Thomas W.P. Slatin

Burn Trauma

No matter how bad a burn patient looks or appears, one cannot under any circumstances express disgust. Showing disgust is not only unprofessional, it is also inhumane due to the fact that burns are the most painful and fearful injuries known to mankind.

90% of caring for a burn patient is mental.  Your first on-scene impression to the patient will ultimately affect patient outcome.

In the 1960’s there were no real ER’s. Instead, there were patient evaluation rooms in the back of the hospital.  Emergency medicine had not yet come into existence. There were no burn centers, and plastic surgeons were only in Hollywood.

In the 1970’s, Firefighters were trained to be Paramedics. Burn kinematics were just starting to become understood.  There existed a misconception at this time that everything had to be sterile when it was used with a burn patient.

In the 1980’s, burn care was born. EMS is in full swing, burn teams were established, and ER’s were in widespread use. A split-thickness graft was also developed.  MAST pants came into use at this time.

In the 1990’s, time became an issue. The Golden Hour and Platinum Ten became guidelines for treatment and transportation.

People at risk in the population include children, Firefighters, stunt people, pilots, race car drivers, steel workers, and people involved in house fires.

Those at risk of mortality are those who are over 60, have over a 40% burn, and burns that have an involvement of the airway.

Types of Burns

• Thermal
  • Fire
  • Liquid
  • Gas
  • It’s all about duration of contact!
• Chemical
  • Acids / Alkalines
• Electrical
  • Electrical burns occur more under skin than what is visible.
• Radiation

Degree of Burns

• Superficial Burns
  • Only affected epidermis.
  • No blister development.
• Partial Thickness Burn
  • Involves dermal layer.
  • Blister development.
  • Painful burns.
  • 2-3 weeks needed for healing.
  • Usually no scarring involved, if properly cared for.
• Full Thickness Burn
  • Often very little or no pain.
  • Skin grafting is necessary for healing.

• Jackson’s Zones
  • Coagulation (Inner Zone, No Longer Viable)
  • Hyperemia (Reddened, Likely Viable)
  • Stasis (Outer Area, Only Basic Care Necessary)

Measuring Burns

• The Rule of Nines
• Palmer Method (Patient’s Palm Represents 1% of Skin Surface)
• Lund-Browder Chart

Airway!

Edema to the airway is common. Common signs are soot around the airway, singed or burned nasal hair, facial burns, lack of eyebrows, burns to the neck, etc.

Additionally, when a fire occurs in a house, people retreat to various places including bath tubs, closets, under beds, etc.  Therefore, any person who has been in a confined space with a fire for more than 30 minutes, they likely have an airway burn.

Intubate early, if possible. Moreover, burns release potassium, which will irritate the heart. Use caution with intubation as it may put the patient into V-Fib.

Critical Burns

Critical Burns Include:

• All inhalation burns.
• All electrical burns.
• Burns associated with trauma.
• Patients with increased risk.
  • Very young.
  • Very old.
  • Poor health.
• Burns to Ears.
• Burns to Eyes.
• Burns to Face.
• Burns to Hands.
• Burns to Feet.
• Burns to Genitalia.

Burn Treatment
Dry vs. Wet?

There is a difference between stopping the burning and applying a wet dressing.

A wet dressing draws more contaminants into the wound through capillary action.  It will wick contaminants towards the wound.  Also, a wet dressing will put the patient into hypothermia, though a wet dressing will alleviate some of the pain associated with the burn.

Gauze dressings are pours to air due to the fact that they are weaves.  It is the exposure to air that causes pain. Therefore, apply an occlusive dressing such as a trauma dressing or telfa dressing. A burn dressing is perfect.

In New York State, 10% or less, wet is acceptable. Over 10% is dry only.  However, dry dressings are acceptable with any burn.

IV’s

Burn patients will swell tremendously, so IV’s will require a long catheter due to swelling.  If at last resort, you can put an IV through a burn.

- Adults: 2-4 mL lactated Ringer’s X body weight in kilograms (kg) X percent TBSA burn

- Children: 3-4 mL lactated Ringer’s X body weight in kilograms (kg) X percent TBSA burn

- First half in the first 8 hours after burn.

- Second half in the following 16 hours after first 8 hours.

Remember the Parkland Formula!

Pain Management

If a patient stops breathing due to too much drug administration, so be it. If the patient is unconscious, they are not in pain.

LOC In Burn Patients

A patient does not lose consciousness from burns.  If a patient has an LOC, consider a head injury.  Or, consider carbon monoxide, or cyanide from partially burned plastics.

A patient does not bleed from burns.

A patient does not go into shock from burns. If a patient does go into shock, it’s likely in their abdomen.

The most dangerous burn is a circumferential burn around the chest simply because the skin is like leather and does not allow the patient to breath. Some protocols allow prehospital escharotomy.

Skin Grafting

Autografts - Patient’s own skin is used. It is harvested from a different region of the body and is done every 14 days.

Xenografts - Skin used from pigs which is nothing more than a temporary barrier. The problem occurs with rejection by the body.

Allografts - Grafts taken from cadaver skin. Skin is not usually rejected by the body.

Electrical Burns

There is an equal number of deaths from high voltage as low voltage. The issue is amperage of the current.

The skin of the human body is a poor conductor.  However, the human body itself is a good conductor.

The most sensitive part of the body is the tongue. At just 45 micro amps, one can feel the tingle on the tongue

• Alternating Current (AC):
  • 10 to 15 milliamps is the let-go threshold.  Anything greater than this will prevent the person from letting go.
  • 150 milliamps can cause a tremor.
• Direct Current (DC) has no let-go properties.  DC will only create heat energy.

Electricity travels best through nerves and blood vessels as these are excellent conductors.

Acute CNS Changes:

• Respiratory Arrest
• Seizures
• Coma
• Amnesia

Paraplegia is quite common with electrical burns.  This is due, in part, to the nerves being destroyed by electricity.

About 4 to 6 months, cataracts are common.

Additionally, a pregnant woman will almost always lose her child.  The fetus is surrounded by water and electricity will travel directly to the fetus.

Treatment

“Trauma Naked” Look for entrance wounds and exit wounds.  The entrance wound is usually small and may be difficult to find.

Monitor EKG. With DC current, patient may likely be in astoyle.

Treatment begins with 20 to 40 cc/kg normal saline.

Posted under Everything Else

Soft Tissue Trauma

Types of soft tissue trauma:

• Avulsion
• Lasceration
• Evisceration
• Degloving
• Incision
• Penatration

Goggle use in addition to gloves is very important!  Wear gloves and goggles when there is any chance that one may come in contact with splashing or squirting body fluids.

Risks associated with soft tissue trauma include infection, loss of body fliuds, etc.

When soft tissue trauma occurs, the body increases blood flow to the area to provide additional cells and certain chemicals made in the body to assist in fighting infection.  This results in an inflamed appearance which is warm and firm to the touch.

After clotting has completed and infection has been avoided, epithelialization occurs and replaces the skin that was damaged. Also, new blood vessels are created through a process known as neovscularization.

Collagen is a connective tissue that is responsible for giving the skin elastic properties.  It allows for adaptive movement of the skin.

Poor Healing and Anatomic Factors

The region of the injury may be a problem if the region is prone to frequent movement. Such regions include the face, and chest.

Pigmented skin will take longer to heal than non-pigmented skin. People with darker skin will take longer to heal than people who have lighter skin.

NSAID (Non-Steroidal Anti-Inflamitory Drugs) will slow healing as it will slow down a normal healing response.

Chemotherapy destroys the most rapidly dividing cells. Therefore, the skin is affected as chemotherapy may destroy skin cells and will dramatically slow skin healing.

People with diabetes also have a thickened basement membrane in their skin.  This narrows the blood vessels in the skin, which impairs circulation. Moreover, the nerves under the skin are impaired so when a diabetic patient does experience soft tissue trauma, when the body mounts a response, the blood vessels are constricted.

Healing abilities decrease with age, obesity, and due to certain medical conditions.  Additionally, diet has an effect on healing.

HIV / AIDS patients have extreme difficulty healing from soft tissue trauma due to the fact that they have no white blood cells and their body is already overwhelmed  fighting off the AIDS virus.

Alcoholics have poor health due to the fact that they over-exceed their alcohol intake.  Alcohol is detoxified by the liver and in excess, alcohol will be turned into fat. This fat in the liver prevents blood circulation through the liver, preventing the relase of essential body enzymes, leaving the body more open to infection.  Alcohol is also a diruetic, so the alcoholic patient urinates away all the vitimins they take in through digestion.

Any patient with an eating disorder will have problems healing.  These patients conditions include anorexia and bulemia.

Foreign bodies such as materials left behind in the skin as a result of penetrating trauma are high risk wounds.

Injection wounds such as those resulting from hydraulic lines are also high risk.

Any biological or radiological wounds that have left behind contaminants are high risk due to the posibility of infection.

Not all wounds are closed. Some wounds are left open to air, either on accident or on purpose. Reasons to leave wounds open include drainage needs or wound packing.

Contusions are simply closed tissue trauma which results in bleeding under the skin.  The blood accumulation from the capillary bed forms the contusion.

A hematoma is a collection of blood within the skin layers.  It is similar to a contusion, except that the collection of blood is within the skin layers. Typically a hematoma can accumulate up to one unit of blood.

Abrasions are breaks in the skin resulting from trauma in which the top layer of skin has been scraped off.

A laceration is a jagged cut to the skin that goes into the underlying structures such as muscle and/or bone. They can appear in either straight lines or L-shaped lines.

