LIFELINE (512-639) by Junep Ocampo

START OF PART 4 (PAGES 512-‐639)

LIFELINE PREHOSPITAL EMERGENCY CARE

THE nervous system is like the computerâ&#x20AC;&#x2122;s CPU -- it controls virtually all parts of the body, particularly the five senses, the ability to think and reason, voluntary and involuntary functions, and regulates blood flow and blood pressure. Because of this, injuries to the head and the spine will have a significant effect on other parts of the body. Prompt and timely treatment must therefore be given

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to those with nervous system emergencies. In this chapter, you would learn about different kinds of nervous system emergencies, particularly those caused by head, neck and spine injuries. The spinal cord primarily transmits signals between the brain and the rest of the body, and controls reflexes. Injuries to the spine can cause a person to lose the inability to move parts of the body.

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Central Nervous System Trauma Anatomy of the head and the spine Skull fractures and brain injuries Glasgow coma scale Caring for spine injuries A person may have a spinal or head injury if he was in a road accident. And such accident is what you, as a future EMT, would be likely to respond to. The number road crashes in the Philippines is on the rise, and many of them involve motorcycles. This chapter, therefore, is very important for you as a future EMT because it will lay down the foundation for what you need to do to provide care for victims of such emergencies.

Tips for immobilizing patients

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CRITICAL CONCEPTS � The two main divisions of the nervous system are the central nervous system and the peripheral nervous system. � You should maintain a high index of suspicion for head or spine injury whenever there is a relevant mechanism of injury. � You must provide cervical spine stabilization before beginning any other patient care when head or spine injury is suspected. � Altered mental status is an early and important indicator of head injury. Monitor and document your patient’s mental status throughout the call. Ang injury sa ulo at sa spine ay napakadelikado. Posible itong magdulot ng panghabambuhay na pagkabalda o kamatayan kung hindi maaagapan. Kung pangunahin ang tamang pagsusuri at pagbibigay ng ABC sa pasyente, pangalawa naman sa pinakaimportante na dapat tutukan ang pagtugon sa injury sa ulo at sa spine.

PRINCIPLES OF EMT CLINICAL PRACTICE

CENTRAL NERVOUS SYSTEM TRAUMA

UNIT DAY 2

LEARNING OBJECTIVES • Access the most current information on any aspect of neurology. • Recognize the clinical manifestations of neurologic disorders and describe current options for diagnosis, management and therapy, including the efficacy, doses, and interactions of individual drugs. • Evaluate and treat neurologic manifestations of systemic disorders. • Identify risk factors for and strategies to prevent neurologic disorders. • Define and discuss the epidemiology (including the morbidity/mortality and preventative strategies), pathophysiology,

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assessment findings, and management for neurologic problems. Describe and differentiate the major types of seizures. Describe the phases of a generalized seizure. Define and discuss the pathophysiology, assessment findings, and management for nontraumatic spinal injury, including: Low back pain, herniated intervertebral disk and spinal cord tumors. Differentiate between neurologic emergencies based on assessment findings.

INTRODUCTION You have probably noticed that, throughout the earlier chapters of this book, there have been many cautions for patients with possible injuries to the head and spine. This is because injuries to these areas are extremely serious and may result in severe permanent disability or death if improperly treated or missed during your assessment. Second only to proper assessment and care of the ABCs. proper assessment and care for head and spine injuries will be your most important responsibility as an EMT.

NERVOUS AND SKELETAL SYSTEMS

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The following segments briefly review the anatomy of the nervous system, head, and spine.

Nervous System The components of the nervous system are the brain and the spinal cord as well as the nerves that enter and exit the brain and spinal cord and extend to the various parts of the body. The nervous system provides overall control of thought, sensations, and motor functions, whereas the skeletal system provides support and protection. The skull protects the brain, whereas the bones of the spine protect the spinal cord. Whenever the skull or the spine is injured, suspect nervous system damage as well. The nervous system is divided into two subsystems: the central nervous system and the peripheral nervous system. The central nervous system consists of the brain and the spinal cord. The peripheral nervous system includes the pairs of nerves that enter and exit the spinal cord between each pair of vertebrae, the 12 pairs of cranial nerves that travel from the brain without passing through the spinal cord, and all of

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the body’s other motor and sensory nerves. Neurons are the opposite side of the body. This is why an injury to the the specialized nerve cells that transmit nervous system left side of the brain may produce effects such as weakness impulses throughout the body. or lack of sensation on the right side of the body. UNIT 3 Messages from the body to the brain are carried by Some nerves control involuntary functions—those OF EMT CLINICAL PRACTICE PRINCIPLES OF EMT DAY CLINICAL PRACTICE 20 PRINCIPLES sensory nerves. Messages from the brain to the muscles we do not consciously control — including heartbeat, are carried by motor nerves. The motor nerves control breathing, control of the diameter of your vessels, control voluntary movements, or those we consciously control, of the round sphincter muscles closing your bladder such as running or grasping. As the nerves exit the brain, and bowel, and digestion. These nerves are part of the The nervous system is divided into two subsystems: the central nervous system autonomic nervous system. (Autonomic means automatic.) and theprior to travelling down the spinal cord, they cross over to peripheral nervous system. The central nervous system consists of the brain and the spinal cord. The peripheral nervous system includes the pairs of nerves that enter and exit the spinal cord between each pair of vertebrae, the 12 pairs of cranial nerves that travel from the brain without passing through the spinal cord, and all of the body's other motor and sensory nerves. Neurons are the specialized nerve cells that transmit nervous system impulses throughout the body.

THE SKULL

Anatomy of the Head

The skull is made up of the cranium

Messages from the body lo the brain are carried by sensory nerves. Messages and the facial bones. The cranium, the from the brain to the muscles are carried by motor nerves. The motor nerves conportion of the skull that encloses the trol voluntary movements, or those we consciously control, such as running or grasping. As the nerves exit the brain, prior to travelling down the spinal cord, brain. is formed by the forehead, top. back, they cross over to the opposite side of the body. This is why an injury lo the left and upper sides of the skull. The cranial side of the brain may produce effects such as weakness or lack of sensation on floor is the inferior wall of the brain case, the right side of the body.

the bony floor beneath the brain. The

cranial bones are fused together to form Some nerves control involuntary functions—those we do not consciously controlincluding heartbeat, breathing, control of the diameter of your vessels, control of immovable joints. the round There are 14 irregularly shaped bones sphincter muscles closing your bladder and bowel, and digestion. These nerves arc part of the autonomic nervous system. (Autonomic means automatic.) forming the face. The facial bones are fused into immovable joints, except for

the mandible, which joins on each side of Anatomy of the Head

the cranium with a temporal bone to form the temporomandibular joint, sometimes referred to as the TM joint.

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The skull is made up of the cranium and the facial bones. The cranium, the portion of the skull that encloses the brain. is formed by the forehead, top. back, and upper sides of the skull. The cranial floor is the inferior wall of the brain case, the bony floor beneath the brain. The cranial bones are fused toThe upper jaw is made up of two gether to form immovable joints.

fused bones called the maxillae. Each is

There are 14 irregularly shapedknown as a maxilla. The upper third, or bones forming the face. The facial bones are fused into immovable joints, except for the mandible, which joins on each side bridge, of the nose contains two nasal of the cranium with a temporal bone to form the temporomandibular joint, bones. There is a cheek bone on each sometimes referred to as the TM joint.

side of the skull which can be called the

The upper jaw is made up of malar or zygomatic bone. The malars two fused bones called the maxillae. Each is known as a maxilla. The upper third, or bridge, of the nose contains two nasal and the maxillae form a portion of the bones. There is a cheek bone on each side of the skull which can be called the orbits (sockets) of the eyes. malar or zygomatic bone. The malars and the maxillae form a portion of the The brain is held within the skull. orbits (sockets) of the eyes.

The spinal cord exits the base of the

The brain is held within the skull. The spinal cord exits the base of the brain brain and leaves the skull through a and leaves the skull through a large hole where the spinal column is attached. large hole where the spinal column is The brain is bathed in a fluid called cerebrospinal fluid (CSF). which also circulates down the spine around theattached. The brain is bathed in a fluid spinal cord.

called cerebrospinal fluid (CSF). which also circulates down the spine around the spinal cord.

THE SKULL (SIDE VIEW) ² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

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Anatomy of the Spine The spine is made up of 33 irregularly shaped calledNERVOUS vertebraeSYSTEM (singularTRAUMA CENTRAL Day 20 bones, vertebra), which sit one on lop of another to form the spinal column. Each vertebra has a spinous process, a bony bump you can feel along the center of a The spine is made up of 33 irregularly person's back. Every vertebra has a holshaped bones, called vertebrae (singular low space like the hole in a donut . These vertebra), which sit one on top of another to form the spinal column. Each vertebra hollow spaces form a channel that runs has a spinous process, a bony bump you the length of the spinal column and concan feel along the center of a personâ&#x20AC;&#x2122;s tains the spinal cord, which is cushioned back. Every vertebra has a hollow space by the cerebrospinal fluid. like the hole in a donut . These hollow

Anatomy of the Spine

spaces form a channel that runs the length of the spinal column and contains The vertebrae are divided into five areas. the spinal cord, which is cushioned by From top to bottom, they are: 7 cervical the cerebrospinal fluid. The vertebrae (in the neck). 12 thoracic (to which the are divided into five areas. From top to bottom, they are: 7 cervical (in the neck). ribs attach), 5 lumbar (mid-back), 5 sacral 12 thoracic (to which the ribs attach), (lower back), and 4 coccygeal (in the 5 lumbar (mid-back), 5 sacral (lower coccyx, or tailbone i Both the sacral and back), and 4 coccygeal (in the coccyx, or coccygeal vertebrae are fused together, tailbone). Both the sacral and coccygeal vertebrae are fused together, forming the forming the posterior portion of the pelposterior portion of the pelvis. vis.

DIVISIONS OF SPINE

INJURIES TO THE AND AND BRAIN INJURIES TO SKULL THE SKULL BRAIN

Scalp Injuries

ScalpThe scalp has many blood vessels, so any scalp injury may Injuries

Brain Injuries

Brain injuries can be classified as direct or cause a profuse amount of bleeding Control scalp bleeding by indirect. Direct injuries to the brain can occur in Theapplying direct pressure. Dress and bandage as you would other scalp has many blood vessels, so any scalp injuryopen head injuries, with the brain being lacerated, may cause a profuse soft-tissue injuries. However, be careful about applying direct punctured, or bruised by the broken bones or by amount of bleeding Control scalp bleeding by applyingforeign objects. Indirect injuries to the brain may direct pressure. Dress pressure when there is a possible skull injury. Do not apply andpressure if the injury site shows bone fragments or depression bandage as you would other soft-tissue injuries.occur with either closed or open head injuries. In However, be careful of the bone or if the brain is exposed Instead, use a loose gauze an indirect injury, the shock of impact on the skull about applying direct pressure when there is a possible skull injury. Do not dressing. is transferred to the brain. Indirect injuries to the apply pressure if the injury site shows bone fragments or depression of the brain include concussions and contusions

bone or if the brain is exposed Instead, use a loose gauze dressing.

Skull Injuries

Kapag may suspetsa ka na may injury sa skull o sa utak ang pasyente, malamang na may if severe enough, there can also be injuries to the brain. injury din ito sa spine. Isa sa unang senyales na Skull injuries can be either open or closed. With most may injury ito sa utak ay ang pag-iiba ng takbo Skull injuries include fractures to the cranium and the face, if severe enough, injuries, the words open and closed refer to whether or not the ng pag-iisip nito. Madalas, ang nagiging there can also be injuries to the brain. skin and its underlying tissues have been broken. With head suspetsa ay lasing lamang o naka-droga injuries, however, the words open and closed refer to the cranial ang pasyente, pero yun pala ay may bones When the bones of the cranium are fractured, and the head injury siya. Huwag Skull injuries can be either open or closed. With most injuries, the na words open over-lying scalp is lacerated, the patient has an open head injury. na huwag mong babaleandIf the scalp is lacerated but the cranium is intact, it is considered closed refer to whether or not the skin and its underlying tissues walain ang senyales nghave altered been broken. With head injuries, however, the words open andstatus. closed refer to to be a closed head injury. In practice, you may not be able to mental Suriin mabuti ang pasyente para malaman thedetermine if a head injury is open or closed. It b safest to assume cranial bones When the bones of the cranium are fractured, and the over- ang that there may be an open head injury beneath any contusion or tunay na problema lying scalp is lacerated, the patient has an open head injury. If the scalp isnito. lacerlaceration of the scalp You should tin be aware that a head injury ated but the cranium is intact, it is considered to be a closed head injury. In may be present with no external injury.

Skull Skull injuries include fractures to the cranium and the face, Injuries

practice, you may not be able to determine if a head injury is open or closed. It b safest to assume that there may be an open head injury beneath any contu516 LIFELINE PREHOSPITAL EMERGENCY CARE sion or laceration of the scalp You should tin be aware that a head injury may be present with no external injury.

Traumatic Brain Injuries

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A traumatic brain injury (TBI) is an injury that disrupts the normal functioning of the brain. It may be a brief (e.g., concussion) or long-term condition with permanent damage to the brain. The following section describes types of traumatic brain injury. It is not necessary for you as an EMT to diagnose the specific conditions (this is done in the hospital), but knowing the types of injuries and how they present will help you understand these conditions, identify critical patients, and make appropriate transport decisions.

Concussion

UNIT 3 DAY 20

PRINCIPLES OF EMT CLINICAL PRACTICE

A concussion may be so mild that the patient is unaware of the injury. When a person strikes his head in a fall, or is struck by a blunt object, a certain amount of the force is transferred through the skull to the brain. Usually there is no detectable damage to the brain and the patient may or may not become unconscious. Most patients with a concussion will feel a little “groggy” after receiving a blow to the head, and a headache is also common. If there is a loss of consciousness, it usually lasts only a short time and does not tend to recur. Sometimes, after a head ² Limmer (Brady) blow, bystanders will say the patient “just sat there staring ³ Pollack, (AAOS) ⁴ NHTSA off into space for a few minutes.” Some loss of memory (amnesia) of the events surrounding the incident is fairly common. A common saying is that the fighter did not see the punch that did him in. Actually, he probably did see the punch but then forgot it because of the concussion.

Contusion

A bruised brain, or brain contusion, can occur with closed head injuries, when the force of the blow is great enough to rupture blood vessels on or within the brain. A contusion is often caused by a collision or blow that causes the brain to hit the inside of the skull, bounce Off the opposite side, and then rebound to strike the first side of the skull again. When the bruising of the brain occurs on the side of the blow, it is called a coup injury. When it occurs on the side opposite the blow, it is called a countercoup injury.

Laceration

Hematoma

Concussion.

A hematoma is a collection of blood within a tissue.

A concussion may be so mild that the patient is unaware of the injury. When a A hematoma inside the cranium is named according to person strikes his head in a fall, or is struck by a blunt object, a certain amount its location, which may be inside or outside the dura, the A laceration, or cut, to the brain can occur from the of the force is transferred through the skull to Ihe brain. Usually there is no brain’s protective outer covering, or within the brain itself. same forces that might cause a contusion. The inner skull detectable damage to the brain and the patient may or may not become unA subdural hematoma is a collection of blood between the has many sharp, bony ridges that can lacerate a moving conscious. Most patients with a concussion will feel a little "groggy" after rebrain. A laceration or a puncture wound can also be ceivingbrain and the dura. An epidural hematoma is blood between a blow to the head, and a headache is also common. If there is a loss the dura and the skull. An intracerebral hematoma occurs caused by an object penetrating the cranium. of consciousness, it usually lasts only a short time and does not tend to recur. “ when blood pools within the brain. Sometimes, after ahead blow, bystanders will say the patient "just sat there staring off into space for a few minutes." Some loss of memory (amnesia) of the events surrounding the incident is fairly common. A common saying is that the lighter did not see the punch that did him in. Actually, he probably did see the 517 LIFELINE PREHOSPITAL EMERGENCY CARE punch hut then forgot it because of the concussion.

Contusion A bruised brain, or brain contusion, can occur with closed head injuries, when

UNIT 3 DAY 20 Day 20

Intracranial Pressure There is limited room for expansion inside the patient’s hard skull. When a hematoma develops, pressure increases inside the skull. This is referred to as increasing intracranial pressure (ICP). There is a typical progression that is seen with this condition. The hematoma expands and places pressure on the brain, pushing and compressing the brain tissue. Since the cranium is a rigid container, the brain is forced toward the only space available— the opening at the base of the skull called the foramen magnum. The time it takes for symptoms to develop from an increased ICP depends on the rate of bleeding into the skull and the location of the bleed. A small subdural hematoma obtained in an assault or a fall could take from hours up to 2 days before serious symptoms develop, whereas a brisk epidural bleed may almost instantly develop and show symptoms. The body has mechanisms to deal with increasing pressure within the brain. The body’s highest priority is to perfuse the brain with oxygen. When intracranial pressure increases, the body must increase the blood pressure to pump blood into and perfuse the brain. This is why you will see increasing blood pressure in patients with intracranial pressure. As ICP increases and cerebral perfusion decreases, carbon dioxide levels increase, and this causes brain tissue to swell. This swelling worsens intracranial pressure and creates a vicious cycle in which the body increases blood pressure in an attempt to perfuse the brain while carbon dioxide builds and increases swelling. As the hematoma continues to grow, swelling worsens, and the brain is pushed downward toward the foramen magnum, compressing the brainstem. The brainstem regulates our most vital functions, including breathing, heartbeat, and blood pressure. As this area is compressed, in addition to an altered mental status, you may see dilated pupils or sluggish pupil reaction, abnormal respiration patterns, increased systolic blood pressure, and a decreased pulse rate.

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CENTRAL NERVOUS SYSTEM TRAUMA

As the brain and brainstem become severely compressed and pushed downward (herniation), the patient may exhibit decorticate or decerebrate posturing. These may be neurological posturing, such as flexing the arms and wrists and extending the legs and feet (decorticate posture) or extending the arms with the shoulders rotated inward and wrists flexed and with the legs extended (decerebrate posture). These postures may be assumed spontaneously or in response to a painful stimulus. A patient who has an epidural or subdural hematoma (remembering that there are variables such as the size and location of the bleed as well as concurrent injuries) may present in the following sequence: 1. The patient falls and strikes his head. He appears OK at first. 2. He develops a slight altered mental status after about 10 minutes. Because the hematoma is beginning to place pressure on one or both cerebral hemispheres. 3. The altered mental status worsens. Soon the patient responds to loud verbal only by moaning. His blood pressure begins to increase. 4. The patient is now totally unresponsive to any stimuli. His blood pressure is 220/106. You notice his pulse beginning to drop. It had been 88 and now it is 54. His pupils have become unequal or nonreactive. 5. RR become slightly irregular. BP increases. The pulse now drops to 48/minute. 6. The patient begins decerebrate posturing. You may see some seizure activity, followed by decorticate posturing. Death follows if uncorrected by intervention at a trauma center.

PATIENT ASSESSMENT Skull Fractures and Brain Injuries The signs of skull fracture and of brain injury are very similar, as noted in the following list: • Although visible bone fragments and perhaps bits of brain tissue are the most signs of skull fracture, most skull fractures do not produce these signs • The patient may have an altered mental status. Check it by using the AVPU scale (alert, verbal stimulus, painful stimulus, unresponsive). If the patient is alert, check for orientation to person, place, and time. Or use Glasgow Coma Scale. • There maybe a deep laceration or severe bruise or hematoma to scalp or forehead. Do not probe or separate the wound opening to determine wound depth. • Depressions or deformity of the skull, large swellings (“goose eggs”), or anything unusual about the shape of the cranium may be visible • Severe pain may exist at the site of a head injury Pain may range from a headache to severe discomfort Do not palpate the injury site with your fingertips as you may push bone fragments into the injury • “Battle’s sign.” a bruise behind the ear (late sign), may be present. • Pupils ate unequal or nonreactive to light.

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PRINCIPLES OF EMT CLINICAL PRACTICE

RACCOON’S EYES

BATTLES SIGN

Note shock Note that that shock (hypoperfusion) (hypoperfusion) from from blood blood loss loss is is generally generally not not aa sign sign of of head head • ”Raccoon eyes” black eyes/discoloration of soft tissues under both eyes (late sign). injury except in infants. There simply is not enough room within the adult skull • One eye appears to be sunken. • Bleeding exists from the ears and/or nose. to permit enough bleeding to cause shock If there is head injury injury with with shock, shock, • Clear fluid flows from the ears and/or nose. look for • indications of blood loss somewhere else on the body Personality change, ranging from irritable to irrational behavior (a major sign). • The patient has an increased blood pressure and decreased pulse rate With so many factors to consider, possible skull or brain injury can be very diffi(Cushing’s triad, also called Cushing’s reflex). Note that shock (hypoperfusion) from • The patient has irregular breathing patterns. blood loss is generally not a sign of head cult to definitively determine Therefore, assume theinjury except in infants. There simply is patient has a skull or brain • There is a temperature increase (late sign due to inflammation, injury when the mechanism of injury and the location of the injury indicate a infection, or damage to temperature-regulating centers). not enough room within the adult skull to • Blurred or multiple-image vision is present in one or both eyes. permit enough bleeding to cause shock If possible• head injury Impaired hearing or ringing occurs in the patient’s ears. there is head injury with shock, look for • Equilibrium problems exist The patient may be unable to stand still indications of blood loss somewhere else on with his eyes closed or may stumble when attempting to walk (Do the body. not test for this). With so many factors to consider, • Forceful or projectile vomiting may occur. possible skull or brain injury can be • The patient may exhibit decorticate or decerebrate posturing. very difficult to definitively determine • The patient may experience paralysis or disability on one side of the Therefore, assume the patient has a skull or body. brain injury when the mechanism of injury • Seizures may be present. and the location of the injury indicate a • The patient has deteriorating vital signs. possible head injury.

With so many factors to consider, possible skull or brain injury can be very difficult to definitively determine Therefore, assume the patient has a skull or brain injury when the mechanism of injury and the location of the injury indicate a possible head injury

PATIENT CARE

Skull Fractures and Brain Injuries

Emergency care of a patient with skull fractures and brain injuries includes the 519 LIFELINE PREHOSPITAL EMERGENCY CARE the following steps: Emergency care of a patient with skull fractures and brain injuries includes

following steps: 1. 2.

Take appropriate Standard Precautions Assume there is a spine injury Provide manual stabilization of the

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PATIENT CARE Skull Fractures and Brain Injuries

CENTRAL NERVOUS SYSTEM TRAUMA

Emergency care of a patient with skull fractures and brain injuries includes the following steps: 1. Take appropriate standard precautions. 2. Assume there is a spine injury Provide manual stabilization of the head on first patient contact, and use the jaw-thrust maneuver to open the airway. For the unconscious patient, insert an oropharyngeal airway without hyper extending the neck Have suctioning equipment ready, since these patients are prone to vomiting. 3. Monitor the unconscious patient for changes in breathing. Provide artificial ventilations if breathing is inadequate. 4. Apply a rigid cervical collar, immobilize the neck and spine, and, if appropriate, determine the method of extrication, either normal of rapid. 5. Administer high-concentration oxygen by nonrebreather mask, and evaluate the need for artificial ventilations with supplemental oxygen. This is critical if there is any brain damage 6. In some EMS systems, if the patient shows signs of increased intracranial pressure (such as decreased mental status associated with dilated pupils or sluggish pupil reaction. abnormal respiration patterns, increased systolic blood pressure, and a decreased pulse rate), EMTs are instructed to ventilate the patient with supplemental oxygen at the rate of approximately 20 breaths per minute This slight hyperventilation will help reduce brain tissue swelling by lowering carbon dioxide levels and raising oxygen levels. The procedure is not without risk, however Too much ventilation can decrease blood flow to the brain. This process is reserved for patients with critical head injuries, where the benefit is felt to outweigh the risk. Hyperventilating a breathing patient with a bag-valve mask and oral airway is extremely difficult to do and runs a serious risk of inflating the stomach and causing aspiration of stomach contents. Follow your local protocol Hyperventilation is not a routine part of the management for all head injury patientsâ&#x20AC;&#x201D;only those who are believed to have increasing intracranial pressure. 7. Control bleeding. Do not apply direct pressure if the injury site shows bone fragments or depression of the bone or if the brain Is exposed Do not attempt to stop the flow of blood or cerebrospinal fluid from the ears or the nose. If the skull is fractured, you may increase intracranial pressure and the risk of infection Instead, use a loose gauze dressing. 8. Keep the patient at rest. This can be a critical step. 9. Talk in the conscious patient and provide emotional support. Ask the patient questions so that he will have 520

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to concentrate. This procedure also will help you to detect changes in the patientâ&#x20AC;&#x2122;s mental status 10. Dress and bandage open wounds Stabilize any penetrating objects (Do not remove any objects or fragments ofbone). 11. Manage the patient for shock even if signs of shock are not yet present. However, do not elevate the legs unless signs of shock are present and your local protocols permit. Avoid overheating. 12. Be prepared for vomiting. Have a suction unit ready for use. 13. Transport the patient promptly. 14. Monitor vital signs every 5 minutes en route to the hospital. If you are not certain of the severity of the patientâ&#x20AC;&#x2122;s injuries, or if there is evidence of cervical-spine injury, or if the patient with a head injury is unconscious, the patient must be immobilized to a long spineboard. With the entire head. neck, and body rigidly immobilized, the patient may be rotated into a lateral recumbent position so that blood and saliva can freely drain. If the patient vomits, the vomitus is also less likely to cause an airway obstruction or he aspirated (breathed into the lungs) in this position. Some patients with a head injury will vomit without warning. Many vomit without first experiencing nausea. The vomiting is likely to be projectile vomiting (forceful, explosive vomiting). If injuries prevent lateral positioning, constant monitoring and frequent suctioning are required.

Cranial Injuries with Impaled Objects If there is an object impaled in the cranium, do not remove it. Instead, stabilize the object in place with bulky dressings. This, with care in handling, will minimize accidental movement of the object. A lengthy impaled object can make transporting the patient impossible until the object is cut or shortened, fad around the object with bulky dressings then carefully (and rigidly) stabilize the object on both sides of where the cut will be made. Cutting should be done with a tool that will not cause the object to move or vibrate Kung may nakatusok sa when it is finally severed. A ulo ng pasyente, huwag mo hand hacksaw with a fineitong aalisin. Maging maingat tooth blade can be carefully sa pagbebenda nito. controlled and produces only a small amount of heat. In any case in which you may have to cut an impaled object, seek advice from medical direction or the emergency department physician.

Injuries to the Face and Jaw Facial fractures are usually caused by an impact, as when a child is struck in the face by a baseball bat or when someone is thrown against a windshield. Bone fragments may lodge in the back of the pharynx and cause airway obstruction. Blood, blood clots, dislodged teeth, or a separated palate may also block the airway. The mandible is subject to dislocation as well as to Kung may fracture. As with any facial malubhang tama sa injury, there may be pain, mukha ang pasyente, discoloration, swelling, malamang na meron and facial distortion. In addition, when the mandible din itong skull o brain injury. is injured or dislocated, the patient may be unable to move the lower jaw or may have difficulty speaking. There may be an improper alignment of the upper and lower teeth and bleeding around the teeth. The primary concern with facial fractures is the patient’s airway. Be prepared to suction to remove debris, including loose teeth and blood, from the airway. Because of possible spinal injury, use the jaw-thrust maneuver to open the airway. Control profuse bleeding. Apply a rigid collar and immobilize the patient on a spine board. If possible, position the patient to allow drainage from the mouth. Care for shock.

Some systems would immediately transport a patient with a GCS score of less than 14 directly to the trauma center if they are within 30 minutes transport time. When using this score, keep the following considerations in mind:

1. Eye opening. Spontaneous eye opening means that the patient

opens his eyes without your having to do anything. If his eyes are closed, say “Open your eyes” to see if he will obey. Try a normal level of voice. If this fails, shout the command. Should the patient’s eyes remain closed, apply an accepted painful stimulus (such as pinching a toe. scratching the palm or sole, or rubbing the sternum). Note any eye injuries or injuries to the face that prevent the patient from opening the eyes If the injuries are more than minor ones do not ask the patient to open his eyes. 2. Verbal response. In evaluating patient’s verbal responses, use these criteria: • Oriented. The patient, once aroused, can tell you who he is where he is and the day of the week. A person who can answer all three of these questions appropriately is said to be alert on the AVPU scale. • Confused. The patient cannot answer the previous questions, but he can speak in phrases and sentences. • Inappropriate words. The patient says or shouts a word or several words at a time. Usually this requires physical stimulation. The words do not fit the situation or a particular question. Often, the patient curses. • Incomprehensible sounds. Patient responds with mumbling, moans/groans. • No verbal response. Repeated stimulation, both verbal and physical, does not cause the patient to speak or make any sounds. 3. Motor response. The following criteria are used to evaluate motor response: • Obeys command. The patient must be able to understand your instruction and carry out the request. For example, you may ask the patient (when appropriate) to hold up two fingers. Many of the signs or brain injury may be caused by • Localizes pain. If the patient fails to respond to your an internal brain event such as a hemorrhage or blood commands, apply pressure to one of the nail beds for 5 clot. The signs of nontraumatic (not caused by external seconds or firm pressure to the sternum. Note if the patient trauma) brain injury will be the same as those for a attempts to remove your hand. Do not apply pressure over an traumatic injury, except that there will be no evidence of injury site. Do not apply pressure to the sternum if the patient trauma and no mechanism of injury. is experiencing difficulty breathing. • Withdraws, after painful stimulation. Note if the elbow flexes, if the patient moves slowly, Habang naasa lugar if there is the appearance of stiffness if he ng aksidente, huwag ubusin All head-injury patients must be holds his forearm and hand against the body, ang oras sa pag-calculate constantly monitored during transport. Be or if the limbs on one side of the body appear ng score sa Glasgow Coma prepared in case the patient vomits or has a to be paralyzed (hemiplegic position). Scale. Gawin mo ito habang seizure. What you observe and report can • Posturing, after painful stimulation. Note if ibinabiyahe ang have a great bearing on the ED staff’s initial pasyente. the legs and arms extend, if there is apparent actions upon your arrival The early signs of stiffness with these moves and if there is deterioration are subtle changes in mental an internal rotation of the shoulder and status that may be overlooked if you are not forearm. watching for them. Some EMS agencies use • No motor response to pain. Repeated painful the Glasgow Coma Scale (GCS), in addition to stimulation does not cause the patient to AVPU. for ongoing neurological assessment. grimace or make any motions

Nontraumatic Brain Injuries

Glasgow Coma Scale

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521

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GLASGOW COMA SCALE Eye Opening Spontaneous To Voice To Pain None

Verbal Response 4 3 2 1

Oriented Confined Inappropriate Words Incomprehensible Sounds None

Motor Response 5 4 3 2 1

Obeys Command Localizes Pain Withdraws (pain) Flexion (pain) Extension (pain) None

6 5 4 3 2 1

Dressing an Open Neck Wound the head continues to travel forward Some parts of the spine are more at the same speed that the vehicle was susceptible to injury than others. Because FIRST TAKE travelling, even though the body is held it is somewhat splinted by the attached STANDARD PRECAUTIONS by seat restraints. This neck movement ribs, the thoracic spine is not usually may exceed the normal range of motion. damaged except in the most violent 1. Do not delay! Place your Virtually the same thing occurs when the collisions or in gunshot wounds. The gloved palm over the wound. vehicle is struck from behind. pelvic-sacral spine attachment helps 2. Place an occlusive dressing A fall can generate enough force to to protect the sacrum in the same way. over the wound. It must be fracture or dislocate vertebrae. Assume However, the cervical and lumbar heavy plastic and sized to be that any fall three times the patient’s vertebrae are susceptible to injury 2 inches larger in diameter height or with enough force to cause because they are not supported by other than the wound site. open fractures to the ankles will also be bony structures. 3. Seal the dressing with tape accompanied by a spine injury. Need-less The spine is most often injured on all four sides disability has been caused when head by compression or excessive flexion, 4. Cover the occlusive dressing injuries or other injuries resulting from extension, or rotation from falls, diving with a large gauze dressing. a fall were noted and cared for but spinal injuries, and motor-vehicle collisions. Bind a bandage over the injuries were overlooked. Spine injuries in EMS workers often dressing and wrap in a Today, more and more people are result from not adhering With the figure-eight configuration, participating in sports of all kinds: inproper lifting techniques, causing lateral winding the bandage under line skating, mountain biking, surfing, bending or disk injuries. When the the arm opposite the wound. rock climbing, and others too numerous spine is excessively pulled, it can cause Never wind the bandage to mention. Many sports mishaps can a “distraction” injury. This mechanism around the patient’s neck. cause spine injury. Sledding or skiing of spine injury occur in a hanging. Years can hurl a person into a tree or other ago. rescuers were taught to pull traction fixed object, twisting or compressing the spinal column. on the neck of an injured patient sitting in an automobile. There may be no open wound or fracture of an extremity, or However, this actually had the potential to cause injury, so signs of injury may be hidden by bulky clothing. As a result, today EMTs are taught to manually stabilize the head and improper care may be rendered as the patient with a possible neck, or hold it still. Maintain a high degree of suspicion of a potential spine spinal injury is placed on a stretcher without adequate examination and immobilization. injury when your patient is a victim of a motor-vehicle or Diving incidents often produce injury to the cervical motorcycle collision, was struck by a vehicle, received blunt spine. When the diver strikes the diving board, the side or injury to the spine or above the clavicles, was involved in bottom of the pool, or an underwater object, the head can be a diving incident, was found hanging by his neck, or was severely forced beyond its normal limits of motion (flexion, found unconscious due to trauma. extension, or compression). Cervical vertebrae may be The adult skull weighs more than 17 pounds and rests fractured or dislocated, ligaments may be severely sprained, on a very small area of the cervical spine (like a pumpkin and the spinal cord may he compressed or otherwise on a broom handle). Motor-vehicle collisions produce traumatized in the cervical region and at other spots along violent whiplash injuries because of the speed and sudden the cord. deceleration of the vehicle. When a vehicle strikes another Football and other contact sports can generate forces vehicle or a fixed object head on, the neck can whip quickly severe enough to produce spinal injury. Spear tackling, back and forth. Although the vehicle decelerates abruptly, 522

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using the head, has been outlawed in grade schools and high schools for number of years due to the incidence of cervical compression fractures. When a game involves player contact or falling to the ground, you should remain on the alert for spinal injury. The brain is the master organ of life. Messages from all over the body are received by the brain, which determines the body’s response. The brain sends messages to the muscles so that we can move, or to a particular organ so that it will carry out a desired

function. For example, it may tell the adrenal gland to dump epinephrine into the bloodstream, which increases heart rate. Any major head injury can damage the brain, causing vital body functions to fail. The spinal cord is a relay between most of the body and the brain. A large number of the messages to and from the brain are sent through the spinal cord. Therefore, damage to the cord can isolate a part of the body from the brain, resulting in loss of function of this region—possibly forever.

Inside/Outside

THREE EXAMPLES OF DYSFUNCTION FROM SPINAL INJURY The spinal cord is the conduit through which messages are transmitted from the brain to the body and from the body to the brain. These messages may be as simple as the brain telling your hand to move to pick up something or as vital as directing the diaphragm to contract so that breathing takes place. Injuries to the spine can cause many problems, including paralysis. The location of injury on the spine dictates how the body is affected. Perhaps the most catastrophic trauma is injury to the cervical spine. Because of its proximal location, the cervical spine affects the entire body; critically, the primary muscles of breathing are innervated by nerves that originate from the third to the fifth cervical vertebrae (C3 to C5). The phrenic nerve originates primarily from the 4th cervical vertebra (C4), with some innervation also from C3 and C5. The major function of the phrenic nerve is control of the diaphragm. Since the diaphragm is the primary muscle of breathing, if the diaphragm should lose innervation from the phrenic nerve, the patient would no longer be able to breathe effectively and would die. Patients who require a ventilator after a spine injury often have an injury at or above this region of the spine.

Neurogenic shock, is a form of shock (hypoperfusion) resulting from nerve paralysis, which can be caused by spinal cord injuries and can, in turn, cause uncontrolled dilation of blood vessels. The sympathetic nervous system originates from the thoracic and lumbar spine. You will recall that the sympathetic nervous system— the “fight-or-flight” system—is responsible for vital functions such as heart rate, vascular tone, and dilation of bronchiolar smooth muscle. Now imagine a serious spine injury to this region. You would observe a patient who exhibits low blood pressure and hypoperfusion. This is because the body has lost control over the smooth muscle that regulates the size of blood vessels. The vessels increase in size as they lose tone, but the amount of blood inside the vessels remains the same, so the patient’s blood pressure plummets. Since the sympathetic nervous system is no longer functioning and is unable to release epinephrine and norepinephrine, the body cannot increase the heart rate or force of contractions as it normally would to raise blood pressure and combat shock. Remember that not all injuries to the spine result in instant paralysis. It may take a period of

time for the effects to develop. In some cases, the vertebrae protecting the spinal cord remain in positron for awhile but then may lose integrity as the patient moves around or is moved. The patient presentation depends on the location of the spinal injury. The higher the cord injury, the greater the effect it will have on the body. It should also be noted that different spinal tracts are responsible for different functions. For example, a patient who injures the anterior portion of the spinal cord will lose sensation to pain and the ability to move but still may be able to feel light touch (a function of the posterior portion of the spinal cord). This is why sensation or the ability to move does not rule out spinal injury. Hindi lahat ng injury sa spine ay nagreresulta sa instant paralysis ng pasyente. Depende iyon sa lokasyon ng injury. Mas mataas ang natamaang bahagi ng spinal cord, mas matindi ang epekto nito. May mga sitwasyon na nakikita lamang ang epekto ng spine injury ilang oras matapos ang aksidente.

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PATIENT ASSESSMENT Spine and Spinal Cord Injury The most common causes of spinal cord injury are motor-vehicle collisions, falls, diving incidents, and gunshot wounds You must do a complete assessment of the patient. Assume that all unconscious trauma patients have a spinal injury. Whenever in doubt, assume that there are spine injuries and immobilize the patient’s torso, head, and neck The following are common signs and symptoms of spine injury: • Paralysis of the extremities. Paralysis of the extremities may occur. Paralysis of the extremities is probably the most reliable sign of spinal cord injury in conscious patients. • Pain without movement. The pain is not always constant and may occur anywhere from the top of the head to the buttocks. Pain in the leg is common for certain types of injury to the lower spine. Other painful injuries can mask this symptom of spinal injury. • Pain with movement. The patient normally tries to lie perfectly still to prevent pain. However, do not ask the patient to move just to determine if it will cause pain. If the patient experiences pain in the neck or back with voluntary movements, including spinal pain with movement in apparently uninjured shoulders and legs, this is a good indicator of possible spinal injury. • Tenderness anywhere along the spine. Gentle palpation of the injury site, when accessible, may reveal point tenderness These signs and symptoms are reliable indicators of possible spinal injury in the conscious patient If any one of them is present, you have sufficient reason to immobilize the patient. In the field, it is not possible to rule out spinal injury even when the patient has no pain and is able to move his limbs The mechanism of injury alone may be the deciding factor Additional signs of spinal injury may include: • Impaired breathing. Watch the patient breathe. If there is only a slight movement of the abdomen, with little or no movement of the chest, it is safe to assume that the patient is breathing with the diaphragm alone (diaphragmatic breathing). This is also true if there is a reversal of normal breathing patterns with the rib cage collapsing on inspiration and rising on expiration. Damage to the nerves that control the movement of the rib cage can cause this breathing pattern The nerves that control the diaphragm are located high in the cervical area (the third, fourth, and fifth cervical nerves) and are often unharmed, but the intercostal (between-the-ribs) nerves that control the chest muscles are often damaged in cervical and thoracic injuries. As a result, when the diaphragm moves downward to pull in air, the ribs, instead of 524

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expanding collapse When the diaphragm relaxes and air is expelled, the rib cage rises—which is the opposite of the normal pattern. Impaired breathing is characteristic of spinal cord injury. Check abdominal movement from the side by placing your hand on the patient’s abdomen and looking for reversed movements during respiration. Panting due to inspiratory insufficiency may develop. • Deformity. Removing a patient’s clothing to check for deformity of the spine is not recommended. Obvious spinal deformities are rare However, if you note a gap between the spinous processes (bony extensions) of the vertebrae, or if you can feel a broken spinous process, you must consider the patient to have serious spinal injuries it is also possible to feel tight muscles in spasm • Priapism. Persistent erection of the penis is a sign of spinal injury affecting nerves to the external genitalia • Loss of bowel or bladder control. This may indicate spinal injury. • Nerve Impairment to the extremities. The patient may experience loss of use, weakness, numbness, tingling, or loss of feeling in the upper and/or lower extremities— especially below the suspected level of the injury. • Neurogenic shock. This kind of shock can be caused by the failure of the nervous system to control the diameter of blood vessels The pulse rate may be normal—or even slow in the setting of a low or falling blood pressure—because a message to “speed up” the heart may be prevented from getting to the heart due to the cord injury. • Soft-tissue injuries associated with trauma. Traumatic soft-tissue injuries to the head and neck may signal injury of the cervical spine. Traumatic soft-tissue injuries to the shoulders, back, or abdomen may signal injury of the thoracic or lumbar spine. Traumatic soft-tissue injuries to the lower extremities may signal injury of the lumbar or sacral spine. Assessment for a responsive patient with suspected spinal injury includes the following strategies: • Ascertain the mechanism of injury • Ask these questions (and tell the patient not to move while answering) - What happened? - Where does it hurt’ Does your neck or back hurt? - Can you move your hands and feet? - Can you feel me touching (lightly) your fingers? Your toes? - Do you feel “pins and needles’ (tingling) in your legs? Anywhere? • Inspect for contusions, deformities, lacerations, punctures, penetrations and swelling • Palpate for tenderness or deformity

• Assess the patient’s equality of strength in the extremities by checking hand grip or pushing against the patient’s hands and feet • Assessment strategies for an unresponsive patient with suspected spinal injury include the following: • Ascertain from bystanders the mechanism of injury and information about the patient’s mental status prior to your arrival • Inspect for contusions, deformities, lacerations, punctures, penetrations, and swelling • Palpate for areas of tenderness (some unresponsive patients will withdraw from or react to pain) or deformity

PATIENT CARE Spine and Spinal Cord Injury Regardless of where the apparent spinal injury is located on the cord, your care is the same. Perform the primary assessment and rapid trauma assessment and determine the patient’s priority, since this will be important in deciding how to immobilize him. For all patients with possible spinal injury, and for all trauma victims when there is doubt as to the extent of injury, emergency care includes the following steps: 1. Provide manual inline stabilization for the head and neck on first patient contact. Place the head in a neutral inline position unless the patient complains of pain or the head is not easily moved into that position. If that is the case, steady the head in the position found. Maintain manual stabilization until the patient is properly secured to a backboard. 2. Assess the patient’s airway, breathing, and circulation If necessary, open and control the airway with the jaw-thrust maneuver, maintaining in-line stabilization of the head 3. In your rapid trauma exam, assess the head and neck, then apply a rigid cervical collar. Make sure the collar is property sized, as a wrong-size collar may do more harm than good by hyperextending the neck If too large or allowing flexion if too small. Also make sure the collar is not applied in a Huwag ubusin ang oras kakaisip kung may spinal injury ba o wala ang walang malay na pasyente. Kung may senyales na nahulog ito at tumama ang ulo o likod, tratuhin ito na may spinal injury at immobilize agad.

Laging tandaan na ang injury sa spine ng matatanda ay kadalasang resulta ng pagkadulas o pagkalaglag. Puwede rin na resulta ito ng spontaneous fractures o biglaang pagkabali ng buto dahil marupok na ito. Ang spontaneous fractures na ito ay minsan ay dahilan kung bakit natutumba ang matatanda. Lagi ring ilagay sa isip na hindi porke’t nakakalakad ang pasyente, may pakiramdam ito o wala itong sakit na inirereklamo ay wala na itong injury sa spinal cord.

way that will obstruct the airway. Maintain manual stabilization even after the collar is in place until the patient is secured to a backboard, since no collar completely restricts motion. 4. Quickly assess sensory and motor function in all four extremities. If the patient is responsive. 5. Based on the patient’s priority, apply the appropriate spinal immobilization device at the appropriate speed. 6. If the patient has paralysis or weakness of the extremities, administer high-concentration oxygen via nonrebreather mask and evaluate the need for artificial ventilations with supplemental oxygen This is critical should there be any cord damage. 7. Reassess sensory and motor function in all four extremities if the patient is responsive.

PEDIATRIC NOTE

For an infant or child, be sure to use a pediatric-sized collar. If you do not have the right pediatric size, use a rolled towel, maintaining manual support of the infant’s or child’s head

IMMOBILIZATION ISSUES Tips for Applying a Cervical Collar Cervical-spine immobilization devices, or rigid extrication collars, are designed to limit flexion, extension, and lateral movement when combined with an immobilization device such as a long backboard or a vest-style device. Even though there have been marked improvements in collars, there is still no collar that completely eliminates movement of the spine. For this reason, when applying a collar, always manually maintain the neck and head in a neutral position in alignment with the rest of the body.

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525

DAY 20

Spinal Immobilization of a Seated Patient

Day 20

CENTRAL NERVOUS SYSTEM TRAUMA 1. Select an immobiliza-

tion device. 2. Manually stabilize the patient's head in a neutral, in-line position. 3. Assess distal circulaback, or in a confined space. It is also useful when tion, sensation, and motor function (CSM). the short spine board cannot be inserted into a car 4. Apply the appropribecause of obstructions. A number of commercial ately sized extrication vest-style extrication devices, such as the KED, collar. 5. Position the immobiliKansas Backboard, XP-l.and LSP Halfback Vest, are zation device behind the patient. available. Use the devices approved by your EMS 6. Secure the device to system. the patient's torso. 7. Evaluate and pad A short spine board is just a shortened version behind the patient's of a long spine board. It is the original extrication head as necessary. device and has been used for many years. It Secure the patient's head to the device. is used less frequently now, however, because 8. Evaluate and adjust today’s contoured automobile seat backs do not the straps. They must be tight enough so accommodate a flat board. Also, the short spine the device does not board is often too wide and too high to be used move up, down, left, or right excessively, effectively in a small car. but not so tight as to A particular sequence must be followed in all UNIT 3 restrict the patient's breathing. applications, whether of a flexible extrication device DAY 20 9. As needed, position or a short spine board. That sequence is: secure the or secure the patient's wrists and legs. torso first and the head last. This ensures greater 10. Reassess distal circulastability during the strapping process and may help tion, sensation, and Spinal Immobilization motor function (CSM), prevent compression of the cervical spine. If the transfer the paof aand Seated Patient patient has suffered abdominal injuries or displays tient to the long board. diaphragmatic breathing that prevents adequate 1. Select an immobiliza-

Tips for Immobilizing a Seated Patient

When a patient is found in a sitting position, you will need to decide his priority. If the patient is stable and a low priority, use the normal procedure for spinal immobilization. In such situations, where time is not of the essence, the patient must be secured to a short spine board or extrication vest that will immobilize the head, neck, and torso until he can be transferred to a long spine board. In high-priority situations when there is not enough time to apply a short board or extrication vest—or if the patient must be moved rapidly because of dangers at the scene or to provide access to other, potentially more seriously injured patients—the patient should be immobilized manually while moving him onto the long spine board. The normal extrication technique is as follows: You manually stabilize the patient’s head and neck during primary assessment. After examining the head and neck in the rapid trauma assessment, you apply a rigid collar. Then you secure the patient to a short spine board or extrication vest. A vest-style extrication device is a flexible piece of equipment useful for immobilizing patients tion device. with possible injury to the cervical spine. It can be securing of the torso, the torso straps will still be 2. Manually stabilize the needed but care must be taken so as not to interfere used when the patient is found in a bucket seat, in patient's head in a neutral, in-line posia short compact car seat, in a seat with a contoured with breathing. tion. 3.

There are a number of special considerations when applying a short board to the patient: • Assessment of the back, shoulder blades, arms, or collarbones must be done before the device is placed against the patient. • The EMT applying the board must angle it. without sinking or jarring, to fit between the arms of the rescuer who is stabilising the head from behind the patient. • To provide full cervical support, the uppermost holes must be level with the patient’s shoulders. The base of the board should not extend past the coccyx. • Never place a chin cup or chin strap on the patient, as it can prevent him from opening his mouth if he has to vomit. • Avoid applying the first torso strap too lightly. This could aggravate an abdominal injury or limit respirations for the diaphragmatic breathing patient. • Some buckles have quick-release mechanisms. Be careful not to accidentally looses these buckles when moving the patient.

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• Do not pad between the collar and the board. This will create a pivot point that may cause the cervical spine to hyperextend when the head is secured. Instead, pad the occipital region, but only enough to fill any void. This will help keep the head in a neutral position. Sometimes when the shoulders are rolled back to the board, the head will come back to the board far enough so padding is not needed. Never use excessive padding behind the head, because when the patient is placed in a supine position, the shoulders will fall back but the head will not be able to. This will place the patient in an undesirable position of flexion. • Follow the instructions provided by the manufacturer of the device you are using. • After applying the short spine board, the packaging of the patient will be completed.

Assess distal circulation, sensation, and motor function (CSM). 4. Apply the appropriately sized extrication collar. 5. Position the immobilization device behind the patient. 6. Secure the device to the patient's torso. 7. Evaluate and pad behind the patient's head as necessary. Secure the patient's head to the device. 8. Evaluate and adjust the straps. They must be tight enough so the device does not move up, down, left, or right excessively, but not so tight as to restrict the patient's breathing. 9. As needed, position or secure the patient's wrists and legs. 10. Reassess distal circulation, sensation, and motor function (CSM), and transfer the patient to the long board.

Spinal Im I Spinal ofaaSeate Seate of

Sel 1.1. Sele tion tion Ma 2.2. Man pat pati neu neu tion tion Ass 3.3. Asse tion tion mo mot Ap 4.4. App ate atel col colla Pos 5.5. Posi zat zatio the the Sec 6.6. Secu the the Eva 7.7. Eva beh beh hea hea Sec Secu hea hea 8. Eva 8. Eva the the be be the the mo mov or or but but res rest bre brea As 9.9. As ors or wri wris 10. Rea Rea 10. tion tion Spinal mo mot and of aand Se tien tien boa 1. boa

PRINC

3. 4. 5. 6. 7. ² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

10.

PREHOSPITAL EMERGENCY CARE

² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

DAY20 20 DAY

PRINCIPLES OF EMT CLINICAL PRACTICE 4.4. Apply Applythe theappropriappropriately atelysized sizedextrication extrication collar. collar. 5.5. Position Positionthe theimmobiliimmobilization zationdevice devicebehind behind the patient. the patient. 6.6. Secure Securethe thedevice devicetoto the patient's torso. the patient's torso. 7.7. Evaluate Evaluate and and pad pad behind behindthe thepatient's patient's head head asas necessary. necessary. Secure Securethe thepatient's patient's head toto the device. head the device. 8.8. Evaluate Evaluateand andadjust adjust the thestraps. straps.They Theymust must bebetight tightenough enoughsoso the thedevice devicedoes doesnot not move moveup, up,down, down,left, left, oror right excessively, right excessively, but butnot notsosotight tightasastoto UNIT restrict restrictthe thepatient's patient's UNIT 33 breathing. breathing. DAY 20 DAY 9.9. AsAsneeded, needed,position position 20 oror secure the patient's secure the patient's wrists and legs. wrists and legs. 10. distal circula10.Reassess Reassess distal circulation, sensation, tion, sensation,and and motor function (CSM), motor function (CSM), Spinal Spinal Immobilization Immobilization and transfer the paand transfer the paof Seated Patient of atient a tient Seated Patient toto the the long long board. 1. Select 1.board. Select an an immobilizaimmobiliza-

ately sized extrication collar. 5. Position the immobilization device behind the patient. 6. Secure the device to the patient's torso. 7. Evaluate and pad behind the patient's head as necessary. Secure the patient's head to the device. 8. Evaluate and adjust the straps. They must be tight enough so the device does not move up, down, left, or right excessively, but not so tight as to UNIT 3 restrict the patient's breathing. DAY 20 9. As needed, position or secure the patient's wrists and legs. 10. Reassess distal circulation, sensation, and Spinal motor Immobilization function (CSM), transfer the paof aand Seated Patient tient to the long board. 1. Select an immobiliza-

SPINAL IMMOBILIZATION OFIMMOBILIZATION A SPINAL IMMOBILIZATION OF AA SPINAL OF Immobilization mmobilization SEATED PATIENT SEATED PATIENT SEATED PATIENT SPINAL IMMOBILIZATION OF A

edPatient Patient ed

lect an an immobilizaimmobilizaect device. nndevice. anually stabilizethe the nually stabilize tient's head head inin aa ient's utral, in-line posiutral, in-line posin.n. sess distal circulacirculaess distal sensation, and and n,n, sensation, otor function(CSM). (CSM). tor function pply the appropriappropriply the ely sizedextrication extrication ly sized llar. ar. sition theimmobiliimmobiliition the tion device behind behind on device epatient. patient. cure the device device to to ure the epatient's patient'storso. torso. aluate and and pad pad aluate hind the the patient's patient's hind ad as as necessary. necessary. ad cure the patient's patient's ure the ad to the device. ad to the device. aluate and adjust aluate and adjust estraps. straps.They Theymust must tight enough enough so so tight e device device does does not not ove up, down, down, left, left, ve up, right excessively, excessively, right tnot notso sotight tightas asto to UNIT 3 strict the patient's patient's trict the eathing. athing. DAY 20 needed, position position needed, securethe thepatient's patient's secure istsand andlegs. legs. sts assessdistal distalcirculacirculaassess sensation, and and n,n, sensation, lotor Immobilization function(CSM), (CSM), tor function d transfer transfer the papadeated the Patient nt to to the the long long nt ard. Select an immobilizaard.

SEATED PATIENT SPINAL IMMOBILIZATION OF A SEATED PATIENT

1. Select an immobilization device. 2. Manually stabilize the OF EMT CLINICALpatient’s head in a neutral, PRACTICE PRINCIPLES OF EMTPRINCIPLES CLINICAL PRACTICE in-line position. 3. Assess distal circulation, sensation, and motor function (CSM). 4. Apply the appropriately sized extrication collar. 5. Position the tion device. tion tion device. device. immobilization device 2. Manually stabilize the 2. 2. Manually Manually stabilize stabilize the the patient's head in a patient's behind the patient. patient's head head in in aa neutral, in-line posineutral, neutral, in-line in-line posiposition. 6. Secure the device to the tion. tion. 3. Assess distal circula3. 3. Assess Assess distal distal circulacirculapatient’s torso. tion, sensation, and tion, tion, sensation, sensation, and and motor function (CSM). 7. Evaluate and pad behind motor motor function function (CSM). (CSM). 4. Apply the appropri4. appropri4. Apply Apply the the approprithe patient’s head as CIPLES OF EMTPRINCIPLES CLINICAL PRACTICE OF EMT CLINICAL PRACTICE ately sized extrication ately ately sized sized extrication extrication collar. necessary. Secure the collar. collar. 5. Position the immobili5. 5. Position Position the the immobiliimmobilipatient’s head to the device. zation device behind zation device behind zation device behind the patient. the 8. Evaluate and adjust the the patient. patient. 6. Secure the device to 6. 6. Secure Secure the the device device to to straps. They must be tight the patient's torso. the the patient's patient's torso. torso. 7. Evaluate and pad 7. Evaluate and pad 7. Evaluate and pad enough so the device does behind the patient's behind behind the the patient's patient's head as necessary. not move up, down, left, or head head as as necessary. necessary. Secure the patient's Secure Secure the the patient's patient's right excessively, but not tion device. head to the device. head to the device. head to the device. Manually stabilize the 8. Evaluate and adjust too tight as to restrict the 8. 8. Evaluate Evaluate and and adjust adjust patient's head in a the straps. They must the the straps. straps. They They must must neutral, in-line posipatient’s breathing. be tight enough so be be tight tight enough enough so so tion. the device does not the 9. As needed, position or the device device does does not not Assess distal circulamove up, down, left, move move up, up, down, down, left, left, tion, sensation, and secure the patient’s wrists or right excessively, or or right right excessively, excessively, motor function (CSM). but not so tight as to but but not not so so tight tight as as to to and legs. Apply the approprirestrict the patient's restrict restrict the the patient's patient's ately sized extrication breathing. 10. Reassess distal circulation, breathing. breathing. collar. 9. As needed, position 9. 9. As As needed, needed, position position Position the immobilisensation, and motor or secure the patient's or or secure secure the the patient's patient's zation device behind wrists and legs. function (CSM), and wrists wrists and and legs. legs. the patient. 10. Reassess distal circula10. 10. Reassess Reassess distal distal circulacirculaSecure the device to transfer the patient to the tion, sensation, and tion, tion, sensation, sensation, and and the patient's torso. motor function (CSM), motor long board. motor function function (CSM), (CSM), Evaluate and pad and transfer the pa-

behind the patient's head as necessary. Secure the patient's head to the device. Evaluate and adjust the straps. They must be tight enough so the device does not move up, down, left, or right excessively, but not so tight as to restrict the patient's UNIT 3 breathing. As needed, position DAY 20 or secure the patient's wrists and legs. . Reassess distal circulation, sensation, and motor function (CSM), and transfer the patient to the long board.

² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

² Limmer (Brady) ² Limmer (Brady) ³ Pollack, (AAOS) ³ Pollack, (AAOS) ⁴ NHTSA ⁴ NHTSA

² Limmer(Brady) (Brady) ² Limmer

³ Pollack,(AAOS) (AAOS) ³ Pollack, NHTSA ⁴ ⁴NHTSA

and and transfer transfer the the papatient tient to to the the long long board. board.

tient to board.

the

long

PRINCIPLES OF EMT CLINICAL PRACTICE

Sa pag-immobilize sa pasyente, laging suriin ang distal circulation, sensation at motor function. Ang ibig sabihin, tingnan palagi kung dumadaloy ba ang dugo, nakakaramdam at naigagalaw ba ng pasyente ang mga dulong bahagi ng katawan nito. Higpitan ang pagkakastrap sa pasyente, pero huwag naman masyadong mahigpit at baha hindi na itoi makahinga. Kung kinakailangan, i-secure mo ang kamay at paa ng pasyente.

²²Limmer Limmer(Brady) (Brady) ³³Pollack, Pollack,(AAOS) (AAOS) ⁴⁴ NHTSA NHTSA

² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

LIFELINE Limmer (Brady) (Brady) ²² Limmer Rapid Extrication Procedure for High-Priority Patients Only Pollack, (AAOS) (AAOS) ³³ Pollack, NHTSA ⁴⁴ NHTSA

Manually stabilize the patient's head and neck and have a second EMT apply a cervical collar.

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NOTE; NOTE; NOTE; NOTE; NOTE; Therapid rapidextrication extricationprocedure procedureisisisonly onlyfor forcritical criticalor orunstable unstablehigh-priority high-prioritypapaThe rapid extrication procedure only for critical or unstable high-priority paThe only unstable The Therapid rapidextrication extricationprocedure procedureis onlyfor forcritical criticalor unstablehigh-priority high-prioritypapaThe rapid extrication procedure isisonly for critical oror unstable high-priority patients who musthe hemoved moved inless less timethan than would be required toapply applyaaaashort short tients who must he moved in less time than would be required to apply short tients who must he moved in less time than would be required to apply short tients who must in time would be required to tientswho whomust musthe hemoved movedininless lesstime timethan thanwould wouldbe berequired requiredtotoapply applyaashort short tients spine boardor orextrication extrication vestinside insidethe thevehicle vehiclebefore before movingthe thepatient patientto to spine board or extrication vest inside the vehicle before moving the patient to spine board vest moving spine Day 20 board spine boardor extricationvest vestinside insidethe thevehicle vehiclebefore beforemoving movingthe thepatient patientto spine board ororextrication extrication vest inside the vehicle before moving the patient toto the long spine board. the long spine board. the long spine board. the long spine board. thelong longspine spineboard. board. the

CENTRAL NERVOUS SYSTEM TRAUMA

RAPID EXTRICATION PROCEDURE FOR HIGH-PRIORITY PATIENTS ONLY 1. Manually stabilize the patient’s head and neck and have a second EMT apply a cervical collar. 2. At the direction of the EMT stabilizing the head and neck, two EMTs each lift the patient by the armpits and buttocks/thighs just enough for a bystander or additional rescuer to slide a long spine board between the patient and the vehicle seat. 3. The EMTs reposition their hands so the EMT on the front seat inside the vehicle holds the patient’s legs and pelvis, while the EMT outside the vehicle holds the upper chest and arms. 4. At the direction of the EMT holding the head and neck, carefully turn the patient a quarter turn so his back is toward the door of the vehicle. 5. The EMT who was holding the pelvis temporarily holds the chest so the EMT who was holding the chest can take over head and neck stabilization. The EMT in the back seat can then reach over the seat and assist with the chest, and the EMT inside on the front seat can move his hands back to the pelvis. 6. At the direction of the EMT at the head and neck, gently lower the patient to the spine board. Note: Sometimes it may be necessary to move the patient inside the vehicle a few inches so there o ample room to lay him down without touching the upper door opening. 7. As a bystander or additional rescuer holds the end of the spine board, the EMTs slide the patient to the head end of the board. 8. Quickly apply straps to the patient’s chest, pelvis, and legs and remove the patient to a stretcher or the ground, under the direction of the EMT stabilizing the head and neck. Note: Since the patient’s head is not yet fully immobilized (it is only being manually held stable by the EMT and collar), DO NOT walk more than a few steps with the patient. Once on stable ground or the stretcher, apply a head immobilizer or blanket roll and wide tape. As you move the patient from a sitting to a supine position, her spine must not bend, twist, or get jolted. Handle her very gently, and make sure you have enough assistance to perform the move correctly. 528

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Ang rapid extrication procedure ay para lamang sa mga pasyente na kritikal ang kondisyon at hindi stable na kailangang-kailangan madala agad sa ospital. Ginagamitan ito ng maiksing spine board o extrication vest para mas mabilis maibiyahe.

²Limmer Limmer (Brady) ²Limmer (Brady) (Brady) ²² Limmer (Brady) ²³Pollack, Limmer (Brady) Pollack, (AAOS) (Brady) ³Limmer (AAOS) Pollack, (AAOS) ³³² Pollack, (AAOS) ³ Pollack, (AAOS) ⁴ NHTSA NHTSA(AAOS) NHTSA ⁴⁴³ ⁴Pollack, NHTSA NHTSA ⁴ ⁴NHTSA

Tips for Applying a Long Backboard The following tips relate to immobilization of the supine patient: cravats or self-adhering roller bandages as a • You will need to log roll the patient to apply backup method. Do not tape or lie the cravats the long backboard. This procedure must be done carefully, keeping the patient’s spine in across the patient’s eyes. alignment. Quickly assess the posterior body • If the patient is a full-term pregnant woman, before rolling the patient back onto the board immobilize her on the backboard. Then tilt Whenever a move is done involving neck the board to the left by propping up the right stabilization, the EMT holding the head calls side to minimize the effect of the uterus for the move (“We will turn on three: One ... compressing the vena cava and causing two... three”). hypotension and dizziness. • Pad voids between the patient’s head and torso • Unless the spine board has straps specifically and the board. Be careful not to cause extra intended to criss-cross the shoulders and movement or to move the patient’s spine out of chest, it is best to strap across the upper chest, alignment. the pelvis, and the thighs. If you will need to • When a patient is secured to a long spine stand the patient up to carry him out of a light board, the head is secured last. Strapping is building, up a basement stairwell, or into a easier with Velcro or speed-clip straps. small elevator, make sure the straps are secure • Additional immobilization for the head and under the patient’s armpits and light on the neck can be provided with light foam-filled thighs. cushions, a commercial head immobilization • lf your service transports to a helicopter, make device (such as the Ferno Washington head sure that your back-board fits. There are some immobilizer, Bashaw CID, or the Laerdal Head restrictions on the size or taper of the long Bed), or a blanket roll. If used, these are apbackboard, depending on the helicopter’s plied after securing the patient’s body to the loading configuration, so know this out ahead long backboard. Secure the head with 3-inch of time. hypoallergenic adhesive tape. The tape offers • For a water rescue or diving injury, there are support, especially if the patient and board various specialty backboards, such as the Miller board, that are designed to float up beneath are to be tilled to allow for drainage. However, the patient and use Velcro closures for case of blood on the patient’s skin and hair may make using tape impractical. You should learn to use application.

Four-Rescuer Log Roll FIRST TAKE STANDARD PRECAUTIONS 1. Stabilize the head and neck. Apply a rigid cervical collar. 2. Place the board parallel to the patient. 3. Have three rescuers kneel at the patient’s side opposite the board, leaving room to roll the patient toward them. Place rescuers at the shoulder, waist, and knee. One EMT will continue to stabilize the head, while the others reach across the patient to properly position their hands. 4. The EMT at the head and neck directs the others to roll the patient as a unit. 5. The EMT at the patient’s waist grips the spine board and pulls it into position against the patient. (This can be done by a fifth rescuer.) 6. Roll the patient as a unit onto the board.

Kung ang pasyenteng ibabiyahe ay anim na taong gulang lamang o mas bata pa, lagyan ito ng unan o padding sa ilalim ng balikat para suportahan ang mas malaking ulo nito. Maganda rin na lagyan ito ng pad mula balikat hanggang paa para maging neutral ang posisyon nito. Kung wala kayong mahabang spine immobilization device na pambata, magpraktis gumamit ng spine board na pang-adult at gamitan na lamang ito ng mga tuwalya o kumot para magsilbing padding sa katawan ng bata. Bilang isang EMT, maging mahusay sa paggawa ng paraan. Magpraktis mag-improvise sa loob muna ng classroom para mas maging mabilis ang pagkilos mo sa field.

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Spinal Immobilization of a Supine Patient FIRST TAKE STANDARD PRECAUTIONS 1. Place the patient’s head in a neutral, in-line position and maintain manual stabilization of the head and neck. Assess distal circulation, sensation, and motor function (CSM). 2. Apply an appropriately sized rigid cervical collar. 3. Position an immobilization device. 4. Move the patient onto the device without compromising the integrity of the spine. Once the pattern is in position, apply padding to avoid between the torso and board. 5. Secure the patient’s torso to the board first. 6. Secure the patient’s legs (above and below the knee), 7. Pad and immobilize the patient’s head last. 8. Reassess the patient’s distal circulation, sensation, and motor function (CSM).

Rapid Extrication from a Child Safety Seat 1. EMT #1 stabilizes the car seat in the upright position and applies manual stabilization of the patient’s head and neck. EMT #2 prepares equipment, and then loosens or cuts the seat straps and raises the front guard. 2. The cervical collar is applied to the patient as EMT #1 maintains manual stabilization of the head and neck. 3. As EMT #1 maintains manual stabilization, EMT #2 places the child safety seat on the center of the backboard and slowly tilts it into the supine position. EMTs are careful not to let the child slide out of the chair. For the child with a large head, place a towel under the area where the shoulders will eventually be placed on the board to prevent the head from tilting forward. 4. EMT #1 maintains manual stabilization and calls for a coordinated long axis move onto the backboard. 5. EMT #1 maintains manual stabilization, as the move onto the board is completed, with the child’s shoulders over the folded towel. 6. EMT #1 maintains manual stabilization, as EMT #2 places rolled towels or blankets on both sides of the patient. 7. EMT #1 maintains manual stabilization, as EMT #2 straps or tapes the patients to the board at the level of the upper chest, pelvis and lower legs. Do not strap across the abdomen. 8. EMT #1 maintains manual stabilization, as EMT #2 places rolled towels on both sides of the head, then tapes the head securely in place across the forehead and cervical collar. Do not tape across the chin to avoid pressure on the neck. The newborn and infant procedure is exactly the same as for a child, except that an arm board is inserted behind the child in Step 2. If the infant is very small, the arm board may actually be used as the spine board. 530

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May mga pagkakataon na reresponde ka sa aksidente sa kotse kung saan may sanggol o bata na nakaupo at naka-strap sa child safety seat. Ang tinuturo noong una ay immobilize ang bata sa mismong safety seat na kinauupuan nito. Pero iba na ang tinuturo ngayon. Dahil hindi ka sigurado kung gaano kaligtas ang safety seat na natagpuan sa kotseng naaksidente, gamitan na ng spine board ang batang pasyente sa pag-immobilize dito.

Tips for Dealing with a Standing Patient When you approach a vehicle and see the tell-tale spider-web-cracked wind-shield, you know whoever sat behind that crack needs full spinal immobilization. Even if this patient is up and walking around at the collision scene, he still has the potential for a spine injury. He simply may not yet have dislocated the fracture or ligament injury site. Since it would be dangerous to have him sit down or lie down on your long backboard, you should use a backboard to carefully but rapidly take him down to the supine position without compromising his spine. Some EMS providers advocate strapping the patient onto the long board while the patient is standing. However, this is often not practical in the field. (It works in the classroom because the simulated patients are not in shock, intoxicated, head injured, combative, or just dizzy!) The easiest technique is the rapid takedown which, like all skills in this text, should be demonstrated by a qualified instructor and practiced in the classroom prior to use in the field. The procedure takes three EMTs, a set of collars, and a long backboard.

Rapid Takedown of a Standing Patient 1. Position your tallest crew member (EMT#1) behind the patient and have him manually stabilize the head and neck. His hands should not leave the patient’s head until the entire procedure is complete and the head is secured to the long spine board. 2. EMT #2 applies a properly sized cervical collar to the patient. EMT #1 continues manual stabilization (the collar aids, but does not replace, manual stabilization) 3. EMT #1 continues manual stabilization, as EMT #2 and another rescuer position a long spine board behind the patient, being careful not to disturb EMT #1 ‘s manual stabilization of the patient’s head and neck. It will help if EMT #1 spreads elbows to give the other rescuers more room to maneuver the spine board, 4. EMT #1 continues manual stabilization. EMI #2 looks at the spine board from the front of the patient and does any necessary repositioning to be sure it is centered behind the patient. 5. EMT #1 continues manual stabilization. EMT #2 and the third rescuer extend the arms that are nearest the patient under the patient’s armpits and grasp the spine board. (Once the board is tilted down, the patient will actually be temporarily suspended by the armpits.) To keep the patient’s arms secure, they will use the other hand to grasp the patient’s arm just above the elbow and hold it against the patient’s body 6. EMT #2 and the third rescuer, when reaching under the patient’s armpits, must grasp a handhold on the spine board at the patient’s armpit level or higher 7. EMT #1 continues manual stabilization. EMT #2 and the third rescuer maintain their grasp on the spine board and patient. EMT #1 explains to the patient what is going to happen, then gives the signal to begin slowly tilting the board and patient to the ground. As the board is lowered, EMT #1 walks backward and crouches, keeping up with the board as it is lowered and allowing the patient’s head to slowly move back to the neutral position against the board. EMT #1 must accomplish all this without interfering with the lowering of the board. EMT #1 may need to rotate somewhat so that, once the board is almost flat, he is holding the head down on the board. Once the patient’s head comes in contact with the board, it must not be allowed to leave the board, to avoid flexing the neck. The job of the two rescuers doing the lowering of the board is to control it so that it is slowly lowered and even on both sides. They should also move into a squatting position as they lower the board to avoid injuring their backs. 8. EMT #1 maintains manual in-line stabilization throughout the procedure.

Patient Found Wearing a Helmet Helmets, are worn in many sporting events and by many motorcycle riders. Even ski resorts are starting to advocate the use of helmets. Sporting helmets are typically open in the front, making it easier to access the patient’s airway than when a patient is wearing a motorcycle helmet, which has a shield and often a full face section that is not removable. Face, neck, and spine care and airway management or resuscitation may call for the removal of the helmet, especially if the helmet will prevent you from reaching the patient’s mouth or nose. If the helmet is left on, shields can he lifted and face guards removed. One EMT must manually steady the patient’s head and neck while the other cuts, snaps off, or unscrews the guard. Do not attempt to remove a helmet if doing so causes increased pain, or if the helmet proves difficult to remove, unless there is a possible airway obstruction or ventilatory assistance must be provided. Indications for leaving the helmet in place or for removing the helmet are summarized in the following text. Indications for leaving the helmet in place: • Helmet fits snugly, allowing little or no movement of the patient’s head within the helmet • There are absolutely no impending airway or breathing problems nor any reason to resuscitate or ventilate the patient. • Removal would cause further injury. • Proper spinal immobilization can be done with the helmet in place. • There is no interference with the EMT’s ability to assess the airway or breathing.

Indications for removing the helmet: • The helmet interferes with the EMT’s ability to assess and manage airway and breathing. • The helmet is improperly fitted, allowing excessive head movement. • The helmet interferes with immobilization. • Cardiac arrest is present.

Many experienced EMS providers put the controversy of removal versus non removal into the following perspective: If your child injured his neck playing football, would you want the trainer and the EMT to work together carefully to remove the helmet at the scene, or would you prefer this to be left to emergency department personnel who probably will not have the help of the trainer nor the benefit of lots of practice in the helmet removal technique? Note that if a football player is wearing shoulder pads and a helmet, you should either remove the pads and the helmet or you should leave them both on. Taking off one, but not the other, will result in hyperflexion or hyperextension because of the space the pads occupy behind the patient’s shoulders.

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Removing Helmet from an Injured Patient 1. EMT #1 is positioned at the top of the of the patient’s head and maintains manual stabilization. Two hands hold the helmet stable while the fingertips hold the lower jaw. 2. EMT #2 opens, cuts, or removes the chin strap. 3. EMT #2 then places one hand on the patient’s mandible and, using the other hand, reaches in behind the neck and stabilizes the occipital region. Using the combination of the hand in front of the chin and the hand behind the neck, EMT #2 should be able to securely hold the patient’s head. If the patient has glasses on, they should be removed now, prior to removal of the helmet. 4. EMT #1 can now release manual stabilization and slowly remove the helmet. The lower sides, or ear cups, of the helmet will have to be gently pulled out to clear the ears. 5. The helmet should come off straight with no backward tilting. A full-face helmet may need to be lilted just enough for the chin guard to clear the nose. EMT #2 must support and prevent the head from moving as the helmet is removed. 6. EMT #1, after removing the helmet, reestablishes manual stabilization and maintains an open airway by using the jaw-thrust maneuver. Kung ang pasyente ay football player at meron itong shoulder pads, huwag mo bastabasta alisin ang shoulder pads. Alisin mo ito mula sa likod ng ulo para hindi mabaluktot ang balikat ng pasyente. Seguruhin na hindi gumagalaw ang pasyente kapag inaalis ang shoulder pads at ang helmet nito. Importante na mailagay agad sa mahabang spine board ang pasyente upang hindi na lumala ang kanyang injury.

CENTRAL NERVOUS SYSTEM TRAUMA

Selective Spine Immobilization The traditional approach to spine immobilization in EMS has been to immobilize any patient whose assessment or mechanism of injury suggests the possibility of spine injury. But what exactly does that mean? A serious MOI to one EMT may not seem serious to another EMT. In some EMS systems, providers now have specific indications for spine immobilization. Use of these indications may be limited to advanced level providers in some systems. In others, EMT level providers may be authorized to use them. This approach is sometimes incorrectly referred to as a “spine clearance protocol.” EMTs do not clear spines (i.e..determine there is no spine injury). Instead, in systems that employ this approach, each patient’s condition and circumstances are evaluated and compared to a protocol to determine whether spine immobilization is indicated for that patient. In some cases, an EMT may immobilize patients he would not have immobilized before institution of such a protocol. Typical elements of such a protocol include evaluation of both the mechanism of injury and the patient’s condition. Patient condition is further broken down into injury-related conditions, such as paralysis, and non-injury-related conditions, such as intoxication, that limit the reliability of the assessment. These protocols may also differentiate patients by age. Differences in elderly and pediatric patients (as compared to adults) pose special assessment and immobilization challenges. Most protocols also allow the EMT an “out” by encouraging the provider to immobilize a patient when clinical judgment suggests that it is appropriate, even if none of the other conditions are present. Although spine immobilization causes pain and discomfort in some patients, that concern is insignificant when compared to the devastating lifelong consequences of failure to immobilize an injured spine. Before you use a selective spine immobilization protocol, be sure you have been trained in the specific indications and contraindications of such a protocol and that your Medical Director has approved it. When in doubt, immobilize!

HELMET REMOVAL—ALTERNATIVE METHOD 1. EMT #1 applies manual stabilization with the patient’s neck in a neutral position. 2. EMT #2 removes the chin strap, 3. EMT #2 removes the helmet, pulling out on each side to clear the ears. 4. EMT #1 maintains manual stabilization as EMT #2 applies a cervical collar.

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TYPICAL ELEMENTS OF A SELECTIVE SPINE IMMOBILIZATION PROTOCOL Immobilize the patient’s spine if one or more of the following are present:

MECHANISM Of INJURY • • • • • • •

Violent impact to head, neck, torso, or pelvis. Moderate-to-high-speed motor-vehicle incident. Pedestrian struck by a vehicle. Explosion. Ejection from a vehicle. Shallow-water diving incident. Fall: Some protocols include all falls, whereas others include only falls greater than a particular height, commonly three times the patient’s height (There may be differences with elderly patients). • Axial load. • Penetrating trauma in or near the spine. • Sports injury to the head or neck.

PATIENT CHARACTERISTICS THAT ARE INJURY RELATED • Spine pain, tenderness, or deformity. • Neurological deficit or complaint. • Pain on movement of the neck or back.

EMT CHARACTERISTICS • The EMT suspects that the patient is not being truthful. • The EMT suspects that there is more to the incident than meets the eye. • The EMT’s clinical judgment or suspicions suggest the patient should be immobilized.

PATIENT CHARACTERISTICS THAT ARE NOT DIRECTLY INJURY RELATED • • • •

Altered menial status. Intoxication from alcohol or other drugs. Inability to communicate. Distracting injury (e.g., a leg injury so painful the patient might not feel a less obvious injury to the spine). • Stress significant enough to prevent the patient from feeling pain.

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LIFELINE PREHOSPITAL EMERGENCY CARE

IN your future work as EMT, there would be times when you would be called in to provide care to victims of gun shooting or stabbing. And many of these victims will have injuries to the chest or the abdomen. How do you handle them? A wound to the chest or the abdomen must be considered life threatening, because it has the tendency to affect other vital organs such as the heart, the lungs, the liver, or the intestines. Critical thinking and rapid assessment, therefore, are the key to responding to such cases. This chapter provides you with the basic steps in dealing with such emergencies. It would teach you how to assess and provide immediate care to injuries outside on the chest and within the chestâ&#x20AC;&#x2122;s cavity and how to dress abdominal wounds. This chapter also includes tips on how to handle multisystem trauma that involves different organs.

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DAY

Chest and Abdominal Trauma Closed and open chest injuries Injuries within the chest cavity Dressing abdominal wounds Managing multisystem trauma

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PRINCIPLES OF EMT CLINICAL PRACTICE

CHEST AND ABDOMINAL TRAUMA LEARNING OBJECTIVES • Describe the incidence, morbidity, and mortality of thoracic injuries in the trauma patient. • Describe the consideration for a chemical burn injury to the eye. • Discuss the anatomy and physiology of the thoracic organs and structures. • Discuss types of thoracic injuries based on mechanism of injury. • Discuss the epidemiology, pathophysiology, assessment findings, and management— including the need for rapid intervention and transport of the patient with: 1. Chest wall injuries- rib fracture, flail segment and sternal fracture. 2. Injury to the lung- simple pneumothorax, open pneumothorax, tension pneumothorax, hemothorax, hemopneumothorax and pulmonary contusion. 3. Myocardial injuries- myocardial contusion, pericardial tamponade and myocardial rupture. 4. Vascular injuries- aorta, vena cava and pulmonary arteries/ veins. 5. Diaphragmatic, esophageal, and tracheobronchial injuries. 6. Traumatic asphyxia. • Discuss special considerations that impact the assessment, management, and prognosis of patients with inhalation, chemical, and electrical burn injuries and with exposure to radiation. • Differentiate between supraglottic and subglottic inhalation burn injuries. • Differentiate between thoracic injuries based on the patient assessment and history.

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INTRODUCTION

Although serious injuries to the chest, abdomen, and genitalia are not that common, they are injuries that EMTs must be comfortable with and able to expeditiously handle. Many of these injuries can be life-threatening. The EMT must be able to recognize injuries that require prompt prehospital treatment and those that require prompt transport to a facility capable of dealing with them. Even injuries that do not appear life-threatening at first can develop into much more serious problems en route to the hospital. The EMTs assessment and reassessment skills will be important to the ultimate outcome of these patients.

Chest Injuries

The chest can be injured in a number of ways:

• Blunt trauma. A blow to the chest can fracture the ribs, the sternum, and the costal (rib) cartilages. Whole sections of the chest can collapse. With severe blunt trauma, the lungs and airway can he damaged. In addition, the great vessels (aorta and venae cavae) and the heart may be seriously injured. • Penetrating objects. Bullets, knives pieces of metal or glass, steel rods, pipes, and various other objects can penetrate the chest wall, damaging internal organs and impairing respiration. • Compression. Compression injuries develop from severe blunt trauma in which the chest is rapidly compressed, such as when a driver strikes his chest on the steering column or when a person is trapped in a trench-wall collapse. The sternum and ribs can be fractured, the heart can he severely squeezed, and the lung can rupture.

Closed Chest Injuries Chest injuries are classified as either closed or open. In a closed chest injury, the skin is not broken, leading many people to think that the damage done is not serious. However, such injuries, sustained through blunt trauma and compression injuries can cause contusions and lacerations of the heart, lungs, and great vessels. Closed chest injuries may cause a condition known as flail chest. This condition is defined as a fracture of two or more consecutive ribs in two or more places. Some sources say three or more ribs in two or more places. The most important factor to remember— even more than the number of broken ribs—is that flail chest leaves a portion of the chest wall unstable, which affects breathing and reduces lung expansion. This can lead to inadequate breathing and hypoventilation. Because the flail segment is not attached, it is free to independently move. When the patient’s chest expands to inhale, negative pressure draws air into the lungs. This negative pressure also draws the flail segment inward. When the patient’s chest moves inward, positive pressure is created that pushes air out of the lungs, and this positive pressure also pushes the flail segment outward. Thus, the movement of the flail segment is opposite to the movement of the remainder of the chest cavity. This is called paradoxical motion.

PATIENT ASSESSMENT Flail Chest

The patient with flail chest will have a mechanism of injury capable of causing it, difficulty breathing, pain at the injury site, and likely signs of shock and hypoxia. The characteristic paradoxical motion may be difficult to observe in early stages since the chest wail muscles will tighten and naturally splint the area. This muscle tightening, combined with efforts necessary to breathe, will eventually cause the patient to become fatigued In turn, this will cause the flail segment to become more visible—and will also make assisting ventilations necessary. When a flail segment is visible, it may be a late sign that appears once the patient becomes tired and weak.

PATIENT CARE Flail Chest

1. Perform a primary assessment. Flail segments should be identified as early in the assessment as possible since they pose a threat to life. 2. Administer oxygen. 3. If the patient is breathing inadequately, assist ventilations. 4. Use a bulky dressing to stabilize the flail segment. Tape the dressing into place. The tape or bandage used should not encircle the chest or interfere with chest expansion. 5. Monitor the patient carefully. 6. Watch the patient’s respiratory rate and depth. If respirations become too shallow, assist ventilations.

Open Chest Injuries Whenever the skin is broken, the patient has an open wound. However, the term open chest wound usually means that not only is the skin broken but the chest wall is also penetrated (for example, by a bullet or a knife blade). An object can pass through the wall from the outside, or a fractured and displaced rib can penetrate the chest wall from within. The heart, lungs, and great vessels can be injured at the same time the chest wall is penetrated. It may be difficult to tell if the chest cavity has been penetrated by looking at the wound. Do not open the wound to determine its depth. Specific signs (as noted in the following Patient Assessment section) will indicate possible open chest injury You must consider .ill open wounds to the chest to be life-threatening wounds. Open chest wounds are usually penetrating puncture wounds, which may penetrate the chest wall one or more

times (for example, a gunshot wound may have both an entrance and an exit wound). An object producing such a wound may remain impaled in the chest, or the wound may be completely open. When air enters the chest cavity, the delicate pressure balance within the chest cavity is destroyed. This causes the lung on the injured side to collapse. Injuries associated with air in the chest cavity are discussed in more detail under the heading “Injuries within the Chest Cavity.”

PATIENT ASSESSMENT

Open Chest Wound

The term sucking chest wound is used when the chest cavity is open to the atmosphere. Each time the patient breathes, air can be sucked into the opening. This patient will develop severe difficulty breathing. The following signs indicate a sucking chest wound: • The patient has a wound to the chest. • There may or may not be the characteristic sucking sound associated with an open chest wound. • The patient may be gasping for air. Keep in mind that the object penetrating the chest wall may have seriously damaged a lung, major blood vessel, or the heart itself.

PATIENT CARE

Open Chest Wound An open chest wound is a true emergency that requires rapid initial care and immediate transport to a medical facility. Follow these steps: 1. Maintain an open airway. Provide basic life support, if necessary. 2. Seal the open chest wound as quickly as possible. If needed, use your gloved hand. Do not delay sealing the wound in order to find an occlusive dressing. 3. Apply an occlusive dressing to seal the wound. When possible, the dressing should be at least 2 inches wider than the wound. If there is an exit wound in the chest, apply an occlusive dressing over this wound, too. Create a flutter-valve dressing with one corner or side unsealed. These dressings will be discussed in detail later under the heading “Occlusive and Flutter-Valve Dressings.” 4. Administer high concentration oxygen. 5. Care for shock. 6. Transport as soon as possible unless other injuries prevent you from doing so. Keep the patient positioned on the injured side. This allows the uninjured lung to expand without restriction. 7. Consider advanced life support intercept if it will not delay the patient’s arrival at the hospital.

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PRINCIPLES OF EMT CLINICAL PRACTICE

Occlusive and Flutter-Valve Dressings Care for an open chest wound involves application of a dressing that will allow air to escape the chest cavity while preventing air from entering. These dressings—called occlusive, one-way, or flutter-valve dressings—usually involve taping the dressing in place and leaving a side or corner of the dressing unsealed. As the patient inhales, the dressing will seal the wound. As the patient exhales, the free corner or edge will act as a flutter valve to release air that is trapped in the chest cavity. The danger of a pneumothorax developing into a tension pneumothorax (see the description of pneumothorax and tension pneumothorax under the heading “Injuries within the Chest Cavity”) is the reason why medical authorities recommend the flutter-valve (three-sided) occlusive dressing instead of an occlusive dressing sealed on all four sides. If you find that blood or tissue begins to accumulate under the dressing and prevents air escape, you may need to briefly remove the dressing, wipe away the accumulated material, and reseal the dressing on three sides. Commercial devices, such as the Asherman Chest Seal, seal all the wound edges and have a valve that allows pressure relief. You may have to maintain hand pressure over the occlusive dressing en route to the hospital. The tape also may not stick well to bloody skin or to skin that is sweaty from shock. Note that if a commercial occlusive dressing is not available, you may have to improvise. Most ambulances carry sterile disposable items that are wrapped in plastic. The inside surface of the plastic is sterile. If you do not have an occlusive dressing, use one of these wrappers or the wrapper from an IV bag. Keep in mind that household plastic wrap is not thick enough to make an effective occlusive dressing fur an open chest wound. It nothing

Injuries within the Chest Cavity Because each of the organs inside the chest cavity is vital to life, any chest injury has the potential to be serious. Since, the blood vessels that run through the chest are the largest in the body, injury to these vessels is often fatal. In fact, the chest can hold over 3 liters of blood. It is possible to bleed to death within the chest cavity and never spill a drop outside the body. Since chest injuries have the potential to be serious— even fatal—it is important to describe some of the specific injuries that may occur within the chest cavity. The signs and symptoms of different chest injuries often overlap, so you may only be able to narrow the possibilities instead of determining the patient’s exact problem. This is sufficient for you to assess and care for them effectively as described at the end of this section.

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else is available, household plastic or saran wrap can be used, but it must be folded several times to be of the proper thickness, liven then, it may fail. If there is no other choice, aluminum foil may be used to make the seal. Be careful, however, as foil edges may lacerate the patient’s skin and may tear when lifted to release pressure. A commercial alternative to taping an occlusive material over a sucking chest wound is the Asherman Chest Seal. Because it includes a one-way valve in its design, there is no need Kahit matakpan na ang sugat sa to leave an edge dibdib, patuloy na obserbahan ang unsealed. To use pasyente at maging handa sa anumang it, quickly dry komplikasyon. Kahit pa gumamit ka the skin around ng flutter valve o commercial chest seal the wound and device, kailangan mong tingnan ang apply the seal’s pasyente kung may namumuong pressure adhesive surface sa dibdib nito. Puwede kasing ang mga to the wound, gilid ng dressing ay dumikit sa dibdib, being careful to at maipon ang dugo sa ilalim ng center the device dressing. Puwede ring (and the one-way masyadong lumalim valve) over the ang dressing at wound. Once the maapektuhan valve is placed ang valve. directly over the wound, air will be able to escape from the thoracic cavity but not enter it.

PNEUMOTHORAX AND TENSION PNEUMOTHORAX

• Pneumothorax occurs when air enters the chest cavity, possibly causing collapse of a lung. The air can enter through an external wound, the air may enter the cavity through a punctured lung, or both events may occur. Tension pneumothorax, which is most often found with a closed chest injury or after a sealed occlusive dressing has been applied to an open chest wound, is especially critical. The lung may be punctured hy a broken rib or other cause. If there is no opening to the outside of the chest, air that leaks from the lung has no avenue of escape. It builds up in the chest cavity and puts pressure on the heart, great blood vessels, and the unaffected lung, reducing cardiac output and the lungs’ ability to oxygenate the blood. Patients with pneumothorax will have diminished or absent lung sounds on the affected side. As the pneumothorax progresses to a tension pneumothorax, the jugular veins in the neck may become distended (unless blood volume is low). Signs of shock will also be present. The trachea may shift to the opposite side but this is a very late sign and one which is difficult to detect.

HEMOTHORAX AND HEMOPNEUMOTHORAX

• Hemothorax is a condition in which the chest cavity fills with blood. With hemopneumothorax. the chest cavity fills with both blood and air. It is easy to compare these two complications with pneumothorax if you remember that pneumo means “air” and hemo means “’blood.” In pneumothorax, there is a build-up of air in the thorax. In hemothorax and hemopneumothorax, blood creates or adds to the pressure. Hemothorax can be caused when lacerations within the chest cavity are produced by penetrating objects or fractured ribs. Blood will flow into the space around the lung, the lung may collapse, and the patient will experience a loss of blood, leading to shock. Hemopneumothorax involves a combination of blood and air that usually produces the same results: a collapsed lung and loss of blood leading to shock. Patients with hemothorax usually present with signs of shock.

TRAUMATIC ASPHYXIA

• Traumatic asphyxia is associated with sudden compression of the chest. When this occurs, the sternum and the ribs exert severe pressure on the heart and lungs forcing blood out of the right atrium and up into the jugular veins in the neck. The pressure of the blood being forced into the head and neck will usually result in blood vessels in and near the skin rupturing, causing extensive bruising of the face and neck. Patients with traumatic asphyxia present with a mechanism of injury that can cause compression of the chest. The patient’s neck and face will be a darker color than the rest of the body (red. purple, or blue). Depending on the amount of pressure and how long the pressure was exerted on the torso, the patient may also have bulging eyes, distended neck veins, and broken blood vessels in the face.

CARDIAC TAMPONADE

• When an injury to the heart causes blood to flow into the surrounding pericardial sac. the condition produced is cardiac tamponade. The heart’s unyielding sac fills with blood and compresses the chambers of the heart to a point where they will no longer adequately fill, backing up blood into the veins. This is usually the result of penetrating trauma like a stab wound. The pericardium is very tough, with limited ability to quickly stretch. It is also “self-scaling.” in that little or no blood will be able to escape when the heart is lacerated. Patients who experience cardiac tamponade will usually have distended neck veins The patient will exhibit signs of shock and a narrowed pulse pressure.

AORTIC INJURY AND DISSECTION

• Trauma can also cause injury to the aorta, the largest artery in the body. Damage to this large, highpressure vessel causes massive, often fatal bleeding. Penetrating trauma can cause direct damage Mine aorta. Blunt trauma, such as deceleration from a severe motorvehicle collision (e.g.. head-on), can sever or tear the aorta. The aorta can also be damaged without trauma. Degeneration of the aorta, often worsened by high blood pressure or other diseases causes weakening of this large vessel. Aortic dissection is a condition where the inner layer of the wall of the aorta begins to tear. Blood from the interior of the vessel leaks into the outer layers and eventually causes a balloon like protrusion, called an aneurysm. As pressure builds in the aneurysm, there is an increased risk of rupture, leading to the patient’s death. The aorta runs from the left ventricle through the chest and abdomen, and these injuries can occur anywhere along its path. The patient with an aortic injury may complain of pain in the chest, abdomen, or back—depending on the injury’s location. The patient will often exhibit signs of shock. The patient may have differences in pulse or blood pressure between the right and left arms (in proximal aortic injury) or differences in pulses between the arms and the legs or the legs themselves (in abdominal aortic injury). In thin patients or those with a large aneurysm in the abdomen, the aneurysm may occasionally be palpated. Other than routine abdominal palpation, however, you should not probe the abdomen specifically for aneurysms, as it may cause injury to the patient, such as rupture of the aorta. Commotio cordis is an uncommon condition that is easy to recognise and treat. When someone gets hit in the center of the chest, the result is usually a bruise or even perhaps a fracture. In commotio cordis (Latin for commotion or disturbance of the heart), however, the impact occurs just when the heart is vulnerable. There are several hundredths of a second during each heartbeat when the heart, if sufficiently stimulated, will go into ventricular fibrillation (VF). A patient in commotio cordis experiences this condition. An example of this is the young athlete w ho tries to catch a baseball, but misses. The ball strikes him in the center of the chest and the patient collapses in cardiac arrest. If you obtain a history like this with a young patient, treat the patient like any other patient in ventricular fibrillation. Do not treat the patient as a trauma patient, delaying defibrillation because of the concern about internal blood loss. If the patient receives defibrillation and CPR quickly enough, the patient has a very good chance of survival. He usually has a very healthy heart that will respond well to CPR and defibrillation.

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PATIENT ASSESSMENT Injuries within the Chest Cavity The following are common signs of pneumothorax:

• Respiratory difficulty • Uneven chest wall movement • Reduction of breath sounds on the affected side of the chest (listen with stethoscope)

Signs of tension pneumothorax include those items in the previous list plus

• Increasing respiratory difficulty • Indications of developing shock, including rapid, weak pulse: cyanosis; and low blood pressure due to decreased cardiac output • Distended neck veins • Tracheal deviation to the uninjured side (which is a late sign and difficult to observe) • Reduced or absent breath sounds on the affected side of the chest

The following signs may commonly indicate a hemothorax

• Signs of pneumothorax plus coughed-up frothy red blood

The following are common potential signs of traumatic asphyxia • • • • •

Distended neck veins Head. neck, and shoulders appearing dark blue or purple Bloodshot and bulging eyes Swollen and blue tongue and lips Chest deformity

The following are common signs of cardiac tamponade

• • • •

Distended neck veins Very weak pulse Low blood pressure Steadily decreasing pulse pressure (Pulse pressure is the difference between systolic and diastolic leadings)

The following are common signs of aortic injury 01 dissection

• Tearing chest pain radiating to the back • Differences in pulse or blood pressure between the right and left extremities or between the arms and legs • Palpable pulsating mass (if the abdominal aorta is involved) • Cardiac arrest

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PATIENT CARE Injuries within the Chest Cavity The treatment is the same for all of the previously noted types of injuries within the chest cavity: 1. Maintain an open airway Be prepared to apply suction 2. Administer high concentration oxygen 3. Follow local protocols as to the preferred type of dressing for any open wound 4. Care for shock 5. Transport as soon as possible 6. Consider ALS intercept if it will not delay the patient‘s arrival at the hospital ALS personnel can perform procedures such as chest decompression that can greatly benefit a patient suffering from certain chest injury complications

ABDOMINAL INJURIES

Abdominal injuries can be open or closed, with a closed injury usually caused by blunt trauma. Internal bleeding can be severe if organs and major blood vessels are lacerated or ruptured. Very serious and painful reactions can occur when the hollow organs are ruptured and their contents leak into the abdominal cavity. Penetrating wounds to the abdomen can be caused by objects such as knives, ice picks, arrows, and the broken glass and twisted metal of vehicular collisions and structural accidents. Very serious penetrating wounds can be caused by bullets, even when the bullet is small caliber. Open wounds of the abdomen may he so large and deep that organs protrude through the wound opening. This is known as an evisceration. A more common condition than an evisceration is blunt trauma to one or more abdominal organs. The liver is the most commonly injured organ because or its relatively large size and position in the upper right quadrant and under the lowermost ribs on the right side. The liver is very vascular; therefore, when it is injured, it can bleed profusely, often to the point of life-threatening blood loss. Another very vascular organ is the spleen, located in the left upper quadrant and under the lowermost ribs on the left. Like the liver, the spleen can produce life-threatening blood loss. The diaphragm is occasionally injured, from either blunt trauma or penetrating trauma. If there is a sudden severe force applied to the abdomen, that pressure can be posteriorly and superiorly transmitted. This can be so great that the diaphragm partially detaches allowing abdominal contents to enter the thoracic cavity. A penetrating injury like a stab wound can also injure the diaphragm. If the resulting wound is significant, abdominal contents can enter the thoracic cavity in this manner, too. Hollow organs in

the abdomen include the stomach, small and large bowel, gallbladder, and urinary bladder. If these organs are injured, they often spill their contents into the abdominal cavity, leading to severe irritation and often peritonitis. This can cause the abdominal muscles to involuntarily contract, leading to rigidity of the abdominal wall. Retroperitoneal organs, located in the posterior abdomen, are less commonly injured than the organs inside the peritoneal cavity. The pancreas, for instance, lies across the spine. Unless a knife or bullet hits it or there is significant force to the center of the abdomen, this organ is rarely injured. The kidneys are also retroperitoneal, with protection from the muscles of the back and the lower ribs that cover their superior portion. If a kidney is injured, it is usually from a direct blow.

PATIENT ASSESSMENT Abdominal Injury Gunshot wounds without exit wounds can cause serious abdominal damage, just as those with exit wounds do. A misconception about bullet wounds is that internal damage can be easily assessed. On the contrary any projectile entering the body can be deflected, or it can explode and send out pieces in many directions. Do not believe that only the structures directly under the entrance wound have been injured Also, keep in mind that the bullet’s pathway between the entrance wound and exit wound is seldom a straight line. Further complicating the problem, penetrating abdominal wounds can be associated with wounds in adjacent areas of the body. For example, a bullet can enter the chest cavity, pierce the diaphragm, and cause widespread damage in the abdomen. A complete patient assessment is essential in determining the probable extent of injuries. Always assess for an exit wound. The following are some common signs and symptoms of abdominal injury: • Pain, often starting as mild pain then rapidly becoming intolerable • Cramps . Nausea, weakness and thirst • Obvious lacerations and puncture wounds to the abdomen • Lacerations and puncture wounds to the pelvis and middle and lower back or chest wounds near the diaphragm • Indications of blunt trauma such as a large bruised area or an incense bruise on the abdomen • Indications of developing shock, including restlessness; pale, cool and clammy skin, rapid shallow breathing, a rapid pulse: and low blood pressure (Sometimes patients with abdominal injury who are in extreme pain show an initial elevated blood pressure)

• Coughing up or vomiting blood: the vomitus may contain a substance that looks like coffee grounds (partially digested blood) • Rigid and/or tender abdomen, which the patient tries to protect (guarded abdomen) • Distended abdomen • Patient who tries to lie very still, with the legs drawn up in an effort to reduce the tension on the abdominal muscles

Inside/Outside The Path of the Bullet

A patient who has gunshot wounds in the lower ribs and at the same level in the back may appear to have a chest wound. In reality, you need to treat him for both a chest wound and an abdominal wound. It is obvious that the bullet may have penetrated the lung, but since the Spleen and liver are posterior to the lower most left and right ribs, you must assume they may have been injured at the same time. If the patient was inhaling deeply when he was shot (resulting in the abdominal organs taking up less space in the chest), the spleen and liver may not have been in the direct path of the bullet. But bullets often take paths that are not straight. If the bullet tumbled or produced cavitation, the spleen or liver may very well have sustained serious injury. You will need to be alert to the possibility of both a chest and an abdominal injury.

PATIENT CARE Abdominal Injury

Some emergency care steps apply to both closed and open abdominal injuries. However, other additional care steps are necessary for open abdominal injuries For both closed and open abdominal injuries: 1. Stay alert for vomiting and keep the airway open. 2. Place the patient on his back, legs flexed at the knees, to reduce pain by relaxing abdominal muscles 3. Administer high concentration oxygen 4. Care for shock 5. Give nothing to the patient by mouth. This could induce vomiting or pass through open wounds In the esophagus, stomach, or intestine and enter the abdominal cavity. 6. Constantly monitor vital signs 7. Transport as soon as possible 8. Control external bleeding and dress all open wounds. 9. Do not touch or try to replace any eviscerated, or exposed, organs. Apply a sterile dressing moistened with sterile saline over the wound site. Some EMS systems may recommend that you apply an occlusive dressing as well

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541

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PRINCIPLES OF EMT CLINICAL PRACTICE

NOTE:

PRINCIPLES PRINCIPLES OF OF EMT EMTPRINCIPLES CLINICAL CLINICAL PRACTICE PRACTICE OF EMT CLINICAL PRACTICE

Dressing an Open Abdominal Wound

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UNIT UNIT 33 CLINICAL PRACTICE OF EMT PRINCIPLES PRINCIPLESOF OF EMT EMT CLINICAL CLINICAL PRACTICE PRACTICE

DAY DAY21 21

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EVISCERATION EVISCERATION MANAGEMENT MANAGEMENT 1. 1. BSI BSI on. on. And And check check scene scene safety. safety. Prepare Prepare necessary necessary equipment equipment and and materials materials 2. 2. Use Use aa bulky bulky dressing dressing and and apply apply itit on on top top of of the the inintestine. testine. (make (make sure sure that that the the dressing dressing isis moist—to moist—to maintain maintain the the moisture moisture of of the the intestine/organ) intestine/organ) 3. 3. Place Place aa clean clean plastic plastic to to help help maintain maintain the the moismoisture ture inside. inside. 4. 4. Secure Secure the the dressing dressing with with aa triangular triangular bandage bandage spespecifically cifically abdominal abdominal banbandage dage under under broad broad cravat. cravat. 5. 5. Tie Tie itit using using square square knot knot and and reassess reassess patient patient concondition. dition. Document. Document. 6. 6. Transfer Transfer accordingly. accordingly.

1. 2.

3. 4.

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EVISCERATION MANAGEMENT BSI on. And check scene safety. Prepare necessary equipment and materials Use a bulky dressing and apply it on top of the intestine. (make sure that the dressing is moist—to maintain the moisture of the intestine/organ) Place a clean plastic to help maintain the moisture inside. Secure the dressing with a triangular bandage specifically abdominal bandage under broad cravat. Tie it using square knot and reassess patient condition. Document. Transfer accordingly.

² Limmer ² Limmer (Brady) (Brady) ³ Pollack, ³ Pollack, (AAOS) (AAOS) ⁴ NHTSA ⁴ NHTSA

Cover the dressed wound to maintain warmth. Secure the covering with tape or cravats tied above and below the position of the exposed organ. Open abdominal wound with evisceration.

² Limmer (Brady) ² Limmer (Brady)

³ Pollack, (AAOS) ³ Pollack, (AAOS) ⁴ NHTSA ⁴ NHTSA

ng ingwith witha a age dage spespenal inal banbandadcravat. cravat. are uareknot knot atient ent conconnt. . gly. ngly.

EVISCERATION MANAGEMENT

1. BSI on. And check scene safety. Prepare necessary equipment and materials 2. Use a bulky dressing and apply it on top of the intestine. (make sure that the dressing is moist—to maintain the moisture of the intestine/ organ) 3. Place a clean plastic wrap to help maintain the moisture inside. 4. Secure the dressing with a triangular bandage specifically abdominal bandage under broad cravat. 5. Tie it using square knot and reassess patient condition. Document. 6. Transfer accordingly. ²²Limmer Limmer(Brady) (Brady) ³³Pollack, Pollack,(AAOS) (AAOS) ⁴⁴ NHTSA NHTSA

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² Limmer (Brady) ² Limmer (Brady) ³ Pollack, (AAOS) ³ Pollack, (AAOS) ⁴ NHTSA ⁴ NHTSA

PREHOSPITAL EMERGENCY CARE

FIRST TAKE STANDARD PRECAUTIONS.

² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

1. Cut away clothing from the wound. 2. Soak a sterile dressing with sterile saline. 3. Place the moist dressing over the wound. It may be necessary to re-moisten the dressing with additional sterile saline to keep the eviscerated organ or organs from drying out. 4. Apply an occlusive dressing over the moist dressing if your local protocols recommend taking this action.

Sa paglalagay ng dressing, basain muna ito ng sterilized saline solution. Mahalaga na basa ang dressing para hindi matuyo ang organ na tatakpan nito.

MULTISYSTEM TRAUMA LEARNING OBJECTIVES • Explain the elements of trauma assessment. • Explain the management of head, facial, and neck injury patients. • Explain the management of spinal injury patients. • Explain the management of abdominal injury patients. • Explain the management of musculoskeletal injury patients. • Explain the management of softtissue injury patients.

MULTISYSTEM TRAUMA

INTRODUCTION There are many differences between trauma patients and medical patients. Medical patients generally call for a single complaint. In contrast, trauma patients often have more than one problem—a head injury and a broken leg, for example. When an emergency concurrently causes damage to more than one area of the body, this is referred to as multisystem trauma and is a serious condition.

The multiple trauma patient has more than one serious injury. The multisystem trauma patient has one or more injuries serious enough to affect more than one body system. For example, a patient with a gunshot wound to the chest and a painful, swollen, deformed extremity is a multiple trauma patient, having more than one serious injury. He is also likely to be a multisystem trauma patient. He has a possibility of spinal injury, which will affect the nervous system. Additionally, the gunshot wound to the chest may well affect some or all of the heart and great blood vessels (cardiovascular system), the lungs (respiratory system), and perhaps nearby organs such as the spleen, pancreas, liver, kidneys, stomach, and intestines (endocrine, hepatic, renal, and digestive systems). When the mechanism of injury suggests that your patient has more than one serious injury, or has an injury or injuries that are likely to affect more than one body system, decisions beyond w hat are called for on more typical EMS runs become necessary. For example, consider the patient who has fallen 10 feet from some scaffolding and has an angulated forearm injury. Your primary assessment reveals him to be unresponsive with the airway partially occluded by his tongue. Do you spend time applying a rigid splint to his arm? The answer in this case is no. This patient has life threatening injuries affecting at least

the respiratory system that can only be treated in a hospital emergency department or operating room. Spending additional time at the scene to treat an injury that is life threatening may reduce the patient’s chances of survival. Now consider an alert patient with no signs or symptoms of shock who has pain and tenderness in the middle of his thigh as well as an angulated forearm. In this case, the patient is stable enough to allow you a few minutes to apply a splint and prevent further injury. In each of these two examples, your actions as an EMT should provide the most benefit to the patient while at the same time reducing risk as much as possible. These decisions are made easier when your crew works well together and each member knows what to expect from another. This is called teamwork. Crew members also must be aware of the importance of moving a multisystem trauma patient to definitive care as soon as possible, since it is rarely possible for EMS providers (even paramedics) to truly stabilize a trauma patient in the field. This is called timing. Finally, the appropriate destination must be chosen for the patient. This is a transport decision. In areas where some hospitals are designated trauma centers it is important that protocols specify which patients need to be taken there and when it is (or is not) appropriate for EMS to bypass another hospital.

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Determining Patient Severity When you first approach a trauma scene, you will need to take in as much information as possible in order to make the best decisions. There will be times when you will come upon a horrific crash and see a patient standing there, seemingly uninjured, whereas in a similar crash on a different day you will find a critically injured patient. Although you have heard much about critical decision making, perhaps the most critical decisions you will make for any trauma patient are determining 1. patient priority/severity. 2. whether to limit scene time or not. and 3. which hospital or transport method is best for your patient. These decisions are a foundation for the entire call. A wrong decision about patient severity or transport— especially one that delays transport of a patient who needs it—will result in a delay of necessary surgical care at the hospital and create a disorganized, chaotic scene while you try to play catch up with a crashing patient. It is also worthwhile to note that there are so many variables at trauma scenes that it is impossible to provide exact guidelines for each situation. The decisions you make will be based on several things, including your patient’s condition, the proximity of hospitals, options available for transport (e.g.. air medical evacuation), your protocols, and the advice of medical direction. Ano ang gagawin mo sa mga sumusunod na sitwasyon. Posibleng isa ka sa mga EMT na binabanggit dito: 1. Ang lugar kung nasaan ang EMT ay limang minutong biyahe lamang sa trauma center, kaya naman maiksi lamang ang oras na ginugugol niya sa scene at mabilis niyang dinadala sa trauma center ang pasyente. 2. Ang lugar kung nasaan ang EMT ay 30 minutong biyahe ang layo sa trauma center at meron siyang pasyente na dumudugo ang daanan ng hangin. Nahihirapan ang EMT na kontrolin ang pagdurugo. Sa kasong ito, kailangan ng tulong ng Advance Life Support o kaya ay dalhin ang pasyente sa mas malapit na ospital. Kaya lamang, baka hindi na umabot sa ospital ang pasyente kung hindi ito matutulungang huminga. 3. Ang ikatlong EMT ay nasa isang lugar sa probinsya at 45 minutong biyahe ang layo ng pinakamalapit na ospital at 2 oras naman ang layo ng trauma center. Sa kasong ito, kailangan ng helicopter para madala ang pasyente sa trauma center nang mas mabilis.

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You will need to consider many factors when making determinations about patient severity, priority, and transport destination. The next section will cover some of these issues. Follow local guidelines for trauma triage and transport to trauma centers. You may use these three main factors into consideration: physiological determinants, anatomic criteria, and mechanism of injury. You will encounter various determinants at different times in the call. You will notice the mechanism of injury as you size-up the scene, observe specific injury patterns as you approach, and notice the patient’s menial status and vital signs as you begin to assess the patient. Each of these factors will play into your transport decisions. Finally, each of the criteria discussed next— physiologic criteria, anatomic criteria, and mechanism of injury—should be considered separately and in sequence, addressing the first of these criteria before the second and addressing the second before the third, for example, if you encounter a patient who is physiologically unstable, he would be transported to a trauma center. However, if your patient is physiologically stable, you would move on to consider the anatomic criteria, and so on.

Determining Severity: Physiologic Criteria It is believed that the most valuable findings during an assessment are the patient’s physiologic conditions. Any time you have a patient with an altered mental status, hypotension, or an abnormally slow or rapid respiratory rate, you should place this patient at a high priority and transport him promptly to a trauma center when available and following your local protocols. • Altered mental status (GCS <14) is a significant indicator of head injury (which may present with unresponsiveness, confusion, or otherwise altered mental status) and hypoxia (which may present with anxiety and/or restlessness). • Hypotension (systolic blood pressure <90 mmHg) is a definitive sign for shock and indicates some sort of internal bleeding or other circulatory disturbance. • Abnormal respiratory rates are also indicative of serious injury. Rapid respiratory rates (>28) usually indicate shock. Abnormally slow rates (<10). in contrast, may indicate head injury or later stages of shock. In infants, respiratory rates below 20 are an extremely grave sign.

CDC Trauma Triage Guidelines: Physiologic Criteria Glasgow Coma Scale

CDC Trauma Triage Guidelines: Anatomic Criteria

Systolic blood pressure

< 90

Respiratory rate

<10 or >29 (<20 in infant less than 1 year)

Determining Severity: Anatomic Criteria Injuries of certain types or to specific areas of the body require care that is usually available only in a trauma center. For example, it makes sense that injuries to the head and chest could be serious. Other specific injuries require prompt surgical intervention for the patient to recover to the fullest extent possible. This list includes multiple musculoskeletal injuries (more than two long bone fractures = multiple trauma), amputations, and severely mangled extremities. Pelvic injuries are associated with significant internal bleeding.

