EMT
TABLE OF CONTENTS Introduction .................................................................................................................................... 1 Section 1: Airway, Respiration and Ventilation .............................................................................. 4 Airway Management ................................................................................................................... 4 Terms to Know about Respiration .............................................................................................. 5 The Phenomenon of Gas Exchange............................................................................................. 5 What is Hypoxia? ......................................................................................................................... 6 Airways in Children...................................................................................................................... 6 Evaluating the Airway.................................................................................................................. 7 Airway Techniques ...................................................................................................................... 7 Oxygenation .............................................................................................................................. 10 Ventilation ................................................................................................................................. 11 Tracheal Intubation ................................................................................................................... 13 Rapid Sequence Intubation ....................................................................................................... 16 Respiratory Distress .................................................................................................................. 17 Respiratory Failure and Respiratory Arrest............................................................................... 22 Key Takeaways .......................................................................................................................... 29 Quiz............................................................................................................................................ 30 Section 2: Cardiology and Resuscitation ....................................................................................... 40
Chest Pain .................................................................................................................................. 40 ACS EMS Protocol ...................................................................................................................... 43 Cardiac Rhythm Disturbance ..................................................................................................... 45 Ventricular Fibrillation............................................................................................................... 47 Cardiac Arrest ............................................................................................................................ 49 Hypotension/Hypertension from Cardiovascular Cause........................................................... 56 Key Takeaways .......................................................................................................................... 60 Quiz............................................................................................................................................ 61 Section 3: Trauma ......................................................................................................................... 71 Bleeding ..................................................................................................................................... 71 Chest Trauma ............................................................................................................................ 73 Abdominal/GU Trauma ............................................................................................................. 77 Orthopedic Trauma ................................................................................................................... 79 Soft Tissue Trauma .................................................................................................................... 81 Head/Neck/Face/Spine Trauma ................................................................................................ 83 Key Takeaways .......................................................................................................................... 92 Quiz............................................................................................................................................ 93 Section 4: Medical / Obstetrics / Gynecology ............................................................................ 103 Neurological Emergencies ....................................................................................................... 103
Abdominal Disorders ............................................................................................................... 107 Immunology Emergencies ....................................................................................................... 110 Urticaria ................................................................................................................................... 112 Infectious Disease.................................................................................................................... 115 Acute Bacterial Meningitis ...................................................................................................... 115 Endocrine Disorders ................................................................................................................ 121 Psychiatric Emergencies .......................................................................................................... 125 Toxicology Emergencies .......................................................................................................... 130 Hematology Emergencies........................................................................................................ 133 GU/Renal Emergencies............................................................................................................ 135 Gynecology Emergencies ........................................................................................................ 137 Obstetrics Emergencies ........................................................................................................... 140 Key Takeaways ........................................................................................................................ 143 Quiz.......................................................................................................................................... 144 Section 5: EMS Operations ......................................................................................................... 154 Maintain vehicle and equipment readiness ............................................................................ 154 Operate emergency vehicles................................................................................................... 156 Provide Scene Leadership ....................................................................................................... 158 Resolve an emergency incident .............................................................................................. 159
