attached To Ligaments
    • Oral Airways ONLY Keep The Tongue Out Of The Way
• Glottis
  • MRI studies have shown that this tissue blocks the airway more often than the tongue.
    • Vallecula is located behind the eppiglottis. It closes the eppiglottis when food or liquid is swallowed.
  • Hard Pallete
  • Soft Pallete
  • Uvula
  • Pharynx
  • Tonsil
  • False Cords

Blade Measurement:

• Straight Blade
  • Measure blade from Adam’s Apple to lips.
  • A blade too large can cause tissue injury and/or a false passage.
  • Using the wrong size blade is your responsibility if harm is done.
• Curved Blade
  • Measure from just above the Adam’s Apple to the lips.
• CPAP - Constant Positive Airway Pressure
  • Used to treat sleep apnea.
  • Instills air into lungs

Larynx:

• Thyroid Cartilage
• Glottic Opening
• Arytenoid Cartilage

ONCE YOU SEE THE GLOTTIC OPENING, YOU NEVER TAKE YOUR EYES OFF OF IT!

The “Gold Standard” of intubation is observing the tube passing through the vocal cords.

Lower Airway:

• Cricoid Ring
• Cricoid Ring

15% of drownings are “Dry Drownings” due to the fact that the vocal cords contract and may stay closed for a long duration of time.

Passive regurgitation requires 20 pounds of pressure on the cricoid membrane.

Anatomy of the Lower Airway

Located at about the 4th cervical vertibre, and is responsible for actual respiration (chemical).

Carina - The bifercation of the airway responsible for the division of the trachea into two seporate lungs.

The trachea is lined with cells that produce mucus.  Cilia grows on the lining of the trachea and elevates the mucus.  Smoking (Carbon Monoxide) may parylize the cilia; smokers are at an increased risk of bronchitis.

Autonomic Nervous System

Sympathetic

Parasympatheti c

Fight or Flight

• Dialatio n
• Epineffe rine Release

Feed and Breed

• Constriction
• Acetycholine Release

Beta 1:
Heart (”One Heart”)
Beta 2:
Lungs (”Two Lungs”)

Pediatric Airways

Balloon Cuffs are NOT used in Pediatric Intubations.

• Pharynx
  • Tongue is Proportinally Larger
• Trachea
  • Smaller
  • Crichoid Ring is the Smallest Part of the Airway
  • Funnell Shaped
  • To About Age 10 (Based On Physical Development)
• Chest Wall
  • Very Soft (Easy To Collapse)
    • Sternal Collapse
    • Resistance To Fracture

ANY PEDIATRIC FRACTURE INDICATES AN EXCESSIVE AMOUNT OF FORCE INVOLVED TO CAUSE THE FRACTURE.

Lung / Respiratory Volumes:

• Total Lung Volume - 1:1 Ratio
  • (Blood Liters) = (Air Liters)
  • (10-15 CC) / (KG)
• Tidal Volume - Top 1/3 Of Lungs
  • Approximately 500 CC
• Dead Air Space - 150 to 250 CC
• Anatomic Dead Space - Trachea, Lyrnx; Tubes where gas exchange does not occur.
• Physioloc Dead Space - Area of lungs where air sits.

Minute Volume:

• Tidal Volume - (Dead Air Space Volume) * (Respiratory Rate)
• Functional Reserve Capacity - How much you could possibly breathe in and then breath out.
  • Asthma - Low Functional Reserve Capacities
• Residual Volume - What is left behind in lungs.

The primary drive to breath is based on blood acidosis.  It is sensed in the aortic arch and corittod arteries.

Primary Drive - pH; Brain — Secondary Drive - Hypoxia; Brainstem

COPD Patients have high levels of Carbon Dioxide; these patients rely on hypoxic sensors to regulate respirations.  Never withold supplemental oxygen.

Inhallation - Active — Exhallation - Passive

COPD or Asthmatic patients may sometimes use active exhallation intentionally to exhale air from their lungs.

97% to 98% of hemoglobin is bound together.  As age increases, the bound hemoglobin may decrease to about 95%.

For every decade of life past 40 years of age, 10% of lung capacity is lost.

Respiratory Rate - The Number of Times You Breathe In One Minute

In times gone by, patients were placed into an iron lung machine to facilitate breathing.  Today, a pacemaker-sized machine stimulates breathing.

Common Obstructions:

• FBAO (Foregn Body Airway Obstruction)
• Laryngospasm
• Fractured Larynx

Snoring Respirations indicate a partially-obstructed airway. Treatment is a jaw-thrust, which opens the airway.

Foregn Body Airway Obstructions may also be large objects stuck in the esophogus which directly puts pressure on the back of the trachea.

IM Injection of Glucogon will relax the esophogus and thus will stop the spasm in the esophogus.  Ultimately the object will be “let go” by the esophogus and will pass by.

Liquids are aspirated more than solids.  This is due to the fact that the opening to the trachea occurs at about a 90 degree angle.  Therefore, nursing homes increase the risk of aspiration in their patients by serving liquified foods.

When the lyrnx goes into spasm, they may be difficult to open. Some stimulation may cause them to open. At last resort, the intubation tube may be forced through the cords. This in itself carries a high risk of irreversable complications.

Rule of thumb… It is better to assist breathing while they are still breathing and sitting up than to wait until they stop breathing and lie down to begin providing assistance.