Incisions are generally smooth and from a doctor’s point of view, the injury may have impacted an underlying organ.

Avulsions come in two types; partial and full. Partial avulsions are hanging on by tissue and/or muscle, while full are completely removed. In this case, the injury site is jagged and torn.

Note:
A dressing is sterile, a bandage is not. One applies a dressing to the wound, the bandage holds the dressing to the wound.

Occlusive dressings are used generally for suching chest wounds, over an eviseration, or for any wound that must be protected from air.

Non-adherant dressings, such as telfa dressings are used for burns or any time that the dressing must be prevented from sticking to the wound.

An absorbant gauze sponge is used for soaking up bleeding. It implies that one is losing a lot of blood from a wound.  However, one wants to allow the blood to clot, and using an absorbant gauze sponge will prevent clotting because it draws the blood away from the wound.

An EMT should ask their patients about tetanus immunizations due to the fact that tetanus will cause lockjaw (trismus). Tetanus causes muscle contractions and it shows in the jaw because the jaw is a small group of muscles.  Tetanus kills a person by cramping their backs until the spine breaks, causing death.

Crush Syndrome

Compartment Syndrome is known as the smiling death due to the fact that the patient is usually smiling and happy to be rescued, then they die the next day from the complications.

Loss of venous outflow results in build-up of pressure within the muscle bundle which is restricted by the fascia and cell death occurs.

Fascia is a thin, cellophane-like connective tissue that seporates tissues. It does not stretch very much, which is what causes a build-up in pressure in compartment syndrome.

Signs and symptoms of compartment syndrome include swelling edema, a decreased range of motion, and diminished pulses.

The 5 P’s:

• Pain
• Pallor
• Paralysis
• Paresthesia
• Pulselessness

EMS Treatment:

• Oxygen (0₂)
• Splint
• IV at KVO
• Morphine Sulphate for Pain
  • For a patient with compartment syndrome, upwards of 20 mg of Morphine Sulphate is not uncommon.
• Transport
• Field Fasciotomy (Tactical EMS)

Morphine Sulphate

Class: Opioid Analgesic
Indications: Moderate to severe acute and chronic pain, pulmonary edema.
Contraindications: Head injury, exacerbated COPD, depressed respritory drive, acute abdomen, decreased LOC.
Side Effects: Respritory Depression, decreased BP, decreased LOC, N & V, decreased HR.

Note:
The depth and rate of respiration indicates respritory function, not simply the rate or the depth.

Pathophysiology of crush syndrome:

• Loss of arterial pulses.
• Anerobic metobolism.
• Lactic acids and free radicals.
• Holes in cell membranes; cytoplasm leakage.
• Potassium and Purines (later converted to lactic acid).

The two ways of dying from crush syndrome include death on scene or death 24 hours later.

Death on scene is due to body fluids rushing into the dehydrated tissue.  This results in systemic hypovolemia within a few hours.  This releases a high level of potassium and acidosis into the blood stream which leads to cardiac dysrhythmias.  Death on scene results.

If the patient survives, about 24 hours later, kidney failure often occurs.  Myoglobin is released now as a protien in the blood.  This myoglobin is insoluable in acidic blood. It forms renal casts which prevent kidney function. Proper treatment in the field by EMS can save the kidneys!

An EMT can establish two (2) large-bore IV’s prior to entanglement.  Oxygen is also important, as is ventillation.  MAST pants are not a good idea. Draw blood samples, administer a 2-3 liter bolus (1.5 liters per hour), and 1-2 amps of Sodium Bicarbonate.

Consider Insulin and D50; consult with medical control.  An alternative is Albuterol with Bicarbonte, which drives K+ (Potassium) back into the cells.

If a patient goes into V-Fib due to crush syndrome, dminister 2 amps of bicarb via IVP, administer albuterol down the ET tube, flush IV line, administer epinepherine, flush IV line, and administer calcium chloride.

Posted under Everything Else

Sports Medicine

Skin / Fat / Fascia

The skin provides protection to the underlying tissues, as well as connective tissue.

Protect the skin as much as possible, as it will ultimately protect against infection, enviornmental temperature changes, and circulation.

Types of Muscles

Cardiac, Smooth, And Skeletal

Blood vessels supply nutrients to muscle as well as blood circulation to the body. With any injury, check pulses distal from the injury site.

The pelvis both holds and protects vital organs, nerves, and blood vessels. Therefore, with pelvic trauma and/or fracture, special care must be taken during assessment and treatment.

Functions of Bones

Bones provide structrual form and movement, protection of organs, reservoir for minerals, and the  production of red blood cells.

Age Associated Changes In Bones

• Decreased hydration of discs
• Osteroporosis
• Degenerative joint disease
• Ossification of costal cartilages
• Pathologic fractures from porus, brittle bones.
• Most of these conditions are preventble if the patient takes good care of their bones in their younger years.

Articulations

Fibrous Joints - No movement, bones held together by fibrous connective tissue.

Cartilagenous Joints - Slight movement possible, bones held together by cartilage.

Synovial Joints - Freely Moveable, articular capsule encloses the joint and contains synovial fluid for nutrition and lubrication. Articular cartilage on bone surfaces allow for smooth movement.

Types of Synovial Joints

• Gliding - Movement in any direction.
• Hinge - Flexion and Extension
• Pivot - Rotation
• Ball and Socket - Head of one bone goes into the cup of another.
• Condyloid - One surface concave, the other slightly convex.  Flexion, extension, abduction, adduction, and circumduction.
• Saddle - Similar to condyloid except two surfaces are the same.

Musculoskeletal Injuries
Fractures, Dislocations, Sprains, and Strains

Complications

• Hemmorrhage
• Instability
• Loss of Tissue
• Infection
• Ischemia
• Long Term Disability

Types of Open Fractures

• Type 1: Low energy, wound <1 cm, from inside-out injury.
• Type 2: Wound >1 cm, significantly more injury, more energy absorption during fracture.
• Type 3: Extensive wounds >10 cm, fracture fragement comminution, large amount of soft tissue damage.

Types of Closed Fractures

• Simple Fractures
• Lower risk of infection
• Necessry to assess neuro compromise
• It may be difficult to tell the difference between a sprain, dislocation, or a fracture.

Pediatric Fractures

• Greenstick Fracture
• Epiphyseal Fracture
  • Salter-Harris Classification (Search Yahoo!)
• Proper treatment is necessary to prevent growth arrest.

Fractures of the Hand

• Metacarpal or Phalangeal
  • Boxer’s Fracture (Base of the 5th Metacarpal)
• Rotational deformity or joint involvement
• Avulsion is common with a  hyperextension or hyperflexion injury.
• Neurovascular function is critical
• Treatment for an open fracture to the hand is critical due to the high risk of infection and the potential for long-term disability.

Fractures of the Wrist

• Navicular (Most Common Carpal Fracture)
• Fall to an outstretched hand
• Palpable pain in anatomical snuffbox
• Inappropriate management leads to avascular necrosis.

Humeral Fractures

• Shaft Fracture - Shortened, crepitus, and pain.
• Humeral Neck Fracture
• Humeral Head Fracture
• Neurovascular exam is critical!

Pelvic Fractures

• Mortality rate for open is 30-50%, closed is 8-15%.
• Mechanism of Injury is helpful for diagnosis.
• Associated Injuries Common

Femur Fractures

• Femoral Neck - Intracapsular, shortening and external rotation of extremity.
• Lesser Trochanteric - Rare, avulsion of iliopsoas muscle
• Greater Trochanteric - Direct or Indirect Trauma

Femur Fractures

• Subtochanteric Fracture - Result of high energy trauma.  Typically occurs with young to middle aged adults.
• Shaft Fracture - Result of severe trauma, extensive tissue injury, bleeding, shock.
• Condylar Fracture - Rare, result from vrus of valgus stress to the knee.

Tibia Fractures

• Shaft - Torsional Stress, displacement rare due to intact fibula.
• Plateau - Axial loading combined with varus or valgus force, ligament damage associated with injury.
• Distal Tibia - Ankle joint, impressive swelling, soft tissue damage.

Ankle Fractures

• Fibular Shaft - Uncommon isolated fracture, non-weight bearing bone.
• Bimalleolar Fracture - Medial and lateral malleolus
• Trumalleolar Fracture - Medial, lateral, and posterior malleoli.

Foot Fractures

• Calcaneus - Fall from height, rare, 5% are bilateral.
• Base of the 5th metatarsal, eversion mechanism, point tenderness, pain with weight bearing.
• Metatarsals - Direct Trauma
• Phalanges - Great Toe
• Tarsometatarsal Dislocations *Linsfranc) - Dorsal lateral, open wound, vascular impairment, swelling

Fracture Management

• Evaluate Patient
• Cover Open Fracture
• Splint joint above and below
• Check motor, pulse, and sensation
• Gentle in-line traction
• Long Bone - Straight “splintable” position
• Cold treatment
• Compression
• Elevation
• Immobilization (Improvisation Is The Key!)

Splint to provide comfort, while at the same time, not preventing circulation, nerve function, circulation, etc.

Joint Injuries

• Dislocation - Complete disarticulation of bone ends in a joint.
• Subluxation - Partial Dislocation
• Sprain - Stretch or tear of ligaments causing instability, pain, and swelling.

Muscle Injuries

• Strain - Microtearing of muscle fibers, usually a result of forceful contraction, inadequate warm up and stretching prior to athletics, muscle agonist and antagonist imbalance.
• Tendon rupture - Complete tear of tendon resulting in loss of function, palpable defect.