• All penetrating injuries to head, neck, torso, and extremities proximal to elbow and knee. • Flail chest. • Two or more proximal long-bone fractures. • Crushed, degloved, or mangled extremity. • Amputation proximal to wrist and ankle. • Pelvic fractures. • Open or depressed skull fracture. • Paralysis. One example of a patient who will likely require triage In a higher level of care is a geriatric patient who has had a fall, is on anticoagulant medications, and has a head injury. Even if the patient appears fine after the fall, the risk of intracranial bleeding is high for this patient.

CDC Trauma Triage Guidelines: Mechanism of Injury Criteria

Determining Severity: Mechanism of Injury A significant mechanism of injury does not guarantee the patient has a serious injury. In the absence of physiologic or anatomic criteria, however, the fact that significant forces have acted on the body causes us as EMTs to act in a more cautious manner. Some newer vehicles have the ability to transmit data after a crash (telemetry). In addition to notifying police and rescue personnel, the on-board computer in the vehicle may also transmit data such as vehicle speed at the time of the crash, whether the vehicle rolled over or had multiple impacts, which part of the vehicle was struck (e.g.. front end), and whether or not the air bag was deployed.

FALLS

• Adults: >20 feet (one story is equal to 10 feet). • Children: >10 feet or two to three limes the height of the child.

HIGH RISK AUTO CRASH

• Intrusion >12 in. occupant site; >18 in. any site. • Ejection (partial or complete) from automobile. • Death in same passenger compartment. • Vehicle telemetry data consistent with high risk of injury.

AUTO V. PEDISTRIAN/BICYCIIST THROWN, RUN OVER, OR WITH SIGNIFICANT (>20 MPH) IMPACT MOTORCYCLE CRASH >20 MPH

Determining Severity: Special Patients and Considerations You will read in subsequent chapters that not everyone responds to illness and injury the same way. For example, geriatric patients do not efficiently compensate for shock. Children also respond differently and may benefit by transport to a pediatric specialty facility. Patients with certain conditions, such as patients on anticoagulants (blood thinners), those with endstage renal disease, those who are pregnant, and others, may also require transport to a trauma center but are generally decided on a case by case basis.

Iba’t ibang pasyente, iba’t ibang reaksyon din sa pagkakasakit o sa injury. Iba rin siyempre ang pagtugon na gagawin mo bilang EMT.

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Inside/Outside INTERNAL INJURIES Multisystem trauma is that which is serious and that often involves internal organs. This inside/outside feature reviews common internal injuries and their outside presentation as a review/summary for serious trauma

INSIDE

OUTSIDE

Kung may internal organs na nadisgrasya, may mga simtomas ka na dapat tingnan para malaman mo kung ano ang organ na tinamaan. Narito ang listahan na dapat mong tandaan.

PNEUMOTHORAX

• • • •

Diminished or absent lung sounds on one side Respiratory distress Elevated pulse Possible injury on that side of chest

TENSION PNEUMOTHORAX

• • • • • • •

Absent lung sounds on one side Distended neck veins Altered mental status Narrowing pulse pressure Increased pulse and respirations Possible injury (penetrating) to the chest Tracheal deviation (very late sign)

CARDIAC TAMPONADE

• • • •

Distended neck veins Narrowing pulse pressure Increased pulse and respirations Penetrating injury to the chest

SOLID ORGAN DAMAGE

• Solid organs are vascular and can bleed profusely causing shock. • A capsule around solid organs such as the liver can mask bleeding and pain, delaying diagnosis. • Injury to these vascular organs is often (although not always) sharp and in predictable patterns/locations (e.g., referred to shoulder)

HOLLOW ORGAN DAMAGE

• Hollow organ damage (e.g., to the small intestine) may cause a spilling of contents into the surrounding abdominal tissue. This frequently causes severe and diffuse pain because of wide-spread irritation.

CDC Trauma Triage Guidelines: Special Patient or System Considerations AGE

• Older adults: Risk of injury or death decreases after age 55 years • Children: Should be triaged preferentially to pediatric capable trauma centers • Anticoagulation and bleeding disorders

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Burns

• Without other trauma mechanism: triage to burn facility • With trauma mechanism: Triage to trauma center

Time sensitive extremity injury End stage renal disease requiring dialysis Pregnancy > 20 WEEKS EMS PROVIDER JUDGMENT

MANAGING THE MULTISYSTEM TRAUMA PATIENT

The following scenario describes a typical multipletrauma call. As you read, ask yourself these questions: When does the EMT recognize that the patient has multiple injuries? What body systems would the EMT suspect have been affected by this patient’s injuries? What is the EMT’s first decision about managing those injuries, and why do you think he made it? What actions does he take to support the affected body systems? What priorities does he set for his patient?

A Typical Call You receive a call for a motorcyclist who was hit by a car. The scene is safe, so you approach the patient, an adult male you estimate to be about 25 years old. He appears unresponsive in a pool of blood on the road and is not wearing a helmet. Police point to the motorcycle he was riding about 20 feet away. The patient responds purposefully to a painful stimulus: that is, he tries to push your hand away. He is making gurgling sounds with each breath, so you suction some blood out of his airway. He is also making snoring sounds, so you insert an oropharyngeal airway, which he tolerates and which eliminates the snoring sounds. His breathing is shallow and labored at a rate of about 30, so you have your partner ventilate him with a bag-valve mask and high-concentration oxygen as she simultaneously stabilizes his head with her knees. There is a pool of blood around the patient’s left thigh, which appears angulated. You quickly cut away the left leg of his pants and observe an apparent compound angulated mid-shaft femur fracture with blood flowing heavily from the wound. You apply a tourniquet to stop the bleeding. The patient’s radial pulse is rapid and weak, and his skin is pale and sweaty. You assign this patient a high priority for rapid treatment and transport based on the mechanism of injury, altered mental status, and presence of shock (hypoperfusion). You request ALS intercept en route if it is available and will not delay transport. You perform a trauma assessment. At the same time, a firefighter with whom you have worked before gets a long backboard and the other equipment necessary to immobilize the patient. By the time he returns, you have finished the rapid trauma assessment and gained the following information: A hematoma (lump) is present on the left side of the patient’s head. Neck veins are flat. There is no deformity of the cervical spine. Breath sounds are decreased on the left side of his chest. His abdomen is soft. His pelvis seems stable. There is an obvious compound angulated midshaft femur fracture on the left side from which the bleeding has been controlled. There are some non-bleeding lacerations on the left forearm and lower leg. And pulses are

weak but palpable in all extremities except the leg with the tourniquet. With a cervical collar in place on the patient, you roll him as a unit and examine his spine and posterior trunk. You find no further injuries. You roll him down on the hoard, taking care to move the injured leg as little as possible once it is in the anatomical position. As you quickly immobilize the patient on the board (using the board as a splint for the fractured femur), you make sure the firefighter is available to drive the ambulance so you and your partner can tend to the patient in hack. You confirm that the firefighter knows you are to go to the trauma center, not the community hospital that is 5 minutes closer. Your protocols specify that you are to go directly to the trauma center under conditions such as these because of the comprehensive care available there. You move the patient and board onto the stretcher and into the ambulance, making sure your partner is able to continue ventilating him during the move. Once inside the patient compartment, you repeat the primary assessment. Your general impression is of a young adult male with multiple injuries. His mental status remains unchanged: he again tries to brush your hand away when you apply a painful stimulus. His tongue is prevented from obstructing his airway by an oropharyngeal airway. There is a little bit of gurgling as you carefully listen, so you suction some more blood out of his mouth. There are now no abnormal sounds as your partner ventilates him. Oxygen is flowing, and you see the patient’s chest rise with each breath. The bleeding from the thigh remains controlled, and you see no other bleeding wounds. His radial pulse is rapid and weak.The patient is still a high priority. With a second primary assessment completed, you call the trauma center and notify them of the patient’s condition and your estimated time of arrival (10 minutes). You tell them you will give them vital signs as soon as you get them. With the hospital preparing for the patient’s arrival, you try to obtain vital signs. The patient’s pulse is 108, weak regular; blood pressure 92/56; respirations assisted at 12 per minute; and skin pale and sweaty. You relay this information lo the trauma center (injured patient). You have a few minutes before you arrive, so you check with your partner to make sure she is still able to ventilate the patient well before you perform a detailed head-to-toe physical exam. You find the patient has equal pupils that are slow to react, a hematoma (lump) on the left side of his head, nothing unusual in or behind the cars, deformity on both sides of his mandible (you conclude this is what is causing the bleeding into his airway), and flat neck veins (you are unable to palpate the cervical spine because the cervical collar is in place). His breath sounds are still decreased on the left side of his chest, his abdomen seems to be firmer than before, his pelvis seems stable, there is an obvious compound midshaft femur fracture on the left side (it is no longer angulated because you straightened it when you put the patient on the board), and there are some nonbleeding lacerations on the left forearm and lower leg. It is more difficult now to palpate peripheral pulses. LIFELINE

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Day 21 You would like to apply a traction splint but realize you do not have enough time or personnel. With just a few minutes before you arrive at the trauma center, you repeat the primary assessment one more time. The patient will responds purposefully to painful stimuli, will now he also opens his eyes briefly when you pinch him. You find no other changes. You get another set of vital signs: pulse 120, blood pressure 90 by palpation, respirations assisted at 12 per minute, and skin pale and sweaty. You arrive at the emergency department and give a report to the trauma team as you transfer your patient to his bed. The patient becomes a bit more responsive in the emergency department, but he is agitated. The staff stabilizes his vital signs for the moment. The emergency department staff asks you and your partner to help apply a traction splint to the patient’s fractured femur. You are able to quickly and efficiently do so. The patient goes off for further tests and surgery. Later you learn that the patient had a cerebral contusion (bruise of the brain), bilateral fracture of the mandible, left hemothorax (blood in the left side of the chest cavity), and a fractured femur. After a lengthy stay, the patient is able to walk out of the hospital with some temporary assistance from a pair of crutches.

Analysis of the Call The previous scenario about the injured motorcycle rider shows an example of a patient who has critical injuries. Immediate threats to his life included shock (hypoperfusion) and bleeding into an airway that was partially obstructed by his tongue. Other serious injuries included an apparent head injury, inadequate ventilation, a presumed chest injury, a mandible injury, a compound angulated femur fracture, and a suspected spine injury (based on the mechanism of injury). The EMT in the scenario gave his patient the best possible chance of survival by following the priorities determined by his assessments. The primary assessment revealed several immediate life threats that the EMT could do something about: • The airway was partially obstructed by blood, which he suctioned. • The patient’s tongue was partially blocking the airway, causing snoring sounds with breathing, for which he inserted an artificial airway. • The patient’s breathing was shallow and labored at a rate of about 30. which indicated inadequate ventilation, for which the EMTs partner instituted assisted ventilations with high-concentration oxygen.

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PRINCIPLES OF EMT CLINICAL PRACTICE The EMT then picked upon the seriousness of the patient’s condition and made the decision not to treat some injuries the way he ordinarily would. That is, normally he would have applied a traction splint and dressed and bandaged the limb lacerations. Although it was tempting to do so, he realized this would delay transport for a patient who might have very little time to waste. A patient who has bleeding into his airway does not have any time to spare. Accordingly, the EMT used a backboard as a universal splint for the femur and did not bandage the lacerations because they were not bleeding. There were two additional ways in which the EMT showed good judgment: he postponed taking vital signs, and he gave the hospital staff time to prepare. That is, the patient was ready to be put in the ambulance before the EMT was able to get vital signs, so he appropriately postponed taking them until they were en route. As tempting as it might be to complete an assessment all at once, the EMT realized that vital signs were not going to change anything he could do and taking them would delay transport. He also called the hospital and gave them an admittedly incomplete report so that they could begin preparations. He made sure to tell them he would get them the patient’s vital signs as soon as possible and then he did. This gave the hospital some additional time to notify the trauma team.

General Principles of Multisystem Trauma Management Prepare for a call to a multisystem trauma patient by practicing for it. If you have a regular partner or crew, determine your individual roles beforehand. For example, someone should be designated to manually immobilize the patient’s head and. if necessary, ventilate with a bag-valve mask. Depending on the number of people available, you may have to have each person handle several roles. En route to the call, if you have reason to believe you might care for a multisystem trauma patient, review the roles each person will have. At the scene, follow the assessment steps as you learned them in your EMT course. Follow the priorities you discover in your primary assessment (airway, breathing, and circulation). Then balance the need for scene interventions with the time needed to perform them. As you may recall, the concept of the golden hour refers to the need for critical trauma patients to get to surgery within 1 hour of injury (not 1 hour from when you get to the patient). Although the time the patient has to get to surgery has not been scientifically proven to be an hour, the concept is still a useful one in avoiding delays at the scene.

Sa mga pasyente na kritikal ang kondisyon, limitahan ang gamutan sa lugar sa mga sumusunod: 1. Pag-stabilize sa cervical spine. 2. Pag-suction sa daanan ng hangin. 3. Pagbabalik ng paghinga ng pasyente sa pamamagitan ng pagtatakip sa sugat nito sa dibdib. 4. Pagbibigay ng oxygen sa pasyente. 5. Pagkontrol sa pagdurugo. 6. Pag-immobilize sa pasyente sa pamamagitan ng cervical collar at mahabang spine board. Principles of multisystem trauma management also include the following: • Scene safety is paramount. Different kinds of trauma tend to have different kinds of dangers. Blunt trauma, which is more common in rural and suburban areas, can be associated with such dangers as bent power poles leaking fuel, sharp glass and metal edges, and passing traffic. Penetrating trauma, such as stab wounds and gunshot wounds, tend to occur more commonly in urban iron. Risks you will need to consider include, the presence of the assailant (especially one who is upset because you are trying to save a person he tried to kill), presence of multiple weapons (on the victim, assailant, and bystanders), absent or delayed police response, and angry crowds, • Ensure an open airway. If you are unable to ventilate your patient without assistance. try other approaches until you find one that works. You might get another person to assist you en route or you might have to switch places with your partner. Other alternatives include using a different device to ventilate, such as a pocket mask with supplemental oxygen, or you and your partner may have to work together to ventilate the patient. • Perform urgent or emergency moves as necessary. For example, if a critical patient is sitting in a vehicle, you will need to perform a rapid extrication. • Adapt to the situation. When a patient is trapped, for example, and part of the patient’s body is not accessible, assess as much of him as you can. Keep in mind that when he is extricated you will need to perform a complete examination. For a multisystem trauma patient, your overall goal is to treat immediate threats to life, which you can treat with prompt transportation to a facility that will provide definitive care (or as close to it as is available). Guard against the temptation in these cases to spend time at the scene treating all of the patient’s injuries and immobilizing him perfectly. It is not good patient care to arrive at the hospital with the world’s best-packaged corpse.

Trauma Scoring In some EMS systems, hospitals ask EMTs and other providers not only to perform the usual assessment of trauma patients but also to evaluate trauma patients according to a numerical rating system. By evaluating certain patient characteristics and assigning a number to each of them, the provider can determine a trauma score that may do two things. First, calculating the trauma score may help to determine whether a patient should go to a trauma center. A patient who needs the resources that a trauma center can provide (like 24-hour-a-day availability of trauma surgeons and nurses, operating rooms, special intensive care beds, and so on) should be transported there as expeditiously as possible. In rural areas, this typically means EMS transports to the local hospital where the patient receives enough care to quickly stabilize his condition before he is transferred to a distant trauma center. In more densely populated areas where some local hospitals are trauma centers and some are not. there will be local protocols describing when EMS should transport a patient directly to a trauma center, even if it is necessary to go past a hospital that is not a trauma center. This is where a trauma scoring system can help. By objectively describing the severity of a patient’s condition, the score can direct more severely injured patients directly to trauma centers and allow less seriously injured patients to go to local hospitals. The second major function of a trauma scoring system is to allow trauma centers to evaluate themselves in comparing the outcomes of trauma patients who have similar severity of injuries, In this way. they can improve the quality of care their trauma patients receive and conduct research on trauma care. Several systems are in use to achieve these purposes. One of the most useful and widely utilized is the Revised Trauma Score (RTS). The RTS evaluates three characteristics of the patient’s condition: the Glasgow Coma Scale or GCS, systolic blood pressure, and respiratory rate. The original trauma score included other characteristics that were difficult to evaluate consistently under field conditions and turned out to be unnecessary. The list shows the values assigned to the EMT’s assessment findings in the Revised Trauma Score. Up to four points are assigned for each of the elements of the RTS. The lower the score, the more seriously injured the patient is and the less likely he will survive, even with excellent care. Follow your local protocols for use of a trauma scoring system, but do not let it interfere with patient care. Manage airway problems and control other immediate threats to life before trying to use a score. In some systems, EMTs are asked to determine the score en route. In others, they may be asked simply to gather all the elements used to calculate the score, but not to assign numerical values. By reporting this information, a physician or nurse at an emergency department can calculate the score and advise you on the appropriate destination for your patient. Follow your local protocol.

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Day 21

REVISED TRAUMA SCORE

Source: Champion H.R., Sacco W.J., et al. A Revision of the Trauma Score. J Trauma 29 (5): 623-9, 1989

CHARACTERISTIC Glasgow Coma Scale

Systolic Blood Pressure

Respiratory Rate

Revised Trauma Score (Total)

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CRITERION

RTS POINTS

13 — 15

9 — 12

6—8

4—5

> 89 mmHg

76 — 89 mmHg

50 — 75 mmHg

1 — 49 mmHg

10 — 29/ min

> 29/min

6 — 9/min

1 — 5/min

Lifeline in Action

A CAR CRASHED THROUGH THE TIRE BARRIER AND FLIPPED TO ITS SIDE. LUCKILY THE DRIVER WAS UNHURT.

A CRASH AT THE RACE TRACK By Paul Violeta

I was advised to take the shift early because there would be a standby for a car race at the Batangas Racing Circuit. We were short of treatment officers so it was a two-man team that was deployed. I did not expect anything would happen because most of the drivers were not professional racers. I brought my DSLR camera, my laptop and even speakers to keep me occupied while waiting for the event to finish. The ambulance was located inside the track so we could respond to any emergency as quick as we could. Yet my mindset was, “nothing’s going to happen today.” But I was wrong. We had a call that day. A car crashed through the tire barrier and flipped to its side. Luckily the driver was unhurt. I thought we could already call it a day for one case, but to our disappointment, a serious crash happened. The marshal was running towards the ambulance waving his flag and was yelling “Tumaob! Tumaob yung isang kotse!” It was like Murphy’s Law was in effect. Indeed, the thing that we were not expecting happened. We waited for all the race cars to clear the track before we moved. It was an adrenalin-filled moment. We drove as fast as we could

through the race track to get to the wrecked car. We found the vehicle upside down. I asked my treatment officer to bring the gurney close to the crash as I assessed the patient. The race marshal said the car that crashed tried to overtake from the outer lane into the inner lane, bumped the car ahead and spun to its side towards the barriers. Another marshal noted that the car flipped thrice before landing on its roof. We got the driver out quickly. He was conscious and complaining of a pain in his right shoulder. He tried to remove his suit and we saw redness on his clavicle. There was no other sign of injury. The only thing we noticed was he could not fully rotate his arms. We immobilized the affected shoulder with an arm sling, and flush the driver’s eyes to protect it from bits of glass from the shattered windshield of the car. All these we did inside the ambulance while still at the race track. We could not proceed yet to the hospital as we still had to wait for the backup ambulance that would take our place. As soon as we knew that the other ambulance was near, we sped off to Taguig to bring the patient to the hospital for further assessment.

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DAY

Environmental Emergencies THE Philippines is one of the most disaster-prone countries in the world. Our country is located in what is labeled as the Pacific Ring of Fire, which is the reason why we have so many active volcanoes and regularly experience earthquakes. We are also in experts call as the typhoon belt, with an average of more than 20 typhoons and tropical storms affecting us every year. As a future EMT, your services would be called to assist victims of natural disasters. It is, therefore, necessary for you to know how to handle emergencies brought about by the environment. In this chapter, you would learn the basics of providing care for patients suffering from too much cold or too much heat. You would also learn what to do in cases of drowning or in diving accidents. And finally, you would learn the basics of water rescue.

Dealing with hypothermia Managing hyperthermia Caring for drowning victims Diving accidents Basics of water rescue

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ENVIRONMENTAL EMERGENCIES

INTRODUCTION

LEARNING OBJECTIVES • Describe the various ways that the body loses heat. • List the signs and symptoms of exposure to cold and heat. • Explain the steps in providing emergency medical care to a patient exposed to cold or heat. • Recognize the signs and symptoms of water-related emergencies. • Describe the complications of near drowning. • Discuss the emergency medical care of bites and stings

EXPOSURE TO COLD How the Body Loses Heat If the environment is too cold, body heat can be lost faster than it can be generated. The body attempts to adjust to these temperature differences by reducing perspiration and circulation to the skin—shutting down avenues by which the body usually gets rid of excess heat. Muscular activity in the form of shivering and the rate at which fuel (food) is burned within the body both increase to produce more heat. At a certain point, however, not enough heat is generated to be available to all parts of the body. This may result in damage to exposed tissues and a general reduction or cessation of body functions. To be able to prevent or compensate for heat loss, the EMT must be aware of the ways in which your body loses heat:

Conduction.

• The transfer of heat from one material to another through direct contact is called conduction. Heat will flow from a warmer material to a cooler one. Although body heat transferred directly into cool air is a problem, water chill is greater problem because water conducts heat away from the body 25 times faster than still air. Patients with wet bodies or clothing are especially susceptible to water chill in cold environments. Heat loss through conduction can be a major problem when a person is lying on a cold surface. However, a person who is standing or walking around in cold weather will lose less heat than a person who is lying on the cold ground.

Convection. 554

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Environmental emergencies can occur in any setting—wilderness, rural, suburban, and urban areas. They include exposure to both heat and cold; drownings and other water-related injuries; and bites and stings from insects, spiders, snakes, and marine life. The keys to effective management are recognizing the patient’s signs and symptoms and providing prompt and proper emergency care. However, as an EMT, you also must recognize that exposure may not be the only danger to the patient. Environmental emergencies can involve pre-existing, or cause additional medical problems and injuries.

• When current of air or water passes over the body, carrying away heat, convection occurs. The effects of a cold environment are worsened when moving water or air surround the body. Wind chill is a frequent problem. The faster the wind speed, the greater the heat loss. For example, if it is 10 º C with no wind, the body will lose heat, but if there is a 20 mph wind, the amount of heat lost by the body is much greater.

Radiation

• In conduction and convection, heat is “picked up” by the surrounding (still/moving) air/water. In radiation, the body’s atoms and molecules send out rays of heat as they move and change. If you were in the vacuum of outer space with no air/water around to pick up heat, you would still lose heat by radiating it out into space. Most radiant heat loss occurs from a person’s head and neck.

Evaporation.

• Evaporation occurs when the body perspires or gets wet. As perspiration or water on the skin or clothing vaporizes, the body experiences a generalized cooling effect.

Respiration.

• Respiration causes loss of body heat as a result of exhaled warm air. The amount of heat loss depends on the outside air temperature as well as the rate and depth of respirations.

Generalized Hypothermia When cooling affect the entire body, a problem known as hypothermia, or generalized cooling, develops. Exposure to cold reduces body heat. With time, the body is unable to maintain its proper core (internal) temperature. If this cooling is allowed to continue, hypothermia leads to death.

Predisposing Factors

Patients with injuries chronic illnesses, or certain other conditions will show the effects of cold earlier than healthy persons. These conditions include shock (hypoperfusion), burn, head and spinal-cord injurie, generalized infection, and diabetes with hypoglycemia. Those under the influence of alcohol or other drugs also tend to be affected more rapidly and more severely than others. The unconscious patient lying on the cold surface is prone to rapid heat loss through conduction and will tend to develop greater coldrelated problems than to someone who is conscious and able to walk around. Ang hypothermia ay puwedeng makuha kahit pa ang temperatura ng paligid ay malayo sa freezing point.

GERIATRIC NOTE Hypothermia is often a serious problem of the aged. The effects of cold temperature on the elderly are more immediate. During winter, many older citizens on small fixed incomes live in unheated rooms or rooms that are kept too cold. Failing body systems, chronic illnesses, poor diets, certain medications, and lack of exercise may combine with the cold environment to bring about hypothermia.

PEDIATRIC NOTE Since infants and young children are small with large skin surface areas in relation to their total body mass and have little body fat, they are especially prone to hypothermia. Because of their small muscle mass, infants and children do not shiver very much or at all—another reason why the very young are susceptible to the cold. A crucial part of the care for newborn infants is to dry them (to prevent heat loss by evaporation) and cover their heads (to prevent heat loss from radiation and convection).

CORE BODY TEMPERATURE FAHRENHEIT

CELSIUS

SYMPTOMS

99°F — 96°F

37.0°C — 35.5°C

Shivering.

95°F — 91°F

35.5°C — 32.7°C

Intense shivering, difficulty of speaking.

90°F — 86°F

32.0°C — 30.0°C

Shivering decreases and is replaced by strong muscular rigidity. Muscle coordination is affected and erratic or jerky movements are produced. Thinking is less clear, general comprehension is dulled, possible total amnesia exists. Generally, patient is able to maintain the appearance of psychological contact with surroundings.

85°F — 81°F

29.4°C — 27.2°C

Patient becomes irrational, loses contact with the environment, and drifts into a stuporous state. Muscular rigidity continues. Pulse and respiration are slow and cardiac dysrhythmias may develop.

80°F — 78°F

26.6°C — 20.5°C

Patient loses consciousness and does not respond to spoken words. Most reflexes cease to function. Heartbeat slows further before cardiac arrest occurs.

STAGES OF HYPOTHERMIA Obvious and Subtle Exposure

At times, it is obvious that a patient has been exposed to cold and is probably suffering from hypothermia. With other patients, however, exposure is subtle—that is, not so obvious, and not the first thing you may think about. Consider, for example, the elderly patient who has fallen during the night and is not discovered until morning. A broken hip or other injuries may claim your attention, but if your patient has been on the cold floor all night, he is probably also suffering from hypothermia. The patient trapped in a wrecked auto is probably suffering a variety of injuries, but if the weather is cold and extrication from the vehicle takes a while, the patient can easily develop hypothermia as well. LIFELINE

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Consider the possibility of hypothermia in the following situations when another condition or injury may be more obvious: • Ethanol (alcohol) Ingestion. Has the intoxicated patient passed out on a cold floor or been wandering around outdoors in cool or cold weather? • Underlying illness. Does the patient have a circulatory disorder or other condition that makes him especially susceptible to cold? • Overdose or poisoning. Has the patient been lying in a cold garage or on a cold floor? Is he sweating heavily in a cool environment with evaporation causing excessive heat loss? • Major trauma. Has the patient been lying on the ground or trapped in wreckage during cold weather? Is shock (hypoperfusion, or inadequate circulation of the blood) preventing parts of the body from being warmed by circulating blood? • Outdoor resuscitation. Is your patient getting too cold? If your patient is a drowning patient who has been in the water, has exposure to cool water caused hypothermia?

• Decreased ambient temperature (for example, room temperature). Is your patient living in a home or apartment that is too cold?

Remember that the injured patient is more susceptible to the effects of cold than a healthy individual, Protect the patient who is entrapped or for any other reason must remain in a cool or cold environment for a period of time. The major course of action is to prevent additional body heat loss. It may be neither practical nor possible to replace wet clothing, but you can at least create a barrier to the cold with blankets, a salvage cover, an aluminized blanket, a survival blanket, or even articles of clothing. A plastic trash bag can serve as protection from wind and water. Keep in mind that the greatest area of but loss may be the head, so provide some sort of head covering for the patient. When the patient’s injuries allow, place a blanket between his body and the cold ground or between him and the wreckage he is pinned in. Rotate warm blankets from the heated ambulance to the patient. If the patient will remain trapped for a period of time, plug holes in the wreckage with blankets.

PATIENT ASSESSMENT Hypothermia Consider the impact of the following factors when assessing a patient air temperature, wind chill and/or water chill, the patients age. the patient’s clothing, the patient’s health including underlying illness and existing injuries, how active the patient was during exposure, and possible alcohol or drug use. 556

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The following list contains common signs and symptoms of hypothermia. Note that decreasing; mental status and decreasing motor function both correlate with the degree of hypothermia. • Shivering can occur in early stages when the core body temperature is above 32°F In severe cases, shivering decreases or is absent. • Numbness, or reduced-to-lost sense of touch. • Stiff or rigid posture in prolonged cases. • Drowsiness and/or unwillingness or inability to do even the simplest activities In prolonged exposures, the patient may become irrational, drift into a stuporous state, or actually remove clothing. • Rapid breathing and rapid pulse in early stages, and slow to absent breathing and pulse in prolonged cases. (The patient’s slow pulse and respirations require that you spend at least 30 to 45 seconds to check for pulse and respirations). Blood pressure may be low to undetectable. • Loss of motor coordinator), such as poor balance, staggering, or inability to hold things. • Joint/muscle stiffness, or muscular rigidity. • Decreased level of consciousness, or unconsciousness. In extreme cases, the patient has a ‘glassy stare”. • Cool abdominal skin temperature. (Place your hand inside the clothing with the back of your hand against the patient’s abdomen). • Skin may appear led in early stages In prolonged cases, skin is pale to cyanotic In most extreme cases, some body parts are stiff and hard (frozen). During primary assessment, be sure to check a concious patient’s orientation to person, place, and time. (Can he tell you his name? Where he is? What day it is?) Perform a secondary assessment to help you estimate the extent of hypothermia. Assume severe hypothermia if shivering is absent.

Passive and Active Rewarming Passive rewarming allows the body to rewarm itself. It involves simply covering the patient and taking other steps, including removal of wet clothing, to prevent further heat loss. These actions allow the body to naturally regain its warmth. Active reforming includes application of an external heat source to the body. All EMS systems permit passive rewarming. Although some allow the active rewarming of a hypothermic patient who is alert and responding appropriately, many do not. Follow your local protocols. Active rewarming can prove to be a dangerous process if the patient’s condition is more serious than believed. If you are allowed to rewarm a patient with hypothermia who is alert and responding appropriately, do not delay transport. Rewarm the patient while en route. The emergency care steps that follow assume a protocol that permits active rewarming of a patient who is alert and responding appropriately to your intervention. Follow your local protocols.

PATIENT CARE Hypothermic Patient Who Is Alert and Responding Appropriately For the hypothermic patient who is alert and cool the vital central areas of the body, possibly responding appropriately, proceed with active causing cardiac arrest. If transport is delayed, move rewarming; the patient to a warm environment if at all possible 1. Remove all of the patient’s wet clothing. Keep the 3. Provide care for shock Provide oxygen, warmed and patient dry, dress the patient in dry clothing, or wrap humidified if possible. the patient in dry warm blankets. Keep the patient 4. Give the alert patient warm liquids at a slow rate. still and handle him very gently. Do not allow the When warm fluids are given too quickly, the patient’s patient to walk or exert himself. Do not massage his circulation patterns change. Blood is sent away extremities. from the core and instead routed to the skin and extremities. Do not allow the patient to eat or drink 2. During transport, actively rewarm the patient. Gently apply heat to the patient’s body in the form of heat stimulants. packs, hot water bottles, electric heating pads, warm 5. Except in the mildest of cases (shivering), transport air, radiated heat, and even your own body heat. Do the patient Continue to provide high concentration not warm the patient too quickly. Rapid warming will oxygen and monitor vital signs. Never allow a patient circulate peripherally stagnated cold blood and rapidly to remain or return to, a cold environment Take the following precautions when actively rewarming a patient • Rewarm the patient slowly. Handle the patient with great care, just as if there were unstabilized cervical-spine injuries. • Use central rewarming. Heat should be applied to the lateral chest, neck, armpits, and groin. You must avoid rewarming the limbs. If they are warmed first, blood will collect in the extremities due to vasodilation (dilation of blood vessels), possibly causing a fatal form of shock. If you rewarm the trunk and leave the lower extremities exposed, you can control the rewarming process and help prevent most of the problems associated with the procedure. • If transport must be delayed, giving the patient a warm bath is very helpful. However, keep the patient alert enough so that he does not drown. Do not warm the patient too quickly. • Keep the patient at rest. Do not allow the patient to walk Since the blood is coldest in the extremities, exercise or unnecessary movement could quickly circulate the cold blood and lower the core body temperature. • Avoid any rough handling of the hypothermic patient Such activity may set off fatal dysrhythmias, especially ventricular fibrillation.

PATIENT CARE Hypothermic Patient Who Is Unresponsive or Not Responding Appropriately A patient who is unresponsive or not responding appropriately has severe hypothermia. For this patient, provide passive rewarming Do not try to actively rewarm the patient with severe hypothermia. Remove the patient from the environment and protect him from further heat loss. Active rewarming may cause the patient to develop ventricular fibrillation and other complications. Active rewarming can be initiated after arrival at the emergency department in a more monitored setting. Para sa mga pasyente na may hypothermia, tiyakin na: 1. Nakakahingang mabuti ang pasyente. 2. Bigyan ng high-concentrated oxygen na pinadaan sa medyo mainit na humidifier ang pasyente. Tiyakin na medyo mainit ang oxygen na nasa ambulansya n’yo. 3. Balutin ang pasyente sa kumot. Kung posible, gumamit ng kumot na insulated o mas makapal. Maging maingat sa paghawak sa pasyente dahil ang ang mga ugat nito ay sensitibo. 4. Ibiyahe agad-agad ang pasyente sa pinakamalapit na ospital.

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Extreme Hypothermia In cases of extreme hypothermia, you will find the patient unconscious with no discernible vital signs. The heart rate can stow to less than 10 beats per minute, and the patient will feel very cold to your touch (core body temperature may be 36.5-37.5°C). Even so, it is possible that a patient in this condition is still alive! Provide emergency care as follows: • Assess the carotid pulse for 10 seconds. If there is no pulse, start CPR immediately and prepare to apply the AED while rewarming. • If there is a pulse, follow the care steps for a patient who is unresponsive or not responding appropriately as previously listed. Because the hypothermic patient may not reach biological death for over 30 minutes, the hospital staff will not pronounce a patient dead until after they have rewarmed him and applied resuscitative measures. This means you cannot assume that a severe hypothermia patient is dead on the basis of body temperature and lack of vital signs. As medical personnel point out. “You’re not dead until you’re warm and dead!”

Localized Cold Injuries Cold-related emergencies also can result from local cooling. Local cooling injuries, those affecting particular (local) parts of the body, are classified as 1. Early or superficial and 2. Late or deep. Local cooling most commonly affects the ears. nose. face, hands, and the feet and toes. When a part of the body is exposed to intense cold, blood flow to that part is limited by the constriction of blood vessels. When this happens, tissues freeze. Ice crystals can form in the skin and, in the most severe cases, gangrene (localized tissue death) can set in, which may ultimately lead to the loss of the body part. As you read the following pages, notice how the signs and symptoms of early or superficial cold injuries are progressive. First, the exposed skin reddens in lightskinned individual In dark-skinned individuals, the skin color lightens and approaches a blanched (reduced-color or whitened) condition. As exposure continues, the skin takes on a gray or white blotchy appearance. Exposed skin becomes numb because of reduced circulation. If the freezing process continues, all sensation is lost and the skin becomes dead white.

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PATIENT ASSESSMENT Early or Superficial Local Cold Injury Early or superficial local cold injuries (sometimes called frostnip) are brought about by direct contact with a cold object or exposure to cold air. Wind chill and water chill also can be major factors. In this condition, tissue damage is minor and response to care is good. The tip of the nose, tips of the ears, upper cheeks, and fingers (all areas that are usually exposed) are most susceptible to early or superficial local cold injuries. The injury, as it’s name suggests, is local-ized with clear demarcation of its limits. Patients are often unaware of the onset of an early local cold injury until someone indicates that there is something unusual about the person’s skin color. Ang mga sumusunod ay simtomas ng injuries dahil sa lamig: 1. Ang apektadong bahagi na may maputing balat ay namumula. Para naman sa mga pasyenteng maitim ang balat, ang bahaging apektado ay namumuti. 2. Ang apektadong bahagi ay namamanhid o walang pakiramdam.

PATIENT CARE Early or Superficial Local Cold Injury Emergency care for early local cold injury is as follows: 1. Get the patient out of the cold environment. 2. Warm the affected area. 3. If the injury is to an extremity, splint and cover it. Do not rub or massage the area, and do not reexpose it to the cold. Usually, the patient can apply warmth from his own bare hands, blow warm air on the site, or, if the fingers are involved, hold them in the armpits. During recovery from an early local cold injury, the patient may complain about tingling or burning sensations, which is normal. If the condition does not respond to this simple care, begin to treat for a late or deep local cold injury.

PATIENT ASSESSMENT Late or Deep Local Cold Injury Late or deep local cold injury (also known as frostbite) develops if an early or superficial local cold injury goes untreated In late or deep local cold injury, the skin and subcutaneous layers of the body part are affected. Muscles, bones, deep blood vessels, and organ membranes can become frozen The following list contains common signs and symptoms of this condition: • Affected skin appeals white and waxy When the condition progresses to actual freezing, the skin turns mottled or blotchy, and the color turns from white to grayish-yellow and finally to grayish-blue Swelling and blistering may also occur. • The affected area feels frozen, but only on the surface. The tissue below the surface is still soft and has its normal resilience, or “bounce” With freezing, the tissues are not resilient and feel frozen to the touch. Sa mga injury na sanhi ng sobrang lamig, huwag pisilin o diinan ang laman ng pasyente. Maingat na hawakan ito na tila may nabaling buto. Huwag din ito haplusin nang mabilis o madiin. At huwag sumunod sa mga kuwento-kuwento na nagsasabing dapat haplusin ng snow ang bahagi ng katawan na nanigas dahil sa lamig. Kung ang ugat ng pasyente ay meron nang ice crystals, ang pagdiin dito ay lalo lamang magpapagrabe sa sitwasyon dahil puwedeng pumutok ang mga ugat ng pasyente. Huwag din paglakarin ang pasyente kung ang paa nito ay naninigas na sa lamig.

PATIENT CARE Late or Deep Local Cold Injury Initial emergency care for late or deep local cold injury— frostbite and freezing—is as follows 1. Administer high concentration oxygen 2. Transport to a medical facility without delay, protecting the frostbitten or frozen area by covering it and handling it as gently as possible 3. If transport must be delayed, get the patient indoors and keep him warm. Do not allow the patient to dunk alcohol or smoke, because constriction of blood vessels and decreased circulation to the injured tissues may result Rewarm the frozen part as per local protocol, or request instructions from medical direction

Active Rapid Rewarming of Frozen Parts Active rewarming of frozen parts is seldom recommended. The chance of permanently injuring frozen tissues with active rewarming is too great. Consider it only if local protocols recommend it, if you are instructed to do so by mcdic.il direction, or if transport will be severely delayed and you cannot reach medical direction for instructions. If you are in a situation where you must attempt rewarming without instructions from a physician, follow the procedure described here. You will need warm water and a container in which you can immerse the entire site of injury without the limb touching the sides or bottom of the container. If you cannot find a suitable container, fashion one from a plastic bag supported by a cardboard box or wooden crate. Proceed as follows: 1. Heat water to between 37.8°C and 40°C. You should be able to put your finger into the water without experiencing discomfort. 2. Fill the container with the heated water and prepare the injured part by removing clothing, jewelry, hands, or straps. Thawed areas often swell, so you need to remove potentially constricting items beforehand. 3. Fully immerse the injured part. Do not allow the injured area to touch the sides or bottom of the container. Do not place any pressure on the affected part. Continuously stir the water. When the water cools below 100°F, remove the affected part and add more warm water. The patient may complain of moderate pain as the affected area re-warms or he may experience intense pain. Pain is usually a good indicator of successful rewarming. 4. If you complete rewarming of the part (it no longer feels frozen and is turning red or blue), gently dry the affected area and apply a dry sterile dressing. Place dry sterile dressings between the patient’s fingers and toes before dressing his hands and feet. Next, cover the site with blankets or whatever is available to keep the area warm. Do not allow these coverings to come in direct contact with the injured area or to put pressure on the site. First try to build some sort of framework on which the coverings can be placed. 5. Keep the patient at rest. Do not allow the patient to walk if a lower extremity has been frostbitten or frozen. 6. Make certain that you keep the entire patient as warm as possible without overheating him. Cover the patient’s head with a towel or small blanket to reduce heat loss. Leave the patient’s face exposed. 7. Continue to monitor the patient. 8. Assist circulation according to local protocol (some systems recommend rhythmically and carefully raising and lowering the affected limb). 9. Do not allow the limb to refreeze. 10. Transport as soon as possible with the affected limb slightly elevated. LIFELINE

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EXPOSURE TO HEAT Effects of Heat on the Body The body generates heat as a result of its constant internal chemical processes. A certain amount of this heat is required to maintain normal body temperature. Any heat that is not needed for temperature maintenance must he lost from the body. If it is not. the result is hyperthermia, an abnormally high body temperature. If left unchecked, it will lead to death. Heat and humidity are often associated with hyperthermia. As you learned earlier, heat is lost through the lungs or the skin. Mechanisms of heat loss include conduction, convection, radiation, evaporation, and respiration. Consider what can happen to the body in a hot environment. Air being inhaled is warm, possibly warmer than the air being exhaled. The skin may absorb more heat than it loses. When high humidity is added, the evaporation of perspiration slows. To make things even more difficult, consider all this in an environment that lacks circulating air or a breeze, which would increase convection and evaporative heat loss. Since evaporative heat loss is reduced in a humid environment, moist heat can produce dramatic body changes in a short time. Moist heat usually tires people quickly and frequently stops them from harming themselves through overexertion. Dry heat, in contrast, often deceives people. They continue to work or remain exposed to excess heal far beyond what their bodies can tolerate. The same rules of care apply to heat emergencies as to any other emergency. You will need to perform the appropriate steps of assessment, remaining alert for problems other than those related to heat. Collapse due to heat exhaustion, for example, may result in a fall that can fracture bones. Pre-existing conditions such as dehydration, diabetes, fever, fatigue, high blood pressure, heart disease, lung problems, or obesity may hasten or intensify the effects of heat exposure, as will ingestion of alcohol and other drugs. Age, diseases and existing injuries all must be considered. The elderly may be affected by poor thermoregulation. prescription medications, and lack of mobility. Newborns and infants also may have poor thermoregulation. Always consider the problem to be greater it the patient is a child or elderly person who is injured or living with a chronic disease. 560

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ENVIRONMENTAL EMERGENCIES

Patient with Moist, Pale, Normal-to-Cool Skin Prolonged exposure to excessive heat can create an emergency in which the patient presents with moist, pale skin that may feel normal or cool to the touch, a condition generally known as heat exhaustion. The individual perspires heavily, often drinking large quantities of water. As sweating continues, the body loses salts, bringing on painful muscle cramps (sometimes called heat cramps). A person who is actively exercising can lose more than a liter of fluid through perspiration per hour. Healthy individuals who have been exposed to excessive heat while working or exercising may experience a form of shock brought about by fluid and salt loss. This condition is often seen among firefighters, construction workers, dock workers, and those employed in poorly ventilated warehouses. It is a particular problem during prolonged heat waves early in the summer, before people have become acclimatized to summer heat.

PATIENT ASSESSMENT Heat Emergency Patient with Moist, Pale, Normal-to-Cool Skin The following are common signs and symptoms of a heat emergency patient with moist, pale, and normal-to-cool skin: • Muscular cramps, usually in the legs and abdomen • Weakness or exhaustion, and sometimes dizziness or periods of faintness • Rapid, shallow breathing • Weak pulse • Heavy perspiration • Loss of consciousness is possible, but is usually brief if It occurs

PATIENT CARE Heat Emergency Patient with Moist, Pale, Normal-to-Cool Skin Emergency care of a heat emergency patient with moist, pale, and normal-to-cool skin includes the following steps. 1. Remove the patient from the hot environment and place him in a cool environment (such as in shade or an airconditioned ambulance). 2. Administer oxygen by nonrebreather mask at 15 liters per minute. 3. Loosen or remove clothing to cool the patient by fanning

without chilling him. Watch for shivering. 4. Put the patient in a supine position with legs elevated Keep him at rest. 5. If the patient is responsive and not nauseated, have him drink small sips of water. If this causes nausea or vomiting, do not give any more water. Be alert for vomiting and airway problems. If the patient is unresponsive or vomiting, do not give water. Transport the patient to the hospital on his left side. 6. If the patient experiences muscular cramps, apply moist towels over cramped muscles. 7. Transport the patient.

Patient with Hot Skin, Whether Dry or Moist

When a person’s temperature-regulating mechanisms fail and the body cannot rid itself of excessive heat, you will see a patient with hot, dry, or possibly moist skin. When the skin is hot—whether dry or moist—this condition, generally known us heat stroke, is a true emergency. The problem is compounded when, in response to loss of fluid and salt, the patient stops sweating, which prevents heat loss through evaporation. Athletes, laborers, and others who exercise or work in hot environments are especially at risk for this condition, as are the elderly who live in poorly ventilated apartments without air conditioning and children left in cars with the windows rolled up.

PATIENT ASSESSMENT Heat Emergency Patient with Hot Skin, Whether Dry or Moist The following are common signs and symptoms of a heat emergency patient with hot and dry or hot and moist skin • Rapid shallow breathing. • Full and rapid pulse. • Generalized weakness. • Little or no perspiration. • Loss of consciousness or altered mental status (Altered mental status is mandatory for a determination of heat stroke). • Dilated pupils. • Potential seizures, no muscle cramps.

PATIENT CARE Heat Emergency Patient with Hot Skin, Whether Dry or Moist

Emergency care of a heat emergency patient with hot and dry or hot and moist skin is as follows: 1. Remove the patient from the hot environment and place him in a cool environment (in the ambulance with the air conditioner running on high). 2. Remove the patient’s clothing. Apply cool packs to his neck, groin, and armpits. Keep the skin wet by applying water by sponge or wet towels. Aggressively fan the patient. 3. Administer oxygen by nonrebreather mask at 15 liters per minute. 4. Transport immediately. If transport is delayed, continue to attempt to cool the patient with ice packs. Additionally, you can moisten the patient’s clothes and fan the body to enhance heat loss by evaporation.

Para sa mga sanggol at batang pasyente, ang pagpapalamig ay nagsisimula sa paggamit ng maligamgam na tupig. Ang tubig na ito ay puwedeng palitan ng medyo malamig kung irerekomenda ng medical director. Huwag basta-basta maniniwala sa sinasabi ng pasyente o ng mga kamag-anak nito. Madalas kasi na iniisip nila na hindi seryoso at hindi delikado ang sobrang init sa pasyente. Suriin mabuti ang pasyente. Kung duda ka sa kondisyon ng pasyente, ipaliwanag mo dito kung bakit kailangan na dalhin mo siya sa ospital. May mga pagkakataon na kailangan mong makipag-usap ng masinsinan sa pasyente para magtiwala ito sa iyo.

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HYPOTHERMIA AND HYPERTHERMIA INSIDE

OUTSIDE

The body undergoes many changes as hypothermia develops. The cardiovascular and central nervous systems are perhaps the most affected by hypothermia. The heart becomes more irritable and prone to dysrhythmias as the body becomes colder. The CNS becomes more sluggish and less responsive.

Hypothermia with normal mental status.

At about 91.5째F (33째C) electrical activity in the brain activity becomes abnormal.

Hypothermia with altered mental status.

Hyperthermia with cool skin indicates the body is still able to deal with the heat through normal mechanisms (e.g., sweating). Body temperature is a balance of inside and outside temperatures.

Hyperthermia with cool skin.

The skin is the major cooling mechanism of the body. When the skin is hot. It indicates that this system is no longer able to dissipate enough heat to maintain a nor-mal body temperature and rapid cooling is necessary. A core temperature that has reached about 105.8째F (41 째C) is the critical point.

Hyperthermia with hot skin.

Ang hypothermia at hyperthermia ay mga seryosong kondisyon na nangangailangan ng agarang pagtugon. Kung hindi ito maaagapan, maaaaring mamatay ang pasyente. Makikita sa chart sa kaliwa ang mga simtomas na dapat obserbahan sa pasyente na may mga ganitong kondisyon.

Huwag na huwag magtatangka na sagipin ang isang pasyente na nasa malalim na tubig kung ikaw ay walang sapat na pagsasanay para gawin ito. Maaari mo lamang itong gawin sa mga mabababaw na swimming pool o dun sa mga lugar na pantay ang ilalim. Ang problemang dala ng pagsagip sa nalulunod na pasyente ay napakalaki at hindi ito kaya ng isang rescuer na hindi masyadong mahusay lumangoy at walang kasanayan sa pagliligtas. Magsanay muna sa ilalim ng Philippine Red Cross. Meron itong ibinibigay na Water Safety and Rescue Course. Kung magtatangka kang sumagip sa nalulunod nang hindi ka pa nakakapagsanay, malaki ang posibilidad na malunod ka rin.

WATER-RELATED EMERGENCIES

Drowning is the first thing people think of in connection with water-related accidents. However, there are many types of injuries resulting from many types of accidents that can occur on or in the water. Boating, water-skiing, wind surfing, jet skiing, diving, and scuba diving accidents can produce fractured bones, bleeding, soft-tissue injuries, and airway obstruction. Even auto collisions can send vehicles or passengers into the water, resulting in any of the injuries usually associated with motor vehicle collisions as well as the complications caused by the presence of water. Medical problems such as heart attacks can also cause, or be caused by water accidents or can simply take place in, on, or near the water. Remember, too that some water accidents happen far away from pools, lakes, or beaches. For example, bathtub drownings do occur. Adults, as well as children, can drown in only a few inches of water.

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U D

PATIENT ASSESSMENT Water-Related Incidents

Learn to look for the following problems in waterrelated-incident patients: • Airway obstruction. This may be from water in the lungs, foreign matter in the airway, or swollen airway tissues (which is common if the nock is injured in a dive). Spasms along the airway may to present in some cases of drowning. • Cardiac arrest. This is often related to respiratory arrest or occurs before drowning • Signs of heart attack. Some untrained rescuers too quickly conclude that chest pains are due to muscle cramps as a result of swimming • Injuries to the head and neck. These are expected to be found in boating, water skiing, and diving accidents, but they are also very common in swimming accidents. • Internal injuries. While doing the physical exam, stay alert for musculoskeletal injuries, soft tissue injuries. and internal bleeding. • Generalized cooling, or hypothermia. The water does not have to be very cold and the length of stay in the water does not have to be very long for hypothermia to occur • Substance abuse. Alcohol and drug use are closely associated with adolescent and adult drownings Elevated blood alcohol levels have been found in over 30 percent of drowning patients The screening for drug use has not been as extensive as that done for alcohol, but research indicates that other drugs are a UNIT 3 contributory factor in many water-related accidents PRINCIPLES OF EMT CLINICAL PRACTICE DAY 22 • Drowning. The patient may be discovered under or face down in the water. He may be unconscious and without discernible vital signs it may be conscious, Drowning breathing, and coughing up water.

Drowning In 2002, the World Health Organisation (WHO) adopted a definition of drowning that is different from the traditional one. According to the WHO, “Drowning is the process of experiencing respiratory impairment from submersion/immersion in liquid. Drowning outcomes are classified as death, morbidity, and no morbidity.” Morbidity means the patient experiences illness or other adverse effects, like unconsciousness or pneumonia. The American Heart Association has also adopted this definition of drowning. The WHO definition does not describe near drowning. Hence, the term near drowning is no longer used. The process of drowning often begins as a person struggles to keep afloat in the water. He gulps in large breaths of air as he thrashes about. When he can no longer keep afloat and starts to submerge, he tries to take and hold one more deep breath. As he does, water may enter the airway. There is a series of coughing and swallowing actions, and the patient involuntarily inhales and swallows more water. As water flows past the epiglottis, it triggers a reflex spasm of the larynx. This spasm seals the airway so effectively that no more than a small amount of water reaches the lungs. Unconsciousness soon results from hypoxia (oxygen starvation). About 10 percent of the people who die from drowning die just from the lack of air. In the remaining patients, the person typically attempts a final respiratory effort and draws water into the lungs, or the spasms subside with the onset of unconsciousness and water freely enters the lungs. Some patients who drown in cold water can be resuscitated after 30 minutes or more in cardiac arrest. Once the water temperature falls below 70°F, biological death may be delayed. The colder the water, the better the patient chances for survival, unless generalized hypothermia produces lethal complications.

Rescue Breathing In Or Out Of The Water Transport for the drowning patient should not be delayed. You may initiate care when the patient is out of the water (already out when you arrive or in the water when you arrive but rescued by others before you initiate care). At other time, you may need to initiate care while the patient is still in the water—especially rescue breathing and immobilization for possible spine injuries. Chest compressions will be effective only after the patient is out of the water. If needed, rescue breathing should begin without delay. If you can reach the nonbreathing patient in the water, provide ventilations as you support him in a semi-supine

In 2002, the World Health Organisation (WHO) adopted a definition of drowning that is different from the traditional one. According to the WHO, "Drowning is the process of experiencing respiratory impairment from submersion/immersion in liquid. Drowning outcomes are classified as death, morbidity, and no morbidity." Morbidity means the patient experiences illness or other adverse effects, like unconsciousness or pneumonia. The American Heart Association has also adopted this definition of drowning. The WHO definition does not describe near drowning. Hence, the term near drowning is no longer

LIFELINE

PREHOSPITAL EMERGENCY CARE

563

DAY DAY

Day 22

ENVIRONMENTAL EMERGENCIES

position. Continue providing ventilations while the patient is being immobilized and removed from the water. If the patient is already out of the water, begin rescue breathing or CPR on the land. You may encounter airway resistance as you ventilate the drowning patient. However, you will probably have to ventilate more forcefully than you would to other patients. Remember, you must provide air to the patient’s lungs as soon as possible. A patient with water in the lungs usually has water in the stomach, which will add resistance to your efforts to provide rescue breathing or CPR ventilations. Since the patient may have spasms along the airway, or swollen tissues in the larynx or trachea, you may find that some of the air you provide will go into the patient’s stomach. Remember, the same problem will occur if you do not properly open the airway or if your ventilations are too forceful If gastric distention interferes with artificial ventilation, place the patient on his left side. With suction immediately available, the EMT should place his hand over the epigastric area of the abdomen and apply firm pressure to relieve the distention. This procedure should be done only if the gastric distention interferes with the EMT’s efforts to artificially ventilate the patient in an effective manner.

Care for Possible Spinal Injuries in the Water

Injuries to the cervical spine are seen with many waterrelated accidents. Most often, these injuries are received during a dive or when the patient is struck by a boat, skier or ski, or surfer or surfboard. Even though cervical-spine injuries are the most common of the spine injuries seen in water-related accidents, there can be injury anywhere along the spine. In water-related accidents, assume that the unconscious patient has neck and spinal injuries. If the patient has head injuries also assume that there are neck and spinal injuries. Keep in mind that a patient found in respiratory or cardiac arrest will need resuscitation started before you can immobilize the neck and spine. Also, realize that you may not be able to carry out a complete assessment for spinal injuries while the patient is in the water. Take care to avoid aggravating spinal injuries, but do not delay basic life support. Do not delay removing the patient from the water if the scene presents an immediate danger. When possible, keep the patient’s neck rigid and in a straight line with the body’s midline. Use the jawthrust maneuver to open the airway. If the patient with possible spinal injuries is still in the water, you are a good swimmer with proper training, and you are able to aid in the rescue, secure the patient to a long spine board before removing him from the water This will help prevent permanent neurological damage or paralysis. This type of rescue requires special training in the use of the spine board while in the water. This rigid device can “pop up” very easily from below the water surface. Make certain that you know how to control the board and how to work in the water. 564

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PREHOSPITAL EMERGENCY CARE

Head HeadSplint Splint––This Thismethod method used usedby byaarescuer rescuerwhen whenresc res ing ingaacasualty casualtywith withsuspecte suspec spinal spinalinjuries injuriesininshallow shallowwat wa ––no nodeeper deeperthan thanthe theheight height the therescuer. rescuer.