Abnormal Respritory Patterns:

• Cheyenne-Stokes
• Kussmall’s
• Biots
• Central Neurogenic Hyperventilation
• Agonal

Increasing periods of apnea indicate that breathing is getting worse.

Oxygenation is supplemental; ventillation is more urgent than oxygenation.

An EMT should NOT wait to see cyanosis to begin oxygen administration.  Cyanosis may be a late sign.

Any patient that shows signs of altered mental status is automatically assumed to be hypoxic until proven otherwise.  It can be treated easilly, and supplemental oxygenation can do no harm.

Pulse Oxymeters MUST be calibrated at least anually and prior to being put into service.

Common O₂ Tank Equations:

(PSI) * (0.28) = Volume
(Volume) / (LPM) = Duration in Minutes

Rule of 6’s: Never run a nasal cannula greater than 6 LPM, Never run a NRB Mask below 6 LPM.

Humidification with oxygen requires large-bore tubing. Typically 15 MM diamater is sufficient.

The Ease of Ventillation is called compliance. Harder ventillation may indicate a lost or compromised airway.

Posted under Everything Else

Pre-Hospital Radio Reports

Medical Control:

• Online
  • Talk to Doctor
• Offline
  • Protocols

Types Of Radio:

• AM - Amplitude Modulated
  • First Radio
  • Long-Distance Radio
  • Line-Of-Sight
• FM - Frequency Modulated
• SW - Short Wave
• VHF - Very High Frequency
  • Low Band
    • 46 Series
    • 86 Series
  • High Band
    • 155 Series
• UHF - Ultra High Frequency
  • Reflects Off Objects
  • Used In Urban Settings
  • 800 MHz
  • 900 MHz
  • Trunking
    • “Frequency Sharing”
    • Computer Program For Re-Transmitting; Records signal and waits for an open channel.
    • Allows for multi-priority communication deligation and message routing.
    • Computer-Guided Communications, Typically used with UHF.
• Apcor
• Celluar
  • Privacy
    • Anybody with an 800 or 900 MHz enabled scanner can hear conversations and celluar phone calls.
• Sattellite Phones
  • Anywhere on Earth.
  • No blind spots.
• Repeater Stations
  • Re-Transmitter Station(s)
  • Used By
    • New York State Police
    • Rural-Metro Medical Services
• Simplex
  • One-Way-At-A-Time
    • “Over…”
• Duplex
  • Both Parties Can Speak At The Same Time
  • Example: Cell Phones (Radio Telephone)
    • 90/90 Rule - 90% Reliable over 90% of the Time.
    • Limited number of calls per celluar tower.
    • Land Line(s)
• Multiplex
  • Both Parties Can Speak At The Same Time
  • Includes An Extra Data Line (Digital)
• Redundancy
  • Back-Up Plan of Communications
    • EMS Radio
    • Fire Radio
    • Alternative Communication Device
• Analog
  • Waves
  • No Security
• Digital
  • Series of “On” or “Off”
  • Sends a series of packets.
  • Requires a Digital reciever.
  • High-Level Encryption Available

Types of Radio Communications in EMS:

• Consultation
  • “Requesting A Consultation…”
    • This lets the MD know that there is an extended transmission.
  • Do NOT Call For Standing Orders
  • Expended protocol options.
    • “Physician Option”
• Medical Control Request
  • Immediate need to speak with MD.
  • Short, Brief, To-The-Point
  • No Greater Than 30 Seconds
• Notification
  • Notify Hospital of What You’re Enroute With
  • Just a Notification of transport.
• On-Scene Report
  • General Description of Problem
    • Vehicle Hit A Tree
    • Structural Collapse
    • Hazards
      • HAZ-MAT
      • Power Lines
      • Fire
  • Request For Assistance (If Needed)
    • Request Fire Department
    • Request Police Department
  • Staging Area (If You Have One)
    • Keep Staging Area Seporate From Command Post
  • Transmit a More Precise Location
  • Establish Yourself as “EMS Command”
    • Example: “Rescue 557 Establishing EMS Command.”
• Second Critical Incident Report
  • Age
  • Sex
  • Weight
    • Trauma (If Trauma Involved)
    • Mechanism of Injury
    • Pertinant History
    • Procedures
    • Estimated Time of Arrival (ETA)
    • Request For Orders (Very Concise!)

General Radio Procedures:

• Hailing
• Introduction
• Problem Statement

Principles of Radio Communications:

• 10 Codes
• Used To
  • Shorten time or Legnth of Radio Transmission
  • Get the Message Across
• Problems
  • May Be Misunderstood
  • May Be Intercepted By Public
• Solutions
  • Plain English
    • KISS - (Keep It Simple, Stupid)

ECHO Technique:

1. Physician Gives You Order(s)
2. Paramedic Repeats The Order(s) to MD
3. Physician Confirms The Order(s)
4. Write Down The Order(s).

Pearls of Wisdom:

• Time
• Phone Talk
  • Doctor’s Time Is Valuable
  • Be To-The-Point
  • This Is NOT A Social Call
• Protocols

Posted under Everything Else

Cardio-Thoracic Physical Examination

Inspection of the Thorax:

Things to look for:

• Tripoding
• “Bobbing”
  • Open-Mouth Breathing
• Posture
• Contour
• Motion and Expansion
• Only 1 in 12 patients with chest pain are indeed cardiac-related.
• 2 Kinds of Pain
  • Visceral Pain
    • Dull, like a stomach ache. A pressure.
    • Spontanous pneumothorax.
  • Sematic Pain
    • Sharp, like a skin surface cut.  Or the pain resulting from a fractured rib.