Shoulder Reduction

• Traction / Countertraction
• Modified Kocher
• Stimson

Knee injuries are the most common sports injuries seen by EMS.

Football Helmet Removal Criteria
(When to remove the helmet…)

• If the helmet and chin strap do not hold the head securely.
• If the design of the helmet precents proper airway management after face mask removal.
• If the face mask cannot be removed in a reasonable amount of time.
• If the helmet does not allow for proper allignment of c-spine and/or proper immobilization.

Discuss helmet removal with the coach prior to athletic events.  Keep your options of helmet or face mask removal open.

Posted under Everything Else

Abdominal Trauma

Any patient in shock that has internal bleeding that cannot be found, you can generally find the bleeding in their stomach area.

Teres - Ligament that attaches to the liver.

Solid Organs of Abdominal Cavity:

• Liver
• Spleen
• Kidneys
• Ovaries

Hollow Organs of Abdominal Cavity:

• Small Intestine
• Bladder
• Stomach
• Large Intestine
• Pancreas
• Gall Bladder

Mechanism Of Injury + Index of Suspicion = Diagnosis

Blunt Trauma:
Shearing, Tearing, and Compressing

• Penetrating Trauma
  • Soft Tissue Damage
  • Muscle Damage
  • Nerve Damage
  • Vein / Artery Damage
  • Bone Damage

Focused History and Physical Exam (PQRRST)

A patient who holds their legs in a fetal position, they are likely taking pressure off their abdominal region.

Always check femoral pulses in patients who have abdominal trauma.

Cullen’s Sign - Bruising around the umbilicus.

Abdominal Trauma and EMS

A person can lose up to 60% of their liver and still live.

A common injury to the spleen can result in the patient experiencing left shoulder pain.

Grey-Turner’s sign can also be an indication of a spleen injury.

A person can survive without their spleen. Esentially, the spleen removes old red blood cells, as does the liver.

Trauma in Pregnancy

Any woman who states that her water may have broken, you must check her underclothes to determine if blood is present.

Post-Mortum delivery of live infant by ceserian section has been documented successful after 25 minutes of CPR.

Posted under Everything Else

Head And Spine Injury

Neurological Injuries:

• Responsible for 1/2 of all deaths from trauma.
• Major Cause of Long-Term Disability.
• Most from MVA’s and Falls.
• Can be prevented to a certain extent through helmet use.

Anatomy:

• Neuron - Nerve Cell
• Dentrites and Axons = Processes of Neuron
• Peripheral Neurons are Sheathed With Myelin
• Impulses are transmitted through synapses.

The major neurotransmitter for the sympathetic nervous system is eppineferine.

Acetocholine is the major parasympathetic nervous system neurotransmitter.

Head Injuries:

• Severity depends on amount of primary and secondary brain injury.
  • Primary injuries are the initial injury, such as trauma.
• Main cause of secondary injury is hypoxia.
  • Secondary injuries are a result of the primary injury being left untreated for too long.
  • Secondary Injuries from Head Injuries can be prevented by medical interventions, such as surgery, steroid infusion, oxygen administration, administration of Solu-Medrol, Lidocaine, etc.
  • Draw bloods enroute as the bloods you draw in the field may save the patient time waiting in the ER for surgery.
• Categories: Open or Closed
  • Open skull fractures open the patient for infection. Bloods are useful to establish a “Baseline”.
• Forces: Shearing and Compressive
  • A compressive force inside the skull may be caused by an epidural bleed crushing down onto the brain.
  • A shearing force inside the skull may be caused by the brain moving too quickly inside the skull and shearing the blood vessels to the brain.

Types of Head Injuries:

• Concussion - Temporary alteration in neurological function (or LOR)
• Cerebral Contusion = Bruised Brain
• Cerebral Hematoma or Blleed
  • Epidural
  • Subdural
  • Subarachnoid
  • Intracerebral

General Signs & Symptoms:

• Headache
• Dizziness
• Nausea / Vomiting
• Amnesia
  • Antrograde - Cannot Establish New Memories
  • Retrograde - Cannot Remember Accident; Epidural Bleed
• Decreasing Level of Responsiveness
• Confusion
• Combativeness
  • Combativeness is due to hypoxia until proven otherwise.
• Loss of Responsiveness

Any patient with a loss of conciousness on scene automatically makes the patient a high-priority.

Any patient who loses conciousness in a seated position, the cause is deeded cardiac in origin until proven otherwise.

The Cycle Of Brain Injury:

Brain Swelling

Increased Intracranial Pressure (ICP)

Hypoxia

Further Secondary Brain Injury

More Swelling

Increased ICP

Brain Swelling

Lasix dose in a head injury patient is 5 mg to 10 mg.

Nitroglycerine will lower blood pressure, but at the same time, it will encourage brain shrinking and therefore allow more room for bleeding inside the skull.

Hyperventillation is a last-ditch effort that will allow the patient about 10 minutes till brain death occurs.  The patient needs to be transported to a trauma center.

Hyperventillation will cause full-brain ischemia due to the fact that the brain will vasoconstrict.

A C-Spine Collar may be questionable if a plan to intubate is in effect, or the patient has a severe head injury. Additionally, the C-Spine Collar may constrict the jugular veins and prevent blood drainage from the brain.

Types of Spinal Cord Injuries:

• Paraplegia - Paralysis of both legs.
• Quadriplegia - Paralysis of both legs and arms.
• Hemiplegia - Paralysis of arm and leg on the same side.
• Partial vs Complete
  • A partial transsection of the cord can become a complete transsection due to a variety of different factors, including mishandling.
• Stable vs Unstable (Cannot Be Classified In The Field; Requires X-Ray)
  • All fractures are assumed unstable until proven otherwise.

Spinal Column Injury Signs & Symptoms:

• Pain at injury site.
• Localized Tenderness
• Self-Splinting or Guarding
• Deformity (Often Not Obvious)

Spinal Cord Injury Signs And Symptoms:

• Loss of sensation, varying degrees
• Abnormal sensation
• Muscle weakness or paralysis
• Signs of neurogenic shock
• Difficulty Breathing
• Incontinence
• Priapism (Painful Penile Erection)

If a patient has a head injury and is hypotensive, they are likely bleeding somewhere else.

Summary & Review

• The main cause of secondary injury is hypoxia.
• A head injury by itself rarely causes shock.
• Every head injury or unresponsive patient must be considered to have a closed head injury or increased ICP.
• Signs & Symptoms of ICP include, increased pulse, increased BP, change in respirations, and non-reactive pupils.
• Two things that can slow the process of increased ICP are to elevate the head, or apply oxygen.
• Spinal cord injury resulting in paralysis of both legs is called parapaligia.

Assessment of Spinal Injuries

Spinal immobolization has become a knee-jerk response to almost any possible spinal injury.

Problems resulting from backboarding patients include a delay on scene, increased cost due to tests in ER (X-Ray, etc.), and an increased risk of injury from patients laying on backboards for an extended period of time.

Paralell to every bone in the human body is a vein, an artery, and a nerve.

Oxygen is given to patients with suspected spinal injuries to assist with oxygenation via collaterial circulation.  This will maximize effenciency and may save some spinal cord from further injury.

Muscles without the control of the spinal cord will eventully contract.

Types of Injuries:

• Hyperflexion - Lips to Chest
• Hyperextension - Back of Skull to Spinal Column
• Hyperotation - Turn too Far
• Axial Loading - Compression Fracture; Diving Accidents
• Axial Distraction - Pulling Away; Hanging Injury

Patients Who WILL Recieve Spinal Immobolization:

• Fall 3x Height
• Motor Vehicle Ejection
• High-Speed Crash
• Hanging Injury
• Etc.

In 2001, Chicago FD cleared over 14,000 spines and had no instance of mistake.

Pain / Tenderness Exam:

• Spine Pain
• Spine Tenderness
  • Gently Touch Neck
• Motor Function
  • Upper Extremities
    • Abduction / Adduction
    • Finger / Hand Extension
  • Lower Extremities
    • Plantar Flexion
    • Great Toe Dorsiflexion
• Test sensation at two levels
• Abnormal Sensation
  • Numbness
  • Weakness
  • Paraesthesis
  • Radicular Pain
• Pain Sensation
• Possible Unreliable Patients
  • Drunk or Intoxicated Patient
  • Language Barriers
  • Speech Impediment
  • Impared Psychological Development
  • Distracted By Another Injury
  • ASR (Acute Stress Reaction)

At best, rigid cervical collrs provide about 70% of spinal immobolization.  In other words, no mechanical device is better than manual, hands-on stabilization.

A pregnant woman should be placed at 15 degrees to the left to prevent the fetus from placing excess weight onto the blood vessels leading to the lower extremeties.

More Information:

• Goth, Peter. 1995.  Spine Injury: Clinical Criteria for Assessment and Management. Maine EMS.
• Perry, Jim.  1999. Spine Immobilization Training Program. North Coast EMS.
• Karsteadt, Larry, Stiver, Kenneth. 2000.  Assessment of Spinal Injury.  In North Coast Emergency Medical Services Policies and Procedures Manual, Treatment Guidelines - BLS. Policy # 6016.1.

Motorcycle Trauma

Out of 100 people who are killed in motorcycle accidents, 50% will die on scene.

There are over 4.5 million bikers in California alone.

In horseback riding, there is 1 injury in every 350 hours of riding, in motorcycling there is 1 injury in 7,000 hours of riding.

Types of Motorcycles:

• Off-Road
  • 500cc or Less
  • Can lift up alone.
  • Air-Cooled
• On-Road
  • 500 cc or More
  • Cannot lift up alone.
  • Liquid Cooled

To turn off a motorcycle, locate the kill switch, which will be clearly marked in yellow or red in color.