PATIENT CARE Water-Related Incidents

1.1.Activate Activatethe theEMS EMS 2.2.Make Make aa slow slow entry entry inin th water. water. 3.3.Grasp Grasp the the victim victim arms arms juj In all cases of water-related incidents, assume that above abovethe theelbow elbowororatatth triceps. triceps. the unconscious patient has neck and spinal injuries. If 4.4.Then Then slowly slowly move move the the vi the patient is rescued by others while you wait on shore, tim’s tim’sarms armsup upalongside alongsidehih or if the patient is out of the water when you arrive, you her herhead. head. should 5.5.Press Pressthe thearms armsfirmly firmlyagain agai 1. Do a primary assessment, protecting the spine as the theears. ears. 6.6.For Forthe thevictim victimwho whoisisfac fa much as possible. down, down, position position yourself yourself 2. Provide rescue breathing. If there is no pulse, begin the theside sideofofthe thevictim, victim,plac pla CPR and prepare to apply the AED. Protect yourself the thevictim’s victim’sarms armsnext nexttotohih by using a pocket face mask with a one-way valve or her herhead. head. 7.7.Maintain Maintain firm firm pressure pressure o bag-valve-mask unit. the thearms armsnear nearthe theears. ears. 3. Look for and control profuse bleeding. Since the 8.8.Lower Loweryourself yourselfinto intothe theww patient’s heart rate may have slowed down, take ter ter and and roll roll the the victim victim t a pulse for 60 seconds in all cold-water rescue wards wardsyou. you.IfIfthere thereisisspac spa you youcan canmove moveforward forwardwhi wh situations before concluding that the patient is in you youroll rollthe thevictim. victim.This Thisfof cardiac arrest. wardmovement movementwill willcaus cau 4. Provide care for shock, administer high- ward the the victim’s victim’s legs legs toto risr concentration oxygen, and transport the patient as slightly, slightly,which whichwill willmake maketh roll rolleasier. easier. soon as possible. 9.9.Keep Keepan aneye eyetoto the the victi vic 5. Continue resuscitative measures throughout and and check check for for consciou conscio transport. Initial and periodic suctioning may be ness. ness. needed. 10.Move 10.Movethe thevictim victimtotothe theexe point, point,while whilewaiting waitingtototh spine spineboard. board. The drowning patient receiving rescue breathing

or CPR should be transported as soon as possible. If resuscitation and immediate transport are not required, cover the patient to conserve his body heal and complete a secondary assessment. Uncover only those areas of the patient’s body involved with the stage of the assessment. Care for any problems or injuries detected during the assessment in the order of their priority. If spinal injury is not suspected, place the patient on his left side to allow water, vomit, and other secretions to drain from the upper airway. Suction as needed. When transport is delayed and you believe that the patient must be moved to a warmer place, do so, without aggravating any existing injuries. Do not allow the drowning patient to walk. Transport the patient. A significant number of patients who appear normal after a drowning episode have delayed effects, so persuade the patient to accept transport to a hospital. Information supplied to the dispatcher or to the hospital from the scene and during transport is critical in cases of drowning. The hospital emergency department staff needs to know if this is a fresh or saltwater drowning, if it took place in cold or warm water, and if it is related to a diving accident. You may be asked to transport the patient to a special facility or to a center having a hyperbaric chamber when decompression therapy is needed.

PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE YY22 22 PRINCIPLES above above above the the the elbow elbow elbow or or or at at at the the the

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1. 1. 1. When When When you you you find find find aaa patient patient patient face face facedown down down in in inshallow shallow shallow water, water, water, position position positionyourself yourself yourself triceps. triceps. triceps. alongside alongside alongsidethe the thepatient. patient. patient. 4. 4. 4.Then Then Then slowly slowly slowly move move move the the the vicvicvic2. 2. 2. Extend Extend Extend the the the patient's patient's patient's arms arms arms straight straight straight up up up alongside alongside alongside his his his head head head to to to create create create aaa tim’s tim’s tim’s arms arms arms up up up alongside alongside alongside his/ his/ his/ Water WaterRescue Rescuewith withPossible PossibleSpinal SpinalInjury Injury splint. splint. splint. her her herhead. head. head. 3. 3. 3. Begin Begin Beginto to torotate rotate rotatethe the thetorso torso torsotoward toward towardyou. you. you. 5. 5. 5.Press Press Press the the the arms arms arms firmly firmly firmly against against against 4. 4. 4. As As Asyou you yourotate rotate rotatethe the thepatient, patient, patient,lower lower loweryourself yourself yourselfinto into intothe the thewater water water the the theears. ears. ears. HEAD-CHIN HEAD-CHINSUPPORT SUPPORT 5. 5. 5. Maintain Maintain Maintain manual manual manual stabilization stabilization stabilization by by by holding holding holding the the the patient's patient's patient's head head head between between between 6. 6. 6.For For For the the the victim victim victim who who who is is is face face face his his hisarms. arms. arms. down, down, down, position position position yourself yourself yourself to to to Two TwoRescuers RescuersininShallow ShallowWater Water the the the side side side of of of the the the victim, victim, victim, place place place the the the victim’s victim’s victim’s arms arms arms next next next to to to his/ his/ his/ NOTE: NOTE: Unless Unless Unless you you you are are are aaa very very very good good good swimmer swimmer swimmer and and and trained trained trained in in in water water water rescue, rescue, rescue, do do do her her herthe head. head. head. When Whenthere thereare aretwo tworescuers rescuerspresent, present,perform perform thehead-chin head-chinsupport supporttechtech- not not notgo go gointo into intothe the thewater water waterto to tosave save save 7. 7. 7.in Maintain Maintain Maintain firm firm firm pressure pressure pressure on on on nique niquetotoprovide providein-line in-linestabilization stabilizationofofpatient patient inshallow shallowwater. water. the the thearms arms armsnear near nearthe the theears. ears. ears. 8. 8.Lower Lower Lower yourself yourself yourself into into into the the the wawawaOne OneRescuer RescuerininShallow ShallowWater Water 8. ter ter ter and and and roll roll roll the the the victim victim victim tototowards wards wards you. you. you. IfIfIf there there there is is is space space space 1.1. When Whenyou youfind findaapatient patientface facedown downininshallow shallowwater, water,position positionyourself yourself you you you can can canmove move move forward forward forward while while while alongside alongsidethe thepatient. patient. you you you roll roll roll the the the victim. victim. victim. This This This forforfor1. When you find a patient face down in shallow Unless you 2.2. Extend Extendthe thepatient's patient'sarms armsstraight straightup upalongside alongside his his head headtotocreate createaa ward ward ward movement movement movement will will will cause cause cause splint. splint. water, position yourself alongside the patient. are a very good the the the victim’s victim’s victim’s legs legs legs to to to rise rise rise When there are two rescuers 3.3. Begin Begin totorotate rotatethe thetorso torsotoward towardyou. you. 2. Extend the patient’s arms straight up alongside his swimmer and slightly, slightly, slightly, which which which will will will make make make the the the 4.4. present, perform the head-chin As Asyou yourotate rotatethe thepatient, patient,lower loweryourself yourselfinto intothe thewater water head to create a splint. trained in water roll roll rolleasier. easier. easier. 5.5. support technique to provide in-line Maintain Maintainmanual manualstabilization stabilizationby byholding holding the thepatient's patient'shead headbetween between 9. 9. 9. Keep Keep Keep an an an eye eye eye to to to the the the victim victim victim 3. Begin to rotate the torso toward you. rescue, do not go his hisarms. arms. stabilization of patient in shallow and and and check check check for for consciousconsciousconscious4. for As you rotate the patient, lower yourself into the into the water to ness. ness. ness. water. water NOTE: NOTE: Unless Unlessyou youare areaavery verygood goodswimmer swimmerand andtrained trainedin inwater waterrescue, rescue,do save 10.Move 10.Move 10.Move the the the victim victim victim to to to the the the exit exit exit do not notgo gointo intothe thewater watertotosave save 5. Maintain manual stabilization by holding the point, point, point, while while while waiting waiting waiting to to to the the the spine spine spineboard. board. board. patient’s head between his arms. UNIT 3

Water Rescue with Possible Spinal Injury HEAD-CHIN SUPPORT Two Rescuers in Shallow Water

NOTE:

One Rescuer in Shallow Water

UNIT 3 UNIT 3 PRINCIPLESOF OF EMT CLINICALPRACTICE PRACTICE EMT CLINICAL OF EMT CL DAY DAY 2222PRINCIPLES DAY 22 PRINCIPLES

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UNIT 3 DAY 22

² Limmer ² Limmer (Brady) (Brady) ³ Pollack, ³ Pollack, (AAOS) (AAOS) ⁴ NHTSA ⁴ NHTSA

UNIT 3

Head Splint – This method is used by a rescuer when rescuing a casualty with suspected spinal injuries in shallow water – no deeper than the height of the rescuer.

1. Activate EMS 1. Activate thethe EMS 2. Make a slow entry 2. Make a slow entry in in thethe water. water. 3. Grasp victim arms 3. Grasp thethe victim arms justjust above elbow above thethe elbow or or at at thethe triceps. triceps. 4. Then slowly move 4. Then slowly move thethe vic-victim’s arms alongside tim’s arms up up alongside his/his/ head. herher head. 5. Press arms firmly against 5. Press thethe arms firmly against ears. thethe ears. 6. For victim who is face 6. For thethe victim who is face down, position yourself down, position yourself to to the side of the victim, place the side of the victim, place victim’s arms next to his/ thethe victim’s arms next to his/ ²²²her Limmer Limmer Limmer (Brady) (Brady) (Brady) head. her head. Pollack, Pollack, Pollack,(AAOS) (AAOS) (AAOS) 7.⁴³⁴³⁴³Maintain firm pressure on 7. Maintain NHTSA NHTSA NHTSA firm pressure on arms near ears. thethe arms near thethe ears. 8. Lower yourself 8. Lower yourself intointo thethe wa-water and roll the victim ter and roll the victim to- towards you. If there is space wards you. If there is space move forward while youyou cancan move forward while victim. youyou rollroll thethe victim. ThisThis for-forward movement cause ward movement willwill cause victim’slegslegsto toriserise thethevictim’s slightly, which make slightly, which willwill make thethe easier. rollroll easier. 9. Keep an eye to the victim 9. Keep an eye to the victim checkfor forconsciousconsciousandandcheck ness. ness. 10.Move victim 10.Move thethe victim to to thethe exitexit point, while waiting point, while waiting to to thethe spine board. spine board.

1. Activate the EMS 2. Make a slow entry in the water. 3. Grasp the victim arms just above the elbow or at the triceps. 4. Then slowly move the victim’s arms up alongside his/ her head. 5. Press the arms firmly against the ears. 6. For the victim who is face down, position yourself to the side of the victim, place the victim’s arms next to his/ her head. 7. Maintain firm pressure on the arms near the ears. 8. Lower yourself into the water and roll the victim towards you. If there is space you can move forward while you roll the victim. This forward movement will cause the victim’s legs to rise slightly, which will make the roll easier. 9. Keep an eye to the victim and check for consciousness. 10.Move the victim to the exit point, while waiting to the spine board.

UNIT 3 PRINCIPLES OF EMT CLINICAL PRACTICE PRINCIPLES OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE OF DAY 22PRINCIPLES DAY 22

Head Splint – This method is used by a rescuer when rescuing a casualty with suspected spinal Head Splint – This method is Head Splint– –This Thismethod methodis is injuries in shallow water – no deeper than the height Head Splint used by a rescuer when rescuused a rescuer when rescuused byby a rescuer when rescuof the rescuer. ing a casualty with suspected a casualty with suspected inging a casualty with suspected spinal injuries in shallow water spinal injuries shallow water spinal injuries in in shallow water 1. Activate the EMS – no deeper than the height of – no deeper than height – no deeper than thethe height of of the rescuer. rescuer. 2. Make a slow entry in the water. thethe rescuer. 3. Grasp the victim arms just above the elbow or at 1. Activate the EMS Activate EMS 1. 1. Activate thethe EMS 2. Make a slow entry in the Makea aslow slowentry entryin inthethe 2. 2. Make the triceps. water. water. water. 3. Grasp the victim arms just 3. Grasp the victim armsjust just 4. Then slowly move the victim’s arms up alongside 3. Grasp the victim arms above the elbow or at the abovethetheelbow elbowor orat atthethe above his/her head. triceps. triceps. triceps. 4. Then slowly move the vicThenslowly slowlymove movethethevic-vic4. 4. Then 5. Press the arms firmly against the ears. tim’s arms up alongside his/ tim’s arms alongside his/ tim’s arms upup alongside his/ her head. her head. 6. For the victim who is face down, position yourself her head. 5. Press the arms firmly against Press arms firmly against 5. 5. Press thethe arms firmly against the ears. to the side of the victim, place the victim’s arms ears. thethe ears. 6. For the victim who is face victimwho whois isface face 6. 6. ForForthethevictim next to his/her head. down, position yourself to down,position positionyourself yourselfto to down, the side of the victim, place side victim, place 7. Maintain firm pressure on the arms near the ears. thethe side of of thethe victim, place the victim’s arms next to his/ victim’s arms next his/ thethe victim’s arms next to to his/ her head. 8. Lower yourself into the water and roll the victim head. herher head. 7. Maintain firm pressure on Maintainfirm firmpressure pressureonon 7. 7. Maintain towards you. If there is space you can move the arms near the ears. arms near ears. thethe arms near thethe ears. 8. Lower yourself into the waLower yourself into wa8. 8. Lower yourself into thethe waforward while you roll the victim. This forward ter and roll the victim toandrollrollthethevictim victimto-toterterand wards you. If there is space movement will cause the victim’s legs to rise wards you. If there is space wards you. If there is space you can move forward while you can move forward while you can move forward while slightly, which will make the roll easier. you roll the victim. This foryou victim. This you rollroll thethe victim. This for-forward movement will cause wardmovement movementwill willcause cause ward 9. Keep an eye to the victim and check for the victim’s legs to rise victim’slegs legsto torise rise thethevictim’s slightly, which will make the consciousness. slightly, which will make slightly, which will make thethe roll easier. roll easier. roll easier. 10.Move the victim to the exit point, while waiting for 9. Keep an eye to the victim Keepananeye eyeto tothethevictim victim 9. 9. Keep and check for consciousandcheck checkforforconsciousconsciousand the spine board. ness. ness. 10.Move the victim to the exit point, while waiting to the spine board.

Head Splint – This method Head Splint – This method is is used a rescuer when rescuused by by a rescuer when rescua casualty with suspected inging a casualty with suspected spinal injuries in shallow water spinal injuries in shallow water – no deeper than height – no deeper than thethe height of of rescuer. thethe rescuer.

ness. 10.Move victim exit 10.Move thethe victim to to thethe exit point,while whilewaiting waitingto tothethe point, spine board. spine board.

² Limmer (Brady) ² Limmer (Brady) ³ Pollack, (AAOS) ³ Pollack, (AAOS) ⁴ NHTSA ⁴ NHTSA

² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

LIFELINE

PREHOSPITAL EMERGENCY CARE

565

rip –This method of resdesigned to secure the neck, upper spine of a ty face down in the wah suspected spinal inju-

back ofofthe back thevictim’s victim’shead. head. back of the victim’s head. 5.5. Place Place your your other other forearm forearm 5. Place your other forearm along the sternum One Rescuer in Deep Water One One Rescuer Rescuer in in Deep Deep Water Water along thevictim’s victim’s sternum along the victim’s sternum and andplace placeyour yourhand handalong along and place your hand along Vise Vise Grip Grip –This –This method method of of resresthe victim’s jaw or cheekthe victim’s jaw or cheekvictim’s jawposition or cheek1. isisWhen you to find a patient deep water, position yourself 1.1. inWhen When you you find find aa patient patient face face down downthe in in deep deep water, water, position yourself yourself cue cue designed designed to secure secure the the face down bone. bone. bone. beside him. Support his head with one hand and the mandible with beside beside him. him. Support Support his his head head with with one one hand hand and and the the mandible mandible with with head, head, neck, neck, upper upper spine spine of of aa 6. Press firmly both your fore6. Press 6. Press firmly both your foretheface other. the thefirmly other. other.both your forecasualty casualty face down down in in the the wawaarm to the chest and back of arm to the chest and back of arm to the chest and back of 2. with Rotate the patient byinjuducking under2.2.him. Rotate Rotatethe thepatient patientby byducking duckingunder underhim. him. ter ter with suspected suspected spinal spinal injuthe victim victim minimize exces3. Continue to rotate until the patient 3. is face up. totominimize 3.the Continue Continue to to rotate rotateexcesuntil until the thepatient patientisisthe face facevictim up. up. to minimize excesries. ries. sive movement ofofthe spine. sive movement the spine. sive movement of the 4. Maintain in-line stabilization until a4. isin-line used to immobilize 4.backboard Maintain Maintain in-line stabilization stabilization until until aa backboard backboard isis used used to to spine. immobilize immobilize 7. For a victim who is face 7. For a victim who is face 7. For a victim who is face the patient's the thepatient's patient'sspine. spine. 1.1.Activate Activate EMS EMS spine. down, submerge yourself inin down, submerge yourself down, submerge yourself in 2.2.Make Make aa slow slow entry entry in in the the the thewater waterand androll rollthe thevictim victim the water and roll the victim water waterto tominimize minimizethe themovemovetoto aa face up position. face up position. to a face up position. ment. ment. 8.8. Keep Keepananeye eyetotothe thevictim victim 8. Keep an eye to the victim 3.3.Slowly Slowlyswim swimto tothe thevictim. victim. and check for consciousand check for consciousand check for conscious4.4.Place Placeone oneforearm forearmalong alongthe the ness. ness. ness. spine spine and and your your hand hand at at the the 9.9. Swim together totothe exit Swim together the exit 9. Swim together to the exit back backof ofthe thevictim’s victim’shead. head. point while waiting for the point while waiting for the point while waiting for the 5.5.Place Place your your other other forearm forearm spine board. spine board. spine board. along along the the victim’s victim’s sternum sternum

Day 22

vate EMS e a slow entry in the er to minimize the movet. wly swim to the victim. e one forearm along the e and your hand at the k of the victim’s head. e your other forearm g the victim’s sternum place your hand along victim’s jaw or cheeke. s firmly both your foreto the chest and back of victim to minimize excesmovement of the spine. a victim who is face n, submerge yourself in water and roll the victim face up position. p an eye to the victim check for conscious. m together to the exit t while waiting for the e board.

ENVIRONMENTAL EMERGENCIES

One Rescuer in Deep Water

UNIT UNIT33 UNIT 3 1. When you find a patient PRINCIPLESOF OF EMT EMTCLINICAL CLINICALPRACTICE PRACTICE DAY DAY 22 22 PRINCIPLES DAY 22 PRINCIPLES OF EMT CLINICAL PRACTICE and and place place your your hand hand along along face down in deep water, the the victim’s victim’s jaw jaw or or cheekcheekposition yourself beside bone. bone. 6. 6. Press Press firmly firmly both both your your foreforehim. Support his head with arm armto tothe thechest chestand andback backof of one hand and the mandible the thevictim victimto tominimize minimizeexcesexcesVise ViseGrip Grip–This –Thismethod methodofofresresVise Grip –This method of ressive sivemovement movementof ofthe thespine. spine. cue cueis isdesigned designedtotosecure securethe the with the other. cue is designed to secure the 7.7.For For aa victim victim who who isis face face head, head,neck, neck,upper upperspine spineofofa a head, neck, upper spine of a down, down, submerge submerge yourself yourself in in 2. Rotate the patient by casualty casualty face face down down in in the the wawacasualty face down in the wathe thewater waterand androll rollthe thevictim victim ter ter with with suspected suspected spinal spinal injuinjuducking under him. ter with suspected spinal injuto toaaface faceup upposition. position. ries. ries. ries. 8.8.Keep Keep an an eye eye to to the the victim victim 3. Continue to rotate until the and and check check for for consciousconscious1. 1. Activate Activate EMS EMS ness. ness. 1. Activate EMS patient is face up. 2. 2. Make Makea aslow slowentry entryininthe the 9.9.Swim Swim together together to to the the exit exit 2. Make a slow entry in the 4. Maintain in-line water water toto minimize minimize the the movemovepoint point while while waiting waiting for for the the water to minimize the movespine spine board. board. ment. ment. ment. stabilization until a 3. 3. Slowly Slowly swim swim toto the the victim. victim. 3. Slowly swim to the victim. backboard is used to UNIT 3 4. 4. Place Place one one forearm forearm along along the the 4. Place one forearm along the UNIT33 spine UNIT 3 UNIT spineand andyour yourhand handatatthe the spine and your hand at the PRINCIPLES OF EMT CLINICAL PRACTICE immobilize the patient’s DAY 22 PRINCIPLES OF EMT CL PRINCIPLES OF EMT PRINCIPLES CLINICAL PRACTICE OF EMT CLINICAL PRACTICE DAY22 22 back back ofof the the victim’s victim’s head. head. DAY 22 DAY back of the victim’s head. 5. 5. Place Placeyour yourother otherforearm forearm spine. 5. Place your other forearm along alongthe thevictim’s victim’ssternum sternum and andplace placeyour yourhand handalong along the thevictim’s victim’sjaw jawororcheekcheekbone. bone. 6. 6. Press Pressfirmly firmlyboth bothyour yourforeforearm arm toto the the chest chest and and back back ofof the the victim victim toto minimize minimize excesexcessive sive movement movement ofof the the spine. spine. 7. 7. For Fora avictim victimwho whois isface face down, down,submerge submergeyourself yourselfinin the the water water and and roll roll the the victim victim toto a face a face upup position. position. 8. 8. Keep Keepananeye eyetotothe thevictim victim and and check checkforfor consciousconsciousness. ness. 9. 9. Swim Swimtogether togethertotothe theexit exit UNIT 3 UNIT point pointwhile whilewaiting waitingfor forthe the 3 spine spine board. board. DAY 22 22 DAY

along the victim’s sternum and place your hand along the victim’s jaw or cheekbone. ² Limmer (Brady) ² Limmer (Brady) ³ Pollack, (AAOS) ³ Pollack, (AAOS) 6.⁴ Press firmly both your foreNHTSA ⁴ NHTSA arm to the chest and back of the victim to minimize excessive movement of the spine. 7. For a victim who is face down, submerge yourself in the water and roll the victim to a face up position. 8. Keep an eye to the victim and check for consciousness. 9. Swim together to the exit point while waiting for the spine board.

ViseVise Grip –This Vise Grip –This method of resViseGrip Grip–This –Thismethod methodofofresrescue is designed to secure the method of rescue is designed cueisisdesigned designedtotosecure securethe the cue head, neck, upper spine of a head, neck, neck, upper upper spine spine ofof aa head, to secure the head, neck, casualty face down in the wacasualtyface facedown downininthe thewawacasualty ter with suspected spinal injuterwith withsuspected suspectedspinal spinalinjuinjuupper spine of a casualty ter ries. ries. ries. face down in the water with 1. Activate EMS ActivateEMS EMS EMS 1.1.Activate suspected spinal injuries. 2. Make a slow entry in the Make aa slow slow entry entry inin the the slow entry in the 2.2.Make water to minimize the move1. Activate EMS watertotominimize minimizethe themovemoveo minimize the movewater ment. ment. ment. 2. Make a slow entry in the 3. Slowly swim to the victim. Slowlyswim swimtotothe thevictim. victim. wim to the victim. 3.3.Slowly 4. Place one forearm along the Placeone oneforearm forearmalong alongthe the ne forearm along the water to minimize the 4.4.Place spine and your handUNIT at the 3 spineand andyour yourhand handatatthe the PRINCIPLES OF OF EMT EMT CLINICAL CLINICAL PRACTICE PRINCIPLES nd your hand at the movement. spine back of the victim’sPRACTICE head. DAY 22 PRINCIPLES backofofthe thevictim’s victim’shead. head. the victim’s head. back 5. Place your other forearm 3. Slowly swim to the 5. Place your other forearm your other forearm 5. Place your other forearm along the victim’s sternum along the the victim’s victim’s sternum sternum he victim’s sternum victim. along and place your hand along andplace placeyour yourhand handalong along ce your hand along and the victim’s jaw or cheekthe victim’s victim’s jaw jaw oror cheekcheek4. Place one forearm along tim’s jaw or cheekthe bone. bone. bone. Vise Grip Grip –This –This method method of of resresVise 6. Press yourofforeVise Gripfirmly –Thisboth method resthe spine and your hand Pressfirmly firmlyboth bothyour yourforeforemly both your fore6.6.Press cue isis designed designed to to secure secure the the cue arm the chest backthe of cue is to designed toand secure armtotothe thechest chestand andback backofof he chest and back of at the back of the victim’s arm head, neck, neck, upper upper spine spine of of aa head, the victim minimize head, neck, to upper spineexcesof a thevictim victimtotominimize minimizeexcesexcesm to minimize excesthe casualty face face down down in in the the wawacasualty sive movement of the spine. casualty face down in the wasivemovement movementofofthe thespine. spine. vement of the spine. head. sive ter with with suspected suspected spinal spinal injuinjuter 7. victim who is injuface terFor witha suspected spinal For aa victim victim who who isis face face victim who is 5. face Place your other forearm 7.7.For ries. ries. down, submerge yourself in ries. down,submerge submergeyourself yourselfinin submerge yourself in down, the water and roll the victim thewater waterand androll rollthe thevictim victim er and roll the victim along the victim’s the 1.Activate ActivateEMS EMS 1. a face EMS up position. 1. to Activate faceup upposition. position. e up position. totoaaface 2.Make Make aa slow slow entry entry in in the the 2. 8. eye to the in victim 2. Keep Make an a slow entry the sternum and place your Keep an an eye eye toto the the victim victim n eye to the victim 8.8.Keep waterto tominimize minimizethe themovemovewater and for consciouswatercheck to minimize the moveand check check for for consciousconsciousheck for conscious- hand along the victim’s and ment. ment. ness. ment. ness. ness. 3.Slowly Slowlyswim swimto tothe thevictim. victim. 3. 9. to victim. the exit 3. Swim Slowly together swim to the jaw or cheek-bone. Swim together together toto the the exit exit ogether to the exit 3 9.9.Swim 4.Place Place one one forearm forearm along along the the 4. UNIT while waiting for the 4. point Place one forearm along the point while waiting for the 6. Press firmly both your while waiting for the point while waiting OF for theEMT CLINICAL spine and and your your hand hand at the the spine at spine board. and your hand at the PRACTICE DAY 22 PRINCIPLES spineboard. board. oard. spine backof ofthe thevictim’s victim’shead. head. back back of the victim’s head. fore-arm to the chest 5.Place Place your your other other forearm forearm 5. 5. Place your other forearm along the the victim’s victim’s sternum sternum along and back of the victim along the victim’s sternum and place place your your hand hand along along and and place your hand along to minimize excessive the victim’s victim’s jaw jaw or or cheekcheekthe the victim’s jaw or cheekbone. bone. bone. movement of the spine. –This method of res6. Press firmly both your fore6. Press firmly both your fore6. Press firmly both your foreesigned to secure7. theFor a victim who is face armto tothe thechest chestand andback backof of arm arm to the chest and back of ck, upper spine of a the victim to minimize excesthe victim to minimize excesthe victim to minimize excesface down in the wa-down, submerge yourself sivemovement movementof ofthe thespine. spine. sive sive movement of the spine. suspected spinal injuin the water and roll 7.For For aa victim victim who who isis face face 7. 7. For a victim who is face down, submerge submerge yourself yourself in in down, down, submerge yourself in the victim to a face up the water water and and roll roll the the victim victim the the water and roll the victim e EMS to a face up position. to a face up position. position. to a face up position. a slow entry in the 8. Keep an eye to the victim 8. Keep an eye to the victim 8. Keep an eye to the victim to minimize the move8. Keep an eye to the and check check for for consciousconsciousand and check for consciousness. ness. ness. swim to the victim. victim and check for 9.Swim Swim together together to to the the exit exit 9. 9. Swim together to the exit one forearm along theconsciousness. point while waiting for the point while waiting for the point while waiting for the and your hand at the spineboard. board. spine spine board. 9. Swim together to the exit f the victim’s head. your other forearm point while waiting for the victim’s sternum ace your hand alongthe spine board.

–This method of ressigned to secure the k, upper spine of a ace down in the wauspected spinal inju-

² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

² ²Limmer Limmer(Brady) (Brady) ³ ³Pollack, Pollack,(AAOS) (AAOS) ⁴ ⁴NHTSA NHTSA

² Limmer ² Limmer (Brady) (Brady) ³ Pollack, ³ Pollack, (AAOS) (AAOS) ⁴ NHTSA ⁴ NHTSA

² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

ctim’s jaw or cheek-

irmly both your forethe chest and566 back ofLIFELINE PREHOSPITAL EMERGENCY CARE ² Limmer (Brady) tim to minimize exces³ Pollack, (AAOS) ⁴ NHTSA ovement of the spine. victim who is face submerge yourself in ter and roll the victim ce up position. an eye to the victim

² Limmer (Brady) ² Limmer (Brady) ³ Pollack, (AAOS) ³ Pollack, (AAOS) NHTSA ⁴ ⁴NHTSA

² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

OF EMT CL

Diving Accidents

Water-related accidents often involve injuries that occur when individuals attempt dives or enter the water from diving boards. In the majority of these accidents, the patient is a teenager. Basically, the same types of injuries are seen in dives taken from diving boards, pool sides, docks, boats, and the shore. The injury may be due to the diver striking the board or some object on or under the water. From great heights, injury may result from impact with the water. Most diving accidents involve the head and neck, but you will also find injuries to the spine, hands, feet, and ribs in many cases. Any part of the body can be injured depending on the position that the

Scuba-Diving Accidents

diver is in when he strikes the water or an object. This means that you must perform a primary assessment. You must also perform a secondary assessment on all diving accident patients. Do not overlook the fact that a medical emergency may have led to the diving accident. Emergency care for diving accident patients is the same as for any accident patient if they are out of the water. Care provided in the water and during removal from the water is the same as for any patient who may have neck and spine injuries. Remember, you should assume that any unconscious or unresponsive patient has neck and spinal injuries.

LINICAL PRACTICE

LINICAL

Scuba (self-contained underwater breathing apparatus)-diving accidents have increased with the popularity of the sport, especially since many untrained and inexperienced persons are attempting dives. Today, more than 2 million people scuba dive for sport or as part of their industrial or military job. Added to this are a large number who decide to “try it one time.” without the benefits of lessons or supervision. Well-trained divers seldom have problems. However, those with inadequate training place themselves at great risk. PRACTICE Scuba-diving accidents include all types of body injuries and drownings. In many cases, the scuba-diving accident was brought about by medical problems that existed prior to the dive. There are two special problems seen in scuba-diving accidents: air emboli in the diver’s blood and decompression sickness. An air embolism—more accurately called an arterial gas embolism (AGE)—is the result of gases leaving a damaged lung and entering the bloodstream. Severe damage may lead to a collapsed lung. Air embolism (gas bubbles in the blood) are most often

associated with divers who hold their breath because of inadequate training, equipment failure, underwater emergency, or attempts to conserve air during a dive. However, a diver may develop an air embolism in very shallow water (as little as 4 feet). An automobilecollision patient also may suffer an air embolism if, when trapped below water, he takes gulps of air from air pockets held inside the vehicle. When freed, the patient may develop air emboli in the same way as a scuba diver. Decompression sickness is usually caused when a diver comes up too quickly from a deep, prolonged dive. The quick ascent causes nitrogen gas to be trapped in the body tissues and then in the bloodstream. Decompression sickness in scuba divers takes from 1 to 48 hours to appear, with about 90 percent of cases occurring within 3 hours of the dive. Divers increase the risk of decompression sickness if they fly within 12 hours of a dive. Because of this delay, carefully consider all information gathered from the patient interview and reports from the patient’s family and friends. This information may provide the only clues relating the patient’s problems to a scuba dive.

The following are common signs and symptoms of scuba-diving problems: Air Embolism (Rapid Onset of Signs and Symptoms) Decompression Sickness • Blurred vision • Chest pains • Numbness and tingling sensations in the extremities • Generalized or specific weakness, possible paralysis • Frothy blood in the mouth or nose • Convulsions • Rapid lapse into unconsciousness • Respiratory arrest and cardiac arrest

• Personality changes • Fatigue • Deep pain to the muscles and joints (the “bends”) • Itchy blotches or mottling of the skin • Numbness or paralysis • Choking • Coughing • Labored breathing • Behavior similar to intoxication (such as staggering) • Chest pains • Collapse leading to unconsciousness LIFELINE

PREHOSPITAL EMERGENCY CARE

567

Day 22

ENVIRONMENTAL EMERGENCIES

For a patient with signs and symptoms of either air embolism or decompression sickness, follow the same emergency care steps:

Ang isang scuba diver na dumaan sa tamang pagsasanay ay gumagamit ng nakaplanong dive chart. Sa dive chart na ito ay nakakaman niya ang mga importanteng impormasyon sa lugar ng kanyang sisisirin at kung gaano siya katagal sa ilalim. Tiyakin na kasama ang chart na ito kapag dinala sa ospital ang pasyente.

1. Maintain art open airway. 2. Administer the highest possible concentration of oxygen by nonrebreather mask. 3. Rapidly transport all patients with possible air embolis or decompression sickness. 4. Contact medical direction for specific instructions concerning where to take the patient. You may be sent directly to a hyperbaric trauma care center. 5. Keep the patient warm. 6. Position the patient either supine or on either side. Continue to monitor the patient. You may have to reposition the patient to ensure an open airway.

UNIT UNIT33 DAY DAY22 22

Water Rescues

The following is the order of procedures far a water rescue, most of which can be performed Stick Stick- -This Thistechnique techniqueuse useeven even short of going into the water: reach, throw and tow, row and go.

Reach

• When the patient is responsive and close to shore or poolside, try to teach him by holding out an object for him to grab. Then pull him from the water. Make sure your position is secure. Line (rope) is considered the best choice. If no line is available, use a branch, fishing rod, or stick, or other object—even a towel, blanket, or article of clothing. If no object is available or you have only one opportunity to grab the person (e.g.. in strong currents), position yourself flat on your stomach and extend your hand or leg to the patient. (This is not recommended for the non-swimmer.) Again, make certain that you are working from a secure position.

Throw and tow

• If the person is conscious and alert but too far away for you to reach and pull from the water, throw an object that will float. A personal flotation device or ring buoy (life preserver) works best. Other buoy-ant objects include foam cushions, logs, plastic picnic containers, surfboards, flat boards, large beach balls, and plastic toys. Two empty, capped, plastic milk jugs can keep an adult afloat for hours. Inflatable splints can be used if there is nothing at the scene that will float. Once the conscious patient has a flotation device, try to find a way to tow him to shore. From a safe position, throw the patient a line or another flotation device attached to a line. If you are a good swimmer and you know how to judge the water, wade out no deeper than waist high, wear a personal isolation device, and have a safely line that is secured on shore.

568

LIFELINE

PREHOSPITAL EMERGENCY CARE

Row

PRINCIPLES PRINCIPLESOF OFE

Water WaterRescues—RE Rescues—R

ifif you you don’t don’t know know how how toto swim swim and and ifif there’s there’s available available materials materialswithin withinyour yourarea areafor for example exampleaastick stickororpole. pole.

• When the patient is too far from shore to allow 1.1. Grab for throwing and towing, or is unresponsive, Grabaapole poleand andlook lookatatthe the victim victim you may be able to row a boat to the patient. 2.2. Hand Hand itit toto the the victim victim and and However, do not attempt to row to the patient make make sure sure that that your your toes toes if you cannot swim. Even if you are a good are areclip clipatatthe theedge edgeofofthe the pool swimmer, wearing a personal flotation device is poolfor foryour yoursafety safety 3.3. Instruct Instruct the the victim victim toto grab grab required while you are in the boat. If the patient and andhold holdthe thepole poletightly tightly is conscious, tell him to grab an oar or the stern 4.4. Pull Pullthe thevictim victimtowards towardsyou you (rear end) of the boat. You must exercise great oror near near toto the the exit exit point point and care when helping the patient into the boat. This and perform perform assessment assessment and andfirst firstaid aidififneeded. needed. is even trickier when you are in a canoe. It the canoe lips over, stay with it and hold onto its bottom and side. Most canoes will stay afloat.

• As a last resort, when all other means have failed, you can go into the water and swim to the patient. However, you must be a good swimmer, trained in water rescue & lifesaving. Untrained rescuers can become patients themselves.

Clothes– Same technique but if there’s no pole or stick around you.

Water Rescues—REACH Water Rescues—REACH (CLOTHES) (CLOTHES) Water Rescues—REACH (CLOTHES) Water Rescues—REACH (CLOTHES) Water Rescues—REACH (CLOTHES) Clothes– Same Clothes– Same technique technique but but Clothes– Same technique but

1. Remove your shirt and look at the victim 2. Hand it to the victim make half kneel close to the edge of the pool 3. Instruct to hold tightly pull him/her towards you or to the exit point 4. Perform first aid and assessment if needed

UNIT UNIT 33 UNIT 3 DAY 22 DAY DAY 22 22

Clothes– Same technique but if if there’s there’s no no pole pole oror stick stick around aroundyou. you.

ifif there’s there’s no no pole pole or or stick stick around aroundyou. you.

1.1. Remove Removeyour yourshirt shirtand andlook look atatthe thevictim victim 2.2. Hand Handitittotothe thevictim victim make make half halfkneel kneelclose closetotothe theedge edge ofofthe thepool pool 3.3. Instruct Instructtotohold holdtightly tightlypull pull him/her him/hertowards towardsyou youorortoto the theexit exitpoint point 4.4. Perform Performfirst firstaid aidand andassessassessment mentif ifneeded needed

1.1. Remove Removeyour yourshirt shirtand andlook look atatthe thevictim victim 2.2. Hand Handititto tothe thevictim victim make make half halfkneel kneelclose closeto tothe theedge edge of ofthe thepool pool 3.3. Instruct Instruct to to hold hold tightly tightly pull pull him/her him/hertowards towardsyou youor orto to the theexit exitpoint point 4.4. Perform Performfirst firstaid aidand andassessassessment mentififneeded needed

PRINCIPLES PRINCIPLES OF OF EMT EMT CLINICAL CLINICAL PRACTICE PRACTICE Water Rescues—REACH (STICK) Stick - This technique use even if you don’t know

UNIT 3 DAY 22

how to swim and if there’s available materials within Water Water Rescues—REACH (STICK) Water Rescues—REACH Rescues—REACH (STICK) (STICK) your area, for example a stick or pole. Stick - This technique use even Stick Stick- -This Thistechnique techniqueuse useeven even if you don’t know how to ifif1. you don’t you don’t know know how how to to Grab a pole and look at swim and if there’s available swim and swimthe victim. and ifif there’s there’s available available materials within your area for materials materials within within your your area area for for example a or pole. 2. Hand it to the victim and example aastick stick example stickor orpole. pole.

Water Rescues—REACH Clothes– Same technique but if there’s no pole or stick around you.

make sure that your toes 1. a and look at the 1.1. Grab Grab aapole pole Grab poleand andlook lookat atthe the are clip at the edge of the victim victim victim pool for your safety. 2. Hand it to the victim and 2.2. Hand Hand itit to to the the victim victim and and make sure that your toes 3. Instruct the victim to make sure make sure that that your your toes toes are clip at the edge of the are clip grab and hold the pole are clip at at the the edge edge of of the the pool for your safety pool for pool foryour yoursafety safety tightly. 3. Instruct the victim to grab 3.3. Instruct the Instruct the victim victim to to grab grab 4. Pull the victim towards and hold the pole tightly and tightly andhold holdthe thepole polePRACTICE tightly EMT EMT4.4.4.CLINICAL CLINICAL PRACTICE Pull the victim towards you you or near to the exit Pull the Pull thevictim victimtowards towards you you or near to the exit point or near to the exit point orpoint and perform near to the exit point and perform assessment and perform and perform assessment assessment assessment and first aid if and first aid if needed. and first and firstaid aidififneeded. needed. needed.

EACH (STICK) REACH (STICK)

PRINCIPLES OF EMT C

UNIT3 3 UNIT UNIT UNIT33 PRINCIPLES OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE OF PRINCIPLES OF EMT CLINICAL PRINCIPLES OF EMT CLINICALPRACTICE PRACTICE DAY 22PRINCIPLES DAY 22 DAY DAY22 22

Clothes– Clothes–Same Sametechnique techniquebut but if ifthere’s there’snonopole poleororstick stick around you. around you. 1. 1.Remove your shirt and look Remove your shirt and look at at the victim the victim 2. 2.Hand it to the victim Hand it to the victimmake make half kneel close toto the edge half kneel close the edge of of the pool the pool 3. 3.Instruct to hold tightly pull Instruct to hold tightly pull him/her towards you oror toto him/her towards you the exit point the exit point 4. 4.Perform first aidaid and assessPerform first and assessment if needed ment if needed

² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

Water Rescues—REACH(CLOTHES) (CLOTHES) Water Rescues—REACH Water (CLOTHES) WaterRescues—REACH Rescues—REACH (CLOTHES) Clothes–Same Sametechnique techniquebut but Clothes– there’snonopole poleor orstick stick if ifthere’s around you. around you.

² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

Remove your shirt and look 1. 1.Remove your shirt and look victim at at thethe victim Hand it to victimmake make 2. 2.Hand it to thethe victim half kneel close edge half kneel close to to thethe edge pool of of thethe pool Instruct hold tightly pull 3. 3.Instruct to to hold tightly pull him/her towards you him/her towards you or or to to the exit point the exit point Perform first and assess4. 4.Perform first aidaid and assessment if needed ment if needed

² Limmer (Brady) ² Limmer (Brady) ³ Pollack, (AAOS) ³ Pollack, (AAOS) ⁴ NHTSA ⁴ NHTSA

² Limmer ² Limmer(Brady) (Brady) ³ Pollack, ³ Pollack,(AAOS) (AAOS) ⁴ ⁴NHTSA NHTSA

Water Rescues—REACH (CLOTHES) ² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

² Limmer (Brady) (Brady) Limmer(AAOS) (Brady) ³² ²Limmer Pollack, Pollack,(AAOS) (AAOS) ⁴³ ³Pollack, NHTSA ⁴ ⁴NHTSA NHTSA

Clothes– Same technique but if there’s no pole or stick around you. 1. Remove your shirt and look at the victim. 2. Hand it to the victim make half kneel close to the edge of the pool. 3. Instruct to hold tightly pull him/her towards you or to the exit point. 4. Perform first aid and assessment if needed. ² Limmer (Brady) ² Limmer (Brady) ³ Pollack, (AAOS) ³ Pollack, (AAOS) ⁴ NHTSA ⁴ NHTSA

² Limmer (Brady) ² Limmer (Brady) ³ Pollack, (AAOS) ³ Pollack, (AAOS) ⁴ NHTSA ⁴ NHTSA

LIFELINE

PREHOSPITAL EMERGENCY CARE

569

T 3 T T3 3 22 22 22

m m m

1. Get down on the floor while your your other other hand hand while holding to to the the edge edge of of the the holding pool pool 2. Brace Brace yourself yourself and and reach reach 2. yourone onefoot footto tothe thevictim victim your 3. Instruct Instruct him/her him/her to to hold hold 3. yourfoot foot your 4. Move Move him/her him/her towards 4. towards youor orat atthe theexit exitpoint point you 5. Make Make him/her him/her hold hold the the 5. edgeor orgutter gutterof ofthe thepool pool edge 6. Assist Assist him/her him/her out out in in the the 6. pool in in perform perform first first aid aid ifif pool needed needed

2. 3.

while your other hand holding to the edge of the pool Brace yourself and reach your one foot to the victim Instruct him/her to hold your foot Move him/her towards you or at the exit point Make him/her hold the edge or gutter of the pool Assist him/her out in the pool in perform first aid if needed

UNIT 3 UNIT 3 OF EMT4.CLINICAL PRACTICE DAY 22 PRINCIPLES PRINCIPLES OF EMT CLINICAL PRACTICE DAY 22 ENVIRONMENTAL 5.EMERGENCIES Day 22 6.

Water Rescues—REACH (FOOT) Water Rescues—REACH (FOOT) Feet – If you can’t find a pole

Water Rescues—REACH (HAND) Feet – If you can’t find a pole or stick and if you don’t have excess clothes

or stick and if you don’t have excess clothes

THROWING THROWING– –Thi T nique niqueusing usingthe theresr ment like heavy jug ment like heavy ju bag. bag.

Heavy HeavyJug– Jug–This This compose composeofofjag jagw amount amountofofwater watera about 3030 meters lon about meters lo

Arms – 1.this technique perform within arm reach. Get down on the floor 1. Get down on the floor and hold the gutter or the edge of while your other hand holding to the edge of the the pool . OF PRINCIPLES EMT pool PRINCIPLES OF EMT CLINICAL CLINICAL PRACTICE PRACTICE 2. Brace yourself and reach out your one arm. 2. Brace yourself and reach your one foot to the victim 3. Hold and pull “victim” towards you. 3. Instruct him/her to hold your foot 4. Make “victim” hold the gutter or the edge. 4. Move him/her towards 5. Assist “victim” out in the pool and apply first aid if Water Rescues—REACH you or at the exit point (HAND) Water Rescues—REACH (HAND) Water Rescues—REACH (HAND) 5. Make him/her hold the needed. edge or gutter of the pool 1. Get down on the floor while your other hand holding to the edge of the pool 2. Brace yourself and reach your one foot to the victim 3. Instruct him/her to hold your foot 4. Move him/her towards you or at the exit point 5. Make him/her hold the edge or gutter of the pool 6. Assist him/her out in the pool in perform first aid if needed

1. 1.Hang Hangthe therope ro palm palmdon’t don’thold ho vent from knottin vent from knott 2. 2.While Whileononthe theo UNIT 3 hold the jug atat th hold the jug DAY 22 3. 3.Your Yourfoot footis isininfr step onon the end o step the end 6. Assist him/her out in the totomake makeit itsec s pool in perform first aid if sure THROWING –loo sureyour yourlooki THROWING –( needed Water Rescues—REACH victim. nique using victim. nique usingthe the Feet – If you can’t find a pole 4. 4.Throw the jug alj ment like heavy Throw the jug ment like heavy or stick and if you don’t have victim bag. victimbut butmak ma bag. excess clothes over head. over head. 5. 5.Instruct 1. Get down on the floor Instructthe thevicti vic while your other hand and hold the rop Heavy Jug– Th Heavy Jug– T and hold the ro holding to the edge of the 6. 6.Pull compose ofvictim compose ofjag jat Pullthe thevictim pool the exit point, amount of wate amount watle the exit of point, 2. Brace yourself and reach hold about 30 meters about 30edge meter your one foot to the victim holdthe the edgeorl a while. 3. Instruct him/her to hold a while. Hang ro your foot 7. 7.1. Assist the victim 1. Hang the UNIT Assist thethe victim UNIT33 UNIT 3 4. Move him/her towards palm don’t water, perform palm don’th water, perform DAY you or at the exit point DAY22 22 vent DAY 22 5. Make him/her hold the needed. ventfrom fromkno kn needed. 2.2.While Whileononthe th edge or gutter of the pool hold holdthe thejug juga 6. Assist him/her out in the 3.3.Your Yourfoot footis isin pool in perform first aid if Water (FOOT) WaterRescues—REACH Rescues—REACH (FOOT) Water step neededRescues—REACH (FOOT) stepononthe theene Feet – If you can’t find a pole Feet – If you can’t find a pole Feet – If you can’t find a pole toto make make–it–itT ororstick THROWING THROWING stickand andififyou youdon’t don’thave have or stick and if you don’t have ² Limmer (Brady) sure your lo sure your excess ³ Pollack, (AAOS) excessclothes clothes nique nique using using the therl Limmer(Brady) (Brady) ² ²Limmer excess clothes ⁴ NHTSA victim. Pollack,(AAOS) (AAOS) ³ ³Pollack, victim. NHTSA ment like like heavy heavy ju ⁴ ⁴ NHTSA 4.ment 1.1. Get Get down down on on the the floor floor 4.Throw Throwthe thejug ju 1. Get down on the floor bag. bag. while victim while your your other other hand hand victimbut butm while your other hand holding holdingtotothe theedge edgeofofthe the over holding to the edge of the overhead. head. pool pool 5.5.Instruct the v pool Instruct the 2.2. Brace Heavy Heavy Jug– Jug– This Tr Brace yourself yourself and and reach reach 2. Brace yourself and reach and the andhold hold the your yourone onefoot foottotothe thevictim victim compose compose of of jag jag your one foot to the victim 6.6.Pull victim Pullthe vict 3.3. Instruct Instruct him/her him/her toto hold hold amount amount ofthe ofwater wat 3. Instruct him/her to hold the exit point your the exit poilo yourfoot foot your foot about about 30 30 meters meters 4.4. Move hold Move him/her him/her towards towards holdthe theedge edg 4. Move him/her towards you youororatatthe theexit exitpoint point a awhile. while. you or at the exit point 1. 1. Hang Hang the the ro 5.5. Make him/her hold the Make him/her hold the 7.7.Assist the 5. Make him/her hold the Assist thevict vi edge palm palm don’t don’t ho edgeororgutter gutterofofthe thepool pool edge or gutter of the pool water, perfor water, perfo 6.6. Assist Assist him/her him/her out out inin the the vent vent from from knot kn 6. Assist him/her out in the needed. needed. pool pool inin perform perform first first aid aid ifif 2. 2.While While ononthe th

d d d e e e ut ut ut ooottte e e

PRINCIPLES OF EMT C

PRINCIPLES CLINICAL PRACTICE PRINCIPLESOF OFEMT EMT CLINICALOF PRACTICE PRINCIPLES EMT CLINICAL PRACTICE

needed needed

² Limmer (Brady)

³ Pollack, (AAOS) ⁴ NHTSA

pool in perform first aid if needed ² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

hold hold the the jug jug at 3. 3.Your Your foot foot is is in step step onon the the ene totomake makeit its sure sureyour yourlool victim. victim. 4. 4.Throw Throw the the jug ju victim victimbut butmam over over head. head. 5. 5.Instruct Instructthe thevi and and hold hold the the ro 6. 6.Pull Pullthe thevictim vict the theexit exitpoint, poin hold hold the the edge edg a while. a while. 7. 7.Assist Assist the the victi vic water, water,perform perfo needed. needed.

Water Rescues— REACH (FOOT)

Feet – If you can’t find a pole or stick and if you don’t have excess clothes: 1. Get down on the floor while your other hand holding to the edge of the pool. 2. Brace yourself and extend your one foot to the “victim.” 3. Instruct “victim” to hold your foot. 4. Move “victim” towards you or at the exit point. 5. Make “victim” hold the edge or gutter of the pool. 6. Assist “victim” out in the pool and perform first aid if needed. ² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

² Limmer (Brady) (Brady) ³²² Limmer Pollack, (AAOS) Limmer (Brady) ⁴³ Pollack, NHTSA (AAOS) ⁴³ Pollack, NHTSA (AAOS) ⁴ NHTSA

570

LIFELINE

PREHOSPITAL EMERGENCY CARE

UNIT 3 palm don’thold holdit ittoto predon’t prePRINCIPLES OF EMTpalm CLINICAL PRACTICE PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE CLINICAL PRACTICE DAY vent from knotting. DAY DAY 22 22PRINCIPLES vent from knotting. DAY22 22 PRINCIPLES OF EMT

Water WaterRescues—THROW Rescues—THROW(IMPROVISE (IMPROVISE WaterRescues—THROW Rescues—THROW(IMPROVISE (IMPROVISE Water FLOATING FLOATING FLOATINGDEVICE) DEVICE) FLOATINGDEVICE) DEVICE)

is is istechThis techscue equiprescue equipand throw ug and throw

Water Rescues— THROW (IMPROVISE FLOATING DEVICE)

sequipment equipment with witha alittle little and anda arope rope ng. ong.

e totoyour ope your d preUNIT oldit ittoto pre- 33 UNIT ng. ting. DAY 22 DAY 22 other hand other hand he handle. the handle. ront frontofofyou you ofof the rope d the rope cured.Make secured.Make ing atisatisthe This techoking the This tech(FOOT) erescue rescueequipequiplong to the throw along to the yjug jugand and throw ke akesure sureit’sit’s

PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE PRINCIPLES PRINCIPLES PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE THROWING –

CLINICAL PRACTICE

Water WaterRescues—THROW Rescues—THROW(IMPROVISE (IMPROVISE FLOATING FLOATINGDEVICE) DEVICE)

im ctimtotograb grab pe. his This equipment ope.equipment towards with little ag witha ato little m towards to etlet him/her er and a arope and rope ,ter him/her r gutter for long. rsorlong. gutter for

ope toto your out the rope your UNIT UNIT 33 m outin in the hold itaid first if preitto topremhold first aid if DAY DAY22 22 otting. notting. eheother otherhand hand gatatthe thehandle. handle. ninfront frontofofyou you nd endofofthe therope rope t secured.Make secured.Make This This is is techooking attechthe looking at the erescue rescueequipequip-

WaterRescues—THROW Rescues—THROW(IMPROVISE (IMPROVISE Water FLOATING DEVICE) FLOATING DEVICE)

a while. a while. Hang the the rope rope toto your your 1.1. Hang 7. 7.Assist Assist the the victim victim out out in in the the palmdon’t don’thold holdit ittotopreprepalm water, water, perform perform first firstaidaidif if ventfrom fromknotting. knotting. vent needed. needed. Whileon onthe theother otherhand hand 2.2.While holdthe thejug jugatatthe thehandle. handle. hold Yourfoot footis isininfront frontofofyou you 3.3.Your stepon onthe theend endofofthe therope rope step make it it secured.Make secured.Make toto make sureyour yourlooking lookingatatthe the sure victim. victim. Throwthe thejug jugalong alongtotothe the 4.4.Throw victimbut butmake makesure sureit’sit’s victim ² Limmer (Brady) overhead. head. ² Limmer (Brady) over ³ Pollack, (AAOS) (AAOS) Instructthe thevictim victimtotograb grab ⁴³ Pollack, ⁴ NHTSA 5.5.Instruct NHTSA andhold holdthe therope. rope. and Pullthe thevictim victimtowards towardstoto 6.6.Pull theexit exitpoint, point,letlethim/her him/her the holdthe theedge edgeororgutter gutterfor for hold while. a awhile. Assistthe thevictim victimout outininthe the 7.7.Assist water,perform performfirst first aidif if33 UNIT water, aid UNIT needed. needed.

PRINCIPLES PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE Water WaterRescues—THROW Rescues—THROW(IMPROVISE (IMPROVISE FLOATING FLOATINGDEVICE) DEVICE)

yug jug and and throw throw gug along alongtotothe the make makesure sureit’sit’s

victim totograb grab This s victim equipment equipment erope. rope. g with with a a little little m towards toto tim towards rter and a arope rope t, and let him/her int, let him/her ong. s long. egeororgutter gutterfor for

ope rope totoinyour your tim out ictim inthe the old hold it out ittoto preprerm first aid orm first aidif if notting. tting. heother otherhand hand t at the the handle. handle. n in front front ofof you you nd end ofof the the rope rope secured.Make secured.Make oking lookingat atthe the

PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE DAY DAY22 22 PRINCIPLES

gug along along toto the the ake makesure sureit’sit’s

ictim victimtotograb grab eope. rope. mtimtowards towardstoto nt, , letlethim/her him/her ege oror gutter gutter forfor

Whileononthe theother otherhand hand 2.2.While hold the jug the handle. hold the jug atat the handle. Yourfoot footis isininfront frontofofyou you 3.3.Your step the end the rope step onon the end ofof the rope makeit itsecured.Make secured.Make totomake THROWING THROWING – looking –This Thisis at istechsureyour your looking attechthe sure the nique nique using using the the rescue rescue equipequipvictim. victim. ment like like heavy heavy jug jug and and throw 4.Throw Throw thejug jug along tothe the 4.ment the along tothrow bag. bag. victimbut butmake makesure sureit’sit’s victim over head. over head. Instructthe thevictim victimtotograb grab 5.5.Instruct Heavy Heavy Jug– Jug– This This equipment equipment and hold the rope. and hold the rope. compose of of jag jagwith with a alittle little 6.Pull Pullthe the victim towards 6.compose victim towards toto amount amount ofexit ofwater water and and ahim/her arope rope theexit point, lethim/her the point, let about about 3030 meters meters long. long. hold the edge orgutter gutterforfor hold the edge or a while. a while. 1. 1. Hang Hang the the rope rope to to your Assistthe thevictim victimout out inthe the 7.7.Assist inyour UNIT 3 palm palm don’t don’t hold hold itfirst ittoUNIT topreprewater, perform aid water, perform first aid if if 3 vent vent from from knotting. knotting. DAY needed. needed. DAY22 22 2. 2.While Whileononthe theother other hand hand This is hold hold the the jugjug at at the the handle. handle. a technique using the rescue 3. 3.Your Your foot foot is is in in front front of of you you equipment like heavy jug and step step onon the the end end of of the the rope rope totomake makeit itsecured.Make secured.Make throw bag. THROWING – This Thisatisat isthe techTHROWING –looking techsure sureyour yourlooking the nique usingthe therescue rescueequipequipnique using victim. victim. ment like heavy jugand and throw ment like heavy jug throw 4. 4.Throw Throw the the jugjug along along toto the the bag. bag. victim victimbut butmake makesure sureit’sit’s over over head. head. 5. 5.Instruct Instructthe thevictim victimtotograb grab Heavy Jug– This equipment equipment Heavy Jug– This and and hold hold the the rope. rope. compose ofjag jag witha ato little compose ofvictim with little 6. 6.Pull Pullthe thevictim towards towards to amount ofpoint, water and rope amount of water and a arope the theexit exit point, letlet him/her him/her about 30 meters long. about 30 meters long. hold hold the the edge edge oror gutter gutter forfor

² Limmer (Brady) ² Limmer (Brady) ³ Pollack, (AAOS) ³ Pollack, (AAOS) ⁴ NHTSA ⁴ NHTSA

im ctim out out in in the the orm m first firstaidaidif if

² Limmer (Brady) ² Limmer (Brady) ³ Pollack, (AAOS) ³ Pollack, (AAOS) ⁴ NHTSA ⁴ NHTSA

THROWING THROWING –– This This isis techtechnique niqueusing usingthe therescue rescueequipequipment mentlike likeheavy heavyjug jugand andthrow throw bag. bag. Heavy Heavy Jug– Jug– This This equipment equipment compose compose ofof jag jag with with aa little little amount amountofofwater waterand andaarope rope about about30 30meters meterslong. long. 1.1. Hang Hang the the rope rope toto your your palm palmdon’t don’thold holditittotopreprevent ventfrom fromknotting. knotting. 2.2. While While on on the the other other hand hand hold holdthe thejug jugatatthe thehandle. handle. 3.3. Your Yourfoot footisisininfront frontofofyou you step stepon onthe theend endofofthe therope rope toto make make itit secured.Make secured.Make sure sure your your looking looking atat the the victim. victim. 4.4. Throw Throwthe thejug jugalong alongtotothe the victim victim but but make make sure sure it’s it’s over overhead. head. 5.5. Instruct Instructthe thevictim victimtotograb grab and andhold holdthe therope. rope. 6.6. Pull Pullthe thevictim victimtowards towardstoto the theexit exitpoint, point,let lethim/her him/her hold holdthe theedge edgeororgutter gutterfor for aawhile. while.