Fixing of Clavicles:

• Self-Splinting
  • Holding arms in a cross-armed fashon.
  • Guarding.

Shapes of Chests:

• 2 Diamaters
  • Anterior
  • Posterior
• Twice as wide as it is deep.
  • AP Diamater
  • Pexis Evacatum (Pigeon Chest); Sternum is Depressed.
  • Dowinger’s Hump
  • Scoliosis (Curviture of the Spine)
    • Steel rods are used to keep the spine straight and upright in extreme cases.
    • May cause a decrease in lung volume.
    • Lordosis (An extreme curviture in the lower back.)

GSW (Gun Shot Wound):

• Check for exit wound.
• Occlusive Dressing
  • Tape Glove On Wounds
    • Commercially-Available Occlusive Dressings Are Generally Ineffective.
      • C-Spine Precautions, if shot in axial skeleton area.
  • Protect Airway
    • O2 Mask, Consider BVM
    • Consider Intubation
    • Pneumothrorax Is Possible
  • Fluid Replacement (IV)
  • IV is to be done enroute to hospital, NOT on scene.
  • If female, DO NOT cut the bra.
    • Bras may be used to hold dressings.
    • Elastic is useful!

You can’t assess what you can’t see.

PMI - Point of Maximum Intensity

Cardiac Heaves:

• Dime Sized
• Quarter Sized
• Half-Dollar Sized

Types of Breathing:

• Eupnea - Normal Breathing
• Hypernea - Deep Breathing
• Tachpnea - Fast Breathing
• Apnea - No Breathing

Oscultation of Chest:

• Throat (As Applicable)
  • Croup
  • Burns
  • Allergic Reaction
  • Gaseous Inhallation
• Rule of Thumb: When you can hear it without a stethescope, it’s too late!
• Bronchi
  • Broncial Sounds
    • Mid-Clivicular Line, Second Intercostal Space
    • Over The Bronchi
• Sternal Border
  • 5th Intercostal Space
  • The Bronchioles
  • The Avoeilli
    • Crackling (Pneumonia)
    • Posterior Side - Bottom of Scapula (Shoulder Blade)
      • Move stethescope up scapula 1 inch at a time, and document when you stop hearing crackles. Doctors order Lasix based on these observations.
• Sides
  • Midaxillary Line, 5th Intercostal Space
    • Crackles (Railes)
      • Loud
      • Soft

HAPE - High Altitude Pulminary Edema

4 Levels of Pulminary Edema:

• Diminished
• Wheezing
• Crackles
• Absence

Palpation of Chest:

• Fractures
  • Clavicles
    • Fractured Clavicle can result in a pneumothroax.
  • Sternum
    • Closed Fist
  • Sides of Ribs
• Symmetry of Breathing
• Asemectrical Breathing
  • Ruptured Diaphragm
  • Spinal Injury
  • Frozen Diaphragm
  • Stroke
  • Traumatic Rupture
  • Bowel Sounds in the Chest is a bad sign.
• Cardiac Region
• JVD - Jugular Vein Distention
  • Angle of Jaw to Mid-Clavicular Line
    • IV Access

Abnormalities:

• Stridor
• Crackles; Early Inspirtory, and Late Inspiratory.
  • Short, Non-Musical Explosions
    • Soft Crackles (Rales)
    • Loud Crackles (Ronchi)
• Wheezes
• Rubs
• Fluids

Normal:

• Inspiration Short
• Expiration Long

Website Of Interest:
www.vh.org - Virtual Hospital

Abdominal Examination:

• Look
• Listen
• Feel

Abdominal Cavity:

• Starts Below Diaphragm
  • 5th Intercostal Space
• Organs
  • Liver
  • Spleen
  • Kidneys
  • Pancreas
  • Stomach
  • Gall Bladder
  • Intestines
  • Esophogus

Quadrants:

• 4 - Quadrant (EMS)
• 9 - Quadrant (Medical)
  • Umbilicus
  • Epigastric and Hypogastric
  • Right and Left Hypochondriac
  • Right and Left Lumbar
  • Right and Left Iliac

Look:

• Abdominal Distention
  • Bloated Abdomen
    • 50% of blood volume is trapped.
• Ascites
• Discoloration
  • Grey-Turner’s Sign
    • Retnal-Perinetal Bleeding (Brusing)
  • Cullen’s Sign
    • Bruising Around The Embilicus

Listen:

• Borborygmi
  • Stomach Rumbling
• Tinkling
• Bruit
  • Rushing Sound; “Running Faucet”

Medical Terms For Examining:

• Inspection
• Oscultation
• Palpation
  • Deep Palpation
  • Bimanual Palpation
  • Percussion
    • Blunt Percussion
    • Taps

Neurological Exam:

• LOC
  • Concious
  • Unconcious
    • Minimum 30 seconds of sustained pain to prove true unconciousness.
  • Unresponsive
    • Hypothermia
    • Barbituate Coma
    • Narcotic Overdose

Gross Cranial Exam:

• Smell (Cranial Nerve I)
• Pupillary Check (Cranial Nerves II-III)
  • Equality
  • Unequal
    • (20% of the population; within 2 mm)
  • Reactivity
    • Brisk (Normal)
    • Sluggish (Abnormal)
      • Head Injury
      • Hypoxia
  • Size
  • Accommodation
  • Consensual Reaction
• Visual Fields (Cranial Nerves III, IV, VI)
  • Cardinal Gazes
    • “Star of Life” visual field pattern test
    • Extra-Ocular Movement (EOM)
    • Head Trauma
    • Nystagmus
    • Rotary (Inner-Ear Disturbance)
      • ETOH
      • Cocaine
• Depth Perception
• Binocular Vision
• Peripheal Vision

Speech:

• Thick, Slurred
  • Loss of hearing
  • Stroke

Pronator Drift - Outstretched arm will drift on the stroke side.

Gait Testing:

• Heel-To-Shin
• Heel-To-Toe

Posted under Everything Else

Advanced Patient Assessment for Paramedics

Upon Arrival On Scene:

1. Scene Size-Up  (Medical or Trauma, Mechanism of Injury, # of patients.
2. Safety (Hazards, Hazardous Material, Potential Hazards, Fire, etc.)
3. Priority (Yourself, Your Partner, The Public, The Patient)
4. Situation - First In Report (Request Additional Aid, Lighting, Traffic Control, Etc.)

Initial Assesment - To assess and treat life threatening injuries.

LOC: Alert & Oriented, Verbal, Responds To Pain, Unresponsive

Pain Responses:

• Smart Response - Push Stimilus Away
• Withdraw - Move Away From Stimilus
• Posturing - Decorticate, Decebrite, Flaccid

Types Of Assessment:

• Comprehensive Assessment
• Focused or “Vectored” Assessment
• On-Going Assessment

Chest Pain Mneumonics:

• Onset
• Provocation
• Quality
• Radiation / Relief / Reoccurance
• Severity (0 to 10)
• Time of Onset

HPI - History of Present Illness

Data Collection:

• Subjective (History) - What is said!
• Objective (Medic) - What is seen, heard, felt.

All of the patient’s symptoms are considered subjective.

Facilitation:
“To help along.”

• Ask open-ended questions.
• Eye-Contact.
• Take Notes
• Contact if appropriate.
• Soft tone speech in a manner in which they can understand.

Techniques To Gather Information

• Reflection: (Stating the patients’ words back to them.)
  Example:
  Patient: “I’m having chest pain.”
  Medic: “Does your chest hurt?”
• Clarification:
  Example:
  Patient: “I’m having chest pain.”
  Medic: “What does the pain feel like?”
• Empathy:
  Example:
  Patient: “I’m having chest pain.”
  Medic: “This must hurt, how and where does it hurt?”
• Conferentation (Use Cautiously!):
  Example:
  Patient: “I don’t know why my wife called. I don’t want to go to the hospital.”
  Medic: “You’re rubbing your chest. Are you having a problem?”
  • Psychology Behind This Behavior:
    Father is convinced that he has to stay home and take care of the family. They are usually worried about losing control of the family leadership role.
  • Resolution(s):
    • Get wife on your side.
    • Get the eldest / most capable son to take care of family.

Consider that the patient may be lying to you. Consider that your patient might really be looking for a trip to the hospital for reasons other than medical.  For example, a trip to the hospital will likely include: shelter, a warm bed, a warm meal, attention, etc.

• Interpretation: (Very Helpful Technique!)
  Restating the patient’s own words, but with your words.
  Example:
  Patient: “I’m having chest pain, back pain, my leg hurts, etc..”
  Medic: “I understand you have had chest pain since yesterday, your leg hurts, and you are having back pain.  What is bothering you the most?”
  • Identify the main reason why you are there.  Consider the fact that your patient may be in denial.
  • Ask the pertinant question:
    “Do you think you may be having a heart attack?”
  • If the patient admits that they are in fact experiencing a heart attack, encourage them to seek transport and treatment. Reassurance and letting them know what your plan of care is key.

Data Orginization:

• Body Systems Model (Medical Model)
• EMS Model:
  • Initial Assessment
  • Focused Assessment
  • Comprehensive Assessment

Tools Of The Trade:

• Stethoscope
  • Chacteristics of a Quality Stethoscope:
    • Earpiece must me turned forward.
    • Earpieces must have good tension.
    • Variety of earpieces.
      • (If you can leave it in your ear for 30+ minutes, you have the right ones.)
    • Legnth Matters (18 Inches Maximum!)
    • 2 Tubes are better than 1.
    • Earpiece should have a bell and a diaphragm.
      • Diaphragm - High Pitched Sounds, Bell - Low Pitched Sounds
    • Weight to the head.  It must be heavy enough to sit on your patient by itself without moving.
• Sphygmomanometer
  • Correct Use:
    • Use center of the bladder over the artery. Do not trust the arrows on the cuff.
    • Select the correct size. The bladder must be greater than 1/2 but no more than 2/3 the circumference of the arm.
    • Velcro must be covered by 70% or more.
  • Only use a Sphygmomanometer with a Pinless Gauge.
• Ophthalmoscope
• Tongue Blades
• Thermometer
• Penlight
• Reflex Hammer

Thermometer:

• Types of Thermometers
  • Rectal - For hypothermic patients. Ordinary thermometers do not go deep enough.
    • Color: Red
  • Oral - For general use.
    • Color: Blue

TPRBP:

• Temperature
• Pulse
• Respirations
• Blood Pressure

Patient Positioning:

• Seated - High Fowlers
  • Fowlers (45 degrees)
  • High Fowlers (90 degrees)
• Supine (Face Up)
• Sims / Coma
  (a.k.a. Recovery Position)
• Knee-Chest
• Modified Lithotomy
  (OB-GYN Position, Back Upright @ 45 Degrees)

Draping And Dignity:

• Unconcious = Trauma Naked
• Draped In Public = Preserve Dignity
• Expose only as necessary.
• Hospital Gowns are Helpful!