Look for the ignition key and or battery if  kill switch is not available.

66% of motorcycle accidents also involve fuel leaks.

Most motorcycle riders wear leather for warmth, bugs, cigarette butts, weather protection, and protection from accidents.  Unfortunately, insurance companies do not cover leather. If you must cut leather, cut along the seams only, if possible.

In New York State, you are required 4 square inches of reflective materil on your helmet.

Dr. Hurt�s study of 4,500 motorcycle accidents:

• 25% of bikers just dumped their bike.  75% involved another vehicle.
• 2/3 of accidents are due to right-of-way issues.
• 50% of motorcycle accidents involved alcohol.
• The average speed of the motorcycle at the time of the accident was 21.5 miles per hour.
• 96% of motorcycle accidents had at least one injury.
• The most common injuries were to the lower extremeties.

Other Statistics:

• 14.4% are with fixed objects.
• 39% ae alcohol related.
• 41% involve speeding.
• 50% of riders involved in accidents did not use their rear brakes.
• 20% of fatalities involve riders with no valid motorcycle license.

Posted under Everything Else

Facial Trauma

Facial Trauma is completely different from Head Trauma.

In the United States, there are over 7 million facial injuries per year.

25% of facial trauma results in litigation.

Facial injuries are rarely fatal, though they can be quite traumatic to the patient.

75% of motor vehicle accident victims are seen in the emergency room for face, neck, or head injuries.

Early Anatomists:
Guillotin, LeForte

LeForte studied facial fractures using stones on rope arcs.  By measuring the arc, the weight of the stone, and the amount of force, LeForte was able to predict injuries based soly upon the amount of force inflicted.

30 neutons of force to break nasal bones, 70 neutons to break angle of mandible, 200 neutons to fracture the orbit of the eye.

Facial bones are rounded so that they can take a lot of force withut breaking, and thus protect the organs behind them. However, when a facial fracture occurs, the fracture is usually on both sides.

When a person is assulted in the face, the most common injury is a broken nose.

Zygomatic Arch - The Orbit of The Eye.

A fracture will cause the eye to drop out of the socket. Placing a bandage over both eyes will help considerably.

Treatment of Blow-Out Fractures:
Tape bandage over both eyes. If patient leans forward, patient may lose vision in the affected eye. Blindless may result.

• LeForte 1
  • Hard Pallete & Upper Mouth Detachment
• LeForte 2
  • Sinus and Eye Orbits are Detached as well as everything below. A nose bleed is a common sign. Nasal intubation is not an option with a Leforte 2 fracture.
• LeForte 3
  • “Pumpkin Face”.  Fracture through both Eye Orbits All supporting structures of the face are broken; face collapses in.  The only option is to pull the face forward and hold it until arrival at the hospital.

LeForte 2 and 3 fractures usually involve leakage of CSF (Cerebralspinal Fluid) from the nose and ears.

With any facial fracture, there is an inherant risk of spinal injuries.  Your first priority is the airway, control of hemorrhage, and C-Spine control.

Only 5% of patients with significant facial injuries have associated spinal injuries.

Do not be too concerned with facial lascerations as the patient has up to 24 hours to get the wound sutured. However, any debris in the would should be removed as soon as possible. To remove debris, use a 30 cc syringe filled with Normal Saline Solution to spray the contaminants away.

Skull Fractures

The primitive brain is the brainstem.  The brainstem controls heart rate, breathing, and all the basic systems that are required to sustain life.

Signs of an injury include difficulty swallowing, change in vital signs, and a chance in conciousness.

The cerebellum is responsible for balance, speech, etc.  An injury might include slurred speech, dizzyness, and fine tremors in the eyes.

The frontal lobe is responsible for conciousness.  It allows you to be aware of yourself, your surrounds, and your personality. The frontal lobe also deals with word association. Injuries to the frontal lobe affect personality, word association, and expressive speech. It may also include problems to perform complex tasks, persistance of a single thought, changes in social behavior, and an inability to express language.

The Pariatal lobe gives a person the ability to touch objects / coordinate eye-hand coordination, and perform some abstract thinking.  Problems include the ability to read, write, and perform math calculations.

The Temporal lobe deals with hearing.  An injury may result in decrease in sexual behavior, and/or an increase in aggressive behavior.

The cranium is a structure that protects the brain.  The hair on the head is part of the protection.  Also, the shape of the cranium is egg-shaped and therefore is stronger.  There is a series of two wafers of bone, stuck together by dipole.  For this reason, the cranium is difficult to break.

On the inside of the cranium is where the brain is located.  The brain itself is held within a membrane filled with Cerebralspinal Fluid. The brain itself is hollow, and these hollow areas are called ventricles.

In a way the brain is similar to an egg in that no matter how much the egg is shaken, the inside never gets scrambled.

The Human brain has more brain surface than any other animal on Earth. Humans have the greatest capacity for thought and intelligence.

Head Injuries

• Epidural Bleeds - Arterial Bleed; Rapid LOC followed by Lucid Intervals. It is not uncommon for patients with these injuries to die enroute to the hospital.
  • Any patient with a severe head injury that has lost conciousness is a high priority transport. A patient who has lost conciousness will not remember the accident.
  • If a patient has an injury in the front of their brain, there will likely be an injury to the back of their brain.
• Subdural Injury - Venous Bleeding. This bleed is a slower bleed than that of an arterial bleed.  An acute subdural can appear within minutes or up to about 24 hours.
  • Elderly and Pediatric patients have a brain that is smaller than their cranium.  On average, an elderly patient will lose about 10% of their brain size.
  • Due to the smaller size of the brain, the brain has more room to move around in.  This is the result of shaking baby syndrome, or an elderly person who has fallen. When you treat a patient with this complaint, perform both a trauma and a neuro exam.
• Chronic Subdurals - Common in Alcoholics.  Symptoms include slurred speech, dizzyness, etc.  Autopsy studies have shown changes in the brain; these changes can show how long the person has been an alcoholic.  In about 7 to 10 days, the chronic subdural will bleed. Due to the fact that they are alcoholics, they are short of clotting factors in their blood.

Visible Human Project (…)

Signs of Increased Intracranial Pressure

The only outlet of the cranium is the foramen magnum (base of the skull).  And for this reason, an increase in ICP will cause the brain to press down upon the brain stem.  This is called Tentorial Herniation Syndrome.

Levels Of Head Injury (1 to 3)

LOC

RR

P

B/P

Pupils

Level 1

Unconciou s

Unchange d Rate, Change In Pattern

Increase in Diastolic Pressure

Unchange d

Decorticate Posturing Upon Stimulation; Cerebrial Cortex Affected.

Level 2

Unconciou s

Central Neurogeni c Hypervent illation

Bradycard ia

Increased Blood Pressure

Fixed & Non-React ive

Deceribrate Posturing Upon Stimulation; Cerebellum Affected. No meaningful survival.  Patient will generally be a vegtable or profoundly mentally retarded.

Level 3

Unconciou s

Agonal Respiratio ns

Questiona ble HR/Pulses

Falling Blood Pressure

Pupils Blown

Unresponsive; Brain Stem Affected. Death of patient.

Average BP is 60 mm Hg.  A head injury patient may have one as high as 120 mm Hg. A pressure 150 mm Hg to 180 mm Hg will compress the brain and may lead to brain herniation.

Seizures cause the highest instance of mortality in patients with severe head injuries.  The action of a seizure will spike the ICP and can be catistrophic to patient survival.

Spinal Injuries

Corticospinal - Motor Nerves To Body
Spinothalmic - Sensation From Body To Brain

A fracture of the spine (complete transsection) at 3, 4, or 5 will only allow the patient to shrug shoulders and have sensation around their shoulders.

Most common mechanisms of spinal injuries are Motor Vehicle Accidents.

• Hyperflexion
  • Head over extends backwards.
• Hyperextension
  • Head over extends forwards.
• Axial Loading
  • Seen in swimming pool accidents where head impacts down upon the spine.
• Distraction
  • Seen typically in hanging injuries where the vertibre seporate.
• Primary Injuries
  • Happened at the time of the accident.
• Secondary Injuries
  • Happened after the accident, typically a result of mishandling or spinal swelling.
  • Secondary injuries are rare.

Document any parylasis found on scene before moving the patient in any way.

Complete cord transsection can result in quadrapaligia or parapaligia.

Anterior Cord Syndrome is usually the result of bone fragments.  These are typically categorized by the patient complaigning of neck pain in the middle of their neck.

Central Cord Syndrome is typically the result of falls in which the chin is pulled during the fall.  This is also seen in football players.  In central cord syndrome, use of the upper extremeties is usually lost before the lower extremeties.

People left on backboards can sometimes suffer more pain and injury by lying on the backboard for an extended period of time.

An X-Ray vs. A Physical Exam each carries with it an error rate of about 4%.

Mechanisms Requiring Spinal Immobolization (Positive Mechanism of Injury):

• Falls 3x Greater Than Height
• Gun Shot Wounds To Central Body
• Parylasis / Numbness
• Pain In Spine or Back
• Severe Motor Vehicle Accident (MVA)

A UCLA study of 10,000 patients, Paramedics have been shown to be more conservative than Doctors in clearing spines.

ASR - Acute Stress Reaction; You cannot clear these patients because they are not paying attention to you or obeying commands.

Intoxication will hinder the patients ability to answer questions, follow commands, etc.