Water WaterRescues—THROW Rescues—THROW(IMPROVISE (IMPROVISE FLOATING DEVICE) FLOATING DEVICE) ² Limmer ² Limmer (Brady) (Brady) ³ Pollack, ³ Pollack, (AAOS) (AAOS) ⁴ NHTSA ⁴ NHTSA

² Limmer (Brady) ² Limmer (Brady) ³ Pollack, (AAOS) ³ Pollack, (AAOS) ⁴ NHTSA ⁴ NHTSA

LIFELINE

PREHOSPITAL EMERGENCY CARE

571

and and andhold hold holdthe the therope. rope. rope. 6.6. 6.Pull Pull Pullthe the thevictim victim victimtowards towards towardsto to to the the theexit exit exitpoint, point, point,let let lethim/her him/her him/her hold hold holdthe the theedge edge edgeor or orgutter gutter gutterfor for for aaawhile. while. while. 7.7. 7.Assist Assist Assistthe the thevictim victim victimout out outinin inthe the the water, water, water,perform perform performfirst first firstaid aid aidififif needed. needed. needed.

Day 22

ENVIRONMENTAL EMERGENCIES

Water Rescues— THROW (IMPROVISE FLOATING DEVICE) Heavy Jug– This equipment is composed of a jug with a little amount of water and a rope about 30 meters long. 1. Hang the rope to your palm; don’t hold it to prevent from knotting. UNIT UNIT33 2. While on the other hand hold DAY22 22 the jug at the handle. DAY 3. Using your front foot, step on the end of the rope to secure it. Make sure you are looking at the victim. THROWING THROWING– –This Thisis istechtech4. Throw the jug along to the nique niqueusing usingthe therescue rescueequipequipvictim but make sure it’s over ment ment like like heavy heavyjug jug and andthrow throw her head. bag. bag. 5. Instruct the victim to grab and hold the rope. 6. Pull the victim towards the exit Heavy HeavyJug– Jug–This Thisequipment equipment point. Let her hold the edge or compose composeofofjag jagwith witha alittle little gutter for a while. amount amountofofwater waterand anda arope rope 7. Assist the victim out of the about about 3030 meters meters long. long. water. Perform first aid if needed. 1.1.Hang Hang the the rope rope toto your your palm palmdon’t don’thold holdit ittotopreprevent vent from from knotting. knotting. 2.2.While Whileononthe theother otherhand hand hold hold the the jug jug atat the the handle. handle. 3.3.Your Yourfoot footis isininfront frontofofyou you step step onon the the end end ofof the the rope rope totomake makeit itsecured.Make secured.Make sure sureyour yourlooking lookingatatthe the victim. victim. 4.4.Throw Throwthe thejug jugalong alongtotothe the victim victimbut butmake makesure sureit’sit’s over over head. head. 5.5.Instruct Instructthe thevictim victimtotograb grab and and hold hold the the rope. rope. 6.6.Pull Pullthe thevictim victimtowards towardstoto the theexit exitpoint, point,letlethim/her him/her hold holdthe theedge edgeororgutter gutterforfor a while. a while. 7.7.Assist Assistthe thevictim victimout outininthe the water, water,perform performfirst firstaid aidif if needed. needed.

572

LIFELINE

PREHOSPITAL EMERGENCY CARE

PRINCIPLES PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE Water WaterRescues—THROW Rescues—THROW(IMPROVISE (IMPROVISE FLOATING FLOATINGDEVICE) DEVICE)

² Limmer ² ²Limmer Limmer (Brady) (Brady) (Brady) ³ Pollack, ³ ³Pollack, Pollack, (AAOS) (AAOS) (AAOS) ⁴ ⁴NHTSA ⁴ NHTSA NHTSA

UNIT 3 DAY 22

APPROACHES—These are are the the APPROACHES—These technique that that perform perform by by the the technique good swimmer and by those good swimmer and by those who trained trained for for basic basic water water who safety and and rescue rescue for for the the active active safety victim without without the the use use of of resresvictim cue equipments. equipments. cue Front Approach– Approach– This This techtechFront nique is is use use when when the the victim victim is is nique facing to to you. you. facing 1. Using Using aa rescue rescue jump jump get get in in 1. to the the water. water. to 2. Swim Swim to to the the victim victim using using 2. front crawl crawl or or breast breast stroke stroke front head-up. Front Front crawl crawl and and head-up. breast stroke stroke head-up head-up are are breast important when when approachapproachimportant ing the the victim victim to to keep keep an an ing eyesight so so that that you you will will eyesight know where where the the victim victim is. is. know 3. Quick Quick stop stop about about one one meme3. ter to the victim. ter to the victim. 4. Using Using your your right right hand hand grab grab 4. the right right hand hand of of the the vicvicthe tim. tim. 5. Twist Twist and and turn turn the the victim victim 5. up near near you. you. up 6. Using Using your your left left hand hand chin chin 6. up the the victim victim and and push push his/ his/ up

3 2

Front Front Approach– Approach– This This techtechnique niqueisisuse usewhen whenthe thevictim victimisis facing facingtotoyou. you.

Front Front Approach– Approach–This Thistechtechnique niqueis isuse usewhen whenthe thevictim victimis is facing facingtotoyou. you.

UNIT 3

1.1.Using Usinga arescue rescuejump jumpUNIT get getinin 3 totothe thewater. water. DAY DAY22 22 2.2.Swim Swimtotothe thevictim victimusing using front frontcrawl crawlororbreast breaststroke stroke head-up. head-up.Front Frontcrawl crawland and breast breaststroke strokehead-up head-upare are important importantwhen whenapproachapproaching ingthe thevictim victimtotokeep keep an an APPROACHES—These are APPROACHES—These arethe the eyesight eyesight soso that thatyou you will will technique that perform bybythe technique that perform the know know where wherethe the victim victim is. is. good swimmer and by good swimmer and bythose those 3.who 3.Quick Quick stop stop about about one one memewho trained for basic water trained for basic water ter ter toand tothe the victim. victim. safety and rescue forforthe safety rescue theactive active 4.victim 4.Using Using your yourright right hand hand grab grab victim without the ofof reswithout theuse use resthe the right righthand handofofthe thevicviccue equipments. cue equipments. tim. tim. 5.Front 5.Twist Twist and andturn turnthe the victim Front Approach– This techApproach– Thisvictim techup up near you. you. nique isnear use when nique is use whenthe thevictim victimis is 6.facing 6.Using Using your yourleft lefthand handchin chin facing totoyou. you. up upthe thevictim victimand andpush pushhis/ his/ her her lower lower back back by by your your left left 1.1.Using get Usinga arescue rescuejump jump getin in3 UNIT UNIT 3 elbow. elbow. This This is is called called levelleveltotothe thewater. water. DAY 22 ing ing up up so so the head head and and the the 2.2.Swim to the victim using DAY 22 Swim to victim using These are the upper upper body body of ofbreast the thestroke victim victim front crawl oror breast front crawl stroke techniques performed will willfloat floaton on the thewater. water. head-up. Front crawl head-up. Front crawland and 7.7.breast Let Letgo gothe the right right hand handofofare the the by a good swimmer stroke head-up breast stroke head-up are victim victimand and your yourright right hand hand important when approachimportant when approachand by those who are will willthe do dovictim the the cross chest chest ing tocross anan ing the victim tokeep keep trained in basic water carry. carry. sosothat APPROACHES—These are the eyesight you will eyesight thatare you will APPROACHES—These the 8.8.know While While you’re you’re atat the the cross where the victim is.cross technique that perform by the know where the victim is. technique that perform by the safety and rescue chest chest carry carry remove remove your your left left 3.3.Quick stop about one meQuick stopand about one megood swimmer and those good swimmer byby those for the active victim hand hand at atfor his/her his/her chin chin and and ter totothe victim. ter the victim. who trained for basic water who trained basic water use use itrescue ityour torescue to swim swim using using aactive aside side 4.4.Using right hand grab Using your right hand grab safety and for the without the use of safety and for the active stroke stroke going going touse tothe the nearest nearest the right hand of the victhe right hand ofof the vicvictim without the use of resvictim without the resrescue equipment. exit exitpoint. point. tim. tim. cue equipments. cue equipments. 9.5. 9.Twist Let Lethim/her him/her hold hold the thegutter gutter 5. and the victim Twist andturn turn the victim for for aApproach– awhile while and assist assist the the up near you. up near you.and Front This techFront Approach– This techvictim victim out out inin the the water.and water.and 6.6.Using your left hand chin your left hand chin nique is use when the victim is nique isUsing use when the victim is perform perform first firstaid aid if ifneeded. needed. up the victim and push up the victim and pushhis/ his/ facing to you. facing to you. her herlower lowerback backbybyyour yourleft left elbow. This levelelbow. Thisis iscalled calledget Using rescue jump 1. 1.Using aa rescue jump get levelin in ing up so the head and the ing up so the head and the the water. toto the water. upper body ofvictim upperto body ofthe thevictim victim Swim thevictim using 2. 2.Swim to the using will float onon the water. will float the water. front crawl or breast stroke front crawl or breast stroke 7.7.Let right the Letgogothe the righthand handofofand the head-up. Front crawl head-up. Front crawl and victim victimand andyour yourright righthand hand breaststroke strokehead-up head-upare are breast will will dodo the the cross cross chest chest importantwhen whenapproachapproachimportant carry. carry. ingthe thevictim victimtotokeep keepanan ing 8.8.While Whileyou’re you’reatatthe thecross cross eyesight thatyou youwill will eyesight sosoremove that chest your chestcarry carry remove yourleft left know where the victim is. know where the victim is. hand handatathis/her his/herchin chinand and Quick stop about one me3. 3.Quick about one use using ameuseitstop itto toswim swim using aside side to the victim. terter to the victim. stroke going totothe stroke going thenearest nearest Using your right hand grab 4. 4.Using your right hand grab exit exitpoint. point. right hand the vicright hand ofof the vic9.the Let him/her hold the gutter 9.the Let him/her hold the gutter tim. tim. forfora awhile whileand andassist assistthe the 5. Twist and turn the victim 5. Twist and turn the victim victim out ininthe water.and victim out the water.and up near you. upperform near you. first perform firstaid aidif ifneeded. needed. Usingyour yourleftlefthand handchin chin 6. 6.Using up the victim and push his/ up the victim and push his/ her lower back your her lower back byby your leftleft elbow.This Thisis iscalled calledlevellevelelbow. ing the head and the ing upup soso the head and the upperbody bodyofofthe thevictim victim upper will float the water. will float onon the water. the right hand the 7. 7.LetLet gogo the right hand ofof the victim and your right hand victim and your right hand willdodothe thecross crosschest chest will carry. carry. Whileyou’re you’reat atthe thecross cross 8. 8.While chest carry remove your chest carry remove your leftleft handat athis/her his/herchin chinand and hand useit ittotoswim swim usinga aside side use using stroke going the nearest stroke going toto the nearest exit point. exit point. him/her hold the gutter 9. 9.LetLet him/her hold the gutter whileand andassist assistthe the forfora awhile victim out in the water.and victim out in the water.and perform first aid if needed. perform first aid if needed.

1.1. Using get Usingaarescue rescuejump jump getin UNIT UNIT 3in3

totothe thewater. water. PRACTICE PRINCIPLES PRINCIPLESOF OFEMT EMTCLINICAL CLINICAL PRACTICE PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE DAY DAY 22 22PRINCIPLES 2.2. Swim using Swim toto the the victim victim using front frontcrawl crawlororbreast breaststroke stroke head-up. head-up. Front Front crawl crawl and and breast breast stroke stroke head-up head-up are are important importantwhen whenapproachapproaching ing the the victim victim toto keep keep an an APPROACHES—These APPROACHES—These are are thethe eyesight you will eyesight so so that that you will technique technique that that perform perform by by the the know knowwhere wherethe thevictim victimis.is. good good swimmer swimmer and and byby those those 3.3. Quick stop about one meQuick stop about one mewho whotrained trained for for basic basicwater water ter totothe victim. ter the victim. safety safety and rescue rescue for for the the active active 4.4. and Using your hand grab Using yourright right hand grab victim victim without without the use use ofthe of resresthe right hand ofof victhe rightthe hand the viccue cue equipments. equipments. tim. tim. 5.5. Twist Twist and and turn turn the the victim victim up near up nearyou. you. This Front Front Approach– Approach– Thistechtech6.6. is Using your left hand chin Using your left hand nique nique use is use when when the the victim victim ischin is up the victim upto the victimand andpush pushhis/ his/ facing facing to you. you. her lower back by your left her lower back by your left UNIT UNIT elbow. This isisjump called levelelbow. This jump called level1. 1.Using Using a rescue a rescue get get in in33 ing up so and ing up sothe thehead head andthe the to to the the water. water. DAY 22 DAY 22 upper body of victim upper body of the the victim 2. 2.Swim Swim to tothe thevictim victim using using will float on the water. will float on the water. front front crawl crawl or or breast breast stroke stroke 7. Let right hand ofof the 7.head-up. Letgo gothe the right handand the head-up. Front Front crawl crawl and victim and right hand victim andyour your rightare hand breast breast stroke stroke head-up head-up are will the cross chest will do do the approachcross chest important important when when approachcarry. carry. inging thethevictim victimto tokeep keep anthe an APPROACHES—These are APPROACHES—These arethe 8. While you’re atat the cross 8.eyesight While so you’re thewill cross eyesight so that that you you will technique that perform byby the technique that perform the chest carry remove your left chest carry remove your know know where where the the victim victim is.those is. left good swimmer and by good swimmer and bythose hand atat his/her chin and hand his/her chin and 3. 3. Quick Quick stop stop about about one one memewho trained for basic water who trained for basic use itittotoswim using use swim usingawater aside side terter to to thethe victim. victim. safety and rescue for the active safety and rescue for the active stroke strokegoing goingtotothe thenearest nearest 4. 4. Using Using your your right right hand hand grab victim without use victim without the useofgrab ofresresexit point. exit point.the the the right righthand handof ofthethevic-viccue equipments. cue equipments. 9.9. Let Lethim/her him/herhold holdthe thegutter gutter tim. tim. for for aa while while and and assist assist the the 5. 5. Twist Twist and and turn turn the the victim victim Front Approach– This techFront Approach– This techvictim out in water.and victim out inthe the water.and upup near near you. you. nique is use when the victim is nique is use when the victim perform performfirst firstaid aidififneeded. needed.is 6. 6. Using Using your yourleftlefthand handchin chin facing toto you. facing you. upup thethe victim victim and and push push his/ his/ her her lower lower back by by your your left left 1. 1. Using a rescue jump get in Using a back rescue jump get in elbow. This Thisis iscalled calledlevelleveltoelbow. the water. to the water. ing ing upup so the the head head and and the the 2. 2. Swim toso the victim using Swim to the victim using upper upper body body ofthe thevictim victim front crawl orof breast stroke front crawl or breast stroke will will float float onFront on the the water. water. head-up. crawl head-up. Front crawland and 7. 7.Let Let gogo the the right right hand hand of of the the breast stroke head-up are breast stroke head-up are victim victim and and your your right right hand hand important importantwhen whenapproachapproachwill will do do the the cross cross chest chest ing ingthe thevictim victimtotokeep keepanan carry. carry. eyesight eyesightsosothat thatyou youwill will 8. 8.While While you’re you’re at at the the cross know where the victim is.cross know where the victim is. chest chest carry carry remove remove your your left left 3. 3. Quick stop about one meQuick stop about one mehand atthe athis/her his/her chinand and terhand toto the victim. ter victim.chin use use it to ityour to swim swim using using a grab side a grab side 4. 4. Using right hand Using your right hand stroke stroke going going to to the nearest nearest the hand ofthe the theright right hand of thevicvicexit exit point. point. tim. tim. 9. Let Let him/her him/her hold hold the the gutter gutter 5.9. Twist and the victim 5. Twist andturn turn victim for a near awhile while and andassist assistthethe upfor near you. up you. victim victim out out in in the the water.and water.and 6. 6. Using your left hand chin Using your left hand chin perform first first aid aid ifand needed. ifpush needed. upperform the victim and his/ up the victim push his/ her lower back byby your leftleft her lower back your elbow. elbow.This Thisis iscalled calledlevelleveling upup soso the head and the ing the head and the upper upperbody bodyof ofthe thevictim victim will float onon the water. will float the water. 7. 7.LetLet gogo the right hand ofof the the right hand the victim and your right hand victim and your right hand will willdodothe thecross crosschest chest carry. carry. 8. 8.While Whileyou’re you’reat atthe thecross cross chest carry remove your leftleft chest carry remove your hand handat athis/her his/herchin chinand and use it it toto swim using aa side use swim using side stroke going to the nearest stroke going to the nearest exit point. exit point. 9. 9.LetLet him/her hold the gutter him/her hold the gutter forfora awhile whileand andassist assistthe the victim out in in the water.and victim out the water.and perform first aidaid if needed. perform first if needed.

Water WaterRescues—APPROACHES Rescues—APPROACHES(FRONT) (FRONT)

Water Rescues— APPROACHES (FRONT)

Water WaterRescues—APPROACHES Rescues—APPROACHES(FRONT) (FRONT)

UNIT 3 APPROACHES— PRINCIPLES OF EMT C PRINCIPLES CLINICAL PRINCIPLESOF OFEMT EMTPRINCIPLES CLINICALPRACTICE PRACTICE PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE

WaterRescues—APPROACHES Rescues—APPROACHES(FRONT) (FRONT) Water

DAY 22

Water Rescues—APPR Water (FRONT) WaterRescues—APPROACHES Rescues—APPROACHES (FRONT) APPROACHES—These are the technique that perform by the good swimmer and by those who trained for basic water safety and rescue for the active victim without the use of rescue equipments. Front Approach– This technique is use when the victim is facing to you.

UNIT 1. Using a rescue jump get in UNIT33 to the water. PRACTICE PRINCIPLESOF OFEMT EMTCLINICAL CLINICAL PRACTICE DAY DAY22 22 PRINCIPLES 2. Swim to the victim using front crawl or breast stroke head-up. Front crawl and breast stroke head-up are important when approaching the victim to keep an ² Limmer (Brady) ² Limmer (Brady) eyesight so that you will ³ Pollack, (AAOS) ³ Pollack, (AAOS) know where the victim is. ⁴ ⁴NHTSA NHTSA 3. Quick stop about one meter to the victim. 4. Using your right hand grab the right hand of the victim. 5. Twist and turn the victim up near you. 6. Using your left hand chin up the victim and push his/ her lower back by your left elbow. This is called leveling up so the head and the upper body of the victim will float on the water. 7. Let go the right hand of the victim and your right hand will do the cross chest carry. 8. While you’re at the cross ² Limmer ² Limmer (Brady) (Brady) carry remove your left chest ³ Pollack, ³ Pollack, (AAOS) (AAOS) ⁴ NHTSA ⁴ NHTSAhand at his/her chin and use it to swim using a side stroke going to the nearest exit point. 9. Let him/her hold the gutter for a while and assist the victim out in the water.and perform first aid if needed.

Water WaterRescues—APPROACHES Rescues—APPROACHES(FRONT) (FRONT)

APPROACHES—These APPROACHES—Theseare arethe the technique ² Limmer ² Limmer (Brady) (Brady)that technique thatperform performbybythe the ³ Pollack, ³ Pollack, (AAOS) (AAOS) good good swimmerand andbybythose those ⁴ NHTSA ⁴ NHTSAswimmer who whotrained trainedforforbasic basicwater water safety safetyand andrescue rescueforforthe theactive active victim victimwithout withoutthe theuse useofofresrescue equipments. cue equipments. Front Front Approach– Approach–This Thistechtechnique niqueis isuse usewhen whenthe thevictim victimis is facing toto you. facing you. 1.1.Using Usinga arescue rescuejump jumpget getinin

toto the water. the water. PRACTICE PRINCIPLES OF EMT 2.CLINICAL Swim to the victim using 2. Swim to the victim using front frontcrawl crawlororbreast breaststroke stroke head-up. head-up.Front Frontcrawl crawland and breast stroke head-up breast stroke head-upare are important when approachimportant when approaching the victim to keep an ing the victim to keep an ² Limmer (Brady) ² Limmer (Brady) eyesight sosothat eyesight thatyou youwill will ³ Pollack, (AAOS) ³ Pollack, (AAOS) ⁴ NHTSA ⁴ NHTSA know where the victim is.is. know where the victim 3.3.Quick Quickstop stopabout aboutone onememeterter toto the victim. the victim. 4.4.Using Usingyour yourright righthand handgrab grab the theright righthand handofofthe thevicvictim. tim. 5.5.Twist Twistand andturn turnthe thevictim victim upup near you. near you. 6.6.Using Usingyour yourleft lefthand handchin chin upupthe thevictim victimand andpush pushhis/ his/ her herlower lowerback backbybyyour yourleft left elbow. elbow.This Thisis iscalled calledlevelleveling ingupupsosothe thehead headand andthe the upper upperbody bodyofofthe thevictim victim will float on the water. will float on the water. 7.7.Let gogo the right hand ofof the Let the right hand the victim victimand andyour yourright righthand hand will do the cross chest will do the cross chest carry. carry. 8.8.While Whileyou’re you’reatatthe thecross cross ² Limmer (Brady) ² Limmer (Brady) chest carry remove your left chest ³ Pollack, (AAOS) carry remove your left ³ Pollack, (AAOS) ⁴ NHTSA ⁴ NHTSA hand handatathis/her his/herchin chinand and use useit ittotoswim swimusing usinga aside side stroke strokegoing goingtotothe thenearest nearest exit point. exit point. 9.9.Let Lethim/her him/herhold holdthe thegutter gutter forfora awhile whileand andassist assistthe the victim victimout outininthe thewater.and water.and perform first aid if if needed. perform first aid needed.

Water Rescues—APPROACHES (FRONT)

² Limmer (Brady) ² Limmer (Brady) ³ Pollack, (AAOS) ³ Pollack, (AAOS) ⁴ NHTSA ⁴ NHTSA

LIFELINE

² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

PREHOSPITAL EMERGENCY CARE

573

Using your left hand chin p the victim and push his/ her lower back by your left lbow. This is called levelUNIT 3 UNIT ng up so the head and the 3 pper body of theDAY victim 22 DAY 22 will float on the water. et go the right hand of the ictim and your right hand will do the cross chest arry. While you’re at theare cross APPROACHES—These are the PROACHES—These the hest carry remove your technique that perform by the hnique that perform byleft the hand at his/her chin and good swimmer and by those od swimmer and by those se it to swim using a side who trained for basic water ho trained for basic water troke going to the nearest safety and rescue for the active ety and rescue for the active xit point. victim without the use of restim without the use of reshim/her hold the gutter cue equipments. eetequipments. or a while and assist the This This techictim Approach– out in the water.and Front Approach– ont This techerform first aid ifthe needed. nique is use when the victim is que is use when victim is technique is used when the victim is facing to you. ing to you.

Front Approach– This technique is use when the victim is facing to you.

UNIT 3

UNIT 3 1. Using a rescue jump get in OF EMT CLINICAL PRACTICE to the water. PRACTICE DAY 22 PRINCIPLES OF EMT CLINICAL PRINCIPLES OF EMT PRINCIPLES CLINICAL PRACTICE 2. Swim to the victim using Day 22

front crawl or breast stroke

head-up. Front crawl and ENVIRONMENTAL EMERGENCIES breast stroke head-up are

Water (FRONT) importantRescues—APPROACHES when approachWater Rescues—APPROACHES (FRONT) Water Rescues—APPROACHES (FRONT) ing the victim to keep an

Water Rescues— APPROACHES (FRONT) Front Approach–

APPROACHES—These APPROACHES—These are are the the technique technique that that perform perform by by the the good swimmer and by those good swimmer and by those who trained for basic water who trained for basic water safety safety and and rescue rescue for for the the active active victim victim without without the the use use of of resrescue equipments. cue equipments. Front Front Approach– Approach– This This techtechnique nique isis use use when when the the victim victim isis facing facing to to you. you.

3. 4. 5. 6.

eyesight so that you will know where the victim is. Quick stop about one meter to the victim. Using your right hand grab the right hand of the victim. Twist and turn the victim up near you. Using your left hand chin up the victim and push his/ her lower back by your left elbow. This is called leveling up so the head and the upper body of the victim will float on the water. Let go the right hand of the victim and your right hand will do the cross chest carry. While you’re at the cross chest carry remove your left hand at his/her chin and use it to swim using a side stroke going to the nearest exit point. Let him/her hold the gutter for a while and assist the victim out in the water.and perform first aid if needed.

facing you. UNIT33 UNIT 1. 1. Using Using aa rescue rescue jump jump get get in in PRINCIPLES OF OF EMT EMT CLINICAL CLINICAL PRACTICE PRACTICE 1. Using a rescue jump get in 1. get Using a rescue jump, get into the Using a rescue jump in to the water. DAY 22 PRINCIPLES DAY 22 to the water. to the water. to the water. 2. Swim to the victim using water. 2. Swim to the victim using 2. Swim to the victim using Swim to the victim using front front crawl crawl or or breast breast stroke stroke 2. stroke Swim to the victim using front front crawl or breast stroke front crawl or breast head-up. head-up. Front Front crawl crawl and and head-up. Front crawl and head-up. Front crawlcrawl or breast stroke head-up. and 7. breast stroke head-up breast stroke head-up are are breast stroke head-up are breast stroke head-up are Water Rescues—APPROACHES Rescues—APPROACHES (FRONT) (FRONT) Water important when approachimportant when approachFront crawl and breast stroke important when approachimportant when approaching to keep an ing the the victim victim are to keep an APPROACHES—These are the APPROACHES—These the ing the victim to keep an ing the victim to keep an head-up are important when eyesight so you eyesight so that thatby you will technique thatperform perform by thewill technique that the Limmer (Brady) eyesight so that you will eyesight so that you will 8. know the victim is. ³ Pollack, (AAOS) approaching the victim so that know where where the victim is. good swimmer and by those know where the victim is. good swimmer and by those ⁴ NHTSA know where the victim is. 3. Quick stop about one meQuick for stop aboutwater one me3. Quick stop about one mewho 3. trained for basic water who trained basic Quick stop about oneyou will see where the victim is. meter ter to to the the victim. victim. ter to the victim. safety4.and and rescue forthe theactive active ter to the victim. 3. Quick stop about one meter to safety rescue for 4. Using Using your your right right hand hand grab grab 4. Using your right hand grab Using your right hand grab victim without without the useof resvictim the use ofofthe resthe right hand the right hand of the vicvicthe victim. the right hand of the victhe right hand of the viccue equipments. cue equipments. tim. tim. tim. tim. 9. 4. Using your right hand, grab the 5. 5. Twist Twist and and turn turn the the victim victim 5. Twist and turn the victim Twist and turn the victim Front Approach– Approach– This techtechFront This up near you. up near you. right hand of the victim. up near you. up near you. Using your left hand chin nique6. usewhen when the victim nique isisuse 6. Using yourthe leftvictim handisis chin 6. Using your left hand chin Using your leftUNIT hand chin 5. Twist and turn the victim up 3 the facingto toup you. facing you. up the victim victim and and push push his/ his/ up the victim and push his/ up the victim andUNIT push his/ her by your 3 PRINCIPLES near you. EMT CLINICAL UNIT 3 her lower lower back backPRACTICE by your left left UNIT 3 her lower backOF by your left her lower back by your left DAY 22 elbow. This is called levelEMT1.1.CLINICAL Usingelbow. rescue jump getinin Using aarescue get Thisjump isPRACTICE called level- PRINCIPLES PRINCIPLES OF OF EMT EMT CLINICAL CLINICAL PRACTICE PRACTICE 6. Using your left hand, chin up the elbow. This is OF called levelelbow. This is called levelDAY 22 PRINCIPLES DAY 22 DAY 22 ing up so the head and the ing up so the head and the tothe the water. to water. ing up so the head and the ing up so the head and the victim and push his/her lower upper body of the victim UNIT UNIT3 3 body of the victim Swimupper to the the victim using 2.2. Swim to victim using upper body of the victim upper body of the victim will float on the will float on the water. water. back by your left elbow. This is front crawl or breast stroke DAY DAY 22 22 front crawl or breast stroke will float on the water. will float on the water. 7. the hand of 7. Let Let go go the right right hand of the the head-up. Front crawl and head-up. Front crawl and 7. Let go the right hand of the Water Rescues—APPROACHES (FRONT) Let go the right hand of the called leveling up so the head and victim and your right hand victim andhead-up your right hand Water Rescues—APPROACHES (FRONT) breast stroke head-up are victim and your right hand breast stroke are Water Rescues—APPROACHES Rescues—APPROACHES (FRONT) (FRONT) victim and your right hand Water will the cross CHES—These are the the upper body of the victim will will do do theapproachcross chest chest will do the cross chest important when approachimportant when will do the cross chest carry. ACHES—These are the APPROACHES—These are the carry. ecarry. that perform by the APPROACHES—These are the carry. float on the water. ing the victim victim to at keep an ing the to keep an 8. you’re the cross que thatand perform by the 8. While While you’re atby the cross technique that perform by the wimmer by technique that perform the Rear RearApproach Approach– –This Thistechtech8. While you’re at the cross While you’re at those the Let go of the right hand, of the cross eyesight so that you will eyesight so that you will chest carry remove your left 7. swimmer and by those chest carry remove your left nique niqueuse usewhen whenthe thevictim victimis is good swimmer andvictim by those those good swimmer and by ned water chest carry remove your left chest for carrybasic remove your left know where the is. know where the victim is. hand at his/her chin and too too aggressive aggressive that that you you can’t can’t rained for basic water hand at his/her chin and who trained for basic water who trained for basic water hand at his/her chin and dhand rescue the active at for his/her chinvictim and your right hand will and 3. Quick stop about one me3. Quick stop about one meuse itit to swim using aa side perform performthe thefront frontapproach. approach. use to swim using side and for safety and rescue for the active use it to swim using a side safety and rescue for the active thout theswim usethe of active resuse rescue it to using ado the cross chest carry. side terto tostroke thevictim. victim. ter the going to nearest And And this this is also is also forfor the the safety safety of of stroke going to the the nearest without the to usethe ofnearest resvictim without the use use ofgrab resstroke going to the nearest victim without the of resstroke going pments. the the rescuer. rescuer. 4. Using your right hand exit point. 4. Using your right hand grab exit point. 8. While you’re at the cross chest uipments. exit point. cuethe equipments. exit point. cue equipments. Let hold the gutter right hand of of the the victhe9. hand 9. right Let him/her him/her hold thevicgutter 9. Let him/her hold the gutter 1. 1. Using Usinga arescue rescuejump jumpget getin in Let him/her This hold the gutter carry, remove your left hand at Approach– techtim. for tim. for aa while while and and assist assist the the for a while and assist the toto the the water. water. Approach– This techfor a while assist the Front Approach– This techFront Approach– This techvictim out in the water.and use when theand victim is his/her chin and use it to swim 5. Twist and turn the victim 5. Twist and turn the victim victim out in water.and 2. 2. Swim Swim using using front front crawl crawl oror victim out in the water.and svictim use when the victim is nique is useyou. when the nique use when the isis perform first aid ifvictim you. out in the water.and perform first aidvictim if needed. needed. upis near up near you. breast breast stroke stroke head-up head-up going going perform first aid if needed. using a side stroke going to the perform to you. first aid if needed. facing to you. facing to you. totothe theback backof ofthe thevictim. victim. Using your your left left hand hand chin chin 6.6. Using nearest exit point. come comeclose closeto tothe thevictim’s victim’s a rescue jump get in upthe thevictim victimand andpush pushhis/ his/ up ng a rescue jump get in back. back. 1. Using a rescue jump get in 1. Using a rescue jump get in UNIT 33 UNIT water. herlower lowerback backby byyour yourleft left 9. Let him/her hold the gutter for a her he water. 3. 3. Using Using your your right right hand hand chinchintothe thewater. water. to to the victim using elbow. This isis called called levellevelThis DAY 2222 upupthe thevictim victimpush push his/her his/her DAY while and assist the victim out in 2.2. elbow. m to the victim using Swim to the victim using Swim to the victim using crawl ingup upso sothe thehead headand andthe the ing lower lower back back using using your your right right nt crawlororbreast breaststroke stroke frontcrawl crawl orof breast stroke the water and provide first aid if front or elbow elbow toto dodo leveling leveling upup upper body the stroke victim up. upper body ofbreast the victim d-up.Front Frontcrawl crawland and head-up. Front crawl and head-up. Front crawl and 4. 4. Use Useyour yourleftlefthand handtotoperperwillfloat floaton on thewater. water. needed. will the t stroke ast strokehead-up head-upare are form form the the cross cross chest chest carry. carry. breast stroke head-up are

tant when ortant whenapproachapproachhe thevictim victimtotokeep keepanan ght sightsosothat thatyou youwill will where the victim w where the victimis.is. ckstop stopabout aboutone onememethe victim. to the victim. your right ng your righthand handgrab grab ght righthand handofofthe thevicvic-

stand andturn turnthe thevictim victim ar you. near you. ngyour yourleft lefthand handchin chin e victim and the victim andpush pushhis/ his/ wer back lower backbybyyour yourleft left ow.This Thisis iscalled calledlevellevelw. the headand andthe the pup soso the head perbody bodyofofthe thevictim victim float the water. oat onon the water. the right handofofthe the ogo the right hand m andyour yourright righthand hand and the cross cross chest chest dodo the y. ileyou’re you’reatatthe thecross cross st carry remove yourleft left carry remove your dat athis/her his/her chinand and 574 LIFELINE chin it swimusing usinga aside side totoswim ke goingtotothe thenearest nearest going point. oint. him/her holdthe thegutter gutter m/her hold awhile whileand andassist assistthe the m out thewater.and water.and out ininthe

² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

PREHOSPITAL EMERGENCY CARE

breast stroke head-up are Letgo gothe theright right handofofthe the 7.7. Let hand important when approachimportant approachvictim andwhen yourright right hand victim and your hand ing the the victim to keep keep an ing to an will dovictim the cross cross chest will do the chest ² eyesight Limmer (Brady) so eyesight so that that you you will will carry. ³ carry. Pollack, (AAOS) ⁴ know NHTSA knowwhere where the victim is. is. While you’rethe the cross cross 8.8. While you’re atatvictim the Quickcarry stop remove about one one me3.3. chest Quick stop about chest yourmeleft carry remove your left terto tothe the victim. ter hand his/her chin chin and and hand atat victim. his/her Using your right hand grab 4.4. use Using your right hand grab useititto toswim swimusing usingaaside side the right right hand of the the victhe hand of vicstroke going tothe the nearest stroke going to nearest tim. tim. exitpoint. point. exit 5. Twist Twist and turn turn the victim 5.9. and victim Let him/her holdthe thegutter gutter 9. Let him/her hold the upnear near you. and assist the up you. for while for aa while and assist the Using your yourinleft left hand chin 6.6. victim Using chin victim out thehand water.and out in the water.and upthe thevictim victim and pushhis/ his/ up and push perform firstaid aid needed. perform first ififneeded. herlower lowerback backby byyour yourleft left her elbow. This This isis called called levellevelelbow. ingup upso sothe thehead headand andthe the ing upper body body ofof the the victim victim upper willfloat floaton onthe thewater. water. will Letgo gothe theright righthand handof ofthe the 7.7. Let victimand andyour yourright righthand hand victim will do do the the cross cross chest chest will carry. carry. While you’re you’re atat the the cross cross 8.8. While chestcarry carryremove removeyour yourleft left chest hand atat his/her his/her chin chin and and hand useititto toswim swimusing usingaaside side use strokegoing goingto tothe thenearest nearest stroke exitpoint. point. exit Lethim/her him/herhold holdthe thegutter gutter 9.9. Let for aa while while and and assist assist the the for victimout outininthe thewater.and water.and victim

² Limmer (Brady) ² Limmer (Brady)

³³Pollack, Pollack,(AAOS) (AAOS) ⁴⁴ NHTSA NHTSA

² Limmer(Brady) (Brady) ² Limmer ³ Pollack,(AAOS) (AAOS) ³ Pollack, NHTSA ⁴ ⁴NHTSA

5. 5. Remove Removeyour yourright righthand handtoto Rear Approach – –This Rear Approach Thistechtechthe the victim’s victim’s chin. chin. nique use when the victim is is nique use when the victim 6. 6. Use Useit ittotoswim swimside sidestroke stroke tootoo aggressive that you can’t aggressive you can’t and and carry carrythe thethat victim victim to tothe the perform the front approach. perform the front approach. nearest nearest exit exit point. point. And this isthe also for theout safety ofthe this isthe also for the safety of 7.And 7. Assist Assist victim victim out in inthe thethe rescuer. rescuer. water water and and perform perform first first aidaid if if needed. needed. 1. Using a rescue jump getget in in 1. Using a rescue jump to to thethe water. water. 2. Swim using front crawl or or 2. Swim using front crawl breast stroke head-up going breast stroke head-up going to to thethe back of of thethe victim. back victim. come close to to thethe victim’s come close victim’s back. back. 3. Using your right hand chin3. Using your right hand chinupup thethe victim push his/her victim push his/her lower back using your right lower back using your right elbow to to dodo leveling upup elbow leveling 4. Use your leftleft hand to to per4. Use your hand perform thethe cross chest carry. form cross chest carry. 5. Remove your right hand to to 5. Remove your right hand thethe victim’s chin. victim’s chin. 6. Use it to swim side stroke 6. Use it to swim side stroke and carry thethe victim to to thethe and carry victim nearest exitexit point. nearest point. 7. Assist thethe victim outout in in thethe 7. Assist victim water and perform firstfirst aidaid if if water and perform needed. needed.

too too aggressive thatthat youyou can’t aggressive can’t perform the the front approach. perform front approach. AndAnd thisthis is also for the safety of of is also for the safety the the rescuer. rescuer.

UNIT 3 DAY 22

UNIT UNIT 3 3

1. Using a rescue jump get in 1. Using a rescue jump get get in in 1. Using a rescue jump to the water. to the water. to the water. 2. Swim using front crawl or 2. Swim using front crawl or or 2. Swim using front crawl breast stroke head-up going breast stroke head-up going breast stroke head-up going to the back of the victim. to the back of the victim. to the back of the victim. come close to the victim’s come close to the victim’s come close to the victim’s back. back. back. UNIT UNIT33 3. Using your right hand chin3. Using youryour right hand chin3. Using right hand chinup the victim push his/her up up the the victim push his/her victim push his/her DAY DAY22 22 lower back using your right lower back using youryour right lower back using right elbow to do leveling up elbow to do up up elbow to leveling do leveling 4. Use your left hand to per4. Use youryour left left hand to per4. Use hand to perform the cross chest carry. form the the cross chest carry. form cross chest carry. 5. Remove your right hand to 5. Remove youryour right hand to to 5. Remove right hand the victim’s chin. Rear Approach Approach Thistechtechthe Rear victim’s chin. the victim’s chin. – –This 6. Use it to swim side stroke useswim when when the thevictim victimis is 6. Use itnique toit use swim sideside stroke 6. nique Use to stroke and carry the victim to the tooaggressive aggressive that that youthe can’t can’t andtoo carry the the victim to you the and carry victim to nearest exit point. perform perform the the front frontapproach. approach. nearest exitexit point. nearest point. 7. Assist the victim out in the And And this this is is also also for for the the safety safety of of 7. Assist the the victim out out in the 7. Assist victim in the water and perform first aid if the the rescuer. rescuer. water and perform firstfirst aid aid if if water and perform needed. needed. needed. 1.1. Using Usinga arescue rescuejump jumpget getinin toto the the water. water. 2.2. Swim Swimusing usingfront frontcrawl crawloror breast breaststroke strokehead-up head-upgoing going totothe theback backofofthe thevictim. victim. come comeclose closetotothe thevictim’s victim’s UNIT33 UNIT back. back. DAY 22 3.3. Using Usingyour yourright righthand hand chinchinDAY 22 upupthe thevictim victimpush pushhis/her his/her lower lowerback backusing usingyour yourright right elbow elbow toto dodo leveling leveling upup 4.4. Use Useyour yourleft lefthand handtotoperperform form the the cross cross chest chest carry. carry. Rear Approach – This tech5.5. Remove Remove your your–right right hand toto Rear Approach Thishand technique use when thevictim victimis is the the victim’s victim’s chin. chin. nique use when the too aggressive that you can’t 6. 6. Use Use it it to to swim swim side side stroke stroke too aggressive that you can’t perform thefront front approach. and andcarry carry the the victim victim totothe the perform the approach. And this isexit also for the safety nearest nearest exit point. point. And this is also for the safety of of the rescuer. 7. 7. Assist Assist the the victim victim out out in in the the the rescuer. water waterand andperform performfirst firstaid aidif if Using rescuejump jumpget getin in needed. needed. 1. 1. Using a arescue to the water. to the water. Swimusing usingfront frontcrawl crawloror 2. 2. Swim breast stroke head-up going breast stroke head-up going theback backof ofthe thevictim. victim. totothe comeclose closetotothe thevictim’s victim’s come back. back. 3. Using your right hand chin3. Using your right hand chinthevictim victimpush pushhis/her his/her upupthe lower back using your right lower back using your right elbow leveling elbow toto dodo leveling upup 4. Use your left hand to per4. Use your left hand to perform the cross chest carry. form the cross chest carry. (Brady)(Brady) ² Limmer Removeyour yourright righthand handtoto³² Limmer 5. 5. Remove Pollack, (AAOS)(AAOS) ³ Pollack, ⁴ NHTSA ⁴ NHTSA the victim’s chin. the victim’s chin. Useit ittotoswim swimside sidestroke stroke 6. 6. Use andcarry carrythe thevictim victimtotothe the and nearest exit point. nearest exit point. 7. Assist the victim out in the 7. Assist the victim out in the water and perform first water and perform first aidaid if if needed. needed.

PRINCIPLES OF EMT CLINICAL PRACTICE OF EMT CLINICAL PRACTICE DAY PRINCIPLES OF EMT CLINICAL PRACTICE DAY 2222PRINCIPLES PRINCIPLES PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE Water Rescues—APPROACHES (REAR) Water Rescues—APPROACHES (REAR) Water Rescues—APPROACHES (REAR) Water WaterRescues—APPROACHES Rescues—APPROACHES(REAR) (REAR)

Approach – This techRearRear Approach – This technique when victim nique useuse when the the victim is is too aggressive that you can’t too aggressive that you can’t perform front approach. perform the the front approach. is also for the safety AndAnd thisthis is also for the safety of of rescuer. the the rescuer.

Water Rescues— APPROACHES (REAR)

Rear Approach – This technique use when the victim is too aggressive that you can’t perform the front approach. And this is also for the safety of the rescuer.

perform the front approach. And this is also for the safety of the rescuer.

1. Using a rescue jump 1. Using a rescue jump get get in in 1. Using a rescue jump get in to the water. to the water. to the water. 2. Swim using front crawl 2. Swim using front crawl or or 2. Swim using front crawl or breast stroke head-up going breast stroke head-up going breast stroke head-up going to the back of the victim. to the back of the victim. to the back of the victim. come close to the victim’s come close to the victim’s come close to the victim’s back. back. UNIT 33 back. UNIT 3. Using right hand chin3. Using youryour right hand chin3. Using your right hand chinDAY up victim push his/her DAY 22the up 22 the victim push his/her up the victim push his/her lower back using right lower back using youryour right lower back using your right elbow to leveling do leveling elbow to do up up elbow to do leveling up 4. Use hand to per4. Use youryour left left hand to per4. Use your left hand to perform cross chest carry. form the the cross chest carry. form the cross chest carry. 5. Remove right hand 5. Remove youryour right hand to to 5. Remove yourRear rightApproach hand to – –This Rear Approach Thistechtechvictim’s chin. the the victim’s chin. nique the victim’s chin. niqueuse usewhen whenthe thevictim victimis is 6. Use it to swim side stroke 6. Use it to swim side stroke too 6. Use it to swim side strokethat tooaggressive aggressive thatyou youcan’t can’t carry victim to the andand carry the the victim to the perform front and carry the victim the tothe the perform frontapproach. approach. nearest point. nearest exitexit point. And nearest exit point. Andthis thisis isalso alsofor forthe thesafety safetyofof 7. Assist the the victim out out in the 7. Assist victim in the the 7. Assist the victim out in the therescuer. rescuer. water andand perform firstfirst aid aid if if water perform water and perform first aid if needed. needed. 1.1. Using needed. Usinga arescue rescuejump jumpget getinin totothe thewater. water. 2.2. Swim Swimusing usingfront frontcrawl crawloror breast breaststroke strokehead-up head-upgoing going totothe theback backofofthe thevictim. victim. come close to the victim’s come close to the victim’s UNIT33 back. UNIT back. 3.3. Using chinUsingyour yourright righthand hand chinDAY 22 DAY 22 upupthe victim push his/her the victim push his/her lower back using your right lower back using your right elbow elbowtotododoleveling levelingupup 4.4. Use Useyour yourleft lefthand handtotoperperform the cross form the crosschest chestcarry. carry. 5.Rear Remove your right hand toto 5. Remove your right hand Approach– –This ThistechtechRear Approach the victim’s chin. the victim’s chin. nique usewhen when thevictim victimis is nique use the 6.too Use it to swim side stroke Use it to swim side stroke aggressive thatyou youcan’t can’t too6. aggressive that and victim totothe andcarry carry the victim the perform thethe front approach. perform the front approach. nearest exit point. nearest exit point. And this is also the safety And this isthe also forfor the safety ofof 7.the Assist victim out ininthe 7. Assist the victim out the rescuer. thewater rescuer. waterand andperform performfirst firstaid aidif if needed. needed. Using rescuejump jumpget getinin 1.1. Using a arescue the water. toto the water. Swimusing usingfront frontcrawl crawloror 2.2. Swim breaststroke strokehead-up head-upgoing going breast theback backofofthe thevictim. victim. totothe comeclose closetotothe thevictim’s victim’s come back. back. Usingyour yourright righthand handchinchin3.3. Using thevictim victimpush pushhis/her his/her upupthe lowerback backusing usingyour yourright right lower elbow leveling elbow toto dodo leveling upup Useyour yourleft lefthand handtotoperper4.4. Use form the cross chest carry. form the cross chest carry. Removeyour yourright righthand hand(Brady) 5.5. Remove toto ² Limmer (AAOS) the victim’s chin. ⁴³ Pollack, the victim’s chin. NHTSA Useit ittotoswim swimside sidestroke stroke 6.6. Use andcarry carrythe thevictim victimtotothe the and nearest exit point. nearest exit point. 7. Assist the victim out in the 7. Assist the victim out in the waterand andperform performfirst firstaid aidif if water needed. needed.