General Survey:

• Appearance
  • ETOH Use / Consumption
  • Depression
  • Drugs
  • Altered Mental State
  • Homeless
  • Psych Patient
• Level of Consciousness (LOC)
• Facial Expression
• Signs of Distress
  • Degree of Distress
    • Acute Distress:
      • Facial Expressions
      • Agitation
      • State of Panic
      • Sweating
      • Dialated Pupils
      • Pale Skin
      • Cool & Clammy Skin
      • Tremors
      • Guarding
      • Open-Mouth Breathing
    • NAD - No Apparent Distress

Patients with severe pain usually become introverted and withdraw from social contact.

Toxic (Septic):

• Pale
• Sweaty
• Weak
• Lack-Luster Eyes

Vital Statistics:

• Height
• Weight (Everything is Weight-Related)

General Impression:

• Posture, Gait, and Motor Activity
• Dress and Grooming
• Odors and Breath and Body
  • Halitosis
  • Bad Breath
  • Bowel Obstruction
  • Gum Infection
  • Uremic Frost
  • Alcoholic Beverages

ADL - Activities of Daily Living

Red Flags (Enviornmental):

• No food in refrigerator.
• No running water.
• No heat.
• Life-Threatening Enviornment

Melana - Smell of blood in feces.

Vital Signs:

• Pulse
  • 30 seconds, 60 seconds if irregular.
• Respiration
• Blood Pressure
• Orthostatic Blood Pressure
• Temperature

Rule of Respirations:

• Too Fast
• Too Slow
• Just Right

Patters of Respirations:

• Deep & Rapid (Kussmauls)
• Waxing & Waning (Cheyne-Stokes)
• Central Neurogenic Hyperventilation
• Biot Breathing (Periods of Apnea)
• Agonal Breathing (Death Rattle)

Orthostatic Vital Signs:

• Supine / Prone
• Sitting
• Standing

20/20 Rule:  If pulse increases by 20 or systolic BP decreases by 20, administer an IV.  The patient has lost about 1 Liter of blood volume.

Bringing Something Extra:

• Pulse Oxymetry
  • May be used for pulse measurement.
  • Below 90% may be a sign of hypoxia.
• Cardiac Monitoring
  • May not be used for pulse measurement. Measures electrical activity, not pulse.
• Blood Glucose

Focused Examination:

• Head
  • Scalp
  • Mastoid Process
  • TMJ
  • Facial Bones
• Ears (Acoustic Nerve - CN VIII)
  • Hearing
  • Cerumen
  • Inspection (Inner Canal, Light Reflex)
• Eyes
  • Pupillary Response (Reactivity)
  • Visual Acuity (Snellen Chart)
• Nose and Sinuses
  • Inspection
  • Nares (Obstruction)
  • Palpation (Frontal Sinus, Maxillary Sinus, Nasal Bones)
• Throat - “The Paramedics Playground”
  • Oropharynx (Lips, Buccal Mucosa, Lingula, Uvula, Tonsils, Teeth, Tongue)

Posted under Everything Else

Life Span Development — �From cradle to grave: A look at human development across a lifetime.�

What is development?

Physical / Mental:

• Reasoning
• Spatial Relationships
• Psyco-Social

Developmental Diversity - �Different People�

Nature vs. Nurture:

Heritatory or Environment? Some believe that a persons� personality is shaped by genetics (nature), by their environment (nurture), or by a combination of both.Psychologists That Believed In Genetics:
• Kant
• Rousseau
• Galton
• Piaget
• Freud
  • Developed the theory of Oral, Anal, and Genital developmental stages.
  • Developed the theory of the Ego, Superego, and the Id.
  • Theorized that there were three levels of consciousness; Conscious, Precocious, and Unconscious.
  • Experimented with cocaine, psychedelics, etc.
• ChomskyPsychologists That Believed In Environment:
• Locke
• J. S. Mill
• Pavlov
  • Most known for his dog and bell experiments.
• Watson
• Skinner

Erikson�s Theory Of Developmental Stages by Age:

Developmental StageAge (Years)

Trust vs. Mistrust

Birth to 1

Autonomy vs. Shame

1 to 3

Initiate vs. Guilt

3 to 6

Industry vs. Inferiority

6 to 12

Identity vs. Role Confusion

12 to 19

Intimacy vs. Isolation

19 to 25

Generatively vs. Stagnation

25 to 50

Ego Integrity vs. Despair

50 to Death

Dominant-Recessive Relationships:

Affected Parent

Norm al Fathe r

D

R

R

DR
25%

RR
25%

R

DR
25%

RR
25%

Inheritance of a Dominant Gene Disorder

Human Genome Project (…)

Life�s Beginnings:

End of 2nd trimester:  Quickening; feeling the child move. Baby is viable at this point in development, though still small.