A distracting injury such as a broken leg or other painful injury that would distract them from their neck pain cannot have their spines cleared.

Additionally, any patient who is mentally retarded or cannot speak your language cannot be spinally cleared.

In Europe, backboards are not used.  Instead, full-body vacuum splints are used.  Vacuum splints are an advantage because they pad voids and offer more patient comfort.

Posted under Everything Else

Shock Trauma

Shock - Inadequate perfusion of oxygen to the cells in and tissues of the body leading to systematic organ failure and eventually death.

Perfusion - The distribution of blood across the entire body.

Shock is a pathiophysiologic process eventully leading to death.  If left too long, shock will be irreversable and will ultimately result in certain death.

The Critical Electrolytes in the body include Sodium, Calcium, Potassium, Iron, Magnesium, Copper, and Zinc.

The Critical Nutrients in the body include Glucose, Protiens, Starches, and Fats.

There exists a lock-and-key process to run chemical reactions in the body and therefore the body produces enzymes to “unlock” these chemical reactions.  In other words, a vitimin turns-on the enzyme.

It is easier to overdose on fat-soluable vitimins than it is to overdose on water-soluable vitimins. This is due to the fact that fat-soluable vitamins are absorbed into body fat, while water-soluable vitimins are excreted on a daily basis and must be taken every day.

It takes a chemical reaction to move any muscle in the body. The chemical that is used is traponin, and during a cardiac arrest, some of this chemical escapes the cells and is released into the blood stream.

Today, vitamins are added to enriched foods. The classic enriched food is Wonder Bread, which has been highly enriched with numerous vitimins.

Linus Pauling once theorized that Americans suffer a lot of heart attacks due to the lack of Vitimin C.  Vitimin C streghtens blood vessels and promotes good heart function.

Things that inhibit cell function include toxins, poisons, or substances that block the cell or overwhelm the cell in some way.

When the body breaks-down fat, it produces ketyones, and acids.

Acid production is the result of a failure of the excratory system, celluar respiration, or respiration. Too much acid or too little acid will affect the pH, and inhibit chemical reactions.

Hypothermia and Hyperthermia also affect or inhibit chemical rections.  An example of this is an egg in a frying pan. The heat upon the egg white is the exact process of heat upon the fats in the body.

The body tries to maintain a healthy balance of all body processes and homiostasis.

Fick Principle (5 Elements):

1. Oxygenation
2. Ventilation
3. Respiration
4. Circulation
5. Celluar Respiration

3 Parts to Ventillation:

1. Muscles
2. Bones
3. Nerves

Respiration - The gas exchange (diffusion) at the celluar level in the lungs. The only two measurements of respiration are ETCO₂ detectors and Pulse Oxymetry.

Oxygen Toxicity - Over a period of 24 hours or greater, if a patient is given too much oxygen, the aveoli thicken. Therefore, in the hospital, 100% oxygen administration is rarely used.

3 Things Needed For Circulation:

1. Pump
   Problems:  Weakness, Too Fast, Too Slow
2. Pipes
   Problems:  Occlusion, Constriction, Dilation
3. Fluid
   Problems:  Loss of Fluid

Chronotropy - The Speed of The Heart; Example: Positive (+), Negative (-)

Inotropy - Weak Heart; Increasing the stregnth may be accomplished by adding fluid, this increasing ventricular filling (Starling’s Law).

Inotropics are drugs that increase the stregnth of the heart.

Preload is the amount of fluid available to the heart that it can immediately take in and then pump out. This enters on the venous side, and is measured by CVP (Central Venous Pressure).

Full veins indicate adequate preload, whereas flat veins indicate inadequate preload.

Afterload is the resistance in the periferal (systemic) vascular system.

The parasympathetic nervous system dilates blood vessels, while the sympathetic nervous system constricts the nervous system.

Periferal resistance is measured as diasystolic blood pressure.  The systolic blood pressure (inotropy) is the force of contraction as a result of heart function.

A narrow pulse-pressure indicates an inability to adequately perfuse body systems.

Examples:
BP 150/90 = 60 Pulse Pressure
BP 160/30 = 30 Pulse Pressure

The body shunts blood away from organs at the capilary level by use of pre-capilary and post-capilary sphincters.

The body will typically shut down these organs in this order:

1. Fetus (Decreased Heart Rate)
2. Skin (Cool, Moist)
3. Large Muscles (Lethargy)
4. Gastrointestinal / Renal (Nausea & Vomiting)
5. Heart (Tachycardia then Bradycardia) / Lungs / Brain

Early Symptoms of Shock:

• Thirst
• Weakness
• Nausea / Vomiting
• Dizzyness
• Syncope
  • (60% of people who experience a loss of conciousness while sitting had symptoms related to cardiac origin.)
• Shortness of Breath
• Chills (”Cold To The Bone”)
• Impending Sense of Doom (”I’m Gonna Die!”)

3 Stages of Shock:

• 1st Stage — Compensated Shock
  • Limited Ability To Respond
  • Increased Production of Blood Cells
  • Transfer of Fluids From Tissues Into Blood Stream
• 2nd Stage — Decompensated Shock
  • When all of the body’s compensitory mechanisms have failed.  A sign is a loss of blood pressure.
• 3rd Stage — Irreversable Shock
  • Slow organ system shut-down. Typically, the kidneys shut down.  Tissues become aschemic and then necrotic.  Death results in time.

MOSF = Multiple Organ System Failure

Normal tissue perfusion uses oxygen (aerobic metobolism).  Alternatively, without oxygen, tissue uses aneroboc metobolism.  However, anerobic metobolism produces acid.

Orthostatics:
Blood Pressure & Pulse With Patient Supine vs. Blood Pressure & Pulse With Patient Standing Upright

20/20 Rule: 1 Liter Blood Volume Loss, 3 Liter IV Fluid Replacement Needed; Blood Pressure (-20) and Pulse (+20).

A Loss of Blood Pressure of 20 mm/Hg or Greater = Decompensated Shock

The first thing that can be done to reduce acidosis is to provide ventillation.  Secondly, provide dillution using IV fluid bolus.

Killips Classifications of Blood Loss:

Class 1

1 Unit of Blood

500cc

Class 2

2 Units of Blood

1 Liter

Class 3

3 Units of Blood

1.5 Liters

Class 4

4 Units of Blood

2 Liters

Monitor vital signs, jugular veins, and lung sounds whenever administering IV fluids.

Causes of Shock (RNCHAMPS):
Respritory, Neurogenic, Cardiogenic, Hypovolemia, Anaphylactic, Metabolic, Psycogenic, Septic

Posted under Everything Else

Kinematics - Importance To Your Paramedic Practice

Trauma is the leading cause of death to people under the age of 38.  This is due to the fact that younger people are more likely to take risks as compared to older people.

• Things that have changed and/or reduced trauma death as it applies to motor vehicle use:
  • Guard Rails
  • Rumble Strips
  • Reflective Lane Markers
  • Movement of Telephone Poles Away From The Road
  • Emergency Medical Services

When one goes in to see a medical patient, one can get a rough idea of what the patient is experiencing simply based on past medical history. Unfortunately, trauma is the complete opposite.

With trauma, OPQRST, HAPPYSOCKS, and other pneumonics, EMT’s rely upon the MOI (Mechanism Of Injury). For example, the chief complaint might read, “My head hurts.”, and the history might read, “Car into tree @ 35 miles per hour.”

Physics For EMT’s

• Inertia
  • Three (3) Collisions
    • Car Strikes Tree
    • Body Strikes Car
    • Organs Strike Inside Of Body
• Momentum
  • [Mass] x [Velocity] = [Momentum]
• Kinetic Energy
  • KE = [Mass/2] x [Velocity 2]

Energy can neither be created nor destroyed. Therefore, when a car stikes a tree, the velocity of the traveling car transforms into sound, friction, heat, and a portion of the energy gets transferred into the object(s) that the car hits. The remainder of the enrgy that has not been dissipated gets transferred into the vehicle, deforming it, and any energy that has not been absorbed or dissapated by the accident gets absorbed by the patient.

Accident Reconstruction (In 1 Second)

• 0:00:10 - Car strikes object with bumper.  Car and patient are still moving.
• 0:00:20 - Car hood crumples, front wheels still spinning.
• 0:00:30 - Driver is coming off seat. Back wheels are coming off ground.
• 0:00:40 - Motor stiking tree, rear of car is 3-4 feet off ground.
• 0:00:50 - Driver impacts chest upon steering wheel.  Internal organs are still moving.
• 0:00:60 - Drivers head strikes windshield. Spinning wheels are digging themselves into the dirt.
• 0:00:70 - Drivers seat is broken free of it’s mounting.  Hollow organs of abdomen are striking against the steering wheel.
• 0:01:00 - Patient Trauma Death

Kinematics of Collision

• Head On
  • Up And Over (70% of Patients)
    • Head impacts windshield.
    • Crushing Chest Injuries
    • Head Trauma
    • Spinal Compression Fracture(s)
    • Femur Fracture(s)
  • Down And Under (30% of Patients)
    • Typically, the patient anticipated the impact and braced accordingly.
    • Open Ankle Fracture
    • Femur Dislocation(s)
• Rear End
  • Biggest issue is whiplash injuries.
• Lateral
  • The side of a car is the weakest part of the car.  To correct this, Boron Steel is used to stregthen the side. Boron Steel is stronger than hardened steel.
  • The location and height of where the collision takes place seriously affects injuries to the patient.
• Rotational
  • Combination of Lateral and Frontal.
  • Common at intersections and in urban settings.
• Roll Over
  • Was the patient ejected? Any patient who was ejected and unrestrained is automatically high-priority.