Provide emotional support ..................................................................................................... 161 Maintain medical/legal standards........................................................................................... 161 Maintain community relations ................................................................................................ 162 Provide administrative support............................................................................................... 163 Enhance professional development........................................................................................ 163 Key Takeaways ........................................................................................................................ 166 Quiz.......................................................................................................................................... 167 Summary ..................................................................................................................................... 177 Course Questions and Answers .................................................................................................. 179
INTRODUCTION The purpose of this course is to help a prospective EMT pass their EMT test. This course covers each of the five sections an EMT must be familiar with as a practicing professional. This includes airway management and topics related to heart disease and cardiac resuscitation. Trauma is also covered as this is a big part of EMS operations. There are numerous medical emergencies an EMT must know about and be able to manage in the field. Finally, EMS operations are covered including things like maintaining and operating the emergency vehicle and having control over the scene. The topics of section one of the course are airway, respiration, and ventilation. As an EMT, airway management is a vital task associated with assessing and transporting a patient. Some patients will only need an airway and have the ability to ventilate on their own. Others will be unable to ventilate, and require interventions such as the bag-valve-mask and endotracheal intubation. It is crucial to be able to identify a patient in respiratory distress, which will be covered in this section. Identifying and managing serious disorders like upper and lower airway emergencies are within the job description of the EMT. The most severe respiratory emergency include respiratory failure and arrest, which are discussed in this section. Section two of the course covers the topic of cardiology and resuscitation. This includes the evaluation and management of chest pain, including acute coronary syndrome. There is also a discussion regarding cardiac arrhythmias and their management. Cardiac arrest protocols are covered as are stroke and stroke-like symptomatology. Post resuscitation care is an important
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part of EMS practices and will be covered. Finally, syndromes of hyper- and hypotension secondary to cardiac causes are discussed. Section three in the course examines the EMT’s role in trauma. In traumatic situations, the EMT is often one of the first skilled responders on the scene. They must deal with internal and external bleeding and the often-deadly problems involving chest and abdominal trauma. Orthopedic and soft tissue trauma usually go together and can be life-threatening. Issues of head, neck, facial, and spinal trauma are often seen together in a trauma situation. On many occasions, the EMT must handle the complexities of multi-system trauma, which must be handled in a specific order, ranging from the most severe to minor traumatic injuries in the multiply injured patient. Section four of the course covers a wide range of topics, including various medical, obstetric, and gynecological emergencies. It starts with coverage of the various neurological emergencies the EMT deals with and progresses to a discussion of abdominal emergencies. Immunological, infectious disease, and endocrinological emergencies must be understood by the EMT so the patient can be managed in the prehospital setting. Psychiatric emergencies are important to manage as well as emergencies related to toxicological exposures. Hematology and genitourinary emergencies are discussed in this section. Finally, emergencies related to obstetrics and gynecology are examined. The goal is to have a broad base of medical knowledge regarding the majority of medicine-related conditions. Section five in the course explores EMS operations. There are many aspects of EMS care that don’t directly relate to medicine. For example, the EMT must maintain the ambulance and must keep the equipment operable. There is also a need to learn how to operate an emergency vehicle in an emergency. At each and every scene, there is a need to establish leadership to maintin control over the circumstances. If there are incidents at the scene, the EMT needs to learn how to resolve them. Sometimes, emotional support is just as important as medical support—both for the patient and their loved ones. It is also the EMT’s responsibility to maintain adequate community relations, for example by teaching injury prevention. Some EMTs are also administrators and need to manage a team of EMTs of varying skill levels. As 2
many protocols in EMS change, the EMT is responsible for professional development, which is covered in this section.
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SECTION 1: AIRWAY, RESPIRATION AND VENTILATION As an EMT, airway management is one of the most important tasks associated with assessing and transporting a patient. Some patients will only need an airway and have the ability ventilate on their own. Others will be unable to ventilate and require interventions such as the bag-valve-mask and endotracheal intubation. It is crucial to be able to identify a patient in respiratory distress, which will be covered in this section. Identifying and managing serious disorders like upper and lower airway emergencies are within the job description of the EMT. The most severe respiratory emergency are respiratory failure and respiratory arrest, which are also discussed in this section.
AIRWAY MANAGEMENT The normal individual goes through a cycle called inhalation and exhalation. Inhalation is also referred to as “inspiration”, in which the diaphragm contracts and moves in a downward direction. There is contraction of the intercostal muscles as well, which expands the ribcage. This is an unconscious, active process that utilizes negative pressure in the chest cavity, which causes air to rush into the lungs. Expiration or “exhalation” is also unconscious but it is passive. The diaphragm relaxes and moves upward. The intercostal muscles relax and the ribcage moves inward. This decreases the size and increases the relative pressure of the chest cavity ad air is forced outward. Disorders of inspiration and expiration can be structural or neurological.
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There are several factors that affect the rate and depth of respirations. They include the following: A. The hypercarbic drive: this is the drive that is in place in normal, healthy individuals. There are chemoreceptors in major arteries that detect the level of CO2 in the arterial blood. If the CO2 level is elevated, the individual feels the urge to breathe. B. The hypoxic drive: this is the drive where oxygen chemoreceptors regulate respiration (among patients with COPD, including chronic bronchitis and emphysema). Because respirations are dependent upon the oxygen (O2) level, the lower the O2 level, the greater the respiratory drive to breathe. This means that prolonged oxygen administration in a COPD patient could cause the individual to stop breathing.