Risk Factors:

• Genetic Abnormalities
• Teratogen Exposure (ETOH, Drugs, Alcohol, Etc.)
• Maternal Age (Over 40 years, or Under 18 years)
  40+ Years = Higher risk of Downs Syndrome
  18- Years = Small pelvic opening; risk of child becoming stuck in birth canal.
• Maternal Malnutrition
• Low SES
• Lack of prenatal care
• Disease (Aids, Rubella, Taxoplosmosis, Etc.)

70% of pregnant women are battered.  Complications may be fatal to both mother and child.  Look for signs & symptoms of abuse and battery.

Childbirth, By Stages:

1. �Water Breaks�
2. Presentation
3. Placental Delivery

The Infant Years:

APGAR - Appearance, Pulse, Grimace, Activity, Respiration;
Document all APGAR scores in patient chart when dealing with a newborn child.

Reflexes:

• Survival
  • Breathing
  • Sucking
  • Eyeblink
  • Rooting
  • Swallowing
  • Pupillary
• Primitive - Vestiges of reflexes at earlier stages of Human evolution.
  • Moro
  • Tonic Neck
  • Stepping
  • Grasping
  • Babinski
  • Swimming

Language Milestones:

• Phonology
• Lexicon
• Semantics
• Pragmatics
• Syntax

By 16 to 18 months, a child will usually know approximately 200+ words.

Kohlberg�s Levels Of Moral Judgement:

1. Preconventional
2. Conventional
3. Post-Conventional

Menopause:

• End of childbearing years
• Osteroperosis
• Increased risk of death from M.I. (Heart Attack)
• Most women typically live 30 years past menopause.
• Women will show different signs of M.I. onset.
• HRT (Hormone Replacement Therapy)
  • Increased risk of breast cancer.

Intelligence:

• Fluid
  • Facts
  • Figures
  • Etc.
• Crystallized
  • Life Experiences

Today:

• The oldest world society that has ever existed.
• Life expectancy is at an all time high, and keeps increasing.

Theories of Aging:

• Wear & Tear
• Celluar Theories
• Programming Theories

Stages In Lifespan Development

Stage

Age Period

Cognitiv e Stage (Piaget)

Psychosocial Crisis (Erikson)

Moral Stage (Kohlberg)

Prenatal

Conception to Birth

None

None

None

Infancy

Birth to About 18 Months

Sensorimot or

Trust vs. Mistrust

Premoral (Stage 0)

Early Childhood

18 Months to 6 Years

Preoperational

Autonomy vs. Shame & Doubt

Obedience vs. Punishment (Stage 1)

Initiative vs. Guilt

Reward (Stage 2)

Late Childhood

6 to 13 Years

Concrete Operational

Industry vs. Inferiority

Good Child (Stage 3)

Adolescence

13 to 20 Years

Formal Operational

Identity vs. Role Confusion

Law & Order (Stage 4)

Young Adulthood

20 to 45 Years

Intmacy vs. Isolation

Social Contract (Stage 5)

Middle Age

45 to 65 Years

Generativity vs. Stagnation

Principles (Stage 6)

Old Age

65 Years to Death

Integrity vs. Despair

Posted under Everything Else

Paramedics do in fact make diagnosesses. Even if the outcome is stating that the patient has shortness of breath, this in itself is a diagnoses. These can be found in the “Table Of Contents” in the book of EMT protocols.

• 90% of a medical patient’s diagnosis is based on medical history.
• 90% of a trauma patient’s diagnosis is based on the mechanism of injury.

Interviewing Techniques:

• Eye contact is important.
  • Get to the patient’s level, but never sit or bear weight on one knee.
  • Proper introductions go a long way.
• Remember your “space”.
  • Public Space: 4-6 Feet (Arm’s Length Away)
  • Personal Space: Less than 4 Feet
  • Private Space: Up Close
• Sickness increases space limits x 2.
• Approach face-to-face.
• Talk to somebody in terms that they can understand.  “Normal Language”, not all medical terms.

Fact Gathering (”Just the facts, Maam.”):

• Open Questions

Chief Complaint:
What the patient tells you is wrong, in their own words. Sometimes what they complain about is false, but you should treat the things they tell you is the problem.

However, don’t take everything they tell you as being factual. By giving you a chief complaint, this gives you the legal right to give treatment.

HPI - History of Present Illness

PAIN - OPQRST

• Onset (When did it start?)
• Provocation (What makes it worse?)
• Quality (How does it feel? i.e. Dull, Sharp, Achy, Pressure, etc.)
• Radiation (Where does the pain travel?)
• Reoccurrence (Does it come and go, stay, etc.? Have you had this pain before, if so, when and what happened? What was it from?)
• Relief (What stops the pain? Medication?  Change of position? Consider OTC’s — Over-The-Counter Medications)
• Severity (On a scale of 0 to 10; 10 being the worst pain they’ve had in their life, 0 is no pain at all.  Establish an individualized scale for the patient.)

4 Pertinent Negatives:
If any of those are (+), it is ALS-Worthy. They Are:

• LOC (Loss Of Consciousness)
• Cx Pn (Chest Pain)
• SOB (Shortness Of Breath)
• Abd Pn (Abdominal Pain)

This may not indicate an ALS call, but the Paramedic should do an ALS work-up. Make sure you document all of these negatives on your patient report.