Rear Approach – This technique is used when the victim is too aggressive that you can’t perform the front approach. And this is also for the safety of the rescuer. PRINCIPLES PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE PRINCIPLES 1. Using a rescue jump get into the water. 2. Swim using front crawl or breast stroke head-up going to the back of the victim. Water Rescues—APPROACHES (REAR) WaterRescues—APPROACHES Rescues—APPROACHES(REAR) (REAR) Get close to the victim’s back. Water Rescues—APPROACHES (REAR) Water 3. Using your right hand, chin-up the victim. Push his/her lower back using your right elbow to do leveling up. 4. Use your left hand to perform the cross chest carry. 5. Remove your right hand from the victim’s chin. 6. Use it to swim side stroke and carry the 3 PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE victim to the nearest exit point. PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE 2PRINCIPLES PRINCIPLES 7. Assist the victim out in the water and perform first aid if needed. Water WaterRescues—APPROACHES Rescues—APPROACHES(REAR) (REAR) Water WaterRescues—APPROACHES Rescues—APPROACHES(REAR) (REAR)

² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

3 PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE 2PRINCIPLES

Water WaterRescues—APPROACHES Rescues—APPROACHES(REAR) (REAR)

² Limmer (Brady) ² Limmer (Brady) ³ Pollack, (AAOS) ³ Pollack, (AAOS) ⁴ NHTSA ⁴ NHTSA

² Limmer (Brady)(Brady) ² Limmer ³ Pollack, (AAOS)(AAOS) ³ Pollack, ⁴ NHTSA ⁴ NHTSA

² Limmer ² Limmer (Brady) (Brady) ³ Pollack, ³ Pollack, (AAOS) (AAOS) ⁴ NHTSA ⁴ NHTSA

² Limmer (Brady) ² Limmer (Brady) ³ Pollack, (AAOS) ³ Pollack, (AAOS) ⁴ NHTSA ⁴ NHTSA

LIFELINE

PREHOSPITAL EMERGENCY CARE

575

lowing lowing you you even even you you atat the the back. back. 1.1. Rescue Rescuejump jump 2.2. Swim Swimfrontl frontlcrawl crawlororbreast breast 1.1. Rescue Rescuejump jump stroke strokehead-up. head-up. 2.2. Swim Swimfrontl frontlcrawl crawlororbreast breast 3.3. For Forabout aboutone onemeter meteraway away stroke strokehead-up. head-up. Under Water Approach from from the the victim victim submerge submerge 3.3. For Forabout aboutone onemeter meter away away 3 UNIT Under Water UNIT 3 technique use Approach if the vic ininthe thewater waterusing usingfeet feetfirst, first, from from the the victim victim submerge submerge technique use if and the in vi tuck tuckdive diveororpike pikedive. dive. DAY 22 really aggressive ininthe thewater waterusing usingfeet feet first, first, DAY 22 really aggressive and in 4.4. While While you’re you’re under under the the Day 22 tuck tuckdive diveororpike pikedive. dive. direction you go his/he UNIT UNIT water watergrab grabthe thevictims victims both both33 direction youeven go his/he 4.4. While While you’re you’re under under the the lowing you you a knee kneeusing usingright righthand hand and and water watergrab grabthe thevictims victimsboth both DAY lowing you even you DAY22 22 back. turn turntowards towardsyou. you. knee kneeusing usingright righthand handand and Water WATER) back. Water Rescues—APPROACHES Rescues—APPROACHES (UNDER (UNDER WATER) 5.5. While While your your left left hand hand hold hold turn turntowards towardsyou. you. Under Water Approach– This 1. Rescue jump and and support support the the victim’s victim’s Under Water This 5.5. While While your yourApproach– left left hand hand hold hold technique use the victim is 1. Swim Rescue jumpcrawl or waist. waist. technique use if if the the is 2. frontl and and support support the victim victim’s victim’s Water (UNDER WATER) WaterRescues—APPROACHES Rescues—APPROACHES (UNDER WATER) really aggressive and 2. stroke Swim head-up. frontl crawl or 6.6. Remove Removeyour yourright righthand handtoto really aggressive and in in every every waist. waist. direction you go his/her folUnder This the theWater victim’s victim’s knee kneeand andput put itit direction you goright his/her Under WaterApproach– Approach– This stroke head-up. 6.6. Remove Remove your your right hand handfoltoto 3. For about one meter lowing you you at the technique use ifpull victim is is totothe thechin chin it itup up do dothe the lowing you even even the technique usepull ifthe the victim the thevictim’s victim’s knee kneeyou and andat put put itit 3. from For about one meter the victim subm back. really aggressive and ininvictim every leveling leveling totomake make the the victim back. really aggressive and every totothe thechin chinpull pullititup updo dothe the from the victim This in the water usingsub fee direction his/her float. float. you direction yougo go his/her folfolleveling levelingtotomake makethe thevictim victim in the water using fe 1. Rescue jump lowing you even the 7.7. Do Do the the cross chest chest carry carry 1. float. Rescue jump tuck dive or pike dive. lowing youcross evenyou youatat the float. technique is used if the 2. Swim frontl crawl or breast tuck dive or pike dive back. with withyour yourleft lefthand. hand. 2. Do Swim frontl crawl or breast back. 7.7. Do the the cross cross chest chest carry carry 4. While you’re unde stroke head-up. victim is really aggressive 4. water While grab you’re unde 8.8. Swim Swimside sidestroke strokeand andcarry carry stroke head-up. with with your your left lefthand. hand. the victim 3. For one meter away 1.1.Rescue jump the the victim victim toto the the nearest nearest 3. Swim For about about one meter away Rescue jump waterusing grab right the victim 8.8. Swim side sidestroke stroke and andcarry carry and is following you in knee han from the victim submerge 2.2.Swim frontl from the victim submerge exit exit point. point. Swim frontlcrawl crawlororbreast breast the the victim victim toto the the nearest nearest kneetowards using right in the water using feet first, turn you. han every direction that you go. stroke in the water using feet first, strokehead-up. head-up. exit exit point. point. UNIT 33 UNIT turn towards you. tuck 5. While your left hand 3.3.Rescue jump. For tuck dive dive or or pike pike dive. dive. Forabout aboutone onemeter meteraway away 1. UNIT 3 UNIT 4. the 5. and Whilesupport your leftthe hand DAY from 4. While While you’re you’re under under the 3 DAY 22 22 v fromthe thevictim victimsubmerge submerge water grab the victims both 2. Swim front crawl or DAY 22 and support the v ininthe water using feet first, water grab the victims both the water using feet first, DAY 22 waist. knee using right hand and tuck dive or pike dive. knee using right hand and waist. your right ha tuck dive or pike dive. breast stroke head-up. 6. Remove turn 4. While turn towards towards you. you. While you’re you’re under under the the 6. the Remove your right h victim’s knee and 5. left hold 3. 4.For about one meter water Under Water Approach– This 5. While While your your left hand hand WATER) hold Water Rescues—APPROACHES (UNDER watergrab grabthe thevictims victimsboth both Water Rescues—APPROACHES (UNDER WATER) the victim’s knee andd and support to the chin pull it up knee using right hand and and support the the victim’s victim’s Water Rescues—APPROACHES (UNDER WATER) knee using right hand and technique use if the victim is away from the victim, Water Rescues—APPROACHES (UNDER Under Water Approach– This to theWATER) chin pull itthe up waist. Under Water Approach– This turn you. leveling to make waist. turntowards towards really aggressive and in every Under Water Water Approach– Approach– This use ififyou. the victim isis 6. to technique useleft the victim submerge into the leveling to make the Under This 5.technique While your hand hold 6. Remove Remove your your right right hand hand to 5. While your left hand hold float. technique use if the victim is really aggressive and in every direction you go his/her folthe put really and invictim’s every technique use knee if theand victim and support the float.the cross chest the victim’s victim’s knee and put isit it andaggressive support the victim’s water using feet first, 7. Do really aggressive and indo every direction you to the it the lowing you even you at the direction you go go his/her his/her folfolreally and in every waist. to aggressive the chin chin pull pull it up up do the waist. 7. with Do your the cross chest direction you go his/her following you even you at the left hand. leveling to make the victim lowing you even you at to the tuck dive or pike dive. back. direction you his/her fol6.6. Remove leveling to go make the victim Removeyour yourright righthand hand to with your hand. lowing you even you at the back. float. 8. Swim side left stroke and lowing the float.you even you at the thevictim’s victim’sknee kneeand andput putit it 4. back. While you’re under the back. the cross chest carry 8. the Swim side stroke 7. back. victim to theand n totothe chin pull it itup do the 7. Do Do the cross chest carry the chin pull up do the 1. Rescue jump 1. Rescue with the point. victim to the n 1.water, grab the victim’s Rescuejump jump leveling to with your your left left hand. hand. exit leveling tomake makethe thevictim victim 2. Swim frontl crawl or breast 1. Rescue Rescueside jump 2. Swim 8. Swim stroke and carry 2.float. Swim frontl frontl crawl crawl or or breast breast exit point. 1. jump 8. Swim side stroke and carry float. head-up. knees using right hand Swim frontl frontl to crawl or or breast breast stroke stroke head-up. the stroke head-up. 2.2. Swim 7.7.Do chest the victim victim crawl to the the nearest nearest Do the the cross cross chest carry carry strokehead-up. head-up. 3. For about one meter exit 3.and turn them towards. For your about one meter away away 3. For about one meter away stroke with left hand. exit point. point. with your left hand. For about about one one meter meter away away from the victim submerge fromside the stroke victim and submerge 3.3. For from the victim submerge 8.8.While your left hand Swim carry Swim side stroke and carry Under from the the victim victim submerge submerge in water using feet UnderWater WaterApproach– Approach–This This in the the water using feet first, first, from the victim toto the nearest in the water using feet first, the victim the nearest in thewater waterusing usingfeet feetfirst, first, tuck dive or pike dive. technique use if the victim is tuck dive or pike dive. hold and supports the in the exit technique use if the victim isdive or pike dive. exitpoint. point. tuck dive or pike dive. tuckdive 4. 4. While While you’re you’re under under the the tuck or pike dive. really aggressive and in every victim’s waist. really aggressive and in4.4.every While you’re you’re under under the the water 4. While you’re under the water grab grab the the victims victims both both While direction water grabthe thevictims victimsboth both knee water grab the victims both knee using using right right hand hand and and directionyou yougogohis/her his/her folfol- grab 5. Remove your right water knee using using right right hand hand and and turn lowing you even you at atthe turntowards towardsyou. you. knee using right hand and knee lowing you even you the Under Water Water Approach Approac hand from the victim’s Under turntowards towardsyou. you. 5. 5. While While your your left left hand hand hold hold turn back. turn towards you. back. technique use use ifif the the viv technique While your your left left hand hand hold hold and and support support the the victim’s victim’s knee and put it to the 5.5. While 5. While your left hand hold and support support the the victim’s victim’s waist. really aggressive aggressive and and ini really waist. and chin. Pull it up and do and support the victim’s waist. 6. 1. 1.Rescue jump 6. Remove Remove your your right right hand hand to to direction you you go go his/he his/h direction waist. Rescue jump ² Limmer ² Limmer (Brady) (Brady) Remove your your right right hand hand to to the waist. the victim’s victim’s knee knee and and put put itit the leveling to make ³ Pollack, ³ Pollack, (AAOS) (AAOS) 6.6. Remove lowing you you even even you you lowing 2. Swim frontl crawl or breast ⁴ ⁴NHTSA NHTSA 2. Swim frontl crawl or breast ² Limmer ² Limmer (Brady) (Brady) the victim’s knee and put it to to the the chin chin pull pull itit up up do do the the 6. Remove your right hand to the victim’s knee and put it ³ Pollack, ³ Pollack, (AAOS) (AAOS) back. back. the victim float. stroke head-up. tothe thechin chinpull pullititup updo dothe the leveling ⁴ ⁴NHTSA NHTSA leveling to to make make the the victim victim stroke head-up. to the victim’s knee and put it leveling to to make make the the victim victim float. 3. 3.For about one meter away float. 6. Do the cross chest leveling For about one meter away to the chin pull it up do the Rescuejump jump 1.1. Rescue float. 7. 7. Do Do the the cross cross chest chest carry carry float. from the victim submerge carry with your left leveling to make the victim from the victim submerge 7. Do Do the the cross cross chest chest carry carry with Swimfrontl frontlcrawl crawlor o 2.2. Swim withyour yourleft lefthand. hand. 7. in in the water using feet first, withyour yourleft lefthand. hand. float. 8. Swim 8.hand. Swim side side stroke stroke and and carry carry the water using feet first, strokehead-up. head-up. stroke with Swim side side stroke stroke and and carry carry the tuck dive oror pike dive. 7. Do the cross chest carry the victim victim to to the the nearest nearest Forabout aboutone onemete mete 3.3. For tuck dive pike dive.8.8. Swim 7. Swim side stroke and the victim victim to to the the nearest nearest exit exitpoint. point. with your left hand. the 4. 4.While you’re under the from the the victim victim sub su from While you’re under the exitpoint. point. carry the victim to the exit

PRINCIPLES OF EMT CLINICAL PRACTICE

ENVIRONMENTAL EMERGENCIES

PRINCIPLES PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE

Water Rescues—APPROACHES (UNDER WATER)

Under Water Approach–

UNIT 3 DAY 22

PRINCIPLES PRINCIPLES OF OF EMT EMT CLINICAL CLINICAL PRACTICE PRACTICE PRINCIPLES OF OF EMT EMT CLINICAL CLINICAL PRACTICE PRACTICE PRINCIPLES

Water Rescues—

UNIT UNIT33 PRINCIPLES OF EMT CLINICAL PRACTICE DAY DAY22 22 PRINCIPLES OF EMT CLINICAL PRACTIC

U Water WaterRescues—APPROACHES Rescues—APPROACHES(UNDER (UNDERWATER) WATER) D D

UNIT NIT 3 3 PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE AY 22PRINCIPLES Y 22 water grab the victims both

–This This ctim m is is every very rfol-folatthethe

breast east

away way merge erge et first, first,

water grab the victims both knee and kneeusing usingright righthand hand and turn towards you. turn towards you. 5. 5.While Whileyour yourleft lefthand handhold hold WaterRescues—APPROACHES Rescues—APPROACHES (UNDER WATER) Water (UNDER WATER) and support the and support thevictim’s victim’s waist. waist. 6. 6.Remove your right hand toto Remove your right hand the victim’s knee and put it it the victim’s knee and put toto the chin pull it up do the the chin pull it up do the ² Limmer (Brady) leveling toto make the victim ² Limmer (Brady) leveling make the victim ³ Pollack, (AAOS) ³ Pollack, (AAOS) ⁴ NHTSA ⁴ NHTSA float. float. 7. 7.DoDothe thecross crosschest chestcarry carry with your leftleft hand. with your hand. 8. 8.Swim carry Swimside sidestroke strokeand and carry the thevictim victimtotothe thenearest nearest exit point. exit point.

nearest exit point.

rthethe s both both d and and

² ²Limmer Limmer(Brady) (Brady) ³ ³Pollack, Pollack,(AAOS) (AAOS) ⁴⁴ NHTSA NHTSA

dhold hold ictim’s im’s

and d to to put ut it it do thethe victim ctim

carry arry

PRINCIPLES O

576

LIFELINE

8. Swim side stroke and carry the victim to the nearest exit point.

² Limmer (Brady) Limmer (AAOS) (Brady) ³² Pollack, ⁴³ Pollack, NHTSA (AAOS) ⁴ NHTSA

thewater waterusing usingfef ininthe tuckdive diveor orpike pikedive dive tuck While you’re you’re unde und 4.4. While watergrab grabthe thevictim victim water knee using using right right han ha knee turntowards towardsyou. you. turn While your your left left han han 5.5. While and support support the the v and waist. waist. Removeyour yourright righthh 6.6. Remove thevictim’s victim’sknee kneeand an the tothe thechin chinpull pullititup up to levelingto tomake makethe th leveling float. float. Do the the cross cross chest ches 7.7. Do withyour yourleft lefthand. hand. with Swim side sidestroke stroke and an 8.8. Swim the victim victim to to the the n the exitpoint. point. exit

² Limmer (Brady) ² ³Limmer Pollack,(Brady) (AAOS) ³ ⁴Pollack, NHTSA(AAOS) ⁴ NHTSA

PREHOSPITAL EMERGENCY CARE ² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

h– This h– ctimThis is ictim everyis n every er foler folat the at the

breast r breast

PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE DAY22 22 PRINCIPLES DAY UNIT 3 DAY 22 PRINCIPLES OF EMT CLINICAL PRACTICE Water Water Rescues—APPROACHES Rescues—APPROACHES (UNDER (UNDER WATER) WATER) WaterRescues—APPROACHES Rescues—APPROACHES(UNDER (UNDERWATER) WATER) Water UnderWater WaterApproach– Approach–This This Under Water Rescues—APPROACHES (UNDER WATER) techniqueuse useififthe thevictim victimisis technique reallyaggressive aggressiveand andininevery every really directionyou yougo gohis/her his/her folfoldirection lowing you you even even you you atat the the lowing back. back.

Under Water Approach– This technique use if the victim is really aggressive and in every direction you go his/her following you even you at the back.

Rescuejump jump 1.1. Rescue Swimfrontl frontlcrawl crawlororbreast breast 2.2. Swim 1. Rescue jump strokehead-up. head-up. stroke 2. Swim frontl crawl or breast 3 Forabout aboutone onemeter meteraway away 3.3. For UNIT stroke head-up. from the the victim victim submerge submerge from DAY 22 3. For about one meter away thewater waterusing usingfeet feetfirst, first, ininthe from the victim submerge tuck dive or pike dive. tuck dive or pike dive. in the water using feet first, While you’re you’re under under the the 4.4. While tuck dive or pike dive. watergrab grabthe thevictims victimsboth both water Water Rescues—APPROACHES (UNDER WATER) d hold 4. While you’re under the kneeusing usingright righthand handand and knee d hold victim’s water grab the victims both turntowards towardsyou. you. turn Under Water Approach– This Under Water Approach– This victim’s knee using right Whileyour yourleft lefthand handhold hold technique use the victim is 5.5. While technique use if if the hand victimand is —APPROACHES (UNDER WATER) and to turn towards you. and support the victim’s really aggressive and in in every every and support the victim’s really aggressive and hand d put to it 5. While your left hand hold waist. direction you you go go his/her his/her folfolwaist. direction ddoput theit and you support Removeyour yourright righthand handtoto lowing you even the you victim’s at the the 6.6. Remove lowing even you at do the victim waist. the victim’sknee kneeand andput putitit back. the victim’s ² Limmer ² Limmer (Brady) (Brady) back. e victim ³ Pollack, ³ Pollack, (AAOS) (AAOS) 6. Remove your right hand to thechin chinpull pullititup updo dothe the toto the ⁴ NHTSA ⁴ NHTSA carry the victim’s levelingtotomake makethe thevictim victim 1. jump leveling 1. Rescue Rescue jumpknee and put it t carry to thefrontl chin pull it up do the float. 2. crawl or float. 2. 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Do the the cross cross chest chest carry carry with your left hand. with your left hand. or breast r breast 1. Rescue jump 8. Swim side stroke and 1. jump 8. 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PRINCIPLES OF EMT CLINICAL PRACTICE

OF EMT CLINICAL PRACTICE

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PRINCIPLES OF OF EMT EMT CLINICAL CLINICAL PRACTICE PRACTICE PRINCIPLES PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE PRINCIPLES

² Limmer (Brady) ² Limmer (Brady) ³ Pollack, (AAOS) ³ Pollack, (AAOS) ⁴ NHTSA ⁴ NHTSA

LIFELINE

PREHOSPITAL EMERGENCY CARE

577

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578

WaterRescues—APPROACHES Rescues—APPROACHES(RESCUE (RESCUECAN) CAN) Water Water WaterRescues—APPROACHES Rescues—APPROACHES(RESCUE (RESCUECAN) CAN) Rescue RescueCan Can– –Another Anotherap-approach proach with with thethe use use of of rescue rescue can. can.

ENVIRONMENTAL EMERGENCIES

1. 1.PutPut thethe rescue rescue can can strap strap on on Day 22 your your body. body. 2. 2.DoDo thethe rescue rescue jump jump while while dropping dropping thethe rescue rescue can can in in thethewater wateraway awayfrom fromyou you to toavoid avoidinjury injuryto tothetheresrescuer. cuer. Another approach with the use of rescue can. 3. 3.Swim Swim front front crawl crawl or or breast breast stroke strokehead-up head-upgoing goingto to 1. Strap the rescue can on your body. UNIT UNIT 3 3 5. Instruct the victim to hold the rescue can properly thethe victim. victim. 2. Do the rescue jump while dropping the rescue can in DAY DAY 2222 6. properly and relax. 4. 4.Get Getthetherescue rescuecan can and and the water away from you to avoid injury to the rescuer. Swim going to the exit point. Make sure that you are hand hand it to it to thethe victim. victim. 3. Swim front crawl or breast stroke head-up going to the checking the victim if he is still holding the rescue can. 5. 5.Instruct Instruct thethe victim victim to to hold hold properly properly and and relax. relax. victim. (you can use side stroke swimming so that you can 6. 6.Swim Swimgoing goingto tothetheexit exit CAN) Water Rescues—APPROACHES(RESCUE (RESCUECAN) CAN) Water Rescues—APPROACHES 4. Water Get the rescue can and hand it to the victim. keep an eye on the victim all the way to the exit). (RESCUE WaterRescues—APPROACHES Rescues—APPROACHES (RESCUE CAN) point. point. Make Make sure sure your your Rescue Can – Another apRescue Can – Another apchecking checkingthethevictim victimif ifit’sit’s proach with the use of rescue proach with thethe use of rescue stillstill holding holding the rescue rescue can. can. can. can. ( you ( youcan canuse useside sidestroke stroke swimming swimming soso that that you you can can rescue can strap 1. 1.PutPut thethe rescue can strap onon keeping keeping anan eye eye to to thethe vic-vicyour body. your body. timtim all all thethe way way to to thethe exit exit ). ). rescue jump while 2. 2.DoDo thethe rescue jump while dropping rescue can dropping thethe rescue can in in water away from you thethe water away from you avoid injury to to avoid injury to to thethe res-rescuer. cuer. Swim front crawl breast 3. 3.Swim front crawl or or breast strokehead-up head-upgoing goingto to stroke UNIT UNIT 33 victim. thethe victim. Getthetherescue rescuecan can and 4. 4.Get and DAY DAY2222 hand it to victim. hand it to thethe victim. Instruct victim hold 5. 5.Instruct thethe victim to to hold properly and relax. properly and relax. Swimgoing goingto tothetheexitexitCAN) 6. 6.Swim Water WaterRescues—APPROACHES Rescues—APPROACHES (RESCUE (RESCUE CAN) Water WaterRescues—APPROACHES Rescues—APPROACHES(RESCUE (RESCUECAN) CAN) point. Make Make sure sure your your point. checking victimif apifit’sapit’s checking the victim Rescue Rescue Can Can – the –Another Another holding the rescue can. stillstill holding rescue can. proach proach with with thethe use use of of rescue rescue ( you can side stroke ( you can useuse side stroke can. can. swimming that you can swimming so so that you can an to the an eyeeye to the vic1. 1.keeping Putkeeping Put thethe rescue rescue can can strap strap onvicon tim all the way tim allbody. the way to to thethe exitexit ). ). your your body. 2. 2.DoDo thethe rescue rescue jump jump while while dropping dropping thethe rescue rescue can can in in thethe water water away away from from you you to to avoid avoid injury injury to to thethe res-rescuer. cuer. 3. 3.Swim Swim front front crawl crawl or or breast breast stroke strokehead-up head-upgoing goingto to thethe victim. victim. 4. 4.Get Getthetherescue rescuecan canand and hand hand it to it to thethe victim. victim. 5. 5.Instruct Instruct thethe victim victim to to hold hold properly properly and and relax. relax. 6. 6.Swim Swimgoing goingto tothetheexit exit point. point. Make Make sure sure your your checking checkingthethevictim victimif ifit’sit’s ² Limmer (Brady) ² Limmer (Brady) stillstill holding holding thethe rescue rescue can. can. ² Limmer ² Limmer (Brady) (Brady) ³ Pollack, (AAOS) ³ Pollack, (AAOS) ³ Pollack, ³ Pollack, (AAOS) (AAOS) ⁴ NHTSA ( you ( youcan canuseuseside sidestroke stroke ⁴ NHTSA ⁴ NHTSA ⁴ NHTSA swimming swimming so so that that you you can can keeping keeping anan eye eye to to thethe vic-victimtim all all thethe way way to to thethe exit exit ). ).

Water Rescues—APPROACHES (RESCUE CAN) Rescue Can –

PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE PRINCIPLES PRINCIPLES PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE

PRINCIPLES PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE PRINCIPLES PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE

² Limmer (Brady) ² Limmer (Brady) ³ Pollack, (AAOS) ³ Pollack, (AAOS) LIFELINE ⁴ NHTSA ⁴ NHTSA

PREHOSPITAL EMERGENCY CARE

² Limmer (Brady) ² Limmer (Brady) ³ Pollack, (AAOS) ³ Pollack, (AAOS) ⁴ NHTSA ⁴ NHTSA

Ice Rescues Every winter people fall through ice while skating or attempting to cross an ice-covered body of water. Often, the scene becomes a multiple-rescue problem as other individuals fall through the ice while trying to reach the patient. The number one rule in ice rescue is to protect yourself. Formal ice rescue training is available. In addition, you should wear a cold-water submersion suit and personal flotation device during any ice rescue attempt. There are several ways in which you can reach a patient who has fallen through ice: • You can throw a flotation device to the patient. • You can loss a rope in which a loop has been formed to the patient. The patient can put the loop around his body so that he can be pulled onto the ice and away from the danger area. • You can use a small, flat-bottomed aluminum boat for an ice rescue. It can be pushed stern (rear end) first by other rescuers and pulled to safety by a rope secured to the bow (front end). The primary rescuer will remain dry and safe if the ice breaks. The patient can be pulled from the water or allowed to grasp the side of the boat, although he may be unable to grasp or to hold on for long. • A ladder is an effective tool often used in ice rescue. It can be laid flat and pushed to the patient, then pulled back by a connected rope The ladder also can serve as a surface on which a rescuer can spread out his weight if he must go onto the ice to reach the patient. The ladder should have a line that can be secured by a rescuer in a safe position. Any rescuer on the ladder should have a safety line. Remember that the patient may not be able to do much to help in the rescue process. In just a matter of minutes, hypothermia may interfere with his mental and physical capabilities. Whenever possible, do not work alone when trying to perform an ice rescue. If you must work alone, do not walk out onto the ice. Never go onto ice that is rapidly breaking. Never enter the water through a hole in the ice in order lo find the patient. Your best course of action will be to work with others, from a safe ice surface or the shore. When there is no other choice, you and your fellow rescuers can elect to form a human chain to reach the patient. However, this is not the safest method to employ, even when all the rescuers are wearing personal flotation devices and using safety lines. Expect to find injuries to most patients who have fallen through the ice. Treat for hypothermia according to local protocols and treat for any injuries. Transport all patients who have fallen through ice.

BITES AND STINGS Insect Bites and Stings Insect stings, spider bites, and scorpion stings are typical sources of injected poisons, or toxins—substances produced by animals or plants that are poisonous to humans. (Venom is a term for a toxin produced by some animals such as snakes, spiders, and certain marine life forms.) Commonly seen insect stings are those of wasps, hornets bees and ants. Insect stings and bites are rarely dangerous. However, 5 percent of the U.S. population will have an allergic reaction to them, which may result in shock. Those who are hypersensitive develop severe anaphylactic shock that is quickly life threatening. Although all spiders are poisonous, most species cannot get their fangs through human skin. The black widow spider and the brown recluse, or fiddle-back, spider, are two that can, and their bites can produce medical emergencies. Almost all brown recluse spider bites are painless, and patients seldom recall being bitten. The characteristic lesion appears in only 10 percent of cases, and then only after up to 12 hours. EMTs are seldom called to respond to a brown recluse bite. However, black widow bites cause a more immediate reaction. Scorpion stings are common in the Southwest United States. They do not ordinarily cause deaths, but one rare species (centruroides exilcauda) is dangerous to humans and can cause serious medical problems in children, including respiratory failure.

PATIENT ASSESSMENT Insect Bites and Stings

Gather information from the patient, bystanders, and the scene. Find out whatever you can about the insect or other possible source of the poisoning. The following are common signs and symptoms of injected poisoning: • Altered state of awareness • Noticeable stings or bites on the skin • Puncture marks (especially note the fingers, forearms, toes, and legs) • Blotchy skin (mottled skin) • Localized pain or Itching • Numbness in a limb or body part Look for medical • Burning sensation at the site identification devices followed by pain spreading that identify persons throughout the limb • Redness sensitive to certain • Swelling or blistering at the site stings or bites. Some • Weakness or collapse patients sensitive to • Difficult breathing and abnormal stings or bites carry pulse rate medication to help • Headache and dizziness prevent anaphylactic • Chills shock. • Fever • Nausea and vomiting • Muscle cramps, chest tightening, joint pains • Excessive saliva formation, profuse sweating • Anaphylaxis

NOTE:

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ENVIRONMENTAL EMERGENCIES

PATIENT CARE Insect Bites and Stings As an EMT, you are not expected to be able to identify insects and spiders. Proper identification of these organisms is best left to experts. If the patient’s problem was caused by a creature that is known locally and is not normally dangerous (such as a bee, wasp, or puss caterpillar), your major concern regarding the patient will be anaphylactic shock. If anaphylactic shock does not develop, care is usually simple. If the cause of the bite or sting is unknown, or the organism is unknown, a physician should see the patient. Call medical direction or take the patient to a medical facility and let experts decide on the proper treatment for the patient. If possible, transport the stinging object or organism in a sealed container, taking care not to handle it without proper protection, even if it is dead if you can accomplish this safely, you may save precious minutes needed to identify the toxin. To provide emergency care for injected toxins: 1. Treat for shock, even if the patient does not present any of the signs of shock. 2. Call medical direction Skip this only if the organism is known and your EMS system has a specific protocol for care. 3. To remove the stinger or venom sac, the traditional advice was to scrape the site with a blade or a card and to avoid pulling with tweezers (it was thought using tweezers might squeeze more venom into the wound). However, recent research indicates that how you remove the stinger or venom sac is far less important than doing so quickly. 4. Remove jewelry from the patient’s affected limb in case the limb swells, which would make removal more difficult later. 5. If local protocol permits and if the wound is on an extremity (not a joint), place constricting bands above and below the sting or bite site. This is done to slow the spread of venom in the lymphatic vessel and superficial veins. The band should be made of 3/4-inch to 1 and 1/2-inch-wide soft rubber or other wide soft material. It should be placed about 2 inches from the wound The band must be loose enough to slide a finger under it. It should not cut off circulation 6. Keep the limb immobilized and the patient still to prevent distribution of the poison to other parts of the body.

NOTE: Some EMS systems recommend placing a

cold compress on the wound. However, most EMS systems do not use cold for any injected toxin. Follow your local protocols.

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Snakebites Snakebites require special care but are usually not life threatening. Nearly 50,000 people in the United States are bitten by snakes each year. Although over 8,000 of these cases involve poisonous snakes, on the average fewer than 10 deaths each year are reported from snakebites. (In the United States, more people die each year from bee and wasp stings than from snakebites). The signs and symptoms of snakebite poisoning may take several hours to appear. If death does result, it is usually not a rapidly occurring event unless anaphylactic shock develops. Most patients who “die survive” at least 1 to 2 days. In the United States, there Hindi lamang mga ahas are two types of native poisonous ang hayop na may kamandag. snakes—pit vipers (including May mga nag-aalaga ng ibang rattlesnakes, copperheads, and reptiles na nakalalason kung water moccasins) and coral snakes. kumagat. Meron ding mga Up to 25 percent of pit viper bites nag-aalaga ng gagamba o and 50 percent of coral bites kaya ay mga insekto gaya ng are “dry bites” without venom bubuyog. Kaya kahit wala ka injection. However, the venomous sa kagubatan, maaaari kang bite from a diamondback rattler makatagpo ng pasyente na or coral snake is considered very nakagat ng ahas at iba pang serious. Since each person reacts makamandag na hayop. differently to a snakebite, you should consider the bite from any known poisonous snake or any unidentified snake to be a serious emergency. Staying calm and keeping the patient calm and at rest is critical. Since reaction time is slow, there is time to transport the patient without hastle.

PATIENT ASSESSMENT Snakebite Unless you are dealing with a known species of snake that is not considered poisonous, consider all snakebites to be from poisonous snakes. The patient or bystanders may say that the snake was not poisonous, but they could be mistaken. The signs and symptoms of snakebite may include the following: • Noticeable bite on the skin, which may appear as nothing more than a discoloration. • Pain and swelling in the area of the bite, which may be slow to develop, taking from 30 minutes to several hours. • Rapid pulse and labored breathing. • Progressive general weakness. • Vision problems (dim or blurred). • Nausea and vomiting. • Seizures. • Drowsiness or unconsciousness.

If the dead or captured snake is at the scene, your role as an EMT is not to identify the snake but to place it in a sealed container and transport it along with the patient. Arrange for separate transport of a live specimen. Do not transport a live snake in the ambulance. If you see the live, uncaptured snake, take great care or you may be its next victim. When possible, note its size and coloration. Getting close enough to look for details of the eyes or for a pit between the eye and mouth is foolish. The way you classify a snake, whether it is dead or alive, will probably have little to do with your subsequent care of the patient The medical facility staff will arrange to have an expert classify a captured or dead specimen, and they have protocols to determine patient care if the snake has not been captured. Unless you are an expert in capturing snakes, do not try to catch the snake. Never delay care and transport in order to capture the snake.

PATIENT CARE Snakebite

Emergency care of a patient with snakebite includes: 1. Call medical direction to determine the best receiving facility where anti-venom will be most readily available to treat the patient. Rapid transport and the administration of anti-venom are the most effective interventions for the treatment of life-threatening snakebite injuries. 2. Treat for shock and conserve body heat Keep the patient calm 3. Locate the fang marks. There may be only one fang mark 4. Remove any lings, bracelets, or other constricting items on the bitten extremity. 5. Keep any bitten extremities immobilized—the application of a splint will help. Do not elevate the limb above the level of the heart 6. Transport the patient, carefully monitoring vital signs

NOTE:

Do not place an ice bag or cold pack on the bite unless you are directed to do so by a physician or local protocol. Do not cut into the bite and suction or squeeze the bite site. Never suck the venom from the wound using your mouth. Instead, use a suction cup. However, suctioning is seldom done.

Poisoning from Marine Life Poisoning from marine life forms can occur in a variety of ways—from eating improperly prepared seafood or poisonous organisms to receiving stings and punctures from aquatic life forms. Patients who have ingested spoiled, contaminated, or infested seafood may develop a condition that resembles anaphylactic shock. Therefore, they should receive the same care as any patient in anaphylactic shock. During care, you must he prepared in case the patient vomits. Most patients will show the signs of food poisoning. The care for seafood poisoning is the same as for all other food poisonings. It is common for people in the Philippines and other archipelago to eat a poisonous Dahil ang Pilipinas ay napapaligiran variety of marine ng dagat, madalas na may mga emergency life. For all cases na pasyenteng nalason sa jellyfish o dikya. of suspected Sa mga ganitong sitwasyon, maging poisoning due handa na magbigay ng kaukulang lunas to ingestion, para sa allergic reaction. Maging handa call your online rin sa posibleng pagsusuka at pagtigil sa medical direction paghinga ng pasyente. or the poison control center as local protocol directs you. Be prepared for the patient to display vomiting, convulsion, and respiratory arrest. Venomous marine life forms producing sting injuries include the jellyfish, the sea nettle, the Portuguese man-of-war. coral, the sea anemone, and the hydra. For most victims, the sting produces pain with few complications. Some patients may show allergic reactions and possibly develop anaphylactic shock. These cases require the same care as rendered for any case of anaphylactic shock. Stings to the face, especially those near or on the lip or eye, require a physician’s attention. Rinsing the affected area with vinegar will reduce the pain of the sting. However, be careful not to let vinegar gel into the patient’s mouth or eyes. Once the site has been rinsed with vinegar to inactivate the venom, immersion of the site in hot but non-scalding water (maximum temperature 45°C or 113°F) may further reduce the pain. Puncture wounds can occur when someone steps on or grabs a stingray, sea urchin. spiny catfish, or other form of spiny marine animal. Although it is true that soaking the wound in non-scalding hot water for 30 to 90 minutes will break down the venom, you should not delay transport. Puncture wounds must be treated by a physician and the patient may need a tetanus inoculation. Remember, the patient could react to the venom by developing anaphylactic shock. LIFELINE

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LIFELINE PREHOSPITAL EMERGENCY CARE

ASSISTING a mother in giving birth is one of the most beautiful experiences that you would have as an EMT. However, not all childbirth ends up on a happy note. There are some that result in the death of the mother, the baby, or both. According to the United Nations, around 11 Filipino mothers die everyday during childbirth. Thatâ&#x20AC;&#x2122;s an estimated 4,500 women every year due to severe hemorrhage, hypertensive disorders, sepsis, and problems related to obstructed labor and abortion. Your job, therefore, as a future EMT is to prevent such deaths when you are called into action. In this chapter you would review the basic anatomy and physiology of the female reproductive system, the process of childbirth, the needs of the newborn baby and how to provide for them, and the possible problems that may occur during childbirth such as miscarriage, abortion, seizures, among others. You would also learn later in this chapter the basics of providing care for a victim of sexual assault.

582

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DAY

Obstetric Gynecologic Emergencies and Emergency Childbirth The female reproductive system Physiologic changes in pregnancy Labor and delivery Assessing and caring for the neonate Childbirth emergencies Sexual assault

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Day 23

CRITICAL CONCEPTS � Although birth is a natural process that usually takes place without complications, the involvement of EMS usually indicates something unusual has happened. � The EMT’s role at a birth is generally to provide reassurance and to assist the mother in the delivery of her baby. � During the normal delivery, the EMT will evaluate the mother to determine if there should be immediate transport to a medical facility or if birth is imminent and will take place at the scene. � If birth is to take place at the scene, the EMT must prepare for the worst. Have equipment ready and appropriate resources on hand. Always be prepared for neonatal resuscitation. � Complications of delivery represent a true emergency. An EMT must he prepared to initiate rapid transport in the case of breech presentation, prolapsed umbilical cord, limb presentation, premature birth, or meconium staining of the amniotic fluid. � There may also be predelivery emergencies, or emergencies associated with pregnancy (such as excessive bleeding, ectopic pregnancy, seizures, abortion, or trauma to the pregnant mother) that the EMT must be prepared to treat. � Stillbirth, death of the mother, and sexual assault are difficult emergencies the EMT is occasionally called upon to manage.

584

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PRINCIPLES OF EMT CLINICAL PRACTICE

OBSTETRIC GYNECOLOGIC EMERGENCIES AND EMERGENCY CHILDBIRTH LEARNING OBJECTIVES • Identify the following structures: Uterus, vagina, fetus, placenta, umbilical cord, amniotic sac and perineum. • Identify and explain the use of the contents of an obstetrics kit. • Identify predelivery emergencies. • State indications of an imminent delivery. • State and demonstrate the steps in the predelivery preparation of the mother. • Discuss the emergency medical care of a patient with a gynecological emergency. • State the steps to assist in the delivery. • Describe and demonstrate the procedures for the following abnormal deliveries: Breech birth, prolapsed cord, limb presentation. • Differentiate the special considerations for multiple births, meconium and premature baby. • Differentiate the emergency medical care provided to a patient with predelivery emergencies from a normal delivery. • Explain the rationale for understanding the implications of treating two patients (mother and baby). • Establish the relationship between body substance isolation and childbirth

INTRODUCTION Understanding of the female reproductive system is an important element of your assessment and treatment of any female patient. As an EMT, you should know that the anatomy and physiology of this system can be vastly different from patient to patient. In a non-pregnant female, the organs of reproduction are small and well protected, whereas in a pregnant female these same organs are enlarged and exposed. With pregnancy, a woman’s reproductive system will undergo tremendous changes, leading up to the birth of a child. Childbirth is a natural process that existed long before there were EMTs, and the vast majority of births are uncomplicated. However, you should always remember “ that, if EMS has been called, something unexpected has occurred and the likelihood of a problem has increased. With the potential for complications, the best place to deliver a baby is a hospital. Much of our assessment of the woman in labor will be geared toward making a decision on whether to transport the pregnant woman or prepare for an immediate delivery. If it does become necessary to assist with an out-of-hospital delivery, one of your main responsibilities in this situation will be to help calm the patient and family members through your unruffled professional manner. However, because childbirth is not a common occurrence in the prehospital setting, it might be easy to get flustered and seem uncertain about the procedures you are performing. Therefore, it is important that you learn about childbirth and practice the procedures required to assist with delivery. If you are ever called upon to assist in a delivery, your skills will contribute to decrease stress and provide better care for the mother and baby

External Genitalia A woman's external genitalia consist of three major structures: the labia, the perineum, and the mons pubis. The labia consist of soft tissues that protect the entrance to the birth canal. The urethral opening and the nerve-rich center of sexual stimulation, called the clitoris, can be found in the anterior aspects of the labia. These tissues are highly vascular and prone to significant bleeding with trauma.

ANATOMY AND PHYSIOLOGY

External Genitalia The perineum is the soft tissue and muscle found between the vaginal opening

A woman’s external genitalia consist of three major vascular and prone to significant bleeding with trauma. and the anus. This tissue is prone to tearing during childbirth. The mom pubis is structures: the labia, the perineum, and the mons pubis. The perineum is the soft tissue and muscle found a layer of soft tissue that covers and protects the pubic symphysis. It is the area The labia consist of soft tissues that protect the entrance between the vaginal opening and the anus. This tissue is where hair grows as a woman reaches puberty. to the birth canal. The urethral opening and the nerve-rich prone to tearing during childbirth. The mons pubis is a layer center of sexual stimulation, called the clitoris, can be found of soft tissue that covers and protects the pubic symphysis. It in the anterior aspects of the labia. These tissues are highly is the area where hair grows as a woman reaches puberty.

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ANATOMY AND PHYSIOLOGY Internal Genitalia

Unit 3

Day 23

ANATOMY AND PHYSIOLOGY

OB-GYNE EMERGENCIES

A woman's internal genitalia consist of the vagina, the ovaries, the fallopian tubes (also called the oviducts), and the uterus.

Internal Genitalia

The Vagina The vagina is the birth canal. Made up of

smooth muscle, it connects the uterus to the outside world and will stretch to accommodate passage of the fetus during delivery. It is also the passageway for menstrual waste products leaving the uterus at the conclusion of the menstrual cycle.

The Ovaries and Fallopian Tubes The ovaries are small, round organs that

are located on either side of most women’s lower abdominal quadrants. These organs are responsible for producing ova (eggs) for conception. They also produce many of the hormones necessary for the process of reproduction. An ovum produced in the ovaries is transported to the uterus (the place where they will implant and develop) through the fallopian tubes, also called the oviducts. Each ovary is connected to the uterus by a fallopian tube. If fertilization occurs, it will most likely happen in these tubes. A dangerous condition called ectopic pregnancy can occur if the ovum implants in the fallopian tubes. Unlike the uterus, these tubes cannot expand as the fetus develops and are vulnerable to rupture and severe bleeding.

The Uterus The uterus (or womb) is a muscular, hollow organ located

along the midline in most women’s lower abdominal quadrants. This organ is the intended site for the fertilized egg to implant and develop into a fetus. To accommodate that purpose, the uterus is able to stretch and grow as the fetus gets larger. The top, or fundus, of the uterus can be found as high as the xiphoid process in a lateterm pregnant woman. The lower aspect of the uterus is connected to the vagina. A muscular ring called the cervix separates these two organs. In a non-pregnant female, the cervix is constricted to close off the uterus. With labor, the cervix thins and dilates to allow the muscular walls of the uterus to contract and push the fetus out through the vagina and into the outside world.

The Female Reproductive Cycle After a woman reaches the age of puberty, approximately every

24 days her uterus goes through a series of changes to prepare for the potential implantation of a fertilized egg. Hormones such as estrogen and progesterone stimulate these events. In the early phases. the ovaries are stimulated to release an ovum (egg) in a process called ovulation. At the same time, the walls of the uterus thicken in preparation for implantation of the egg if fertilization occurs. The fallopian tubes now move the egg by peristalsis (waves

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of muscular contraction) toward the uterus. Fertilization typically occurs in the fallopian tubes. If fertilization does not occur, hormone levels once again change and the uterus begins to change as well. Without fertilization, the thickened inner walls of the uterus begin to slough off and are expelled through the vagina. This process is called menstruation and is usually characterized by vaginal bleeding for roughly 3-5 days. If the egg is fertilized and successfully implants, hormones induce other changes that occur with pregnancy.

Fertilization If the woman has sexual intercourse in the period

immediately following ovulation and sperm reaches the ova, fertilization may occur. By combining with the sperm, an ovum becomes an embryo and the embryonic stage of pregnancy begins. The embryonic stage occurs roughly from the point of fertilization and lasts 8 weeks During this stage, the embryo attempts to implant in the lining of the uterus and develops basic connections between itself and the mother. At 8 weeks of development, the fetal stage begins. From this point until delivery, the developing baby is referred to as a fetus. The fetus will develop over the next 32 weeks (a typical pregnancy lasts about 40 weeks), during which time the woman’s body will undergo significant changes.

PHYSIOLOGIC CHANGES IN PREGNANCY Changes in the Reproductive System Size is the most significant change that pregnancy brings to the reproductive system. As the fetus grows and develops, the uterus simply gets larger. It becomes thinnerwalled and less protected by the abdominal cavity. Therefore, it becomes more vulnerable to injury. The 9 months of pregnancy are divided into three 3-month periods, or trimesters. During the first trimester, the fetus is being formed. Since the fetus remains quite small, there is little uterine growth during this period. After the third month, the uterus grows rapidly, reaching the umbilicus (navel) by the fifth month and the epigastrium (upper abdomen) by the seventh month. As the fetus develops, other major changes occur in the reproductive system. In addition to the fetus, an organ called the placenta develops in the uterus. Composed of both maternal and fetal tissues, the placenta is attached to the wall of the uterus and serves as an exchange area between mother and fetus. In a process similar to the diffusion between the alveoli and pulmonary capillaries, oxygen and nutrients (and drugs, nicotine, and alcohol) from the mother’s blood vessels are carried across the placenta to the blood vessels of the fetus. Carbon dioxide and certain

other waste products cross from fetal circulation to maternal circulation. Since the placenta is an organ of pregnancy, it is expelled after the baby is born. The mother’s blood does not flow through the fetus’s body. Instead, the fetus has its own circulatory system. Blood from the fetus is sent through blood vessels in the umbilical cord to the placenta where, through diffusion, the blood picks up nourishment from the mother, then returns through the umbilical cord to the fetus’s body. The umbilical cord, which is about 1 inch wide and 22 inches long at birth, is fully expelled with the birth of the baby and the delivery of the placenta. While developing in the uterus, the fetus is enclosed and protected within a thin, membranous “bag of waters” known as the amniotic sac. This sac contains almost 1 quart of liquid, called amniotic fluid. It allows the fetus to float during development, acts as a cushion between the fetus and minor injury, and helps maintain a constant fetal body temperature. In the vast majority of cases, the amniotic sac breaks during labor and the fluid gushes from the birth canal. This is a normal condition of childbirth that also provides a natural lubrication to ease the infant’s progress through the birth canal. In addition to reproductive system changes, other systems are also imparted by the developing fetus. The cardiovascular system responds to pregnancy by increasing blood volume, increasing cardiac output, and increasing heart rate. The blood pressure of a pregnant female is usually slightly decreased, but high blood pressure can occur as well. There is also a massive increase in vascularity (presence of blood and blood vessels) in the uterus and related structures. Pregnancy affects the respiratory system by increasing oxygen demand and consumption. In the later stages of pregnancy, the fetus can also put pressure on the woman’s diaphragm and decrease the volume of air in her lungs. In the gastrointestinal system, a growing fetus puts pressure on the stomach and intestines and can slow digestion. Nausea and vomiting are also very common in pregnancy.

OUTSIDE

INSIDE

Increasing heart rate

Faster pulse

Ligaments stretched, carrying extra weight of fetus

“Swayback” posture, back pain

Increasing blood volume

Pink coloration to skin

Increased O2 demand / Decreased lung capacity

Shortness of breath

Fetus growing, Uterus enlarging

Belly enlarging

Growing uterus, displaces Gl tract

Nausea, vomiting, and heartburn

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UNIT 3 DAY UNIT23 3 DAY 23

DEVELOPING FETUSPRACTICE PRINCIPLES OF EMT CLINICAL UNIT 3 PRINCIPLES OF EMT CLINICAL PRACTICE DAY 23 PRI OB-GYNE EMERGENCIES Unit 3 Day 23 DEVELOPING FETUS Hormones released with DEVELOPING FETUS LAB pregnancy make the ligaments of a

DEVELOPING FETUS

pregnant woman’s musculoskeletal system more elastic and therefore more vulnerable to injury. The additional weight can also affect posture and lead to back pain as well as affect balance. Pregnancy may also impact pre-existing medical conditions in the mother. Diseases such as asthma and diabetes both can be made worse with pregnancy.

The

Labo



Supine Hypotensive Syndrome

First

In the third trimester, near the time of birth, the weight of the uterus, combined with the weight of the infant, placenta, and amniotic fluid, totals approximately 20 to 24 pounds. When the mother is in a supine position, this heavy mass will tend to compress the inferior vena cava, a major blood vessel, reducing return of blood to the heart, thereby reducing cardiac output. The resulting dizziness and drop in blood pressure constitute a “set of signs and symptoms known as supine hypotensive syndrome. This syndrome is also referred to as vena cava compression syndrome. When it senses the drop in blood “ pressure, the body begins to compensate by contracting the uterine arteries and redirecting “ blood to the major organs. This can severely affect the fetus. Although the drop in blood pressure signals shock, traditional methods of treating shock (hypoperfusion) will not be effective in this instance. To take the weigh) off the vena cava and counteract or avoid the possible drop in blood pressure, all thirdtrimester patients should be transported on their left side. A pillow or rolled blanket should be placed behind the back to maintain proper positioning.

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“

The f longstretc long effac

Some uterin usua ing d tract head

² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA ² Limmer (Brady)

Light abdo ing th also b

The proac

INCIPLES OF EMT CLINICAL PRACTICE

LABOR AND DELIVERY BOR AND DELIVERY

Lightening is a term used to describe the fetus’s movement from high in the abdomen down toward the birth canal. Some women will describe experiencing this sensation. At times this occurs well before the start of labor, but it can also be an indicator of the beginning of the labor process. e Stages of Labor The cycle of contractions starts far apart and becomes Labor is the entire process of delivery. There are shorter as birth approaches. Typically, these contractions range three stages of labor: or is the entire • process of delivery. There are three stages of labor: from every 30 minutes at the start down to 3 minutes apart or First stage. This stage starts with regular less near the end.  First stage. This stage starts with regular contraction and the thinning contraction and the thinning and gradual dilation of The contractions of the uterus produce normal labor and gradualthe cervix and ends when the cervix is fully dilated. dilation of the cervix and ends when the cervix is fully pains. Most women report the start of labor pains as an ache dilated. • Second stage. This stage is the time from when the in the lower back. As labor progresses, the pain becomes most baby enters the birth canal until he is born.  Second stage. This stage is the time from when the baby enters the noticeable in the lower abdomen, with the intensity of pain • until Third stage. This stage begins after the baby is born birth canal he is born. increasing. The pains come at regular intervals, lasting from 30 seconds to 1 minute and occur at 2- to 3-minute intervals.  Third stage. and lasts until the afterbirth (placenta, umbilical This stage begins after the baby is born and lasts until the cord, and some tissues from the amniotic sac and the afterbirth (placenta, umbilical cord, and some tissues from the When the uterus starts to contract, the pain begins. As the amnilining of the uterus) is delivered. muscles relax, there is relief from the pain. Labor pains may otic sac and the lining of the uterus) is delivered. start and stop for a while and then start up again.

t Stage

The Stages of Labor

First Stage

Bilang isang EMT, dapat mong orasan ang mga sumusunod na yugto ng pagli-labor ng isang babaeng manganganak: 1. Haba o tagal ng contraction o paghilab. Ito ay maoorasan mo sa simula ng paghilab hanggang sa mawala ang sakit. 2. Dalas ng contraction o paghilab. Malalaman mo ito sa pagtanda sa oras kung kelan humilab ang tiyan ng babaeng manganganak at kung kelan uli ito humilab. Ang mas matagal at mas madalas na paghilab ay nagpapahiwatig na malapit nang lumabas ang sanggol.

When contractions last 30 seconds to 1 minute and are 2 to 3 minutes apart, this indicates delivery of the baby may be imminent. As contractions continue, the cervix gradually shortens and thins enough (reaching wide-mouth-jar shape) to become flush with the There is no way vagina or fully open to the birth to externally assess canal. The full dilation of the cervix the dilation of the signals the end of the first stage of cervix. As an EMT, The first stage of labor is also called the dilation period. first stage of labor is also called the dilation period. Picture the uterus as a labor. Women giving birth for the you will assess the Picture the uterus as a long-neck bottle. In order to expel the -neck bottle.contents, the neck of the bottle must he stretched to the size In order to expel the contents, the neck of the bottle must he first time will remain in this first progression of labor stage of labor for an average of 16 ched to the of a wide-mouth jar. Before the cervix can fully dilate, the size of a wide-mouth jar. Before the cervix can fully dilate, the using other findings. neck of thelong neck of the cervix must be shortened and thinned (this cervix must be shortened and thinned (this process is hours. However, some women may called EMTs do not do remain in this stage for no more than internal cervical cement) to the wide-mouth-jar shape. process is called effacement) to the wide-mouth-jar shape. 4 hours, especially if this is not their examinations. Sometimes, several days or even weeks before the onset first child. of actual labor, the uterine muscles begin mild contractions. etimes, several days or even weeks before the onset of actual labor, the ne muscles These Braxton-Hicks contractions are usually irregular and begin mild contractions. These Braxton-Hicks contractions are As the fetus moves downward ally irregular not sustained and they typically do not indicate impending and not sustained and (hey typically do not indicate impendand the cervix dilates, the amniotic sac usually breaks. This delivery. In contrast, when actual labor begins, the uterus is commonly referred to ns the “water breaking” or the delivery. In contrast, when actual labor begins, the uterus will begin to conwill begin to contract regularly and the cervix will begin regularly and the cervix will begin lo dilate. As this happens, the “rupture of membranes.” It is often felt by the woman as a fetus's to dilate. As this happens, the fetus’s head typically moves gush or trickle of fluid exiting the vagina. Most commonly, d typically moves downward. downward. it immediately precedes labor. However, it can also happen

tening is a term used to describe the fetus's movement from high in the omen down toward the birth canal. Some women will describe experienchis sensation. At times this occurs well before the start of labor, but it can be an indicator of the beginning of the labor process.

cycle of contractions starts far apart and becomes shorter as birth apches. Typically, these contractions range from every 30 minutes at the start

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associated with the first stage of labor are typically still present. As delivery approaches, most women will feel an urge to push or feeling like they need lo move their bowels. This occurs as the baby's body moves and places pressure on the rectum. The urge to push is a sign that birth is near, and the EMT wil have to decide whether to transport the pregnant patient or keep the mother and prepare to assist with delivery. EMERGENCIES Unit 3 where Day 23she isOB-GYNE

Third Stage

well before the onset of labor. This is called premature rupture of membranes and can be a serious problem for the fetus. “ Normally, the amniotic fluid is clear. Fluid that is greenish or brownish-yellow in color may be an indication of maternal or fetal distress and is called meconium staining. There may also be a watery, bloody discharge of mucus (not bleeding) associated with the first stage of labor. Part of this initial discharge will be from a mucus plug that helped to keep the cervix closed during pregnancy. This is usually mixed with blood and is called the bloody show. Watery, bloody fluids discharging from the vagina are typical for all three stages of labor.

Third Stage

CIPLES OF EMT CLINICAL PRACTICE Stage

Second Stage

The third stage of labor begins immediately after the baby is born. In this stage The third stage of labor begins immediately after the the placenta detaches itself from the wall of the uterus and is expelled. Con baby is born. In this stage, the placenta detaches itself from the wall of the uterus and is expelled. Contractions will tractions will resume and continue until the placenta is delivered. The contrac tions and labor resume and continue until the placenta is delivered. The pains may be as painful and severe during this stage as they contractions and labor pains may be as painful and severe were in the second stage. The third stage usually lasts 10 to 20 minutes and during this stage as they were in the second stage. The third ends as the placenta is delivered. stage usually lasts 10 to 20 minutes and ends as the placenta is delivered.

² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

PATIENT ASSESSMENT

Assessing the Woman in Labor

Although you will assess a woman in labor the same way you would any other patient, there are some specific consideration you should keep in mind. You should use your assessment to identify the imminent delivery. Ideally, mothers in labor should be transported to the The second stage of labor begins after the full dilation hospital for delivery: however, it is not always possible nd stage of labor begins after the full dilation of the cervix. During this of the cervix. During this time, contractions become to do so. Fortunately, your assessment may reveal some -tractions become increasingly frequent, and labor pains become increasingly frequent, and labor pains become more key finding that may indicate that the birth is about to ere. In the second stage of labor, the cramping and abdominal pains severe. In the second stage of labor, the cramping and happen. d with the first stage of labor are typically still present. As deliveryA simple series of questions, an examination for apabdominal pains associated with the first stage of labor are typically still present. As delivery approaches, most most women will feel an urge to push or feeling like they crowning, and a determination of vital signs will allow need lo women will feel an urge to push or feeling like they need you to make the decision for transport. However, do not r bowels. This occurs as the baby's body moves and places pressure to move their bowels. This occurs as the baby’s body let the “urgency” of this decision upset the mother. Your ctum. The urge to push is a sign that birth is near, and the EMT will moves and places pressure on the rectum. The urge to patient needs emotional support at this time. Your calm, ecide whether to transport the pregnant patient or keep the professional actions will help her feel more at ease and mother push is a sign that birth is near, and the EMT will have e is and prepare to assist with delivery. to decide whether to transport the pregnant patient or assure her that you will provide the required care for keep the mother where she is and prepare to assist with both her and the unborn child. delivery.

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o e ll r

e, ncy d

Assessment of a woman in labor includes all the elements of a traditional patient assessment including checking airway, breathing, and circulation: taking vital signs: and reviewing a SAMPLE history. There are also a few assessment elements that are specific to the pregnancy and labor. To begin to evaluate the woman in labor: 1. Ask her name, age, and expected due date. 2. Ask if this is her first pregnancy. The average time of labor for a woman having her first baby is about 16 to 17 hours. The time in labor is typically shorter for subsequent births, unless the mother has given birth to more than four or five babies already. In some women with numerous deliveries, the uterus will continue to act like a well-toned muscle; in others, it will be less effective and delivery will take longer. 3. Ask her if she has seen a doctor regarding her pregnancy. This is called prenatal care and is important in identifying such things as multiple gestations (twins, triplets, and so on): known complications or problems with the pregnancy: and possible medical issues with the mother. 4. Ask her when the labor pains started and how often she is having pains. Ask her if her “bag of waters” has broken and if she has had any bleeding or bloody show. At this point, with a woman having her first delivery, you may think that you can make a decision about transport. However, you should continue with the evaluation procedure. Also, begin to time the frequency and length of the contractions. 5. Ask her if she feels the urge to push or if she feels as though she needs to move her bowels. If she says “Yes,” this usually means that the baby has moved into the birth canal and is pressing the vaginal wall against the rectum. However, do not allow the mother to go to the bathroom as she may deliver the infant into the toilet. Birth will probably occur very soon. The mother may tell you that she can feel the baby trying to move out through her vaginal opening. In such cases, birth is likely very near. 6. Examine the mother for crowning. This is a visual inspection to see if there is bulging at the vaginal opening or if the presenting part of the baby is visible. Crowning occurs when the presenting part of the baby first bulges from the vaginal opening. The presenting part is defined as the part of the infant that is first to appear at the vaginal opening during labor. Usually, the presenting part of the baby is the head. The normal head-first birth is called a cephalic presentation. If the buttocks or both feet of the baby deliver first, the birth is called a breech presentation or breech birth. If part of the baby’s head or presenting part is visible with each contraction, then birth is imminent. 7. Feel for uterine contractions. You may have to delay this procedure until the patient tells you she is having labor pains. Tell her what you are going to do, then place the palm of your gloved hand on her abdomen, above the navel. This can be done over the top of the patient’s clothing. You should be able to feel her uterus contract.

All contractions should be timed, so keep track of the duration and frequency of the contractions. The uterus and the tissues between this organ and the skin will feel more rigid as the delivery of the baby nears. 8. Take vital signs. If you do not have a partner to do it, this is the point to check the patient’s vitals. Examining for crowning may be embarrassing to the mother, the father, and any required bystanders. For this reason, it is important that you fully explain what you are doing and why. Be certain that you protect the mother from the stares of bystanders. In a polite but firm manner, ask everyone who does not belong at the scene to leave. Carefully help the patient remove enough clothing to allow you an unobstructed view of the vaginal opening. If this is the woman’s first delivery, she is not straining, and there is no crowning, there is link reason why she cannot be transported to a medical facility for delivery. (A first delivery typically takes longer than subsequent ones.) However, if this is not her first delivery, and she is pushing, crying out. and complaining about hating to go to the bathroom, birth will probably occur too soon for transport. If the mother is having labor pains from contractions that are about 2 minutes apart, birth may be very near. If you determine that delivery is imminent based on the presence of crowning or other signs, local protocol may require you to contact medical direction for the decision to commit to delivery on the site. If delivery does not occur within 10 minutes, contact medical direction again and request permission to initiate transport of the mother. You may find a patient who is afraid of transport because she believes that her baby’s birth will occur along the way. Assure her that you believe there is enough Huwag mong hayaan na time to get to the hospital magpunta sa banyo ang babaeng before delivery. Let her manganganak kahit pa sabihin know that you are trained niya na gusto niyang dumumi. to assist with the delivery Senyales ito na malapit na malapit and that the ambulance is nang lumabas ang bata. Huwag well equipped to handle mo ring hayaan na ipitin ng her needs and care for babae ang kanyang mga hita o the newborn in case anumang paraan para pigilin ang she delivers en route. If panganganak. Pinakamaganda na crowning occurs during ibiyahe ang babaeng manganganak transport, stop the patungo sa ospital. Maliban lang ambulance and prepare kung sa tantiya mo ay for delivery. lalabas na talaga If your evaluation ang bata. of the patient leads you to believe that birth is too near at hand for transport, you and your partner should prepare to assist the mother with delivery. Remember, as part of the preparation, the patient will need emotional support. LIFELINE

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Unit 3

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OB-GYNE EMERGENCIES

Another important assessment goal is predicting the need for neonatal resuscitation. Although the need for resuscitation can never be absolutely predicted, there are some assessment findings that indicate a high probability of that need. Findings That Might Indicate the Need for Neonatal Resuscitation • No prior prenatal care. The patient has not seen an obstetrician and therefore has no idea regarding her health or the health of her unborn baby. • Premature delivery. The earlier the labor, the higher the likelihood of resuscitation. • Labor induced by trauma or medical conditions affecting the mother. • Multiple births. Multiple births, like twins and triplets, significantly increase the likelihood of resuscitation. • History of problems with the pregnancy, especially placenta previa and breech presentations. • Labor induced by drug use, especially narcotics. • Meconium staining with the rupture of membranes (water breaking). The most important outcome of anticipating a neonatal resuscitation is getting help. As you will read later in this chapter, a resuscitation requires a rapid series of actions with full attention focused on the new baby. If that occurs, you will need more help and probably ALS support, if available. Good assessment will enable you to begin assembling these resources prior to delivering the baby.

the woman’s buttocks to place and initially care for the newborn. Having the patient positioned on the stretcher may speed transport if complications arise. 4. Remove any of the patient’s clothing or underclothing that obstructs your view of the vaginal opening. Use Sterile sheets or sterile towels to cover the mother. Clean sheets, clean cloths, towels, or materials such as tablecloths can be used if you do not have an obstetrics kit. 5. Position your assistant—your partner, the father, or someone the mother agrees to have assist you—at the mother’s head. This person should stay alert to help turn the mother’s head in case she vomits. In addition. this person should provide emotional support to the mother, soothing and encouraging her. 6. Position the obstetrics kit near the patient. All items must be within easy reach. Kung ang panganganak ay mangyayari sa loob ng kotse, ihiga ang ina sa upuan. Ibuka ang mga hita ng inang manganganak kung saan ang isang paa nito ay nakapatong sa silya at ang isa pa ay nasa lapag. Tandaan palagi: Hindi EMTs ang nagde-deliver ng sanggol kundi ang mga ina. Ang trabaho mo ay alalayan lamang sila.