Scene Survey

• Approach
  • Airbag Deployment
  • Damage & Deformity of Struck Object
  • Seatbelt Used?
  • Skid Marks on Road
  • Windshield Spidering
• Drivers Compartment
  • Airbag Deployment? Airbags are packed with an irratant powder and when deployed, the powder is forced into the skin.
  • Impaled objects from inside the drivers compartment.
  • Children 12 and under must be in the back seat.
  • Rear-Facing Front car seats pose an extreme risk of serious death or injury to children.
  • Short people who sit close to the airbag are at  higher risk for injury from airbag deployment.
  • Seatbelts
    • If seatbelts are locked, the accident is severe.
    • If seatbelts are unlocked, pull the seatbelt out completely, inspect the belt, and cut the belt if they show signs of damage.  By law, seatbelts must be replaced after every severe accident.  Unfortunately, many insurance companies refuse to replace seatbelts if they do not need to do so.

If a pregnant woman is a traumatic MVA, traumatic uterine rupture can occur. If the mother does not rupture her uterus, the mother may go into labor.

Lap belt syndrome is common with obese patients as the lab belt rides up against the rib cage. Once the crash occurs, the ribs puncture the internal organs.

Additionally, improperly worn lap and shoulder belts have caused severe injuries, up to and including decapitation.

• Motorcycle Collisions
  • Helmet Laws Suck
    • Some motorcycle riders would rather be dead than parylized.
• Pedestrian Versus Car
  • Fact or Fiction?
    • Waddell’s Triad
      • When a small child or person is  hit by a car, they assume the shape of the car, then fly back onto the road.  The truth of the matter is that studies have shown that there is no paticular pattern of pedestrian versus vehicle accidents.
  • If a person knows that they are about to be hit, the person will slap the hood with their hands. A hand print indicates that the person showed a reflexive response to an oncoming threat.
• Street Weapons
  • In America, the right to bear arms is given to citizens because the citizens have the fundamental right to overthrow their own government.
    • In America, one may only use a weapon in their own home, and even this is highly regulated. If you have an opportunity to retreat, you are expected to do so.
• Modern Weapons
  • Self Protection
  • Terrorism
• Importance to Paramedic Practice
  • Note Caliber of Bullet(s), if possible.

Interesting Facts About The United States of America

200 Million Firearms are in the United States; 1 to 3 million are automatic fire.

A violent crime is committed in the United States every 17 seconds.

46% of American Households have a long rifle.  A .22 rifle is enough to penetrate the side of an ambulance.

25% of American Households have a handgun.

70% of guns found in the posession of criminals were stolen and/or sold on the black market.

In 26 States, a person can buy a handgun with a drivers license. In Texas, any gun is legal without a permit as long as it is exposed.

Home made weapons such as Zip Guns and other traps are sometimes used.

In EMS, do not ring a doorbell because it may be loaded with a shotgun shell. When responding to a call, knock on the side of the door, loudly announce your presence, and stand to the side.  Hopefully, the frame of the door will provide protection.

The private space of an individual is usually arms legnth, whereas the private space of a trauma victim or an excited person is about twice arms legnth.

Studies in prisons have shown that 6 or more tattoos are a sign that a person is more prone to violence.

A criminal is typically looking for an escape. Therefore, they will do anything to buy themselves a little bit of time.

School studies have shown that 50% of school-aged children have access to handguns and/or other weapons.

There is no difference between a deadly weapon and a dangerous instrument.  The key is the person who has access to the item; either one of these things can cause serious injury or death.

Injuries to gun shot deal with tearing and crushing. Caliber and velocity are key to judging injury to patient.

• Gun Terms:
  • Caliber - The diamater of the bullet.
  • Rifling - The inside turns of the gun barrel to achieve higher accuracy over distance.
  • Hollow Point - A bullet that spreads out to a mushroom shape when it strikes an object.
  • Cop Killer - A bullet with a jacketed round that travels through body armor.
  • Tumble - The bullet is of such high velocity that it tumbles end over end.  It typically tracks down bones.
  • Fragmentation - Classic “Shotgun” Weapon
  • Velocity
    • Low (Arrows, Knives, etc.)
    • Medium (Handguns, etc.)
    • High (Rifles, Sniper Rifles, etc.)

Damage is usually a function of tissue and muscle. The more dense, the more damage that will occur.

Explosions

Could It Happen Here?  Or in your area?

The Anarchist Cookbook
A how-to guide to survival, anarchy, explosives, weapons, etc.

Deadly Explosives:
How and Why They Work

• Types of Bombs
  • Pipe Bombs
    • Match Head Bombs
    • CO2 Soda Fountain Bombs
    • Gun Powder Bombs
  • Chemical Reaction Bombs
    • Chemical Reaction In A Soda Bottle
  • Letter Bombs
    • Packages sent to or left for people.

Two of the biggest reasons for bombings include attention and/or revenge.

Fireworks may be fatal, such as M80’s and Military explosives. These items are also sometimes used to construct bombs.

• Rules of Engagement For EMS & Fire
  • Don’t touch it if you think it might be a bomb.
  • All explosions are bombs until proven otherwise, however, most explosions are not bombs.
  • Gain distance; 1000+ feet.
  • Do not use your radio on scene.

ABC’s of Blast Injuries:

• Primary Shock Wave Injuries
  • The compressed air blast.  Most impact is upon hollow organs.  The closest people will have collapsed lungs and or ruptured bowels.
• Secondary Injuries
  • The debries that are flying through the air as a result of the blast.
• Teritary Injuries
  • A heat wave that picks up an/or throws a person into other objects.
• Contamination
  • The smoke follows through and the smoke contamintes the area.

Pathology of Blast Injuries:

• Cardio Vascular System
  • Injuries to the heart and/or blood vessels attached to the heart.
• Respritory System
  • Diaphragm rupture; breathing with accessory muscles.
• Central Nervous System
• Gastrointestinal System
  • Trauma to spleen and liver, etc.

Farm Accidents:

Chemicals, silo gases, machinery, and age of the operators are all hazards to farm workers. Older tractors that are out of repair or not equipped pose a higher risk.

Additionally, farm machinery is run by hydraulic action. High-pressure hydraulic fluid that ruptures poses a danger to the operator or bystandars.

PTO Shaft turns around behind the tractor. Most of the new ones are shielded, but older ones and/or ones in disrepair can cause severe injury.  Cutting is not an option as these shafts are hardened steel.

Augers, which unload using a screwing device can rip, tear, and cause severe trauma.

Before removing any patient from machineary, you must render it safe.  One of the best ways is to remove the master link from the chain and remove it from the machine itself.

Chain saws can also cause severe lasceration and/or deep lascerations.  They are also available commercially to the general public.  Typically, consumers have little or know knowledge or training in the safe and proper use of chain saws.

Posted under Everything Else

Pharmacokinetics
“The movement of a drug around the body.”

3 Factors:

1. Absorbtion - Enteral or Perienteral
2. Solubility
3. Site of Absorption

First Pass Metobolism - Sometimes the liver activates and/or inactivates the liver. Some drugs are administered in high doses as to overwhelm the liver and leave behind enough drug to perform the intended action.

EMS avoids much of the problems with gastrointestinal issues such as absorption and/or changes in the drug by administering drugs via IV.

Pharmacodynamics - What the drug does to the body.

Environmental Factors Affecting Drug Disposition

• Genetic Factors
• Starvation - Affects Gastrointestinal Functioning
• Alcohol Intake
  • Affects Liver Function
• Cigarette Smoking
  • Stimulates Parasympathetic Nervous System
• Age
  • Pediatric Considerations
• Sex
  • Pregnancy
  • Body Fat
• Disease(s)
• Occupational Exposure
  • Chemical / Material Exposure
• Drugs
  • Interaction With Other Drugs
• Dietary Factors
  • MAO’s Breaks Down Epineferine
  • Patients Are Sometimes Given MAO Inhibitors
• Gastrointestinal Function
  • Small Bowel Obstruction
  • Constipation Can Increase Time That Drugs Remain In The Body, So Can Diarrhea.
• Renal Function
  • Decreases Circulation To Skin, Then Eventully Decreases Circulation To Kidneys.
• Liver Function
  • Liver Function May Be Needed To Transform Drug
  • Doses May Be Adjusted To Overcome The Liver Functioning.
• Cardiovscular Function
• Fever

Blood-Brain Barrier
The brain prevents drugs from getting out of the blood stream and into the brain.  This is a protection method to keep toxins from entering in to the brain.  Any of the drugs given that affect the brain have to be carried into the brain in much the same way that substances are passed in and out of cells.

Drug Responses

• Adverse Reaction
• Undesirable Drug Action
• Tolerance

Addiction begins either because the body relies on the dose of the chemical because it has stopped making the chemical itself.  Or, the body creates more receptors for the chemical, and therefore the body needs more and more of said chemical to continue normal function.

In the 1800’s in Springfield, Mass., factory workers got headaches when they went home for the weekend. Workers became tolerant with the nitrates in gun powder. To solve this problem, workers carried a small bag of gun powder in their pockets to keep their nitrates level maintained.

Pediatric Considerations

Some drugs have preservatives that may be toxic to pediatric patients.

Geriatric Considerations

• Decreased liver function.
• Multiple Drug Prescriptions
  • Drug Interactions
• Decreased Stomach Acidity
• Decreased Digestive Speed
• Decreased Renal Function (Up To 50%)
• Twice As Many Abnormal Drug Interactions
  • Signs Include
    • Confusion
    • Lethargacy
    • Weakness

Pregnancy Considerations

A placental barrier exists, though some drugs do pass through this barrier. A fetus is most at risk during the first trimester of pregnancy. Drugs are not given to women unless they are absolutely necessary.