TERMS TO KNOW ABOUT RESPIRATION These are some important terms to recognize about breathing: A. Respiration: This refers to the complete process of breathing and the exchange of gases in the alveoli of the lungs. B. Oxygenation: This refers to the process of allowing oxygen to get into the red blood cells and cells of the body. C. Ventilation: This refers to the mechanical act of breathing in and out.
THE PHENOMENON OF GAS EXCHANGE The laws of gas exchange in the lungs involve the process of diffusion. With diffusion, molecules (in this case, O2 and CO2) go from an area of high concentration to an area of low concentration. In the lungs, the concentration of O2 is higher in the alveoli than it is in the capillaries so it diffuses from the alveoli to the capillaries. The reverse is true for CO2, which diffuses from the capillaries to the alveoli. Outside of the lungs (at the tissue level) CO2 diffuses from the cells to the capillaries and O2 diffuses from the capillaries to the cells.
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WHAT IS HYPOXIA? Briefly, hypoxia refers to a lack of oxygen. It can be secondary to decreased or inadequate breathing, shock, carbon monoxide poisoning, blocked airway, or lower airway disease. Evidence of mild hypoxia include tachypnea (an increased respiratory rate), dyspnea (the sensation of shortness of breath), pale or clammy and cool skin, tachycardia (increased heart rate), restless, combativeness, agitation, disorientation or confusion, hypertension, and headache. As the patient develops severe hypoxia, the signs include dyspnea, tachypnea, cyanosis (one of the last signs, which can be seen in the inside of the mouth, the lips, the nailbeds, and the conjunctiva), tachycardia (which progresses to dysrhythmia and finally bradycardia as a late sign), alteration in mental status, and somnolence. The management of hypoxia starts with opening the airway with a jaw-thrust maneuver or head tilt/chin-tilt maneuver. High concentration O2 should be administered via a nonrebreather mask. If under-ventilating, the patient needs positive pressure ventilation.
AIRWAYS IN CHILDREN Children’s airways are more likely to become obstructed because they have a narrower trachea and airway, larger tongue with respect to the rest of their mouth, smaller mouth and nasal cavity, and a larger head/body ratio. The neck, when tilted and lying supine, tends to obstruct the upper airway. The narrow part of the airway is at the level of the cricoid cartilage which is less rigid (more likely to collapse). They require more diaphragm power to breathe than adults and have a softer chest wall (weaker intercostal muscles), resulting in a greater chance of overinflation during artificial respirations. Because of their higher metabolic rate and a decreased O2 reserve, they have a higher risk of hypoxia. Most cardiac arrests in kids is secondary to hypoxia and respiratory arrest.
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EVALUATING THE AIRWAY If the patient is alert, responsive, and talking, they most likely have a patent airway. Patients with an altered mental status have a decreased ability to protect their airway. The lack of a gag reflex can cause aspiration of stomach contents if there is vomiting. In addition, the tongue may obstruct the airway because they have no control over it. Facial injuries (trauma or burns) can deform or obstruct the airway. The phenomenon of snoring is from upper airway obstruction by the tongue or soft palate. An unconscious snoring patient may require a jaw-thrust or head-tilt/chin-lift maneuver. Some may need a nasal or oral airway. The phenomenon of crowing is caused by muscle spasms around the larynx (to be treated with oxygen and ventilation). Gurgling represents liquid in the airway (to be treated by suctioning). Stridor is common in children and represents swelling of the larynx. The treatment is O2 and artificial ventilation.
AIRWAY TECHNIQUES To open the airway, place the patient in a supine position and use the crossed thumb-forefinger to open the mouth using a scissors motion. This will open the mouth but will not necessarily open the airway. In opening the airway, the first-line technique is the head-tilt/chin-lift maneuver. Please refer to figure in your manual to see how this is done. The head is tilted back slightly. This allows for some opening of the airway. Then lift the chin to draw the tongue and mouth structures upward, opening the airway.