AMPLE:

• Allergies (To medications…  Aspirin?  Lidocaine?  Novocain? Morphine?  Sulfur Drugs? Etc…)
  NKDA = No Known Drug Allergies
• Medications (Document the Name of the drug, Dose, and Frequency.)
• Past Medical History (Ask everything that is written on the Past Medical History of a PCR… Stroke? Cancer?  Hypertension? Seizure? Hypertension?  Asthma? Etc…)
• Last… (Whatever… Meal, Bowel Movement, Menstrual Cycle, Medication Dose, Etc.)
• Events Preceding (What happened previous to EMS arrival?)

Smoking is based on pack-year calculation: (Packs) * (Years) = Pack Years

Example: 1/2 Pack for 40 Years = 20 Pack Years; Any patient with 20+ years of smoking will have a higher chance of emphysema.

AEIU TIPS:

• Alcohol (ETOH Intake, # of Drinks, Hx of Alcoholism, Last drink, etc.)
• Epilepsy (Epilepsy is a medical diagnosis given to you. A first time convulsion may be a sign of a brain tumor.)
• Infection (Meningitis? Does your head hurt? Bright lights hurt your eyes? Does your neck hurt?)
• Overdose (Toxicology)
• Uremia (Kidney Failure)
• Trauma (Occult Trauma; Consider slow subdural hematoma.)
• Insulin (Diabetic, Insulin Dependent)
• Psychosis (Psych Patient? Last trip to the hospital? Hypertensive crisis?)
• Stroke (Hx of stroke? First stroke?  Residual weakness?  Onset? New signs & symptoms?)

Assessment Mnemonics:
Memory aids designed to improve History-Taking and patient assessment.

AVPU:

• Alert
• Verbal
• Pain
• Unresponsive

Compartment Syndrome:

• Pulselessness
• Painless
• Pallor
• Paralysis
• Paristethia

Posted under Everything Else

Assessment is an “art” involving:

• Listening Skills
• Observation Skills
• Thinking Skills

Intuition is the subconcious comparison to things in the past. This is one of the best signs of a good medic.  It is an actual ability to connect a present event with a past experience.

Sometimes what you remember best is what you did wrong.  This is the reason that hands-on labs are very important.

Global Assessments can only be learned through lab experiences.  It is a subconcious process due to the vast amount of information.

Safety (In Order Of Importance):

1. YOUR Safety
2. Safety of your co-workers
3. Safety of the public
4. Safety of the patient

The Paramedic has no duty to knowingly enter into an unsafe situation. Their duty is to call for help to respond to the scene to ensure that the scene is safe.

Police Officers Can (Amoung Other Things):

• Establish scene safety
• Traffic Control
• Establish a police presence
• Authority to use force
• Call for additional resources
• Witness to scene events

Firefighters Can Assist With (Amoung Other Things):

• Fire suppression
• Rescue tools
• Lighting
• Forcible entry situations
• Confined space

Patient Assessment:
An orderly and sequencial exam with correction of life threatening injuries.

3 Levels Of Extrication:

• Short Board, C-Spine
• Rapid Extrication (Technique)
• Emergency Move

Mechanism of injury is key idication for treatment of spinal injury, regardless of physical exam.

(A & O) x 3 = Alert & Oriented to: Person, Place, and Time

A person is only unresponsive if they do not respond after 30 seconds of sustained pain. Their response, if there is one, is also important.

Typical Responses:

• Push Away
• Move Away
• Decorticate Posturing
• Deceribrate Posturing

PRN = As Needed

Airway & Spine:

• Breathing & Pulse “Quick Check”
• Secure an open airway without compromising the spine.
• Stabilize the head manually.
• Position & suction PRN.
• Insert an airway PRN.

Open, Assess, Suction, and Secure.

The most common obstruction in an airway is the glottis pressing against the pallete. Therefore, OPA’s do not keep the airway open.

The only way to keep an airway open is to use the head-tilt chin lift, or the jaw thrust. Ultimately, intubation will overcome these problems.

Ventillation: 12 to 24 per min.  However, the decision to ventillate is ultimately a medical one.

Posted under Everything Else

“To know your enemy is to beat your enemy.”  The way to win is to think the same way your enemy does.  You need to know what your enemy is thinking and what they are going to do next.

List of things that other cultures dislike about the United States:

1. Freedom of religion.
2. Fear of losing their own culture due to American influence(s).
3. The American society embraces other cultures, but we do not practice other cultures.
4. Political differences and cultural differences.

This attitude is not isolated to one culture.  This attitude has been responsible for wars in the past towards many different cultures.

We are 10% of the world’s population, but we consume about 75% of the world’s resources.

Terrorism - a criminal act performed to further a belief or political gain.

Domestic Terrorism:
Timothy McVeigh - Oaklahoma City Bomber. McVeigh bombed the Oaklahoma City Building on the annivarsary of WACO.

Colombine School Shootings:
Criminal act to prove a point. Their agenda was to be accepted into school society.  Terrorism?  Possible.

WACO Texas:
US Government accused leader of stachitory rape. US Government burned down the compound with followers trapped inside.

1/2 of the state of Montana is owned by the US government. Citizens living in Montana are generally anti-government.

18th Century:
Bio terrorism was used via throwing corpses over castle walls of people who died from the Bubonic Plague.