FDA Pregnancy Safety Categories

• Category A
  Generally Safe For The Fetus
• Category B
  Animal Studies, No Human Practice Experience
• Category C
  Birth Defects In Animal Studies
• Category D
  Drug is Known To Cause Birth Defects
• Category X
  Drug is Known To Be Fatal To Fetus

Breast Feeding
Most drugs do appear in breast milk, and the baby will be affected by the consumption of the breast milk.  Additionally, the breast milk sometimes concentrates the drug.

Improper Storage of Drugs

Studies have been done on drugs as to their expiration date based on hospital conditions.  These studies have never been performed under EMS conditions in which the temperature fluctuates greatly.

Many of the drugs given in EMS have not yet been tested in EMS conditions.  Therefore, it is a good idea to replace drugs before the expiration date.

Drug Reactions
“Timing is Everything.”

Know the patients History. Allergies, drugs they are taking, and their past history all affect the drugs you are giving.

The Five Rights Of Drug Administration

1. Right Patient
2. Right Drug
3. Right Time
   • Slow
   • Fast
   • Very Fast (20 cc Saline Bolus)
4. Right Dose
   • All drugs are weight related.
   • Pediatric Considerations
   • Geriatric Considerations
5. Right Route

The Three (3) Checks

1. Check Before
   • Check Expiration
   • Check Clarity
   • Check Drug Spelling
2. Check During
   • When You Are Pushing It
3. Check After
   • When You Dispose Of It

A Paramedic can administer more than the standard dose of a medication if directed by a Medical Doctor.

A Paramedic can question the order given to you by a Medical Doctor.  The AMA encourages Paramedics to question the physician concerning the order.

Paramedics cannot refuse the order given to them from the Medical Doctor once the order has been confirmed.  However, should a problem arise, it is the responsibility of the MD. If you question the doctor and a bad outcome arises, it is the responsibility of the medical doctor.

“People not educated as doctors shouldn’t be encouraed to ct as though they were!”
–Court Statement

Evaluate and document your observations after administering a drug.  These include a full set of vital signs, EKG, Pulse Ox, Etc.

Top 5 Drug Errors

1. Omission
   • Failure to follow standing orders.
2. Wrong Dose
   • Whenever possible, consult a chart.  EMS is based on a rough estimate of the patient’s weight.
   • More than 10% or less than 10% is within the legal range of acceptable dose.
   • All prehospital drugs are clear except for Vallium, which is yellow.
3. Extra Dose
   • The Paramedic that goes into the drug box is the one that takes the order.
4. Unordered Drugs
   • Practicing medicine without a license. This happens when a Paramedic gives a drug that they did not recieve an order for.
5. Wrong Route
   • Giving a drug Sub-Q instead of IM, etc.

Common Mistakes

• Critical Incident Reporting (CIR)
• Professional Responsibility
• Criminal and Civil Liability

If you make a mistake, report it.  Tell the doctor about any mistakes that were made, and document them in your paperwork. It is your responsibility to yourself and to the patient to report exactly what happened.

Needle Safety

Needles are your responsibility.

In Odesa Texas Fire Department, a known drug adict in cardiac arrest was left behind at the scene along with bloody gloves. Three children became exposed to the gloves, and the family sued for $5 Million per pair of gloves.

Oriface Patrol

• PO - By Mouth (Slow & Inconsistant Absorption)
• ET - Endotracheal Tube Administration
• SL - Sublingual (Requires Saliva)
• Nasal - Spray
• Rectal - Absorbed Rectally; Must get past the Anus.
• Nasogastric - NG Tube Administration Directly Into Stomach
• Topical - Absorbed Through Skin (Requires warm skin.)
• Intradermal - Inside Skin Layer
• Subcutaneous - Below Skin
• Intramuscular - Administered Into Muscle

Bloody Parts

• Intravenous Bolus / Push
• IV Drip - Continus Drug Dose
• IV Central
• Intracardiac - Drug administered directly into heart.
• Intralingual - Injected directly under the tongue.

Bony Parts

• Intrathecal - Injection into the spine.
• Intraosseous - Injection into bone.

New Technology

• Biojectors
  • Blows a hole open with compressed air, administers drug, and is needle free.
  • Typically used in the Military.
• Phoresors - Drug is administered using an electric current.
• Pumps - Drug dosing is established given a set of pre-programed paramaters.

Methods Of Injection & Medication Administration

• Subcutaneous Injection
  • Indications
    • No Time Consideration; Sustained Action
  • Contraindications
    • Patient In Shock
  • Precautions
    • Accidental Veinipuncture
  • Site Selection
    • In Pediatrics - Deltoid
    • Thigh
  • Medication Prep
    • 45 Degree Angle To The Skin
    • Up to 1 cc
    • 5/8 Inch Needle
• Intramuscular
  • Indications
    • Faster Absorption Than Sub-Q
  • Contraindications
    • Accidental IV
    • Accidental Nerve Stimulation
  • Precautions
    • Use Larger Diamater Needle (19 Ga.)
    • Under 100 LBS = Under 1 Inch
    • Over 100 LBS = 1 Inch
    • Over 200 LBS = 2 Inch
  • Site Selection
    • Upper 1/3 of Thigh For Geriatric
    • Middle Deltoid Muscle (Used Most In EMS)
    • Z-Track Method - Pull Skin, Inject
      • The pain from IM is from the release of medicine through to the skin layer.
    • No more than 2 cc per injection.
• IV Bolus (IVP)
  • Indications
    • Medical Emergencies
  • Contraindications
    • Allergies To Drug
    • Accidental Arterial Injection
  • Site
    • Learn Anatomy - Find Veins
  • Medication Preparation
    • Clamp IV Tubing. Administer drug.   Discard unused portion.
    • Elevate arm. Push 20 cc bolus.  Perform 1 minute CPR.
• Endotracheal
  • Indications
    • Last Resort
  • If Eppineferine is given down the ET tube, a double dose is needed.
  • Minimum of 3 Ventillations Are Needed
  • Minimum of 10 cc’s of volume
  • Eppineferine prevents patient from breathing by constricting the lung tissue.
• Topical
  • Incications
    • Slow, Sustained Action

Potentiation - Giving two drugs together for bigger effect.  1 + 1 = 3

Synnergysm - Newer chemical property.

Antagonism - Drug interfearance with another drug.

Side Effects:
Bold Face or Italic - Predictable Side Effects

Adverse Reaction is not expected.  Examples include Hypersensitivity, Idiosyncratic Reaction, Anafalatic Reaction, Reaction To Preservatives, Reaction To Alcohol.

Some patients will have toxic reactions.

• Intravenous Access
  • Indications:
    • Trauma
    • Hypovolemia
    • Excessive Fluid Loss
    • Massive Infection / Septic Shock
    • Intestinal Obstruction(s)
  • Contraindications:
    • Blood Thinning
    • Head Injury
    • Pulmonary Edema
    • Intracranial Pressure
    • Trauma

Paramedics generally start IV’s on scene because they don’t think that they can start an IV enroute in the hospital.

A Study Of IV Success:
On-Scene Success: 77%
Enroute Success: 86%

• IV Uses
  • * Med-Line
    • Analgesia
    • Breathing Treatment
    • Cardiac Medications
    • Dysrhythmia Meds
  • Stand-By
  • Ease of Access in EMS
  • Save Time
    • Hospitals are Busy
    • If ER Nurse Starts IV, Medic Should Have Started One Enroute

Local IV Complications

• Extravastions
• Thrombophlebitis
  • Blood clot may form around the IV needle.  It will be hot and firm to the touch.
  • Occurs 24 Hours After IV Established

Systemic Considerations

• Hypothermia
  • IV Fluids Are The Temperature Of The Cabinet They Are Stored In.
• Fluid Overload
  • Too Much Fluid

Common IV Solutions

• Colloid
  • Colloids cannot leak out of blood stream.  Therefore they are volume expanders, not volume replacements such as Normal Saline Solution.
  • Whole Blood
    • Not Used In EMS For Multiple Resons
  • Packed Red Blood Cells
  • Albumin
• Crystalloids
  • Normal Saline
    • 0.9% Sodium Chloride
    • 20 to 30 Minutes
    • 3 L of Saline Replaces 1 L of Blood
    • Compatable With Blood Products
  • Ringers
    • Invented by Dr. Ringer as a substitute to human blood.
    • Volume Replacement
    • Ringers lasts only a short time.
    • Popular with surgeons.
• Precautions
  • Clarity
  • Integrity
  • Date
• IV Administration Sets
  • Micro - 60 Drops / cc
  • Macro
  • Legnth Counts
    • Longer Tubing = Slower Flow
    • Smaller Diamater Tubing = Slower Flow
  • Trauma Tubing
    • Hospital Technology Spplied to Prehospital Problems
    • 2 Spikes
    • Large Diamater Tubing
    • Blood Tubing is an Alternative
  • Pediatric Considerations
    • Three-Way Stop Cock
    • Extension Tubing
  • Additions To IV Set-Ups
    • Extension Tubing
    • Pressure Bag
    • Hypothermia Bags (IV Warmer)
• 5 Veins Used With IV
  • Axillary
  • Basiliac (Good For Psych Patients)
  • Cephalic
  • Dorsal Arch (Between Knuckles)
  • EJV - External Jugular Vein
    • Thumb Above, Forefinger Below
    • Distention
    • Tamponade
• Precautions
• Do not start IV’s on limbs with fractures.
• Diabetics
• Steroid Dependant
• Chemotherapy
• Addicts
• Elderly

• Central Access
  • Triple Lumens
• PICC Lines
  • Fiber Optic
  • Inserted Into Heart
• Implanted Port
  • Under Skin
  • Runs Into Heart
  • Requires 90 Degree Needle
• Shunts
  • EMERGENCY ONLY!
  • Used With Dialysis Patients
  • Loops Around; Venous and Arterial Side Connected
• Angioplasty
  • Avoid the Anicubital and Groin!