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Figure 1: Head-tilt/chin thrust maneuver The jaw thrust maneuver is done in instances of possible cervical spine injury. The healthcare provider position themselves behind the victim. Placing both hands on either side of the jaw, the jaw is thrust forward, opening the airway. This is demonstrated in figure 2 in your manual.
Figure 2: The Jaw-Thrust Maneuver Suctioning is done by inserting the tip of the suction device into the mouth but no deeper than the base of the tongue in order to avoid causing the gag reflex. Suctioning should only take place when the catheter is on its way out. Suction for no longer than fifteen seconds at a time in adults and for no longer than five seconds in infants and children. If this results in inadequate ventilation, apply positive pressure ventilation.
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There is a hard, rigid catheter called the Yankauer, tonsil sucker, or tonsil tip—used only to suction the mouth and oral pharynx. The length of the catheter is measure from the tip of the earlobe to the corner of the mouth. A soft catheter, referred to as the “French” catheter can be used instead of a rigid one for the suctioning of the nose and nasopharynx. The catheter size for this type of catheter is measured from the tip of the nose to the earlobe. For patients with a stoma, such as after a laryngectomy, have a hole in the neck that acts as the airway opening. The stoma is where suction is performed into the trachea. Artificial respiration goes through the hole (tracheostomy) as well. For an obstructed airway, the Heimlich maneuver can be performed. It involves abdominal thrusting maneuvers, performed on a conscious, choking patient. The rescuer stands behind the patient, hugs the patient around the upper abdomen from behind, and thrusts inward and upward. In a conscious and choking infant below one year of age, tilt the child downward and slap the baby on the back. Refer to figure 3 to see how the infant’s obstructed airway is cleared.
Figure 3: Black slaps in an infant with obstructed airway Oral and nasal adjuncts include the oropharyngeal airway or oral airway. This is measured by the corner of the mouth to the earlobe for correct sizing. It protects the tongue from blocking the airway. It is inserted upside down and then inverted so it sits at the base of the tongue. Presence of a gag reflex is contraindication to using this type of airway. If the patient is awake and coughing, they still have an intact gag reflex and should not have an oral airway.
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A nasal airway can be utilized on a conscious patient. It is also referred to as a nasopharyngeal airway. It is measured in length from the tip of the nose to the earlobe. It holds the airway open via the nostrils. It is advantageous because it does not elicit the gag reflex. If the patient is breathing spontaneously, they can be protected from aspiration by placing them in a coma/recovery position. The patient is placed on their side with the downside arm behind the head. This allows for vomiting without the risk of aspiration.
OXYGENATION There are several ways to oxygenate a patient without having to ventilate them. This involves providing a passive source of oxygen that the patient can inspire. There are several sources: A. Nasal cannula—this involves giving a two-pronged device connected to an oxygen source. The prongs are placed in the nose. The minimum amount of oxygen that can be given this way is 2 liters per minute. Common doses of oxygen given this way are 2-6 lpm. These can provide 24-40 percent oxygen. B. Simple face mask—this is a mask placed over the mouth and nose with oxygen flowing from an attached tube. It can deliver 5-8 lpm with achievable oxygen concentrations of 28-50 lpm. C. Venturi mask—this is often used for COPD patients and delivers a specific amount of oxygen at concentrations of up to 40 percent. D. Partial rebreather mask—this has a mask with a reservoir bag that can increase the concentration of oxygen to 5-15 lpm or 40-70 percent oxygen. E. Non-rebreather mask—this has high dose oxygen at 8-10 liters per minute though a mask and a reservoir like a partial rebreather mask. The difference is that it has a one-way valve that gets rid of expelled/exhaled air so that it delivers nearly 100 percent oxygen. F. Demand oxygen delivery system or oxygen resuscitator—this is a mask that delivers oxygen only when the patient inhales or when the provider presses a button on the
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mask. This feature makes it possible to use the device for things like CPR. It can deliver up to 100 percent oxygen. G. Pocket mask—this is the simplest positive pressure oxygen delivery device. It allows a rescuer to deliver rescue breaths without having to do mouth-to-mouth resuscitation.