NORMAL CHILDBIRTH Role of the EMT

Your primary role in a childbirth will be to determine whether the delivery will occur on-scene and, if so, to assist the mother as she delivers her child.

Preparing the Mother for Delivery When your evaluation leads you to believe birth is imminent, you must immediately prepare the mother for delivery. To do so, you should: 1. Control the scene so that the mother will have privacy. (Her birthing coach may remain.) If you are not in a private room and transfer to the ambulance is not practical (crowning is present), ask bystanders to leave. 2. In addition to surgical gloves, you and your partner should put on gowns, caps, face masks, and eye protection since there is a high probability of splashing blood and other body fluids during delivery. 3. Place the mother on a bed, floor, or the ambulance stretcher. Elevate her bullocks with blankets or a pillow. Have the mother lie with knees drawn up and spread apart. You will need about 2 feet of work space below 592

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Preparing the Obstetrics (OB) Kit A normal delivery requires some basic equipment that is typically kept in what is called an obstetrics (OB) kit. Although supplies will vary, this kit should include: • Several pairs of sterile surgical gloves to protect you from infection. • Towels or sheets for draping the mother. • 1 dozen 2 X 2 (or 4 X 4) gauze pads (sponges) for wiping and drying the baby. • 1 rubber bulb syringe (3 oz.) to suction the baby’s mouth and nostrils if needed. • Cord clamps or hemostats to clamp the umbilical cord (plus extra clamps in case of a multiple birth). • Umbilical cord tape to tie the cord. • 1 pair of surgical scissors to cut the cord. • 1 baby blanket to wrap the baby and keep him warm. • Several individually wrapped sanitary napkins to absorb blood and other fluids. • Plastic bag.

Occasionally, in an off-duty situation, you may need to assist in the delivery of a baby without using a sterile delivery pack. In this case, a few simple supplies can be used to assist the mother: • Clean sheets and towels to drape around the mother and wrap the newborn. • Heavy flat twine or new shoelaces to tie the cord (Do not use thread, wire, or light string since these may cut through the cord). • A towel or plastic bag to wrap the placenta after its delivery. • Clean, unused rubber gloves and eyewear, as the lack of gloves and eyewear will mean possible exposure to infectious diseases. A head covering for the baby may also be helpful as it dramatically reduces heat loss. A neonatal-sized bag-valve mask (BVM) connected to oxygen should also be prepared prior to the delivery.

Delivering the Baby Position yourself in such a way that you have a constant view of the vaginal opening. Be prepared for the baby to come at any moment. In addition, be prepared for the patient to experience discomfort. Delivering a child is a natural process, but it is accompanied by pain, Your patient may also have intense feelings of nausea. If this is her first child, she may be very frightened. All these factors may cause your patient to be uncooperative at times. You must remember that the patient is in pain and she may feel ill. Therefore, she will need emotional support. Talk to the mother during the delivery. Encourage her to relax between contractions. Continue to time her contractions from the beginning of one contraction to the beginning of the next. Encourage her not to strain unless she feels she must. Remind her that her feeling of a pending bowel movement is usually just pressure caused by the baby moving into her birth canal. Encourage her to breathe deeply through her mouth. She may feel better if she pants, although she should be discouraged from breathing rapidly and deeply enough to bring on hyperventilation. If her “bag of waters” breaks, remind her that this is normal. Kung wala namang komplikasyon, normal ang delivery ng sanggol kung ulo nito ang unang lumabas. Obserbahan kung may kakaibang kulay sa amniotic fluid. May mga pagkakataon na “explosive” ang delivery. Ang ibig sabihin, parang sumasabog ang tubig kasabay ng sanggol. Alalayan mo nang mabuti ang sanggol pero huwag mo itong pipisilin. Hawakan lamang nang magaan ang sanggol lalo na ang malambot na ulo nito.

To Assist The Mother With A Normal Delivery: 1. Continue to keep someone at the mother’s head to provide support, monitor vital signs, and be alert for vomiting. If no one is on hand to help, be alert for vomiting and check vital signs between contractions. 2. Position your gloved hands at the mother’s vaginal opening when the baby’s head starts to appear. Place your hand gently on the baby ‘s head as it bulges out of the vagina to prevent a sudden uncontrolled expulsion of the newborn. Do not touch the area around the vagina except to assist with the delivery. For legal reasons, it is always preferable for both your protection and the patient’s to have your partner present at all times when you are touching a woman’s vaginal area. 3. Place one hand below the baby’s head as it delivers. Spread your fingers evenly, remembering that the baby’s skull contains “soft spots,” or fontanelles. Support the baby’s head, but avoid pressure to these soft areas at the top and sides of the skull. A slight, well-distributed pressure may help prevent an explosive delivery. Keeping one hand on the baby’s head and using the other hand to hold a sterile towel to support the tissue between the mother’s vagina and anus can help prevent tearing of this tissue during delivery of the head. Do not pull on the baby! 4. If the amniotic sac has not broken by the time the baby’s head is delivered, use your finger to puncture the membrane. Pull the membranes away from the baby’s mouth and nose. The amniotic fluid should be clear. Examine the amniotic fluid for meconium staining, which will appear to be a dark green-black or mustard yellow color. Meconium-stained amniotic fluid is caused by fetal feces (wastes) released during labor, usually because of maternal or fetal distress. If meconium is present, immediately prepare to suction the infant. If the meconium is aspirated (breathed in) by the fetus, the baby can develop pneumonia or other complications. 5. Once the head delivers, check to see if the umbilical cord is wrapped around the baby’s neck. Tell the mother not to push while you check. If she can “pant,” or take short quick breaths for just a moment, it may help relieve the urge to push while you check. Then gently loosen the cord, if necessary. Even though the umbilical cord is very tough, rough handling may cause it to tear. If the cord is wrapped around the baby’s neck, try to place two fingers under the cord at the back of the baby’s neck. Bring the cord forward, over the baby’s upper shoulder and head. If you cannot loosen or slip the cord over the baby’s head, the baby cannot be delivered. Therefore, immediately clamp the cord in two places using the clamps provided in the obstetrics kit. Be very careful not to injure the baby. With extreme care, cut the cord between the two clamps. Gently unwrap the ends of the cord from around the baby’s neck, and then proceed with the delivery.

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6. Help deliver the shoulders. The upper shoulder will deliver next (usually with some delay), followed quickly by the lower shoulder. You must support the baby throughout this entire process. Gently guide the baby ‘s head downward, to assist the mother in delivering the baby’s upper shoulder. If the lower shoulder is show to deliver after the upper shoulder has delivered, assist the mother by gently guiding the baby ‘s head upward. 7. Support the baby throughout the entire birth process. Remember that newborns are very slippery. As the lower extremities are born, grasp them to ensure a good hold on the baby. Never pick up babies by the feet as they are very slippery and you could drop the child. Once the feet are delivered, lay the baby on his side with his head slightly lower than his body. This is done to allow blood, fluids, and mucus to drain from the mouth and nose. Keep the baby at the same level as the mother’s vagina until the umbilical cord stops pulsating. (Cutting the cord will be discussed later.) Dry the infant and wrap him in a warm, dry blanket.

THE NEONATE The term neonate is used for a newly born baby and infants less than 1 month old. Remember that a neonate is very different than other infants and must be treated accordingly. Maging malinaw sa paggamit ng mga salita. Ang “ fetus” ay ang bata na nabubuo pa lamang sa sinapupunan ng ina. Ang “neonate” naman ay ang bata na bagong panganak hanggang sa isang buwang gulang.

Assisting in a Normal Delivery FIRST TAKE STANDARD PRECAUTIONS

1. Support the infant’s head. Assist the mother by supporting the baby throughout the birth process. 2. With the other hand, wipe the mouth and nose with sterile gauze pads. II there are excessive secretions, fluids, or meconium present on the baby’s face, use the rubber bulb syringe to suction the baby’s mouth, then the nose. Some EMS systems prefer to withhold suctioning at the perineum, waiting until the baby is fully delivered before suctioning. Follow your local protocols. 3. Aid in the birth of the upper shoulder. 4. Support the trunk. 5. Support the pelvis and lower extremities. 6. Keep the infant level with the vagina until the umbilical cord stops pulsating. 594

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8. Assess the airway. Although most active babies will not require suctioning, for some it will be necessary. Suctioning will be important if positive pressure ventilations are necessary or if secretions threaten the airway or obstruct normal breathing. If necessary, use the rubber bulb syringe to suction the baby’s mouth, then the nose. Compress the syringe before placing it in the baby’s mouth. Suction the mouth first, then the nostrils. Carefully insert the tip of the syringe about 1 to 1 1/2 inches into the baby’s mouth and release the bulb to allow fluids to be drawn into the syringe. Control the release with your fingers. Withdraw the tip and discharge the syringe’s contents onto a towel. Repeat this procedure two or three times in the baby’s mouth and once or twice in each nostril. The tip of the syringe should not be inserted more than 1/2 inch into the baby’s nostril. 9. Note the exact time of birth. Write the mother’s last name and time of delivery on a piece of tape. Fold it so the adhesive does not touch the baby’s skin, and place it around the baby’s wrist.

Assessing the Neonate The neonate should be assessed as soon as he is born. If you arrive on scene after the birth, it is still your responsibility to make the assessments based on your first observations. Remember, however, that care for the infant and the mother should not be delayed. The assessment is meant to take place while these other activities are being performed, Your EMS system may call for a general or a specific evaluation protocol. A general evaluation usually call for noting the neonate’s ease of breathing, heart rate, crying, movement, and skin color. A normal neonate should have a pulse greater than 100/ min, be breathing easily, be crying (vigorous crying is a good sign), be moving his extremities (the more active, the better), and show blue coloration at the hands and feet only. Five minutes later, these signs should still be apparent, with breathing becoming more relaxed. The blue coloration may or may not disappear, but it should not spread to other parts of the body. A specific evaluation protocol that some EMS systems call for is an APGAR score. APGAR scores assign a number value to the neonate’s assessment findings. Always remember that the APGAR score does not guide resuscitation efforts, and efforts to determine the APGAR score must never interfere with resuscitation efforts. The APGAR score is the total of the five values, and ranges from 0 to 10. It is traditionally determined 1 minute after birth and then again 5 minutes after birth. You should always follow the assessment protocol appropriate to your system.

Caring for the Neonate Even with a normal delivery, each step in the care of the baby is essential for his survival.

Keeping the Baby Warm The most important aspect of caring for a neonate is keeping the baby warm. Newly born babies rapidly lose heat. This heat loss not only impacts their comfort, but also can drop their glucose levels and even impact their ability to carry oxygen in their blood. For these reasons, you must consider heat retention a high priority. If the baby is wet. dry her. Discard wet blankets and wrap the baby in dry ones. Consider using a commercially available infant swaddler, as these “space blankets” are specially designed to retain warmth. Cover the baby’s head. Cutting the umbilical cord is a relatively low priority. However, if the cord has not yet been cut, raising the baby above the level of the vagina may transfuse blood back into the placenta.

THE APGAR SCORE 0

Appearance

Blue (or pale) all over

extremities blue, trunk pink

Pulse

<100

Grim ace (reaction to suctioning or flicking of the feet)

No reaction

Facial grimace

Activity

No movement

Only slight activity (flexing extremities)

Respiratory effort

None

Slow or irregular breathing, weak cry

Cutting the Umbilical Cord In a normal birth, the infant must be breathing on his own before you clamp and cut the cord. Additionally, there is increasing evidence that you should wait at least one minute after birth before clamping and cutting the cord unless there is a need for resuscitation. In most cases cutting the cord should be a relatively low priority and there is no rush to complete this task. Before clamping and cutting the cord, palpate the cord with your fingers to make sure it is no longer pulsating. Pulsation typically stops shortly after delivery.

Huwag mong itatali, iipitin o puputulin ang pusod ng bata na hindi humihinga, maliban na lamang kung nakapulupot ito sa leeg ng bata paglabas nito, o kaya ay kailangan mong bigyan ng CPR ang sanggol. Huwag mong puputulin o iipitin ang pusod tumitibok pa.

The general procedure for umbilical cord care is as follows: 1. As already noted, keep the infant warm. Turn the heat up in the ambulance or the room you are in. Dry off the baby and wrap him in a baby blanket or infant swaddler, clean towel, or sheet prior to clamping the cord. Do not wash the infant. Sometimes the mother may request you to do so, but it is best to leave the protective coating (called the vernix) on the infant until he reaches the medical facility. 2. Use the sterile clamps or umbilical tape found in the obstetrics kit when cutting the cord. Use extreme care with any lying done to the cord, forming the knot slowly to avoid cutting the cord. Ties should he made using a square knot (right over left, then left over right). 3. Apply one clamp or tie to the 2 cord about 10 inches from the Pink all over baby. This leaves enough cord for intravenous lines to be used by paramedics or the staff at the >100 hospital if they are needed. Sneeze, cough, 4. Place a second clamp or tie about or cry 7 inches from the baby. The proximal clamp should be about the width of four fingers from the Moving around normally distal clamp. 5. Cut the cord between the clamps or knots using sterile surgical Good breathing, scissors. Use caution and protect strong cry your eyes when cutting the cord as a spurt of blood is very common. Never untie or unclamp a cord once it is cut. The placental end of the cord should be placed on the drape over the mother’s legs to avoid contact with expelled blood, feces, and fluids. Examine the fetal end of the cord for bleeding. Do not attempt to adjust the clamp or retie the knot. If bleeding continues, apply another tie or clamp as close to the original as possible. 6. Be careful when moving the baby so that no trauma is brought to the clamped cord. If the cord does not remain closed off completely, the baby may bleed to death from seemingly little blood loss. In most cases, the cord vessels will collapse and seal themselves.

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Day 23 If you are assisting at a birth when off duty, you will probably be able to find all the items you need to tie and cut the cord. If no clamps or tying devices are on hand, use clean shoelaces or similar soft, clean lies. If you tie the cord, believe it will be some time before you are able to transport and transfer the neonate, and do not have sterile scissors, soak scissors in alcohol for several minutes and use them to cut the cord. If the baby is still attached to the placenta when the organ is delivered, wrap the placenta in a towel and transport the infant and placenta as a unit. The placenta should be placed at the same level as the baby, or slightly higher. Maintain careful monitoring of the baby. Place the baby on the mother’s abdomen and allow the mother to begin breast feeding (if your local protocol allows). During the birth process, the fetus is passive. However, once the baby is born, he very quickly becomes active. Exposure to the air is usually enough to stimulate the infant to breathe. As you suction, dry. and warm the baby, he is stimulated even more. If the baby is breathing adequately and has a heart rate greater than 100/minute but has central cyanosis (blue coloration of the torso), administer blow-by oxygen. If the neonate does not breathe on his own after drying and warming for 30 seconds, begin resuscitation measures.

Neonatal Resuscitation

Neonatal resuscitation follows an inverted pyramid. Most neonates with abnormal assessment findings respond to relatively simple maneuvers. Few require CPR or advanced life support measures. Follow these steps for initial care of the neonate: 1. Provide warmth and assess the baby’s airway, if secretions obstruct normal breathing or if positive pressure ventilation is necessary, use a bulb syringe to suction the mouth first and then the nostrils. Squeeze the bulb before inserting the syringe into the baby’s mouth. Release the bulb to create suction. It may be necessary to use a sterile gauze pad to clear mucus and blood from around the baby’s nose and mouth. 2. Establish that the baby is breathing. Evaluate his respirations, heart rate, and muscle tone. Is the baby crying or breathing? Is the baby active and moving? Usually the baby will be breathing on his own. A neonate should begin breathing within 30 seconds. If he does not. then you must “encourage” the baby to breathe. Usually, a gentle but vigorous rubbing of the baby’s back will promote spontaneous respiration. If this method fails, snap one of your index fingers against the sole of the baby’s foot. Do not hold the baby up by his feet and slap his bottom! You should not become alarmed if the hands and feet of a breathing neonate appear slightly blue. It is not uncommon for this blue color to remain for 596

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OB-GYNE EMERGENCIES the first few minutes. If assessment of the infant’s breathing reveals shallow, slow, gasping, or absent respirations, provide positive pressure ventilation at a rate of 40 to 60 per minute. NOTE: Ventilate the neonate only enough to gain chest rise. These ventilations may be only small amounts of air if using mouth to mask, or small squeezes on the bag if using an infant-size bag-valve-mask device. Reassess the infant’s respiratory efforts after 30 seconds. If there is no change in the effort of breathing, continue with ventilations and reassessment. It is not necessary to attach supplemental oxygen to the bag mask device during neonatal resuscitation. Use room air to deliver the initial ventilations and consider supplemental oxygen only if oxygen saturations remain low following the resuscitation. 3. Assess the infant’s heart rate. If the heart rate is less than 100 beats per minute, then provide artificial ventilations at a rate of 40 to 60 per minute. If the heart rate is less than 60 beats per minute, initiate chest compressions. Chest compressions in the neonate should be delivered at a rate of 120 compressions per minute, applied over the lower third of the sternum with two thumbs and using fingers to support the neonate’s back The depth of compression is one-third of the anteriorposterior depth of the chest. Working at a 3:1 ratio of compressions to breaths in the neonate, the EMT should actually be delivering 120 “events” per minute (i.e.. 90 compressions and 30 ventilations). Take care to allow full recoil of the chest following compression. 4. If the child has adequate respirations and a pulse rate greater than 100 per minute, reassess the airway. Suction if needed and consider oxygen administration. Supplemental oxygen should be administered if cyanosis persists or if oxygen saturation remains low more than ten minutes after birth. Oxygen is best delivered at 15 liters per minute using a nonrebreather mask or oxygen tubing placed close to. but not directly into, the infant’s face. Laging isipin na kailangan ng sanggol na bagong silang na mainitan. Kung hindi ito humihinga at kailangan mong bigyan ng CPR, tiyakin na ipapatong mo ang sanggol sa kumot o mga tuwalya para hindi ito ginawin.

CARE AFTER DELIVERY

Caring for the Mother

Remember that you have two patients to care for: the infant and the mother. Although it is easy to make the baby your primary focus, remember that child-birth presents many risks for the mother. A woman who has just delivered a baby is at risk for serious bleeding, infection, and emboli. Be sure to treat her with the same attention you give the child. Care for the mother includes helping her deliver the placenta, controlling her vaginal bleeding, and making her as comfortable as possible. Note that in some circumstances, like neonatal resuscitation, you may need additional help to accomplish this goal. Hindi na kailangan hintayin pa na lumabas ang placenta o ang inunan ng bata bago ibiyahe ang bagong panganak na sanggol at ang ina nito. May mga pagkakataon kasi na hindi agad-agad humihiwalay ang placenta sa matris o uterus. Pinakaimportante na madala agad sa ospital ang sanggol at ang ina nito. Puwede mong pahintuin ang ambulansya kung sakaling biglang lumabas ang placenta.

Delivering the Placenta The third stage of labor is the delivery of the placenta with its umbilical cord section, membranes of the amniotic sac. and some of the tissues lining the uterus. All of these together are known as the afterbirth. Placental delivery begins with a brief return of the labor pains that stopped when the baby was born. You will notice a lengthening of the cord, which indicates the placenta has separated from the uterus In most cases, the placenta will be expelled within a few minutes after the baby is born. Although the process may take 30 minutes or longer, avoid the urge to put pressure on the abdomen over the uterus to hasten delivery of the placenta. If mother and baby are doing well, and there are no respiratory problems or significant uncontrolled bleeding, transportation to the hospital can be delayed up to 20 minutes while awaiting delivery of the placenta. Save all afterbirth tissues. The attending physician will want to examine the placenta and other tissues for completeness since any afterbirth tissues remaining in the uterus pose a serious threat of infection and prolonged bleeding to the mother. Try to catch the afterbirth in a container. Place the container in a plastic bag. or wrap it in a towel, paper, or plastic. If no container is available, catch the afterbirth in a towel, paper, or a plastic bag. Label this material “placenta “ and include the name of the mother and the time the tissues were expelled.

Controlling Vaginal Bleeding after Birth Delivery of the baby and placenta is always accompanied by some bleeding from the vagina. Although the blood loss is usually no more than 500cc. it may be profuse, which can lead to shock. Your reassessment of the mother must include evaluation of her bleeding and consideration of shock. To control vaginal bleeding after delivery of the baby and placenta, you should: 1. Place a sanitary napkin over the mother’s vaginal opening. Do not place anything in the vagina. 2. Have the mother lower her legs and keep them together. Tell her that she does not have to “squeeze” her legs together. Elevate her feet. 3. Massaging the uterus will help it contract. This will help control the bleeding. Feel the mother’s abdomen until you note a “grapefruit-sized” object. This is her uterus. Rub this area lightly with a circular motion. It should contract and become firm, and the bleeding should diminish. As this action will be very painful for the mother, you must explain that this procedure is necessary to stop serious bleeding. 4. The mother may want to nurse the baby. Although this will aid in the contraction of the uterus, some pediatricians recommend the baby not nurse until a doctor has examined the neonate. A tearing of tissue can occur in the perineum at the vaginal opening during the birth process. The mother may feel the discomfort from this torn tissue. Let her know that this is normal and that the problem will be quickly attended at the medical facility. Treat the torn perineum as a wound. Dress by applying a sanitary napkin and applying some pressure.

Providing Comfort to the Mother Keep in contact with the mother throughout the entire birth process as well as after she has delivered. Your care for the mother does not end when you have completed your duties with the placenta and vaginal bleeding. Frequently take her vital signs. Be aware that she has just undergone a tremendous emotional experience and small acts of kindness will be appreciated and remembered. Childbirth is a rigorous task, and a woman is physically exhausted at the conclusion of delivery. Wiping her face and hands with a damp washcloth and then drying them with a towel will do wonders to refresh her and prepare her for the trip to the hospital. Replace blood-soaked sheets and blankets. Make sure that both she and the baby are warm. LIFELINE

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When delivery occurs at home, ask a member of the family or a trusted neighbor to help you clean up. You should clean up whatever disorder EMS care has caused in the house; however, you should not delay transport in order to complete these activities. In some areas, local protocol may have you return to the house after transport in order to complete the clean-up process. If you do, you will have to be accompanied by a member of the family. Be sure to properly dispose of items that have been in contact with blood and other body fluids in a biohazard container.

CHILDBIRTH COMPLICATIONS Complications of Delivery

Although most babies are born without difficulty, complications may occur during and after delivery. We have already considered three such complications: the cord around the neck, an unbroken amniotic sac, and infants who need encouragement to breathe. These problems can be handled by simple procedures. However, there are other complications that can threaten the life of both mother and newborn and for which definitive treatment is beyond the EMTs level of training. For emergencies such as breech presentation, limb presentation, and prolapsed umbilical cord, you will provide high-concentration oxygen and rapid transport to the hospital.

Breech Presentation

Breech presentation, the most common abnormal delivery, involves a buttocks-first or both legs-first delivery. The risk of birth trauma to the baby is high in breech deliveries In addition, there is an increased risk of prolapsed cord. Meconium staining often occurs with breech presentations.

PATIENT ASSESSMENT Breech Presentation

If you evaluate a woman in labor and find the baby s buttocks or both legs presenting, rather than the head, this is a breech presentation. Breech presentations can spontaneously deliver successfully, but the complication rate is high.

PATIENT CARE

Breech Presentation Emergency care of a patient with a breech presentation includes the following steps: 1. Initiate rapid transport upon recognition of a breech presentation. 598

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2. Never attempt to deliver the baby by pulling on his legs. 3. Provide high-concentration oxygen. 4. Place the mother in a head-down position with the pelvis elevated. 5. If the body delivers, support it and prevent an explosive delivery of the head Insert your gloved index and middle fingers into the vagina to form a “V” on either side of the baby’s nose to lift it away from the vaginal wall in case the baby begins to spontaneously breathe. 6. Care for the baby, cord mother, and placenta as in after cephalic delivery.

Limb Presentation

A limb presentation occurs when a limb of an infant protrudes from the vagina. The presenting limb is commonly a fool when the baby is in the breech position. Limb presentations cannot be delivered in the prehospital selling. In this case, rapid transport is essential to the baby’s survival.

PATIENT ASSESSMENT

Limb Presentation

When checking for crowning, you may see an arm, a single leg, an arm and a leg together, or a shoulder and an arm. If one or more limbs present, there is often a prolapsed umbilical cord as well.

PATIENT CARE

Limb Presentation

Laging isipin na ang panganganak ay isang masayang okasyon. Kausapin mo ang babaeng manganganak na parang kamag-anak. Bigyan mo ito ng lakas ng loob at laging paalalahanan na magiging maayos ang lahat.

When you discover a limb presentation, take these emergency care steps. 1. If there is a prolapsed cord, follow the same procedures as you would for any delivery involving a prolapsed cord. Remember, you have to keep pushing up on the baby until relieved by a physician. The baby must be kept off of the cord if he is to survive. 2. Transport the mother immediately to a medical faculty. 3. Place the mother in a headdown position with the pelvis elevated. 4. Administer high-concentration oxygen with a nonrebreather mask.

Prolapsed Umbilical Cord Sometimes during delivery, the umbilical cord presents first (this is most common in breech births) and the cord is squeezed between the vaginal wall and the baby’s head. This occurrence is known as prolapsed umbilical cord. When this happens, the cord is pinched, and oxygen supply to the baby may be totally interrupted. This is a life-threatening condition to the neonate.

PATIENT ASSESSMENT

Prolapsed Umbilical Cord

If, upon viewing the vaginal area, you see the umbilical cord presenting, the cord is prolapsed.

PATIENT CARE

Prolapsed Umbilical Cord Follow these steps when the umbilical cord is prolapsed: 1. Position the mother with her head down and pelvis raised with a blanket or pillow using gravity to lessen pressure on the birth canal. 2. Provide the mother with high-concentration oxygen by way of a non-rebreather mask to increase the concentration carried over to the infant. 3. Check the cord for pulses and wrap the exposed cord, using a sterile towel from the obstetrics kit. The cord must be kept warm. 4. Insert several fingers of your gloved hand into the mother’s vagina so that you can gently push up on the baby’s head or buttocks to keep pressure off of the cord You will be pushing up through the cervix. This may be the only chance that the baby has for survival, so continue to push up on the baby until a physician relieves you. You may feel the cord pulsating when pressure is released. 5. Keeping mother, child, and EMT as a unit, transport immediately to a medical facility. Be prepared to stay in this position until you reach the hospital. 6. All patients with prolapsed cords require rapid transport Have your partner obtain vital signs while en route to the hospital, if possible.

Multiple Birth When more than one baby is born during a single delivery, it is called a multiple birth. A multiple birth, usually twins, is not considered a complication, provided that the deliveries are normal. However, prematurity and other complications are common with multiple births. Twins are generally delivered in the same manner as a single delivery, with one birth following the other. However, if a multiple birth is encountered, you should have enough personnel and equipment available for multiple resuscitations. Call for assistance if needed. When delivering twins, identify the infants as to order of birth (one and two, or A and B).

PATIENT ASSESSMENT

Multiple Birth

It the mother is under a physician’s care, she will probably be aware that she is carrying twins. Without this information, you should consider a multiple birth to be a possibility if the mother’s abdomen appeals unusually large before delivery, or it remains very large after delivery of one baby If the birth is multiple, labor contractions will continue and the second baby will be delivered shortly after the first The second baby may present in a breech position, usually within minutes of the first birth. The placental(s) are normally delivered.

PATIENT CARE

Multiple Birth

When assisting in the delivery of twins, follow these steps: 1. Assure you have appropriate resources on-scene. Assume you will need to conduct multiple neonatal resuscitations simultaneously while still treating the mother. 2. Clamp or tie the cord of the first baby before the second baby is born. 3. The second baby may be born either before or after the placenta is delivered. Assist the mother with the delivery of the second baby 4. Provide care for the babies, umbilical cords, placenta(s), and the mother as you would in a single-baby delivery. 5. The babies will probably be smaller than in a single birth, so take special care to keep them warm during transport.

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Premature Birth By definition, a premature infant is one who weighs less than 5 1/2 pounds (2 1/2 kilograms) at birth, or one who is born before the 37th week of pregnancy.

PATIENT ASSESSMENT Premature Birth

Since you probably will not be able to weigh the baby, make a determination as to whether the baby is full-term or premature based on the mother ‘s expected due date and the baby’s appearance. If the mother is unsure of her due date, you can make a rough estimate by asking her when she had her last menstrual period and adding 40 weeks. Assessment of the baby itself might indicate prematurity. By comparison with a normal full-term baby, the head of a premature infant is much larger in proportion to the small, thin, red body.

PATIENT CARE

Premature Birth

Premature babies need special care from the moment of birth The smaller the baby, the more important is the initial care You should take the following steps when providing care for the premature infant: 1. Keep the baby warm Premature infants are at great risk of developing hypothermia. Once breathing, the baby should be dried and wrapped snugly in a warm blanket. Additional protection can be provided by an outer wrap of plastic bubble wrap (keep this away from the infant’s face) or a small reflective blanket. Premature babies lack fat deposits that would normally keep them warm. Some EMS systems in cold regions use plastic, bubble wrap, or a bag for the infant, covered by a blanket. This helps maintain warmth and allows for easier visual inspection of the clamped cord to check for bleeding. A stockinet cap should be placed on the baby ‘s head to help reduce heat loss. 2. Keep the airway clear Continue to suction fluids from the nose and mouth using a rubber bulb syringe. Keep checking to see if additional suctioning is required. 3. Provide ventilations and/or chest compressions as outlined earlier based upon the baby ‘s pulse and respiratory effort In some cases, resuscitation may not be possible if the baby is extremely premature. 4. Watch the umbilical cord for bleeding Carefully examine the cut end of the cord. If there is any sign of breeding, even the slightest, apply another damp or tie closer to the baby’s body. 5. Avoid contamination. The premature infant is susceptible to infection. Keep him away from other people. Do not breathe on his face. 600

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6. Transport the infant in a warm ambulance The desired temperature is between 90°F and 100°F. Use the ambulance heater to warm the patient compartment prior to transport. In the summer months, the air conditioning should be turned off and all compartment windows should be closed or adjusted to keep the ambulance at the desired temperature. 7. Call ahead to the emergency department and consider transporting to a facility capable of caring for a premature infant

Meconium As noted earlier, meconium is a result of the fetus defecating (putting out wastes). It is a sign of fetal or maternal distress.

PATIENT ASSESSMENT Meconium

Meconium stains amniotic fluid greenish or brownish-yellow in color Infants born with meconium are at increased risk for respiratory problems, especially if aspiration of the meconium occurs at birth.

PATIENT CARE Meconium

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If the baby requires resuscitation after birth and you see meconium staining to the amniotic fluid or on the baby itself, follow these steps: 1. To reduce the risk of aspiration, do not stimulate the infant before suctioning the oropharynx. 2. Suction the mouth and then the nose. 3. Maintain an open airway. 4. Provide artificial ventilations and/or chest compression as indicated by the infant’s effort of breathing and heart rate. 5. Transport as soon as possible.

Emergencies in Pregnancy A number of pre-delivery emergencies can arise in the pregnant patient prior to labor or childbirth. When assessing a pregnant female, consider the changes that have occurred to her body along with the pregnancy. Remember that you are really assessing two people, both the mother and fetus. Always complete a thorough assessment as you would any other patient. You may also consider asking the woman about bleeding or other vaginal discharge as well as syncope as these can indicate serious problems. Ask about the baby’s movement. Typically after around 20 weeks 1 mother will begin to feel movement of the fetus. Although this is not exact, movement or a lack thereof can be a helpful assessment finding.

When treating a pregnant woman (or a potentially pregnant woman), respect her modesty and privacy. Remember that she may not want to share the information you are asking her with the world.

Excessive Pre-birth Bleeding

PATIENT ASSESSMENT

When treating a pregnant woman (or a potentially pregnant woman), respect her modesty and privacy. Remember that she may not want to share the information you are asking her with the world. A number of conditions can cause excessive

Excessive Pre-birth pre birth bleedingBleeding late in preg-

nancy. You should consider any bleeding inThe following are common signs and late pregnancy a serious emersymptoms of excessive pre-birth bleeding: gency. Whether the vaginal bleeding is associated with abdominal pain or not, • The main sign is usually profuse bleeding A number of conditions can cause excessive pre the risk (o both the mother and the unborn child is great. from the vagina.

Excessive Pre-birth Bleeding

birth bleeding late in pregnancy. You should consider any • The mother may or may not experience bleeding in late pregnancy a serious emergency. Whether associated abdominal pain. the vaginal bleeding is associated with abdominal pain or A pregnant woman does not have to be in• labor to have excessive bleeding During your primary assessment, you should not, the risk to both the mother and the unborn child is look for signs of shock. from the vagina. For example, bleeding in early pregnancy may be due to a great. • Obtain baseline vital signs. A rapid heartbeat miscarriage. If the bleeding occurs late in pregnancy, it may be due to problems A pregnant woman does not have to be in labor to may indicate significant blood loss. have excessive bleeding from the vagina. For example, involving the placenta. bleeding in early pregnancy may be due to a miscarriage. If the bleeding occurs late in pregnancy, it may be due to problems involving the placenta. In one such condition, placenta previa, the placenta is formed in an abnormal In one such condition, placenta previa, the placenta location (low in the uterus and close to or over the cervical opening) that will is formed in an abnormal location (low in the uterus and • If signs of shock exist, treat with highclose to or over the cervical opening) that will not allow not allow for a nor-mal delivery of the fetus. As the cervix dilates, the placenta concentration oxygen and rapid transportation. for a normal delivery of the fetus. As the cervix dilates, tears. Another such condition is abruptio placenta, in which the placenta sepa• Place a sanitary napkin over the vaginal opening. the placenta tears. Another such condition is abruptio Note the time of napkin placement. Do not rates from the uterine wall. This can be a partial or a complete abruption. Either placenta, in which the placenta separates from the uterine place anything in the vagina. Replace pads as wall. This can be a partial or a complete abruption. Either placenta previa or abruptio placenta may occur in the third trimester. Both are they become soaked, but save all pads for use in placenta previa or abruptio placenta may occur in the potentially life-threatening conditions for the evaluating blood loss. mother and fetus. third trimester. Both are potentially life-threatening • Save all tissue that is passed. conditions for the mother and fetus.

PATIENT CARE

Excessive Pre-birth Bleeding

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² Limmer (Brady) ³ Pollack, (AAOS)

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Save all tissue that is passed

Ectopic Pregnancy Unit 3

Day 23

OB-GYNE EMERGENCIES

PATIENT CARE Ectopic Pregnancy

Emergency ewe includes the following steps: 1. Consider the need for immediate transport. 2. Position the patient for shock 3. Care for shock. 4. Provide high-concentration oxygen by nonrebreather mask. 5. Do not give the patient anything by mouth.

Seizures in Pregnancy Seizures in pregnancy, sometimes caused by a condition called eclampsia, tend to occur late in pregnancy. The seizures are typically a result of a condition called preeclampsia. This condition is often related to pregnancy-induced hypertension and may be well known to the patient. Preeclampsia can he recognized by altered mental status; swollen hands, feel, and/ or face: and high blood pressure. Seizures in pregnancy pose a In a normal pregnancy, the fertilized egg will begin to divide in the fallopian serious threat to both the mother and unborn baby. tube and eventually implant in the wall of the uterus In an ectopic pregnancy, the egg may implant outside the uterus—e.g., in the cervix or pelvic cavity. EcIn a normal pregnancy, the fertilized egg will begin topic pregnancies usually occur in the fallopian tube, which ruptures as the to divide in the fallopian tube and eventually implant in fetus grows. This results in internal bleeding. the wall of the uterus In an ectopic pregnancy, the egg may implant outside the uterus—e.g., in the cervix or pelvic cavity. Ectopic pregnancies usually occur in the fallopian tube, which ruptures as the fetus grows. This results in A seizure may be associated with any of the following: internal bleeding. • Existing preeclampsia or pregnancy-induced ² Limmer (Brady) ³ Pollack, (AAOS) hypertension. ⁴ NHTSA • Elevated blood pressure, which increases the risk of abruptio placenta. • Excessive weight gain. • Extreme swelling of the face, hands, ankles, and feet • Altered mental status, headache, or other unusual The problems related to this condition are seen early in neurologic findings. pregnancy Indeed, some women with an ectopic pregnancy may be unaware that they are even pregnant when the signs and symptoms begin. Women may have signs and symptoms including those indicating shock due to internal bleeding This condition can be life threatening and. as the saying goes, “Any woman of child-bearing age with abdominal pain has an ectopic pregnancy until proven Emergency care of a pregnant patient with seizures includes otherwise by the physician in the emergency department.” the following steps. Be alert to recognize the following signs and symptoms as 1. Ensure and maintain an open airway. they develop: 2. Administer high-concentration oxygen by nonrebreather mask. • Acute abdominal pain, often beginning on one 3. Transport the patient positioned on her left side side or the other, which can also be referred to the 4. Handle the patient gently at all times. Rough handling may shoulder. induce more seizures. • Vaginal bleeding (often accompanies pain). 5. Keep the patient warm, but do not overheat. • Rapid and weak pulse (a later sign). 6. Have suction ready. • Low blood pressure (a very late sign). 7. Have a delivery kit ready. • Absent menstrual period, used to indicate a possible 8. Contact ALS for immediate assistance. pregnancy.

Ectopic Pregnancy

PATIENT ASSESSMENT Seizures in Pregnancy

PATIENT ASSESSMENT Ectopic Pregnancy

PATIENT CARE Seizures in Pregnancy

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Miscarriage and Abortion For a number of reasons, the fetus and placenta may deliver before the 28th week of pregnancy—generally before the baby can live on his own. This occurrence is an abortion When it happens on its own, it is called a spontaneous abortion, more commonly known as a miscarriage. An induced abortion is an abortion that results from deliberate actions taken to stop the pregnancy.

PATIENT ASSESSMENT Miscarriage and Abortion Women having a miscarriage that requires them to seek emergency care generally have the following signs and symptoms: • Cramping abdominal pains not unlike those associated with the first stage of labor. • Bleeding ranging from moderate to severe. • A noticeable discharge of tissue and blood (torn the vagina. Ask the patient about the starting date of her last menstrual period. If it has been more than 24 weeks, be prepared with an obstetrics kit. Premature infants may survive if they receive rapid neonatal intensive care.

PATIENT CARE Miscarriage and Abortion 1. Obtain baseline vital signs. 2. If signs of shock are present, provide highconcentration oxygen by a nonrebreather mask. Treatment should be based on signs and symptoms. 3. Help absorb vaginal blooding by placing a sanitary napkin over the vaginal opening. Do not pack the vagina. 4. Transport as soon as possible. 5. Replace and save all blood-soaked pads. 6. Save all tissues that are expelled. Do not attempt to replace or pull out any tissues that are being expelled through the vagina. 7. Provide emotional support to the mother Emotional support is very important. When speaking to the patient, her family, or in an area where bystanders may hear you, always use the term miscarriage instead of spontaneous abortion. Most people associate the word abortion with an induced abortion, not a miscarriage. It is essential to talk with the patient to gain her confidence and to allow you to provide emotional support.

Trauma in Pregnancy Obviously the pregnant patient, like any other patient, can sustain injury. However, especially during the last two trimesters the uterus and fetus are also subject to injuries when the mother is injured. Injuries to the uterus may be blunt or penetrating. In both cases, the greatest danger to the mother and baby is hemorrhage (bleeding) and shock. The most common cause of blunt trauma is automobile collisions although falls and assaults also account for many injuries. The uterus is well designed to protect the baby. The fetus is inside a muscular chamber filled with fluid. In this way. the uterus acts as an efficient shock absorber. Thus, most minor trauma to the abdomen, such as a blow or fall, typically does not harm the fetus. Automobile collisions pose a high risk of injury, as the magnitude of forces in a collision is great. Because of its size and location, the uterus is frequently injured in these collisions. Sudden blunt trauma to the abdomen during the later months of pregnancy may cause uterine rupture or premature separation of the placenta (abruptio placenta). Other blunt trauma injuries, such as a ruptured spleen or liver, may also occur. Rupture of the diaphragm may occur with blunt trauma during later pregnancy. Multisystem trauma with fractures of the pelvis can cause laceration or tearing of the vessels in the pelvis, leading to massive hemorrhage. The common problem with most blunt injuries to the pregnant woman’s abdomen or pelvis is massive bleeding and shock. If a pregnant woman is injured in an incident such as a motor-vehicle collision or a fall, perform a patient assessment and treat her injuries as you would those of any other trauma patient. The best way to keep the fetus alive is to appropriately treat the mother

PATIENT ASSESSMENT Trauma in Pregnancy • During primary assessment and assessment of vital signs, remember the following about the physiology of pregnant women: • The pregnant patient has a pulse that is 10 to 15 beats per minute faster than the non-pregnant female. Therefore, vital signs may be interpreted as being suggestive of shock when they are actually normal for the pregnant female. • A woman in later pregnancy may have a blood volume that is up to 48 percent higher than her non-pregnant state with hemorrhage. About 30 to 35 percent blood loss may occur before otherwise healthy pregnant females exhibit signs or symptoms. • Although shock is more difficult to assess in the

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pregnant patient, it is the most likely cause of prehospital death from injury to the uterus. • Question the conscious patient to determine if she has received any blows to the abdomen, pelvis, or back. • Ask the patient if she has had bleeding or rupture of the bag of waters When in doubt, examine the vaginal area for bleeding, being certain to provide privacy. • Examine the unconscious patient for abdominal injuries, remembering to consider the mechanism of injury.

PATIENT CARE Trauma in Pregnancy Remember that maintenance of respiration and circulation and the control of bleeding are vital not only to the mother but also to the fetus A developing fetus is critically dependent on the uninterrupted oxygenated blood supply that enters the placenta. What is good for the mother is good to the baby Since the mother-to-be may have undetected internal bleeding or the fetus may be injured, provide the following care to the injured mother: 1. Provide resuscitation, if necessary. 2. Provide high-concentration oxygen by using a nonrebreather mask (Oxygen requirements of the woman in later pregnancy are 10 to 20 percent greater than normal. If in doubt, give oxygen ) 3. Because at slowed digestion and delayed gastric emptying, there is a greater risk the patient will vomit and aspirate Be ready with suction 4. Transport as soon as possible. All pregnant women should be transported in the left lateral recumbent position, supported with pillows or blankets, unless a spinal injury is suspected. If so, first secure the mother to a spine board, then tip the board and patient as a unit to the left, relieving pressure on the abdominal organs and vena cava. Be sure to monitor and record the patient’s vital signs. 5. Provide emotional support A pregnant woman who is a trauma victim will naturally worry about her unborn child. Remind her that the developing baby is well protected in the uterus Let her know that she is being transported to a medical facility that can take care of her needs and the needs of the unborn child.

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OB-GYNE EMERGENCIES

Stillbirths

Some babies die in the uterus several hours, days, or even weeks before birth. Such a baby is called stillborn. It is a tragic time for the parents and other family members when a baby is born dead or dies shortly after birth. Your thoughtfulness may provide the distraught parents with comfort. Never lie to the parents. Many death-and-dying experts believe that parents should be allowed to view the baby if they wish to. Unless there is obvious death, all resuscitative efforts should be continued until the infant is transferred to the hospital (follow your local protocols). Also, keep accurate records, of the time of stillbirth and the care rendered for completion of the fetal death certificate.

PATIENT ASSESSMENT Stillbirth

When a baby has died some time before birth death is obvious by the presence of blisters, foul odor, skin or tissue deterioration and discoloration, and a softened head. At other times, a baby may be born in pulmonary or cardiac arrest but in otherwise good condition. These babies have the possibility of being resuscitated.

PATIENT CARE Stillbirth

Emergency care for a stillborn baby is as follows: 1. Withhold resuscitative efforts from stillborn babies who have obviously been dead for some time before birth. 2. Provide full resuscitation measures for any babies who are born in pulmonary or cardiac arrest. 3. Prepare to provide life support when the baby is alive but respiratory or cardiac arrest appears to be imminent

Accidental Death of a Pregnant Woman If a woman in advanced pregnancy dies from trauma and you immediately begin CPR on her, there is a chance of saving the unborn child’s life. CPR must be continued until an emergency cesarean section can be performed. Reposition your hands for compressions 1 to 2 inches higher on the sternum to make up for shifting of the heart due to the large fetus. If CPR is delayed 5 to 10 minutes, chances of saving the baby are fair, whereas a 25-minute delay reduces the chances to almost zero. Continue CPR on the mother until you are relieved in the emergency department.

GYNECOLOGICAL EMERGENCIES Several emergencies may occur that are associated with the reproductive systems of women but not associated with pregnancy, including vaginal bleeding, trauma to the external genitalia, and sexual assault.

Vaginal Bleeding Vaginal bleeding that is not a result of direct trauma or a woman’s normal menstrual cycle may indicate a serious gynecological emergency.

PATIENT ASSESSMENT Vaginal Bleeding Since it will be impossible for the EMT to determine a specific cause of the bleeding, it is important that all women who have vaginal bleeding be treated as though they have a potentially life-threatening condition. This is especially true if the bleeding is associated with abdominal pain. The most serious complication of vaginal bleeding is hypovolemic shock due to blood loss. If a woman has been using pads to absorb bleeding, consider asking her how many pads she has used. This count may be helpful in assessing blood loss.

PATIENT CARE Vaginal Bleeding

Trauma to the External Genitalia

Trauma to a woman’s external genitalia can he difficult to care for because of the patient’s modesty and the severe pain often involved with such injuries. You should always consider assault a possibility in this type of trauma as it is the leading cause of external genitalia trauma.

PATIENT ASSESSMENT Trauma to the External Genitalia Injuries in this area tend to bleed profusely because of the rich blood supply provided to the area Injuries to the female external genitalia are frequently the result of straddle-type injuries: • In sizing up the scene, observe for mechanisms of injury. • During primary assessment, look for signs of severe blood loss and shock. • Consider the potential for additional internal injuries

PATIENT CARE Trauma to the External Genitalia 1. Maintain a professional attitude. 2. Control bleeding with direct pressure over a bulky dressing or sanitary pad (If the patient is alert, she will probably prefer to do this herself). Do not remove the patient’s undergarments unless necessary. Do not pack the vagina. 3. If signs of shock are present, treat with highconcentration oxygen. 4. Respect the patient a privacy. Remove unneeded bystanders and expose the patient’s body only to the extent necessary to provide appropriate care. 5. Consider the possibility of assault. Contact law enforcement and consider providing social service referrals.

1. Take standard precautions. Wear gloves, gown, protective eyewear, and mask as indicated. 2. Ensure an adequate airway. 3. Assess for signs of shock. 4. Administer high-concentration oxygen by nonrebreather mask. 5. Transport.

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PRINCIPLES OF EMT CLINICAL PRACTICE

Sexual Assault

Situations in which a sexual assault has occurred are always a challenge to the EMT. Care of the patient must include both medical and psychological considerations. In addition, law enforcement agencies are also frequently involved. There is no question that the sexual assault patient is under tremendous stress. Because of this, you must be prepared to deal with a wide range of emotions that the patient may exhibit. The best approach is to be non-judgemental and to maintain a professional but compassionate attitude. Unless it delays care, it is generally preferable that an EMT of the same sex as the patient establish rapport and be the primary provider of emergency care.

PATIENT ASSESSMENT Sexual Assault

• Since you may be entering a potential crime scene, ensure that the scene is safe prior to entering. It may be necessary to “stage” your unit near the scene until it is rendered safe by police. • Be professional and compassionate. Be nonjudgmental in your questioning and do not make promises you cannot keep. For example, avoiding saying things like. “It will be ok,” or “He’ll definitely go to jail.” • Be conscious of personal space. Explain your examinations and treatments beforehand. Be sensitive to the patient’s fears and embarrassment. • During assessment, identify and treat both the medical and the psychological needs of the patient.

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PATIENT CARE Sexual Assault

1. Treat Immediate life threats. 2. Be careful not to disturb potential criminal evidence unless it is absolutely necessary for patient care. 3. Examine the genitals only if severe bleeding is present. 4. Discourage the patient from bathing, voiding, or cleansing any wounds, as this may result in loss of important evidence. 5. Fulfill any reporting requirements that are locally mandated. 6. Learn what social service resources are available in your area. Consider providing referrals.

Lifeline in Action They come from different backgrounds. And their reasons for enrolling in Lifeline Academy are as varied as their professions. Yet one common thread binds these Lifeliners – they are all convinced that the training they got from Lifeline has forever changed their lives. We asked around from Lifeliners to find out their motivation for becoming EMTs or what they can say about Lifeline Academy. Here are some of the responses we got: Capt. Emeterio Armada, Philippine Army “As part of the Philippine Army’s First Responders, it is necessary for us to become EMTs in order to save lives. The knowledge and skills I learned here are vital for my job.”

WHY DID THEY BECOME A LIFELINER? Joanna Marie Mejia, Nurse “I chose to become an EMT to remove my worries and nervousness when it comes to treating a patient in emergency situations. EMTs are the coolest and boldest people I’ve ever known.” Jennifer Villacorta, Fire Officer 2 “I chose to become an EMT because I’m in the field wherein quick judgment and valuable knowledge are needed to become competent, that I can respond accordingly to any situation. My Lifeline training devloped my social skills in responding to any scenario.” James Ervin Malasig, Airman First Class “Lifeline made an impact on my career. Whenever I am with family and friends, they know I can help them and I am confident with the skills that Lifeline taught me.”

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THE Philippines has a young population, with more than 35 million under 15 years old. With this number, chances of having emergencies involving children are high. As a future EMT, you will be handling various cases of pediatric emergencies, ranging from choking, shock, respiratory disorders, digestive ailments, and even accidents like drowning. In dealing with these emergencies, you must first realize that a childâ&#x20AC;&#x2122;s body is different from that

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Pediatric Emergencies Pediatric Assessment Respiratory issues

Fever, diarrhea, and seizures Children in motor vehicle collisions of an adult. The care you should provide should, therefore, be different. This chapter will give you the insights you need to understand the anatomy and physiology of children, and the emergencies they often experience. It would equip you with the necessary skills in assessing the condition of your pediatric patients and providing appropriate care in a manner that is designed for their age.

Child abuse and neglect Children with special needs

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PRINCIPLES OF EMT CLINICAL PRACTICE

PEDIATRIC EMERGENCIES LEARNING OBJECTIVES • Identify the developmental considerations for the following age groups: infants, toddlers, pre-school, school age and adolescent. • Identify the signs and symptoms of shock (hypoperfusion) in the infant and child patient. • Describe the methods of determining end organ perfusion in the infant and child patient. • Describe differences in anatomy and physiology of the infant, child and adult patient. • Describe the management of seizures in the infant and child patient. • Describe the medical legal responsibilities in suspected child abuse. • Describe techniques for successful assessment of infants and children. • Describe the general approach to the treatment of children with respiratory distress, failure, or arrest from upper airway obstruction or lower airway disease.

INTRODUCTION

The term pediatric generally refers to patients who have not yet reached the age of puberty. Although sometimes this is difficult to determine in the field, puberty can typically be identified by breast development in females and hair observed on the face, chest, or underarms of males. This population features an enormous range of developmental differences. Consider the significant anatomic differences between a 12-month-old child and a 12-year-old child. Although we would never consider the 12-month-old to be a “little adult,” the 12-yearold child is probably more anatomically similar to an adult than to a baby. What this means to you as an EMT is that you must adjust your expectation to the developmental baselines of the age group. You must understand how anatomic differences impact your treatments and adjust your assessment to accommodate a patient who may or may not be old enough to answer your questions. Dealing with pediatric patients requires specific knowledge, creativity, and patience. This chapter is designed to provide you with the tools you need to manage this special population.

DEVELOPMENTAL CHARACTERISTICS OF INFANTS AND CHILDREN Some important differences should be kept in mind when you are caring for a young patient. For example, since young children do not like to be separated from their parents, you will want to let the child sit in the parent’s lap, if possible, during assessment and treatment. However, during transport the child must be appropriately restrained. Children will exhibit different characteristics as they grow older, and these will require the EMT to adapt treatment strategies, depending on the patient’s developmental age. However, The psychological and social characteristics of infants and children cannot be specifically defined by their age. Often children develop at different rates, even among the same age group. Just as a 6-year-old child is different from a 35-year-old adult, so is a 4-week-old infant different from a 12-year-

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old child. Children are constantly growing, learning, and, therefore, changing. In an ideal world, we might be able to tell exactly how a 4-year-old will behave. In reality, we have to put children into broad categories according to how children of their age group behave on the average. No system of categorizing children is perfect, but each has advantages for particular uses. This applies to psychological and social characteristics, as well as physical development. Children grow at different rates, and their size may not match their social development. After determining a child’s age, if you are able to, attempt to have an age-appropriate conversation with the child. If that doesn’t seem to work, then observe the child’s interaction with a parent or caregiver for clues that might help you with your assessment and treatment strategies.

For basic life support (rescue breathing and CPR), the Philippine Heart Association defines an infant as ages birth to 1 year, and a child as 1 year to puberty. However, these age ranges do not always apply to the care of children in other medical or trauma cases. In general emergency care, the following age categories are more useful to keep in mind: • Newborns and infants: birth to 1 year • Toddlers: 1 to 3 years • Preschool: 3 to 6 years • School age: 6 to 12 years • Adolescent: 12 to 18 years

ANATOMIC AND PHYSIOLOGIC DIFFERENCES COMPARED TO ADULTS

Age ranges will vary somewhat in different listings: for example, in vital sign ranges, as shown in table below. There will be calls when it will not be possible to find out the patient’s age and you will have to make a guess, based on the child’s physical size and emotional reactions.

POTENTIAL IMPACT ON ASSESSMENT AND CARE

Tongue proportionately larger

More likely to partially obstruct the airway

Smaller airway structures

More easily blocked

Abundant secretions

Can block the airway

Deciduous (baby) teeth

Easily dislodged; can block the airway

Flat nose and face

Difficult to obtain good face mask seal

Head heavier relative to body and lessdeveloped neck structures and muscles

Head may be propelled more forcefully than body, creating a higher incidence of head injury

Fontanelle and open sutures (sort spots) palpable on top of young infant’s head

Bulging fontanelle can be a sign of intracranial pressure (but may be normal if infant is crying); sunken fontanelle may indicate dehydration

Thinner, softer brain tissue

Susceptible to serious brain trauma

Head larger in proportion to body

Head tips forward when supine, causing flexion of neck, making neutral alignment of cervical spine and airway difficult

Shorter, narrower, more elastic (flexible) trachea

Can close off trachea with hyperextension of neck

Short neck

Difficult to stabilize or immobilize

Abdominal breathers

Reliant on diaphragm to breathe; difficult to evaluate breathing

Faster respiratory rate

Muscles easily fatigue, causing respiratory distress

Newborns/infants typically nose breathers

Nasal obstruction can impair breathing

Larger body surface relative to body mass

Prone to hypothermia

Softer bones

More flexible, less easily fractured; traumatic forces may be transmitted to, and injure, internal organs without fracturing ribs or other bones

More flexible ribs

Traumatic forces may be transmitted to chest cavity without fracturing ribs; lungs easily damaged with trauma

Spleen and liver more exposed

Injury likely with significant force to abdomen

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Normal Vital Sign Ranges: Infants and Children NORMAL RESPIRATION RATE (BREATHS PER MINUTE, AT REST) Newborn

30 to 50

Infant 0-5 months

25 to 40

Infant 6-12 months

20 to 30

Toddler 1-3 years

20 to 30

Preschooler 3-5 years

20 to 30

School age 6-10 years

15 to 30

Adolescent 11-14 years

12 to 20

Suriin mabuti ang pulso ng bata. Ang mabagal na pulso ay mas delikado kesa mabilis. Ang mabagal at mahinang pulso ay posibleng indikasyon ng papalapit na pagtigil ng puso. Importante na maging alerto. Kadalasan, hindi sinusukat ang blood pressure ng mga batang edad 3 gulang pababa. Sa mga ganitong sitwasyon, aakalain mo na normal ang blood pressure ng bata subalit bigla na lamang itong babagsak pag malapit nang tumigil ang puso.