Tricks Of The Trade

• Heat / Warmers
• Double TQ
• Milk The Vein
• Nitro Paste (Just A Little Smear)
• PPE (Personal Protective Equipment)
  • Gloves
  • Goggles
  • Mask
  • Gown
• Bits And Pieces
  • Commercial Prep Kits
  • IV Roll

Allergies?
If Allergic to Betadine, Antibiotic Ointment Works Well In Small Amounts.

• Needles
  • Butterflys; Used in Hospitals
  • Needle Through Catheter; Wide EMS Use
  • Trauma Line; Large Bore IV Needles
  • Needle Over Catheter; Central Line Use
• Passive Safety Technology
  • Retractable Needle
  • Protected Needle

• Blood Tubes
  • RED
    • EtOH
    • Trauma (2 Tubes)
    • Chemistry
  • BLUE
    • Goag’s
    • AMI
    • Stroke
  • PURPLE
    • Blood Study
    • WBC
    • H & H

Posted under Everything Else

Pharmacology For Paramedics

Responsibilities

Chemotherapy - Drug Therapy

• Prophylaxis
• Pallitative
• Curative

Americans are known to being resistant to treating pain in patients. Americans have been very reluctant to administer pain medication.

Historical Considerations

“One suffers due to the original sin.”

In the middle ages, a woman bearing a child in pain was a biblical punishment for sin.  The harder the labor, the more the pain, and thus the greater the sin.

Each birth brings forth an easier labor and less pain, as each birth of a child is a maricle.

Some of the most powerful pain relievers are opiates.  Under the influence of drugs, a person may experience a variety of different things.  Historically, medical people would test the medicines on themselves before using them on their patients.

In ancient Egypt, the most common medical problems had to deal with disease.  These things included headache, dierhhea, vomiting, etc. Early treatments for dirheea included opium to make stool more firm.  All treatments came from experiences in trial and error.

Asprin comes from the bark of a willow tree. On average, over 1 billion pounds of Asprin is used by the American public per year.

• Drug Sources
  • Plant
  • Animal
  • Mineral
  • Synthetic
  • Genetic

Human Genome Project

Drug Legislation

Pure Food And Drug Act of 1906
This act set national standards, and the government established control of drugs.  Physicians opposed this act as it limited their ability to practice medicine.

Back then, medicine was crude and physicians actually performed experiments on their patients. As time progressed, physicians developed a list of helpful therapies.

However, today a physician is able to write a prescription for any medication.  The physician takes full and ultimate responsibility for the patient outcome.

Harrison Drug Act of 1914
In 1914, the problem was opium.  This was preceeded by the Boxer Rebellion in China.  The British had huge stock in the opium trade.  The British was selling opium in China.  The Chinease accordingly tried to ban the sale of these drugs.  A war resulted between the British and the Chinease.

Opium soon became a problem in the United States.  The Harrison Drug Act of 1914 was to become the first narcodics act.

Pure Food, Drug and Cosmetic Act of 1938
This required people to need a prescription to acquire a drug. This made a traceable trail to help control drugs and protect the public from harm. This ensured that the drugs actually worked and cured the things that they claimed that they could do.

The Narcotic Act of 1956
The end of Cocaine and the removal of Cocaine in Coca-Cola.

1970
Phaarmacists had to have strict security of drugs. Additionally, the double-lock standard applied to narcodics. Interestingly, this did not necessarily apply to EMS.

The FDA also established the DEA and gave DEA numbers to physicians.  Drugs became classified in schedules.

• Schedule 1 - High Abuse, No Use
  • LSD
• Schedule 2 - High Abuse, Limited Use
  • Opium
  • Cocaine
• Schedule 3 - Moderate Use, Limited Use
  • Tylenol 3 (T-3)
• Schedule 4 - Low Abuse, Good Use
• Schedule 5 - Low Abuse
  • Certain Cough Medicines

Drugs Classified

“Standardized By Effects”

• Antimicrobals and Antiparasitics
• Cardiovascular
• Central Nervous System (CNS)
• Autonomic Nervous System
• Respritory System
• Hormonal Agents
  • Fluid and Electrolyte Balance
• Hematological Agents
• Antineoplastic Agents
• Immunomodulation Drugs

Paramedics Give Drugs In Every Classification

How To Learn Your Drugs

• Altered Mental Status
• Chest Pain
• Shortness of Breath
• Abdominal Pain

Drug, Defined - A substance that taken into a living organism that may modify any of its life systems.

Any substance that is taken into the body in excess can be harmful.

Official USP Drugs
UNITED STATES PHARMACOPEIA

Any drug that is manufactured according to United States standards, is registered with the USP.  This is a certification that the substance you are purchasing is in fact consistant with its labeling.

The United States Pharmacopeia certifies drugs that are manufactured and/or sold in the United States. Furthermore, it strictly regulates the manufacture of the drug.

• Drug Names
  • Chemical Name
  • Generic Name
  • Trade Name
  • Street Name

The key is to learn the generic name, as many people are recieving generic versions of medications.

• Drug Forms
  • Solids
  • Extracts
  • Powders
  • Pills
  • Capsules
  • Tablets
• Drug Carriers
  • Suppositories - Drug mixed with wax.
  • Ointments - Paste-Like Substance
• Liquid Drug Solutions
  • Solute and Solvent
    • Suspensions
    • Tinctures (Alcohol is the Solvent)
    • Spirits (Volitle Liquids)
    • Syrups (Drug Mixed With Sugar Syrup Solution)
    • Elixirs (Sugar And Alcohol)
    • Milks (Old Term For Suspensions)
    • Linaments (Lotions; Oil-Based).
• Drug Containers
  • Ampules
    • Single-Use Container
  • Vials
    • Multiple Doses (Not Common In EMS)

Ampules were invented as an air-tight solution before tin, metal, and plastic had become common. Therefore, glass was used to seal the drug air-tight until it was needed.

Drug Abbreviations

ASA = Asprin
APAP = Acetominophen
Dig = Digitalis
EtOH = Ethanol Alcohol
Barb = Phenobarbital
MAO = Monomine Oxidase
MSO4 = Morphine Sulfate
NSAID = Nonsteroidal Anti-Inflammatory Drug

/s = Without
stat. = Immediately
t.i.d. = 3 Times A Day
ut. dict. = As Directed

Drug Dosing

a.c.= before meals
ad lib = as desired
b.i.d. = twice a day
/c = with

Drug Measurements

gm. = Gram
gtt. = Drop
h.s. = At Bedtime
noct. = Night

Drug Scheduling

p.r.n. = As Needed
q.h. = Every Hour
q.i.d. = Four Times A Day
q.s. = Quanity Sufficient (Take As Much As You Need)
q.o.d. = Every Other Day

Weights And Measures

Inches

x

25.4

=

Milimete rs

Feet

x

30.4 8

=

Centime ters

Teaspoo ns

x

4.93

=

Millileter s

Tablespo ons

x

14.7 9

=

Millileter s

Fluid Ounces

x

29.5 7

=

Millileter s

Cups

x

0.24

=

Liters

Pints

x

0.47

=

Liters

Quarts

x

0.95

=

Liters

Gallons

x

3.79

=

Liters

United States Measure to Metric Measure Conversion Table

The Metric System is universally accepted for use in medicine. The above table shows how to convert from American units of measure to the Metric System.

Grain

1/5760 Pound

64.799 mg

1 Dram

60 Grains

1/8 Ounce

3.8879 Grams

8 Drams

1.0971 Ounces

31.1035 Grams

96 Drams

1 Pound

373.242 Grams

Conversion Table of Drams, Ounces / Pounds, and Grams

International System Adopted in 1960

Unit

Quanit y

Symbo l

Legnth

Meter

m

Mass

Gram

gm

Volum e

Liter

l

Metric Units of Measure, Quanity, and Symbol.

Prefixes
Kilogram (kg) 10³ = 1,000 g
Centigram (cg) 10^-2 = 0.01 g
Milligram (mg) 10^-3 = 0.001 g
Microgram (ug) 10^-6 = 0.000,001 g

Decaliter (da) 10 = 10 1
Mililiter ml 0.0001 1

Paramedic Drug Calculations

Patient Weight Conversions Formula
Weight (Kg) = Weight (lbs) / 2.2 (factor)

IV Push Drugs Formula
(Dose To Administer) = (Desired Dose / Concentration)

IV Fluid Rate Calculation - Drip Rate Formula:
(Drops Per Minute) = (Volume To Be Infused) x (Time In Minutes)

Common Tubing Factors
Microdrops = 60 drops / cc (1)
Macrodrop = 10 drops / cc (6)
Macrodrop = 15 drops / cc (4)
Macrodrop = 20 drops / cc (3)

1:1 Ratio
150 cc/hour = 150 drops/minute
250 cc/hour = 250 drops/minute
325 cc/hour = 325 drops/minute

3:1 Ratio
180 cc/hour = 60 drops/minute

Posted under Everything Else