Terrorism - A violent act or an act dangerous to human life, in violation of the criminal laws of the United States or any segment to intimidate or coerce a government, the civilian population or any segment thereof, in furtherance of political or social objectives.
(U.S. Department of Justice).

Where does EMS fit into the war on terrorism?

• Arson
• B-NICE Terrorism Incidents
• Enviornmental Crime
• Industrial Sabotage
• Bombings
• Weapons Of Mass Destruction (WMD)

Recognising Suspicious Circumstances:

• Occupancy or location
• Type of event
• Timing of the event
• On-Scene warning signs

Good Targets:

• Shopping Malls
• Water Supply
• Subway / Mass Transportation
• Hospitals
• Power Plants
• Office Buildings
• Emergency Services Buildings
• US Post Office

Types Of Events:

• Any place where there is a mass gathering.
• Football Game
• Times Square during New Year’s Eve.

Timing Of Event:

• Reenforcement of past diaster days.  i.e. September 11th., July 4th.
• High-Publicity Events

On-Scene Warning Signs:

• Multiple patients with similar complaints.
• Appearance of odd clouds, smoke, fire, etc.
• Nature of the incident.
• Mass casualty incident.

Your Protection(s):

• Time, Distance, and Shielding
  • Minimize time of exposure.
  • Stay as far away as possible.
  • Use personal protective equipment. i.e. SCBA, turnout gear, etc.

SLUDGE
Salivation, Lacrimation, Unination, Defication, Gastronal-Intestional Pain, Emissis

Rx = atropine 15-30 mg

70% of chemical agents are heavier than air. Wear PPE & SCBA. Also look for secondary devices and/or snipers.

Minimum Equipment: Full turnout gear, SCBA, Nitrol or Butyl gloves.

Posted under Everything Else

“Delegated Practice” — A legal right to practice under the license of an MD.

NYS Protocols define BLS care. ALS care is defined by region.

BLS protocols are state-wide; same level of training, and same standards of care. Chance of lawsuit at BLS level is very rare. EMT’s are covered by parts of good samaritan law.

ALS protocols vary by region.  Also, ALS has a higher likelyhood of lawsuits.

In NYS, medics are “Certified”, not “Licensed”.  DOH cannot license, only certify.  There is no difference in the eyes of a court of law in NYS.

NYS takes no responsibility for errors, instead the medical director is personally liable for the errors of a medic.

Certification shows that a person has met a minimum standard for the practice stated. This insures that the EMT meets the minimum compantancy. The DOH is a law enforcement agency; enforcement of health laws.

EMT’s practice on their own; crimes of an immoral nature may prevent a person from attaining an EMT certification.

Civil Case
Crimes between individuals. Proponderance of evidence. Lower standard than criminal.  Seizure of money, property, etc.

Criminal Case
Crimes against society.  Evil intent.  “Mensre”. Beyond a reasonable doubt; higher standards.

#1 crime paramedics are convicted of is vehicular manslaughter.

Practice comes from NYS cirriculum & National EMS Standards.

Malpractice - “Bad Practice”

Good samaritan law does not protect professionals, such as Firefighters, EMT’s, Paramedics, etc.

NYS Law - EMT’s mandated reporter for child abuse, elder abuse, etc. EMT’s are immune from charges for reporting crimes in good faith.

Actual Damages - Documened monetary damages.

Non-Actual Damges - Stress, Loss of Companionship, etc.

Capacity - The ability to understand the concequences of their actions or lack of actions.

Any EMT or Paramedic in New York State may accept any DNR form that they believe to be valid. The rule of thumb is that if you are called to an emergency, you perform care.

RMA - Refusal of Medical Advice. A person who needs minor treatment, but who is able to seek treatment on their own. The condition is not life or limb threatening.

AMA - Against Medical Advice.  Needs immediate attention and will likely result in loss of life and/or limb. Note: Contact medical control ASAP, and request police assistance.

Posted under Everything Else

1967 EMS Established

1928 First Established Rescue Service. Cardiac Arrest was 100% fatal.

1957 Mouth-To-Mouth

May 11, 1959 First Portable Defib. 45 LBS weight.

1959 20 minutes or more for an ambulance to arrive.

1961 Emmerson Recusitator — Aprprox 60 LBS

National Highway Safety Administration Established — “Accidental Death and Disability” Report aka “The White Paper”

1968 First Cardiac Care Mobile Unit

June 1969 The first defib without a MD on location.

1968 911 Established

1969 First EMT Class

December 1971 “Emergency!”

1981 More than 50% of people in the US within 10 minutes of a Paramedic.

Star Of Life:
Detection
Reporting
Response
On-Scene Care
Care In Transit
Transfer To Definitive Car
Staff in center represents healing.

1975 AMA recognises Emergnency Medicine, EMT’s recognised.

1979 Emergency Medicine is 23 recognised medical specialty.

1981 Emergency Medical Dispatch Established

1982 First Personal Computers Released

1987 First electronic tracking of ambulance vehicles.

1989 PASG Garments in use, higher regulation of equipment.

June 1990 GMAC Shooting

1992 LA Riots

1995 Oaklahoma City Bombing

“Caring for others in their time of greatest need.”

Hypocratic Oath:
-Do no harm
-Non Judgemental
-On Your Honor
-Confidentiality

Posted under Everything Else