VENTILATION Ventilation involves the actual act of inspiring and expiring air/gases by the lungs. A patient may have an open airway but cannot ventilate themselves. The mainstay of treatment for a lack of ventilation is the bag-valve-mask (BVM). The BVM can provide rescue breathing to a patient indefinitely. If not performed correctly, however, it can make hypoxia worse and can result in the death of the patient. Refer to figure 4 to see how a BVM is applied.
Figure 4: The application of a bag-valve mask The first step is to recognize that the patient needs ventilation. If the RR is less than 8 breaths per minute or when the tidal volume falls below 300 ml/breath, assisted ventilation is necessary. The cause may be discovered and reversed; however, artificial ventilation must be initiated before attempting to reverse the cause of the apnea/hypopnea. Position the patient, set up the airway, and maintain the proper airway position. The patient needs to be supine and the gurney elevated to about the level of the rescuer’s abdomen. The rescuer should be standing at the level of the crown of the patient’s head. The jaw should be
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thrust forward, pushing the chin upward. Tilting back of the head is appropriate for patients without a suspected cervical spine injury. An adjunct can be helpful in the form of a nasopharyngeal airway. An oral airway can be used if the patient has no gag reflex. This will insure a patent airway. Measure the nasal airway from the tip of the nose to the ear lobe. Choose a mask that fits over the mouth and nose with a complete seal and no leakage. The mask should be sealed to the patient’s face. The rescuer’s thumb should be at the nose end and the fingers should surround the chin end of the mask. See figure 5 in your manual for proper placement of the BVM.
Figure 5: BVM placement of the hands The goal is to provide tidal volume of 800 cc in adults and a target RR of 10 ventilations per minute. A rescuer should listen for breath sounds and should observe the rising of the chest during ventilations. High flow oxygen should be given and a pulse oximeter should be used to measure the oxygen concentration in the blood. The provider should lift the chin up to the BVM instead of pushing the mask down on the face. Pushing the mask will push the tongue into the back of the throat, leading to an obstructed upper airway. The seal should be effective. For this reason, many propose a two-rescuer use of the BVM. One person maintains the seal and the other person ventilates the patient. Use the correct tidal volume (about 800 cc) and don’t over or under-ventilate the patient. Overinflation may cause the stomach to insufflate, leading to vomiting and aspiration. To properly provide BVM ventilation, the provider needs a BVM with a non-rebreathing valve and an oxygen reservoir (allowing a spontaneously breathing patient to draw oxygen from the bag and reservoir) and a clear mask (allowing the provider to identify any regurgitation) that
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permits a tight seal over both the mouth and nose. They should not have a pop-off valve as sometimes high pressures are needed. The main goal of ventilation is to maintain oxygenation. This is evidenced as having a pulse oximeter saturation of O2 of 90 percent or greater. If it isn’t working, check the seal, use of jaw thrust, insertion of oral airway or nasal airway, and mask size. Suction the airway if needed. Squeeze the 1-liter bag about two-thirds of the way for a minimum of 600 cc (up to 800 cc) per squeeze. From a physiological perspective, the BVM ventilation is positive pressure ventilation versus the negative pressure ventilation used by people normally. It forces air into the lungs instead of having air drawn into them. The main side effect is decreased cardiac output from reduced venous return to the right side of the heart—made worse in hypovolemia. This is why ventilation should be minimized in CPR. Another downside to BVM ventilation is barotrauma—most commonly the pneumothorax. This comes from delivering higher than normal tidal volumes during BVM ventilation. Gastric distention and gastric perforation can also occur.
TRACHEAL INTUBATION In some cases, tracheal intubation cannot be done. Some patients respond to a double lumen device instead, which can be blindly inserted with less skill than required for a tracheal intubation. It involves the placement of a flexible tube into the trachea in order to have a protected airway. It mainly allows for ventilation but also is a conduit for the administration of certain drugs. In the conscious or semi-conscious patient, it requires general anesthesia and a neuromuscular blocking drug or a strong local anesthetic. It requires a laryngoscope, flexible fiberoptic bronchoscope, or a video laryngoscope in order to place the device safely. These allow for visualization of the vocal cords, through which the ET tube passes.
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