BLOOD PRESSURE NORMAL RANGES Systolic: Approx. 80 plus 2 x age

Approx. 2/3 Systolic

Preschooler 3-5 years

Average 99 (78 to 116)

Average 65

School age 6-10 years

Average 105 (80 to 122)

Average 69

Adolescent 11-14 years

Average 114 (88 to 140)

Average 76

Anatomic and Physiologic Differences Infants and children differ from adults not only in psychology but also in anatomy and physiology. Be sure to review the special characteristics of infants and children. Understanding some of these differences will help you do a better job of assessing and caring for young patients. It is important to keep in mind the key differences in the following major body systems.

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Diastolic:

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Head A child’s head is proportionately larger and heavier than an adult’s until about the age of 4. Because the head is often the heaviest part of the body, children often fall head first. As a result, you should suspect head injury whenever there is a serious mechanism of injury. Up to about 1 year to 18 months, infants will have a “soft spot” just anterior to the center of the skull, called the anterior fontanelle. The fontanelle is flat and soft while the child is quiet and normally bulges when the infant is crying. A sunken fontanelle may indicate dehydration, whereas a bulging fontanelle may indicate elevated intracranial pressure.

UNIT 3 DAY 24

PRINCIPLES OF EMT CLINICAL PRACTIC Airway and Respiratory System

Airway and Respiratory System CRITICAL CONCEPT

The infant’s and child’s neck muscles are immature and the airway structures are shorter, narrower, and less rigid than an adult’s. Here are several other special characteristics about infant’s and children’s respiratory systems that you should be aware of: • The mouth and nose are smaller and more easily obstructed than in adults. • The tongue takes up more space proportionately in the mouth than in adults. • Newborns and infants typically breathe through their noses. Nasal obstruction can impair breathing. • The trachea (windpipe) is softer and more flexible in infants and children. • The trachea is narrower and is easily obstructed by swelling or foreign objects. • The chest wall is softer, and infants and children tend to depend more on their diaphragms for breathing than do adults. These differences in respiratory anatomy pose several implications for the emergency treatment you provide to an infant or a child: • Because infants are nose breathers, be sure to suction secretions from the nose as needed to help the patient breathe. • Hyperextension or flexion of the neck (tipping the head too far back or letting it fall forward) may result in airway obstruction. A folded towel under the shoulders of a supine infant or young child may help to keep the airway in a neutral inline position. • “Blind” finger sweeps are not performed when trying to clear an airway obstruction in an infant or child because your finger might force the obstruction back and wedge it in the narrow trachea. An attempt to remove a foreign body airway obstruction should be done only when the obstruction is directly observed.

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Chest and Abdomen

The infant's and child's neck muscles arc immature and the airway structures a shorter, narrower, and less rigid than an adult's. 1 here are several other spec The less developed and more elastic chest structures of an infant or child make labored or distressed characteristics about infant's and children's respiratory systems that you shou breathing obvious from a distance. The muscles above the sternum and between the ribs, and the ribs themselves, will pull inward when breathing is labored. Infants and young children are abdominal breathers, be aware of; using their diaphragms for breathing more than adults. Watch the abdomen as well as the chest to evaluate  The mouth and nose are smaller and more easily obstructed than their breathing. adults. Abdominal organs are less protected in a pediatric patient. In adults, the rib cage covers more of the  The tongue takes up more space proportionately in the mouth than abdominal organs. In young pediatric patients, these organs are more exposed and take up proportionately more of the chest and abdomen. Younger patients also have less developed chest muscles and more flexible adults. bones. Because of this, abdominal organs are more susceptible to injury, and the force of trauma is often  Newborns and infants typically breathe through their noses. Nasal o transferred throughout the entire abdomen. struction can impair breathing.  The trachea (windpipe) is softer and more flexible in infants and ch dren. LIFELINE PREHOSPITAL EMERGENCY CARE 613  The trachea is narrower and is easily obstructed by swelling or foreig objects.  The chest wall is softer, and infants and children tend to depend mo on their diaphragms for breathing than do adults.

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Body Surface A child’s body surface area is larger in proportion to the body mass, making the child more prone to heat loss through the skin. This makes infants and children more vulnerable to hypothermia, an abnormally low body temperature. For this reason, temperature should always be a concern when assessing and treating pediatric patients. They must be kept covered and warm Climate control in the patient compartment of the ambulance is very important. Because a pediatric patient s head. body, and extremities are proportioned differently from an adult s (the head being larger, for example), the extent of a burn is estimated differently, using a special formula that was described in topic “Soft-Tissue Trauma.”

Blood Volume

As you would expect, the blood volume of a pediatric patient is less than the blood volume of an adult. A newborn does not have enough blood to fill a 12-ounce soda can, and an 8-year-old has only about 2 liters of blood. Blood loss that might be considered moderate in an adult can be a life-threatening situation for a child.

Psychological and Personality Characteristics Each age group has its own general characteristics of psychology and personality that will affect the way you assess and care for the patient. One thing you should note about crying children: To many of your younger patients, you are a scary stranger. To a child who is already injured or ill, a stranger can bring about a strong response in the form of fear and crying. In younger patients, this is an expected response and a lack of it can often indicate an altered mental status. Remember that you can still assess a crying child. Although the noise may make the assessment more difficult, it is still possible. Consider taking steps to gain as much information as you can before approaching the child. When possible, perform a visual assessment from across the room prior to laying hands on the youngster. Consider also your approach. Do you really need six responders in the room with the scared child? Positioning yourself at the child’s eye level rather than looking over him may make the young patient less afraid. Speak slowly and quietly to the child to help calm him. Often a certain amount of strategy can improve your interaction. Never let the potential of upsetting a child prevent you from delivering appropriate treatment. Although many of the things we do will cause the child to cry, for the most

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part we still need to do those things. Toddlers hate spinal immobilization; however, if it is indicated we need to do it, no matter how much it upsets the child or hurts our ears.

Interacting with the Pediatric Patient You will not be able to interview infants and most toddlers the same way you would an adult patient. However, parents or care providers can usually provide a history of a small child’s illness or injury. Preschoolers can usually be interviewed if you take your time and keep your language simple. School-age children will be able to describe more clearly how they feel and what happened. They will talk with you honestly, but may feel that the injury or illness is a punishment for something they did. They must be reassured and told it is all right to feel sick or hurt or to cry. Before telling the child something or asking him a question, take a second to think about how the child might interpret what you are about to say. This may help you to minimize the child’s confusion or anxiety. Beware of sarcasm and teasing. Often preschoolers do not understand that you are joking. Even older children may feel powerless to answer back or defend themselves. Include parents, teachers, and/or care providers in your interview. Since they are often the most valuable source of information for your assessment, do not exclude them. Seeing that familiar adults are being included gains the child’s confidence if you follow up by talking directly to the child. If the parents are injured, the child needs to know that someone is caring for him as well. All patients have some degree of fear at the emergency scene. Infants and children are usually more fearful than adults because they lack experience with illness and injury. In addition to this, children are easily frightened by the unknown. Since so many details of the emergency scene are unknowns, it is easy to see why emergencies can be scary for children. The elements associated with the emergency (pain, noise, bright lights, cold) can set off a panic reaction in infants. At an emergency, if the child does not understand you. or believes that you do not understand in return, his fear will increase. If the child is to communicate, he must remain calm. Putting the child at ease is a very important part of the care you must provide. Some children, when stressed, will act like a younger child. This is called regression. Any problems faced by the child will be intensified if the parents are not at the scene. Children find security through their parents when facing new problems or emergencies. Asking for mom or dad may be the child’s first priority, even above that of having your help.

When dealing with pediatric patients you should... 1. Identify yourself simply by saying. “Hi. I’m Pat. What’s your name?” 2. Let the child know that someone has called or will call his parents. 3. Determine if there are life-threatening problems and immediately treat them. If there are no problems of this nature, continue at a relaxed pace. Fearful children cannot take the pressure of a rapidly paced assessment and confusing questions fired at them by a stranger. 4. Let the child have any nearby toy that he may want. 5. Kneel or sit at the child’s eye level. Ensure that bright light is not directly behind you and shining into the child’s eyes. 6. Smile. This is a familiar sign from adults that reassures children. 7. Touch the child or hold his hand or foot. A child who does not wish to be touched will let you know. Do not force the issue; smile and provide comfort through your conversation. 8. Do not use any equipment on the child without first explaining what you will do with it. Many children fear the medical items that are familiar to the EMT, thinking

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they will cause pain. Always tell the child what you are going to do as you take vital signs and do a physical exam. Do not try to explain the entire procedure at once. Instead, explain each step as you do it. Use simple language and remember that children tend to take things literally. If you tell a young child. “I’m going to take your pulse.” he may think you are going to take something away from him. Instead say. “I’m going to hold your wrist for a minute.” If the child is older, explain why. 9. Let the child see your face, and make eye contact without staring at the child. Staring makes children uncomfortable. Speak directly to the child, making a special effort to speak clearly and slowly in words he can understand. Be sure the child can hear you. 10. Stop occasionally to find out if the child understands. Never assume the child understood you, but find out by asking questions if the child is old enough to respond. 11. Never lie to the child. Tell him when the examination may hurt. If the child asks if he is sick or hurt, be honest, but be sure to add that you are there to help and will not leave. Let the child know that other people also will be helping.

ASSESSMENT AND CARE STRATEGIES

Newborns and Infants birth to 1 year

• Newborns typically have minimal stranger anxiety and do not mind being separated from their parents. Older infants often fear separation. • Infants are used to being undressed but like to feel warm, physically and emotionally. • The younger infant follows movement with his eyes. • The older infant is more active, and is developing a personality. • Infants do not want to be “suffocated” by an oxygen mask.

• Have the parent hold the infant while you examine him. • Be sure to keep him warm—warm your hands and stethoscope before touching the infant. As infants can easily become hypothermic, keep the ambulance compartment warm and the child properly covered during cool or cold weather. • It may be best to observe breathing from a distance, noting the patient’s work of breathing, the level of activity, and skin color. • Examine the heart and lungs first and the head last. This is perceived as less threatening to the infant and therefore less likely to start him crying. • A pediatric nonrebreather mask may be held near the face to provide “blow-by” oxygen.

Toddlers 1 to 3 years

• Toddlers do not like to be touched or separated from their parents. • Toddlers may believe that their illness is a punishment for being bad. • Unlike infants, they do not like having their clothing removed. • They are frightened easily, overreact, and have a fear of needles and pain. • Toddlers may understand more than they communicate. • They begin to assert their independence. • They do not want to be “suffocated” by an oxygen mask. • Toddlers do not like to be restrained.

• When appropriate, have a parent hold the child while you examine him. • Assure the child that he was not bad. • Remove an article of clothing, examine the area, and then replace the clothing. Do your best to respect the child’s modesty. • Examine in a trunk-to-head approach to build confidence. Touching the head first may be frightening. • Explain what you are going to do in terms the toddler can understand (taking the blood pressure becomes a squeeze or a hug on the arm). • Assert control over the situation, but give the toddler the opportunity to make some decisions: “Which arm would you like me to check your blood pressure on?” • Restrain only when necessary. Restrain well when indicated. LIFELINE

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ASSESSMENT AND CARE STRATEGIES

Preschool 3 to 6 years

• Preschoolers do not like to be touched or separated from their parents. • They are modest and do not like their clothing removed. • Preschoolers may believe that their illness is a punishment for being bad. • Preschoolers have a fear of blood, pain, and permanent injury. • They are curious, communicative, and can be cooperative. • They do not want to be “suffocated” by an oxygen mask.

• When appropriate, have a parent hold the child while you examine him. • Respect the child’s modesty. Remove an article of clothing, examine the area, and then replace the clothing. • Have a calm, confident, reassuring, respectful manner. Beware of teasing a child. Often children do not understand sarcasm. • Be sure to offer explanations about what you are doing. • Allow simple decision making. Allow the child the responsibility of giving the history. • Explain as you examine. • If desired, hold a pediatric nonrebreather mask near the face to provide “blow-by” oxygen.

School age 6 to 12 years

• This age group cooperates but likes their opinions heard. • They fear blood, pain, disfigurement, and permanent injury. • School-age children are modest and do not like their bodies exposed.

• Allow simple decision making. Allow the child the responsibility of giving the history. • Explain as you examine. • Present a confident, calm, and respectful manner. • Respect the child’s modesty.

Adolescent 12 to 18 years

• Adolescents want to be treated as adults. • Adolescents generally feel that they are indestructible but may have fears of permanent injury and disfigurement. • Adolescents vary in their emotional and physical development and may not be comfortable with their changing bodies. • Adolescents are influenced highly by their peers.

• Although they wish to be treated as adults, they may need as much support as children. • Present a confident, calm, and respectful manner. • Be sure to explain what you are doing. • Respect modesty. You may consider assessing adolescents away from their parents. Have the physical exam done by an EMT of the same sex as the patient if possible. • Avoid causing embarrassment in groups. Be sensitive to the adolescent’s dignity.

The Adolescent Patient In many ways, adolescent patients are almost like adult patients. Certainly they like to be treated as adults and are very sensitive to violations of their dignity or being addressed in a manner they believe is patronizing. However, when they are ill, injured, or frightened, they often regress emotionally and need as much support as younger children. Adolescents should be able to tell you exactly what happened and how they feel. However, in the presence of parents or peers, an adolescent patient may not be completely communicative or cooperative. When injured, scared, or anxious, an adolescent may act immature or “act out.” He may be embarrassed, intimidated by the attention, trying to hide the fact that he was doing something wrong, or feel pressure to

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show bravado. Tact may be required to get information from the adolescent patient and assessment may be more productive if this patient can be taken aside or into a private area. Adolescents are especially sensitive to their peers and what they think. Adolescents may also be intimidated by those in authority, such as parents or teachers. Therefore, it is important to be very discrete when asking sensitive questions about drug or alcohol use and medical issues like a possible pregnancy. Such discussions should take place away from anyone who might overhear the conversation (for example, in the back of the ambulance or, if necessary, by waiting until you arrive at the hospital). The young adolescent is often

embarrassed or worried about the changes occurring to his or her body and uncertain if these changes are “normal.” Handling the clothing of a teenager of the opposite sex can be awkward for the EMT as well as for the patient. In most cases, a simple preliminary description of the examination will set the patient at ease. However, you should make sure that both the adolescent and the parents understand what you are going to do and why it must be done. When possible, have the exam conducted by, or in the presence of, an EMT of the same sex as the patient. However, do not delay patient evaluation and care because you or the patient may be embarrassed. As a professional, you must put such feelings aside and act in a manner that will allow the patient to relax and understand that there is no need for embarrassment.

SUPPORTING THE PARENTS OR OTHER CARE PROVIDERS

relative of the parent remove him from the scene. At this point, it should be noted that not all children live with two parents in a traditional nuclear family. The child may have a single parent or may be living with a grandparent, another relative, or even someone who is not related to the child. Whoever the child’s full-time caretaker or guardian is. that person is likely to have the same emotional responses in an emergency as any parent. The EMT should be sensitive to the fact that the child may or may not call this person “Mommy” or “Daddy” and may be upset if asked about his mother or father. Tact is often required to find out who is responsible for the child and what the child calls that person. Though parent or mom and dad appear in this chapter, keep in mind that the terms are being used to stand for any person or persons who act as parents, guardians, or principal caretakers to the child. You need to gain confidence and calm the emotions of all the people around the scene in order to be able to effectively treat the child. If you expect others to be calm, project a calm demeanor. Your interactions with the child will show everyone present your concern, and the manner in which you provide care will show your professionalism.

When your patient is young, you will need to make some adjustments in how you proceed with the assessment and care. This is especially true with regard to communicating with parents or other caregivers or providers. Children are very perceptive and will pick up on confidence as well as fear and anxiety in those they trust. What an EMT says, how he says it, and the calming influence he demonstrates can all make a Patient assessment is an extremely important skill for difference in how a parent may respond and ultimately EMTs to learn, and with pediatric patients it may be even how effectively the EMT can interact with the patient. more significant for two reasons: First, the condition of Parents may react in one of several ways when their sick and traumatized children can rapidly change. Second, child suffers a sudden life-threatening injury or illness. sometimes signs and symptoms in children are subtle and Their first reaction may be one of denial or shock. Some will be missed without close observation. parents will react by crying, screaming, or becoming The pediatric assessment triangle (PAT), which we will angry. Another common reaction is self-blame and discuss next, helps categorize your assessment from across guilt. In all of these instances, be calm, reassuring, the room. It addresses three and supportive. Use simple critical assessment elements and language to explain what has helps identify immediate lifeKung naroon ang mga magulang ng pasyente, happened and what is being threatening problems. hingan mo sila ng tulong para mas mapabilis ang done to and for their child. The information you pagbibigay mo ng lunas sa kanilang anak. In some cases, an upset gather using the PAT must Puwede mong ipahawak sa kanila parent may interfere with be validated by next using ang bata habang sinusuri your care of the child. This is the traditional patient mo ito o nilalapatan ng a natural reaction to protect assessment sequence you lunas. Huwag mo ring the child from further harm. are already familiar with kalimutan na bigyan ng Usually, you can persuade for adults. As already emotional support ang the parent to assist you by noted, you will need to mga magulang. Bukod asking him to hold the child’s customize your assessment kasi sa bata, sila ang hand, give you a medical somewhat to accommodate siguradong nakakaramdam history, or comfort the child. social and anatomic ng pangamba sa kondisyon If the parent is out of control, differences in children. ng kanilang anak. however, and cannot or will not cooperate, have a friend or

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Pediatric Assessment Triangle (PAT)

CRITICAL CONCEPT

The pediatric assessment triangle (PAT) is a method of pediatric assessment from two viewpoints. The first is the general impression formed as you approach the child, often referred to as an assessment “from the doorway.”The second is the impression based on the remainder of the primary assessment that is done next to the patient. Each of the three sides of the triangle represents a different patient presentation that should be evaluated: • Appearance • Work of breathing • Circulation to skin

The first impressions are those formed as you enter the scene and approach the The first impressions are those formed as you enter appearance, you look at mental status using the “PU” patient ("from the doorway").These first few seconds will provide you with a the scene and approach the patient “from the doorway”. part of AVPU (response to pain or unresponsiveness). great deal of informationFor breathing, you start by ensuring that the airway is that can be important in determining the seriousness These first few seconds will provide you with a great deal of information that can be important in determining the of the patient’s condition.open and closely observing the quality of the patient’s This view from the door may also reveal information seriousness of the patient’s condition. This view from the breathing. For circulation, you check for pulse, subtle that will not be there if the child begins to cry. cyanosis, and capillary refill. door may also reveal information that will not be there if The primary assessment is particularly important the child begins to cry. For the first side of the triangle, look at the patient's appearance. Consider the in pediatrics as threats to the airway, breathing, and For the first side of the triangle, look at the patient’s child's mental status using the "AV" part of AVPU (alertness, verbal response). Is circulation are the most common killers of children. appearance. Consider the child’s mental status using the the child acting appropriately? How is the patient's muscle tone and general Use primary assessment to identify life threats and “AV” part of AVPU (alertness, verbal response). Is the interactiveness? Is the child consolable by a parent or caregiver? Is his look or treat them as you find them. child acting appropriately? How is the patient’s muscle Some life threats in children will be subtle. For tone and general interactiveness? Is the child consolable ga/e and speech or cry appropriate? example, mental status is often difficult to determine by a parent or caregiver? Is his look or ga/e and speech or in a child that has not started talking yet. Often these cry appropriate? For the second side of the triangle, observe the patient's breathing (including subtle indications of instability will be missed in a For the second side of the triangle, observe the airway). Are there any abnormal airway/breathing sounds such as hoarseness, patient’s breathing (including airway). Are there any primary assessment. Therefore, unless you are treating muffled speech, grunting, wheezing, stridor, or crowing? Is there any abnormal abnormal airway/breathing sounds such as hoarseness, a life threat found in the primary assessment, you body position such as the sniffing position, tripoding, or refusing to lie down? muffled speech, grunting, wheezing, stridor, or crowing? should always continue on to a thorough secondary Are there retractions, nasal flaring, "seesaw" breathing, or head bobbing? Is there any abnormal body position such as the sniffing assessment. Identify physical signs that might indicate position, tripoding, or refusing to lie down? Are there problems and use a patient history to add information retractions, nasal flaring, “seesaw” breathing, or head to the situation. Remember that caregivers may often For the base of the triangle, look at those signs that might indicate a circulation bobbing? be the most important source of this information. problem, such as pallor, mottling, or cyanosis (a gray-blue coloration). For the base of the triangle, look at those signs that might indicate a circulation problem, such as pallor, tandaanisna The remainder of the primary Laging assessment done up close in a hands-on manmottling, or cyanosis (a gray-blue coloration). ang pagsusuri ay have isang surmised from your first, from-the ner. This confirms what you may already The remainder of the primary assessment is done na tuluy-tuoy ay -doorway impressions and proseso may identify additional presenting problems requirup close in a hands-on manner. This confirms what hindi natatapos. ing immediate interventions. During the hands-on primary assessment, the triyou may already have surmised from your first, fromthe-doorway impressions and may identify additional angle again looks at appearance, breathing (including air-way), and circulapresenting problems requiring immediate interventions. tion—but with more precision. For appearance, you look at mental status using During the hands-on primary assessment, the triangle the "PU" part of AVPU (response to pain or unresponsiveness). For breathing, again looks at appearance, breathing (including airyou start by ensuring that the airway is open and closely observing the quality way), and circulation—but with more precision. For

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of the patient's breathing. For circulation, you check for pulse, subtle cyanosis, and capillary refill.

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The primary assessment is particularly important in pediatrics as threats to the airway, breathing, and circulation arc the most common killers of children. Use primary assessment to identify life threats and treat them as you find them.

Scene Size-Up and Safety—Pediatric When entering an area where there is a pediatric patient, enter slowly and make some important observations. The first is to determine if the scene is safe. Even though it is a rare occurrence, sometimes there may be a risk from violence or abusive behavior, possibly directed toward the child. Look around carefully for any mechanism of injury. Standard Precautions should be taken as appropriate. Additionally, be aware that ordinary childhood diseases can be devastating when contracted by an adult.

PRIMARY ASSESSMENT—PEDIATRIC Forming a General Impression A great deal of information can and should be gathered from the doorway, before you approach—and possibly upset—the patient. From across the room, you can gain a general impression of the child. First decide: Is the child well or sick? The child’s general appearance and behavior will usually provide the answer. A child who is alertly watching your approach, squirming and able to talk with you, or vigorously crying obviously has an open airway, is breathing, and has a pulse and blood pressure. If the child is silent, appears to be sleeping deeply, or is unresponsive, the child’s airway, breathing, and circulation must be immediately assessed. As you approach and form your general impression, use the PAT to make the following observations: • Mental status. The well child is alert. Alternatively, the sick child may be drowsy, inattentive, or sleeping. • Interaction with the environment or others. The healthy child exhibits normal behavior for his age. He moves around, plays, is attentive, establishes eye contact, and interacts with his parents. The sick child may be silent, listless, or unconscious. • Emotional state. The well child’s emotional state is appropriate to the situation. Crying may be his normal response to pain or fear. A with-drawn child or one who is emotionally flat is probably a sick child. • Response to you. A well child may be interested in you or afraid of you. A sick child will give little attention to a stranger. • Tone and body position. A sick child may be limp, with poor muscle tone. Pediatric patients with respiratory distress often assume characteristic positions that seem to help them breathe (e.g.. leaning forward with hands on knees, referred to as tripoding). • Effort of breathing. The well child’s breathing should he unlabored. The sick child be making a visible effort to breathe, including use of flared nostrils and retractions or pulling in of the tissues between the ribs. • Quality of cry or speech. In general, a strong cry or normal speech indicates a well child with good air exchange. The child who can speak only in short sentences or grunts has significant respiratory distress. • Skin color. A sick child may be pale, cyanotic, or flushed.

Assessing Mental Status Use the AVPU method of assessing mental status, taking the child’s age and developmental characteristics into account. You may need to shout to elicit a response to verbal stimulus. If necessary, tap or pinch the patient to test for response to painful stimulus. Never shake an infant or child.

Assessing the Airway Consider not only whether the airway is open but whether it is endangered. A depressed mental status, secretions, blood, vomitus. foreign bodies, face or neck trauma, and lower respiratory infections may all compromise the airway. Be careful not to hyperextend the child’s neck.

Assessing Breathing First, assess whether or not the patient is breathing. If the patient is not breathing or is breathing inadequately, provide artificial ventilations with supplemental oxygen. If the patient is experiencing respiratory distress, provide high-concentration oxygen by pediatric nonrebreather mask. To assess breathing, observe the following: • Chest expansion. There should be equal movement on both sides of the chest. • Effort of breathing. Watch for nasal flaring when the patient inhales, and retractions or “pulling in” of the sternum and ribs with inhalation. • Sounds of breathing, listen for stridor, crowing, or other noisy respirations. Breath sounds should be present and equal on both sides of the chest. Note the presence of grunting at the end of expiration, which is a worrisome sign. • Breathing rate. Normal respiratory rates for infants and children are as follows: 12 to 20 per minute in an adolescent. 15 to 30 per minute in a child. 25 to 50 per minute in an infant. Breathing that is either faster or slower than normal is inadequate and requires artificial ventilation as well as oxygen. • Color. Cyanosis (blue or gray color) indicates that the patient is not getting enough oxygen. LIFELINE

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Assessing Circulation As with an adult, check for normal warm. pink, and dry skin and a normal pulse as indications of adequate circulation and perfusion. For assessment, check the radial pulse in a child and the brachial pulse in an infant. For basic life support, check the carotid pulse in a child and the brachial or femoral pulse in an infant. In infants and children 5 years old or younger, also check capillary refill. When you press on the nail bed or press the top of a hand or foot, the area will turn white. If the patient s circulation is adequate, the normal pink color will return in less than 2 seconds, or in less time than it takes to say “capillary refill.” Check for and control any blood loss.

Identifying Priority Patients A patient who is a high priority for immediate transport is one who: • Gives a poor general impression. • Is unresponsive or listless. • Does not recognize the parent or primary caregiver. • Is not comforted when held by a parent but becomes calm, quiet when set down. • Has a compromised airway. • Is in respiratory arrest or has inadequate breathing or respiratory distress. • Has a possibility of shock. • Has uncontrolled bleeding.

Secondary Assessment At times, the child may be the only source of a history. He may be at school or another place where medical records are not kept or where adults who know his medical history are not present. In this case, get as much history as you can from the child by asking simple questions that cannot be answered with a “Yes” or “No.” A child who cannot tell you where it hurts can usually point to the area. Perform physical exam for medical patient and a rapid trauma assessment for trauma patient, as you would for an adult. Explain to the awake child what you are doing, do the exam in trunk-to-head order to avoid frightening the child. Take and record vital signs, assessing blood pressure only in children older than age 3, using an appropriately sized cuff. Review table for normal ranges of pediatric vital signs. It may be helpful to earn pocket guide/reference card with pediatric vital signs when responding to pediatric calls.

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Physical Exam—Pediatric The EMT normally performs the physical examination or body assessment in head-to-toe order; however, on alert infants and small children this is reversed. Starting with the toes or trunk and working your way toward the head will let the child get used to you and your touch before you attempt to touch him around the head and face. Playing with the infants’ feet often puts them at case. Unless there are possible injuries that indicate the child should not be moved, a young child should be held on the parent’s lap during the physical exam. Many EMS teams carry clean stuffed animals (like teddy bears) that can be given to a child during the physical exam. The toys can provide comfort to the child and allow you to explain the examination by using the toy as a model. Point to an area on the toy to show the child where you must touch and where you will bandage when you need to provide emergency care. This type of one-to-one communication also helps build parent and bystander confidence, letting them know that a professional, compassionate EMT is caring for the child. (If you use a toy. allow the child to keep it.) Most very young children will suffer no embarrassment when you remove or reposition clothing during the exam. Nonetheless, protect the child from the stares of onlookers. Many children around the age of 5 to 8 go through a stage of intense modesty. You may have to keep explaining why you must remove certain articles of clothing. Many parents teachers, and day care personnel teach children that strangers should not remove their clothing or touch them. The children that you examine may not understand your intentions and may resist. Some children may become upset because they feel you are taking something away from them. Take your time and do not rush children into accepting all that is happening. Remember that children rapidly lose body heat, so if you expose them, quickly cover them with a blanket. The assessment of an infant or child is done to look for the same signs of injury and illness as in the case of the adult patient. However, you should take special care with components of the exam as discussed in the following sections.

Head

Do not apply pressure to an infant’s “soft spots” (fontanelles). The skin over the anterior fontanelle is normally level with the top of the skull, or slightly sunken. It may bulge naturally when the infant cries or be abnormally sunken if the infant is dehydrated. Meningitis and head trauma cause the fontanelle to bulge due to increased intracranial pressure. Collisions involving infants and children can often produce head injuries.

Nose and Ears Look for blood and clear fluids coming from the nose and ears. Suspect skull fractures if either fluid is present. Children are nose breathers, so mucus or blood clot obstructions will make it hard for them to breathe.

Neck

Children are vulnerable to spinal cord injuries because of their proportionately larger and heavier heads. The neck offers less support because muscles and bone structures are less developed. In medical emergencies, the neck may be sore, stiff, or swollen.

Airway

Keep the infant’s head in the neutral position and the child’s head in the neutral-plus or sniffing position (chin thrust forward to maintain an open airway). If there is no suspicion of spinal injury, place a flat, folded towel under the patient’s shoulders to get the appropriate airway alignment. Children’s airways are more pliable and smaller than an adult’s. Hyperextension or hyperflexion may close off the airway. For medical respiratory problems, the child will probably want to sit up.

Chest

Listen closely for even air entry and the sounds of breathing on both sides of the chest. Be alert for wheezes and other noises. Check for symmetry, bruising, paradoxical movement, and retraction of the sternum or the muscles between the ribs. Remember that a child’s soft ribs may not break, but there may be underlying injuries to the organs within the chest.

Abdomen Note any rigid or tender areas and distention. Because a child’s abdominal organs (especially the spleen and liver) are large in relation to the size of the abdominal cavity, and because there is little protection offered by the stillundeveloped abdominal muscles, these organs are more susceptible to trauma than an adult’s. Because most children 8 years of age or younger are abdominal breathers, any injury that impedes the movement of the diaphragm can com-promise a young child’s breathing.

Pelvis—

pelvic girdle.

In trauma, check for stability of the

Extremities

Perform an assessment with capillary refill and distal pulse, including a neuro-logical component for motor function with a sensation check. With an infant or young child, you do not have to press on a nail bed. You can quickly check capillary refill by squeezing a hand or foot, forearm, or lower leg. Check for painful, swollen, and deformed injury sites. (The bones of an infant or child are more pliable so they bend, splinter, and buckle before they fracture.)

Reassessment

Pediatric patients are dynamic—that is. constantly changing. Continual assessment is essential to good patient care. A rule of thumb for infants and children is: Don’t take your eyes off them for a minute!

The Pediatric Physical Examination 1. Examine the head. Look for bruising or blood or

swallowed air Divide the abdomen into quadrants and examine each one, while remembering which organs are clear fluid draining from the nose or ears. Palpate located in each quadrant. gently for soft or spongy areas, skull irregularities, or crepitus (feeling of grinding bone fragments). Check the 7. Examine the pelvis for tenderness, swelling, bruising, of crepitus. If the patient complains of pain, injury, or fontanels in infants. other problems in the genital area, assess for bruising, 2. Check the eyes. The pupils should be equal in size and swelling, or tenderness in that area. reactive to light. 3. Examine the neck. Check for the position of the trachea, 8. Examine the extremities. Evaluate pulses, sensation, and warmth. Look for unequal movement. swollen neck veins, stiffness, tenderness, or crepitus. 9. If you have immobilized an extremity, check the 4. Examine the chest. Check for bruising, equal chest patient’s capillary refill and peripheral pulses and rise and fall, and crepitus. Watch for signs of breathing compare them with the other arm or leg. difficulty. While examining the chest, be aware of the contents of the thorax. 10.Examine the back. Assess for tenderness, bruising, and crepitus. If the child requires immobilization, the 5. Auscultate for breath sounds over all lung fields. back can be checked while the child is being loaded onto 6. Examine the abdomen. Check for bruising, tenderness, the spine board. or guarding. Look for swelling that may indicate LIFELINE

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As time permits, you should do the following steps. In some cases in which the patient is seriously ill or traumatized, maintaining the airway and supporting ventilations will keep the EMT from performing a complete physical exam and history: 1. Reassess mental status. 2. Maintain an open airway. 3. Monitor breathing. 4. Reassess the pulse. 5. Monitor skin color, temperature, and moisture. 6. Reassess vital signs: • Every 5 minutes in unstable patients • Every 15 minutes in stable patients 7. Ensure that all appropriate care and treatment are being given.

SPECIAL CONCERNS IN PEDIATRIC CARE

Like adults, infants and children may be subject to either medical problems or trauma. Concerns that frequently apply to both medical emergencies and trauma are airway maintenance, providing supplemental oxygen, supporting ventilations, caring for shock, and protecting the infant or child from hypothermia.

Maintaining an Open Airway Just as with an adult, it is important to position the child’s head and neck to align and open the airway. It is important not to hyperextend or to permit flexion of a child’s neck. The child’s head should be positioned in a more neutral position than an adult’s because of the danger of closing the airway when the neck is flexed or hyperextended. Placing a folded towel under the shoulders of a young infant or child will help to keep the airway aligned. To achieve the proper position, perform a head-till, chin-lift maneuver if there is no trauma, or a jaw-thrust maneuver with spinal immobilization if trauma is suspected. Be prepared to suction the airway as needed. Use suction catheters that are sized for infant and child patients. Do not touch the back of the patient’s throat, as this may activate the gag reflex, causing vomiting. It is also possible to stimulate the vagus nerve in the back of the throat, which can slow the heart rate. Do not suction for more than a few seconds at a time, as cutting off the body’s oxygen supply is especially dangerous to infants and children, causing cardiac arrest more quickly than in adults. You may give a few extra breaths after suctioning. As with adults, the tongues of infants and children are likely to slide back into the pharynx and obstruct the airway. In fact, airway blockage by the tongue is even more likely with infants and children because their tongues are proportionately larger compared to the size of their mouth and pharynx. 622

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If the patient is unconscious and does not have a gag reflex, you may insert an oropharyngeal airway to prevent the tongue from blocking the airway. To insert an oropharyngeal airway, insert a tongue depressor to the base of the tongue. Push down against the tongue while lifting the jaw upward. Then insert the oropharyngeal airway. An important difference to note is that when an oropharyngeal airway is inserted in an adult, it is inserted with the tip pointing toward the roof of the mouth, then rotated 180 degrees into position. For an infant or child, the oropharyngeal airway is inserted with the tip of the airway pointing downward, toward the tongue and throat, in the same position it will be in after insertion. If the patient is conscious but cannot maintain an open airway, a nasopharyngeal airway can be inserted. Note, however, that a nasopharyngeal airway should not be used if the child has facial trauma or head injuries, because the airway could penetrate a breach in the cranium.

Clearing an Airway Obstruction Infants and children are naturally curious. They explore their environment and often put things in their mouths. Because of this, they can easily choke on a foreign object as well as on a piece of food. An airway obstruction can be partial or complete. With many partial obstructions, the child is still able to breathe and get enough oxygen. With other partial obstructions or with complete obstruction of the airway, the supply of air is cut off. The assessment and care summaries that follow detail how to determine if an obstruction is partial or complete and how to manage an obstruction.

Inside/Outside AIRWAY POSITION Children less than 4 years old often have a proportionately larger head with a larger occiput (the round posterior aspect of the skull). They also have a narrower, more flexible trachea. Laying a small child with altered mental status flat could result in flexion of the airway. Looking from the outside, this position would cause the head and neck to be flexed down toward the chest. On the inside, the airway could be obstructed. Overflexion of the airway causes the pliable trachea to bend unnaturally and kink off the flow of air. Additionally, this position may also cause the proportionately larger tongue to obstruct air movement at its base. Simply padding behind the shoulders can compensate for the large head and move the airway back into an open position.

Inserting an Oropharyngeal Airway in a Child 1. Oropharyngeal airways come in a variety of sizes. 2. Size the airway by measuring from the corner of the mouth to the tip of the earlobe 3. Use a tongue depressor to hold the tongue in position. Insert the airway with the tip pointing downward, toward the tongue and throat—the same position it will be in after insertion. 4. The oropharyngeal airway in position.

PATIENT ASSESSMENT Partial Airway Obstruction The following are common signs of a partial airway obstruction in a pediatric patient • Noisy breathing (stridor, crowing) • Retractions of the muscles around the ribs and sternum when inhaling • Normal skin color • Peripheral perfusion is satisfactory (capillary refill under 2 seconds in a child 5 years old or less) • Still alert, not unconscious Iba-iba ang sukat ng Nasopharyngeal Airway na puwede mong gamitin sa batang pasyente. Ang dapat mong gamitin ay yung kasinlapad ng maliit na daliri ng pasyente at ang haba ay mula sa dulo ng ilong hanggang sa tenga.

PATIENT CARE Partial Airway Obstruction Emergency care of a pediatric patient with a mild airway obstruction is as follows: 1. Allow the child to assume a position of comfort, sitting up, not lying down. Assist an infant of younger child into a sitting position. Allow the child to sit on the parent’s lap. 2. Offer high-concentration oxygen by pediatric nonrebreather mask or blow-by technique (described later in this chapter). 3. Transport. 4. Do not agitate the child. Limit your examination to avoid upsetting the child. Do not assess blood pressure

PATIENT ASSESSMENT Severe Airway Obstruction The obstruction may be complete, or a partial obstruction may be severe enough to prevent adequate intake of oxygen Signs of a severe obstruction are: • Cyanosis • Child’s cough becomes ineffective: child cannot cry or speak • Increased respiratory difficulty accompanied by stridor or respiratory arrest • Altered mental status or loss of consciousness

PATIENT CARE Severe Airway Obstruction Follow these steps for emergency care of a severe airway obstruction: 1. Perform airway clearance techniques. For infants less than 1 year old, alternate 5 back blows and 5 chest thrusts. If the patient becomes unconscious begin CPR After 30 compressions, visualize the airway If an object is visible remove it. Do not use blind finger sweeps to clear the airway Attempt to ventilate and continue chest compressions if necessary For children older than 1 year, provide subdiaphragmatic abdominal thrusts (the Heimlich maneuver) until they lose consciousness If they lose consciousness begin CPR and airway visualization as just explained. (Airway clearance sequences are summarized in Table below) 2. Attempt artificial ventilations with a pocket mask or bag-valve-mask unit in the appropriate pediatric size and supplemental oxygen.

Infant and Child BCLS Review For a review of infant and child basic cardiac life support, including CPR (ventilations and chest compressions) and airway clearance techniques see Appendix A, “Basic Cardiac Life Support Review.”

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Providing Supplemental Oxygen and Ventilations As in adults, high-concentration oxygen should be administered to children in respiratory distress, those with inadequate respirations, or those in possible shock. Hypoxia (oxygen starvation) is the underlying reason for many of the most serious medical problems with children. Inadequate oxygen will have immediate effects on the heart rate and the brain, as shown by a slowed heart rate and an altered mental status. However, infants and young children are often afraid of an oxygen mask. For these patients who will not

tolerate a mask, try a “blow-by” technique. In this technique you will hold, or have a parent hold, the oxygen tubing or the pediatric nonrebreather mask 2 inches from the patient’s face so the oxygen will pass over the face and be inhaled. Some departments use blow-by oxygen devices that resemble stuffed animals. These commercially made products may be less threatening to a child than traditional oxygen devices. Follow the manufacturer’s recommendations regarding liter flow per minute when using these devices

PEDIATRIC AIRWAY CLEARANCE SEQUENCES CHILD: 1 YEAR TO PUBERTY

INFANT: BIRTH TO 1 YEAR

Conscious

Ask, “Are you choking?” Perform subdiaphragmatic abdominal thrusts.

Observe signs of choking (small objects or food, wheezing, agitation, blue color, not breathing). Series of five back blows, five chest thrusts.

Loses Consciousness during Procedure

Assist the patient to the floor. Begin 30 chest compressions. Open the airway. Remove any visible objects (no blind sweeps). Attempt to ventilate. If 1 unsuccessful, reposition the head and attempt to ventilate again. If unsuccessful, continue CPR. If alone, call for help after 2 minutes.

Begin 30 chest compressions. Open the airway. Remove any visible objects (no blind sweeps). Attempt to ventilate. If unsuccessful, reposition the 1 head and attempt to ventilate again. If unsuccessful, continue CPR. If alone, call for help after 2 minutes.

Unconscious When Found

Establish unresponsiveness. Open the airway. Attempt to ventilate. If unsuccessful, re-position the head and attempt to ventilate again. If unsuccessful, perform CPR, attempting compressions to ventilations at a 30:2 ratio. Remove any visible objects from the airway (no blind sweeps). Continue CPR until ventilations are successful.

Establish unresponsiveness. Open the airway. Attempt to ventilate. If unsuccessful, reposition the head and attempt to ventilate again. If unsuccessful, perform CPR, attempting compressions to ventilations at a 30:2 ratio. Remove any visible objects from the airway (no blind sweeps). Continue CPR until ventilations are successful.

Artificial Ventilation PUBERTY OVER AGE 1 AND OLDER TO PUBERTY

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BIRTH TO 1 YEAR

Ventilation Duration

1 second

Ventilation Rate

10 to 12 breaths/ minute

12 to 20 breaths/ minute

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Some children respond well when oxygen tubing is pushed through the bottom of a paper cup. especially if the cup is colorful or has a picture drawn inside it. Hand the cup to the child or ask a parent to hold it. Infants and young children instinctively explore new things by bringing them up to their mouths. As the patient handles and explores the cup, he will breathe in the oxygen. Do not use a Styrofoam cup. Styrofoam may flake and the child can inhale the particles. Remember that a nonrebreather mask will always provide more efficient oxygen delivery, and many children tolerate it well. Use blow-by only if more efficient administration methods fail.

Positive pressure ventilations should be provided at the rate of 12 to 20 per minute (one every 3 to 5 seconds) for an infant or child up to puberty, and at 10 to 12 per minute (one every 5 to 6 seconds) if the child has reached puberty. (Note that the rate is higher when performing a neonatal resuscitation. In that case use a rate of 40-60 breaths per minute) Use a pocket face mask or a bag-valvemask unit in the correct infant or child size. Follow these guidelines when ventilating the infant or child patient: • Avoid breathing too hard through the pocket face mask or using excessive bag pressure and volume. Use only enough force to make the chest rise. • Use properly sized face masks to ensure a good mask seal. • Flow-restricted, oxygen-powered ventilation devices are contraindicated in infants and children. • If ventilation is not successful in raising the patient’s chest, perform procedures for clearing an obstructed airway. Then try to ventilate again.

Caring for Shock Shock is another term for hypoperfusion, which is the inadequate circulation of blood and oxygen throughout the body. One common cause of shock in adults—a failure of heart function or of the cardiovascular system—is rare in infants and children. The following are some common causes of shock in infants and children: • Diarrhea and/or vomiting with resulting dehydration • Infection • Trauma (especially abdominal injuries) • Blood loss The following are some less common causes of shock in infants and children: • Allergic reactions • Poisoning It is important to remember that infants and children have a small volume of blood compared to adults (approximately 8 percent of the total body weight). Bleeding that would not be dangerous in an adult may be serious in an infant or child. Shock can develop in the small child who has a laceration to the scalp (with its many blood vessels) or in the 3-year-old who loses as little as a cup of blood. The most important thing to understand about shock in infants and children is that their bodies are able to compensate for it for a long time. When the compensating mechanisms fail, at approximately 30 percent blood loss, hypovolemic shock develops very rapidly. This means that a child may appear to be fine, then “go sour” in a hurry. This is in contrast to the adult patient in whom hypovolemic shock develops earlier and more gradually, making it easier to assess and treat than in a child.

The definitive care for shock takes place at the hospital (usually in the operating room). Since infants and children are prone logo into hypotensive shock—shock in which the blood pressure has dropped severely—so suddenly, it is important not to wait for signs of hypotensive shock to develop. Instead, in any situation in which shock is a possibility, provide oxygen (which boosts the supply of oxygen to poorly perfused tissues and helps keep up heart function) and transport as quickly as possible.

PATIENT ASSESSMENT Shock

Inside/Outside

The following are common signs of shock in pediatric patients: • Rapid heart rate • Mental status changes • Rapid respiratory rate • Pale. cool, and clammy skin • Weak or absent peripheral pulses • Delayed capillary refill, more than 2 seconds (in a child 5 years or younger) • Decreased urine output (Ask parents about diaper wetting, look at diaper.) • Absence of tears, even when crying

PATIENT CARE Shock

Follow these steps for emergency care: 1. Ensure an open airway. 2. Manage severe external hemorrhage, if present. 3. Provide highconcentration oxygen Be prepared to artificially ventilate. 4. Lay the patient flat. 5. Keep the patient warm. 6. Transport immediately Perform any additional assessment and treatments.

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Compensatory changes will begin immediately inside the body of a child who is losing blood. For example, the heart will beat faster to improve blood circulation. Increasing heart rate is a key component in pediatric compensation for shock. In addition, the child’s blood vessels will constrict to move blood toward the body’s core to support the function of essential organs. To compensate for hypoxia, the respiratory rate will increase. If hypoxia persists, brain function may be disrupted. Outside the child’s body, there will be evidence of these compensatory changes. Increased heart rate will be seen as an increased pulse rate (if it can be found peripherally). Vessel constriction will be seen in the form of pale skin and delayed capillary refill. Disrupted brain function will show as altered mental status.

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Protecting against Hypothermia

Hypothermia, or cooling of the body below its normal temperature, is a life-threatening condition in extreme cases. People lose heat more readily if their clothes are wet. if they are exposed to wind, or if they arc submerged in cold water. The body attempts to compensate for a decrease in body temperature, but as these compensatory functions begin to fail, the core body temperature drops. Because children have a large surface area in proportion to their body mass, exposure to cool weather and water can result in hypothermia more easily than with adults. Therefore, hypothermia is always a concern with a pediatric patient. Other causes of hypothermia, in children as well as in adults, include ingestion of alcohol or drugs that dilate peripheral vessels and cause loss of body heat, metabolic problems such as hypoglycemia, brain disorders that interfere with temperature regulation, severe infection or sepsis, and shock. Hypothermia may be a concern in both medical and trauma emergencies. For example, a sick child in a cool

PEDIATRIC MEDICAL EMERGENCIES Respiratory Disorders Respiratory disorders are a great concern in infants and children. For example, it is important to remember that, although cardiac arrest in the adult is likely to be caused by a heart problem, the likeliest cause of cardiac arrest in a child, other than trauma, is respiratory failure. For the pediatric patient, it is important to distinguish whether the probable cause of the breathing difficulty is an upper airway problem or a lower airway problem. The care that you would give for an upper airway obstruction is not indicated for a lower airway disorder. Also, because respiratory problems can have such serious consequences in infants and children, it is critical to be alert for early signs of respiratory failure.

Difficulty Breathing There are a number of respiratory diseases or disorders an infant or child may have that will cause difficulty breathing, ranging from serious ones like epiglottitis to less serious ones like a cold. It is not easy to determine which respiratory problem the child may have. Many signs and symptoms are similar, and age ranges for occurrence overlap. As an EMT, you do not need to decide what respiratory disorder a child is suffering from. Instead, use the following guidelines for recognizing and managing respiratory distress. It is especially important to recognize the signs of early respiratory distress and treat it before it advances to a life-threatening stage or to respiratory arrest. 626

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room or in sheets or nightclothes that have become wet from perspiration or loss of bladder control may be hypothermic. When trauma occurs outdoors, caregivers attending to injuries may forget to protect the patient from a cool or damp environment, and may exacerbate the situation by exposing the patientâ&#x20AC;&#x2122;s body during the physical exam. Field care for children is the same as for adults. It is important to keep the patient warm, so cover the patient to avoid further loss of body heat. Pay special attention to covering the head, as the head is a major area of heat loss. Also, be aware of the temperature in the patient compartment of the ambulance. Consult medical direction for advice on active rewarming of the body by application of hot water bottles or other heat sources if the patient is awake and responding appropriately. Avoid rough handling and inserting anything in the patientâ&#x20AC;&#x2122;s mouth as these actions may cause ventricular fibrillation or cardiac arrest in the severely hypothermic child. Suction very gently if suctioning is necessary, and be alert to the possibility of cardiac arrest. The upper airway starts at the mouth and nose and ends at the opening of the trachea. Upper airway disorders affect structures such as the mouth, the throat (the pharynx and hypopharynx), and the area around the opening of the trachea (the larynx). Common upper airway disorders include foreign body obstructions, trauma, and swelling from burns and infections. In addition to difficulty breathing, upper airway disorders can commonly be identified by the presence of stridor or difficulty speaking. The lower airway begins at the opening of the trachea and ends at the alveoli. Lower airway disorders affect the large and small bronchiole tubes and the alveoli themselves. Common lower airway disorders include asthma, pneumonia, and other respiratory infections. Lower airway disorders commonly cause difficulty breathing, but the distinguishing sign is wheezing lung sounds. It is important to remember, however, that not all lower airway problems will be accompanied by wheezing. Although you may not be able to identify the root cause of the problem, distinguishing an upper airway problem from a lower airway problem will help you properly target your immediate treatments. In general, with suspected airway diseases you should transport as quickly as possible if you see or hear wheezing, breathing effort on exhalation, or rapid breathing. May mga sitwasyon na delikado ang paglalagay ng tongue depressor o daliri sa bibig o lalamunan ng pasyente. Posible kasing maging dahilan ito ng paninigas ng daanan ng hangin ng pasyente at hindi ito makahinga. Kung may makita kang nakaharang sa paghinga ng pasyente, huwag alisin agad ito hanggaâ&#x20AC;&#x2122;t hindi sigurado na ito talaga ang dahilan kung bakit hindi ito makahinga.

Inside/Outside RESPIRATORY OISTRESS VS. RESPIRATORY FAILURE Inside the child with an airway or breathing problem, the body will take steps to compensate for the problem. The pulmonary system will increase respiratory rate and volume. The autonomic nervous system will engage the fight-or-flight response, increase heart rate, and constrict blood vessels. These mechanisms are often successful in temporarily maintaining the body’s oxygenation and ventilation despite the challenge to its respiratory system. When these compensatory mechanisms are working, we typically refer to the patient’s condition as respiratory distress. By that we mean the patient has a respiratory challenge, but the increased respirations and heart rate are temporarily serving to keep the brain oxygenated and ventilated. On the outside, this patient will present with difficulty breathing. You will observe the compensation by recognizing an increased respiratory rate and an increased pulse. You may note pale skin and/or delayed capillary refill. Most

PATIENT ASSESSMENT Difficulty Breathing Recognizing respiratory distress or failure is an important goal in the assessment of a pediatric patient with difficulty breathing. Gather information quickly from the parents and do a rapid assessment of the child. Unless there are clear indications of foreign body airway obstruction, do not put a tongue depressor in the child’s mouth to examine the airway. This may cause spasms that can totally obstruct the airway. Recognize the following signs of early respiratory distress: • Nasal flaring • Retraction of the muscles above, below, and between the sternum and ribs • Use of abdominal muscles • Stridor (high-pitched, harsh sound) • Audible wheezing • Grunting • Breathing rate greater than 60

important, respiratory distress can be recognized by the signs of adequate oxygenation and ventilation. Mental status is a key finding. A normal mental status indicates the brain is receiving oxygen and eliminating carbon dioxide. When this stops or is interfered with, mental status typically changes. Unfortunately, the body can only compensate for a breathing problem for a limited period of time. If not corrected, the compensatory mechanisms just described will eventually fail, and the respiratory distress will become respiratory failure. Inside the body, respiratory failure occurs when the challenge overwhelms the body’s ability to compensate. Continued hypoxia tires the muscles of respiration and they begin to fail. As a result, increased carbon dioxide and low oxygen levels begin to interfere with brain function. Outside, respiratory failure can be identified by all the signs of respiratory distress plus cyanosis of the skin, slowing or irregular respirations, and altered mental status.

In addition to these signs of early respiratory distress, watch for these additional signs of respiratory failure: • Altered mental status • Slowing or irregular respiratory rate • Cyanosis (especially after the addition of supplemental oxygen) • Decreased muscle tone • Poor peripheral perfusion (capillary refill greater than 2 seconds) • Decreased heart rate (a late sign)

PATIENT CARE Difficulty Breathing Provide oxygen to all children with respiratory emergencies. For children in early respiratory distress: • Provide oxygen by pediatric nonrebreather mask or blow-by technique if the patient will not tolerate a mask. For children in respiratory failure (those with respiratory distress and altered mental status, cyanosis even when oxygen is administered, poor muscle tone, or inadequate breathing) or respiratory arrest: • Provide assisted ventilations with pediatric pocket mask or bag-valve mask and supplemental oxygen.

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Respiratory failure will rapidly deteriorate to respiratory arrest if left untreated. As an EMT, you must always be on the alert to quickly treat a patient in this condition. Often the decision to use a bag-valve mask on a breathing child is a difficult one. However, it is critical. If you identify a child (or any patient, for that matter) who is not oxygenating and ventilating well enough to maintain a normal mental status you need to immediately intervene. What the patient is doing on his own is not enough! Beware also of the child who is so fatigued from the effort to meet increased respiratory demand that he can no longer go on (irregular,slowing respirations). She/He, too, needs your immediate help.

Respiratory Diseases Two illnesses that sometimes cause upper airway problems in children are croup and epiglottitis.

PATIENT ASSESSMENT Croup Croup is caused by a group of viral illnesses that result in inflammation of the larynx, trachea, and bronchi. It is typically an illness of children 6 months to about 4 years of age that often occurs at night. This problem sometimes follows a cold or other respiratory infection. Tissues in the airway (particularly the upper airway) become swollen and restrict the passage of air. During the day. the child with croup will usually have these signs: • Mild fever • Some hoarseness At night, the child’s condition will worsen and he will develop: • A loud “seal bark” cough • Difficulty breathing • Signs of respiratory distress including nasal flaring, retraction of the muscles between the ribs, the child lugging at his throat • Restlessness • Paleness with cyanosis

PATIENT CARE Croup Emergency care of a pediatric patient with croup is as follows: 1. Place the patient in a position of comfort (usually sitting up). 2. Administer high-concentration oxygen When possible, this should be from a humidified source (Do not delay oxygen administration in order to humidify.) 628

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3. Move slowly to the ambulance The cool night air may provide relief as the cool air reduces the edema in the airway tissues. 4. Do not delay transport unless ordered to do so by medical direction.

PATIENT ASSESSMENT Epiglottitis Epiglottitis is most commonly caused by a bacterial infection that produces swelling of the epiglottis and partial airway obstruction. Although routine childhood vaccinations have made this disease in children rare, it should be suspected when treating any child with stridor (a high-pitched sound caused by air moving through narrowed passageways), especially in children who are unvaccinated.

Lahat ng kaso ng epiglottitis o impeksyon sa epiglottis ay dapat ituring na delikado at puwedeng makamatay. Ang epiglottis ay cartilage na nakaharang sa daanan ng hangin. At ang impeksyon dito ay puwedeng maging dahilan para hindi makahinga ang pasyente.

The following are common signs of epiglottitis: • A sudden onset of high fever • Painful swallowing (the child often will drool to avoid swallowing) • Patient will assume a “tripod” position, sitting upright and leaning forward with the chin thrust outward (sniffing position) and the mouth wide open in an effort to maintain a wide airway opening. • Patient will sit very still, but the muscles will work hard to breathe, and the child can tire quickly from the effort • Child appears more generally ill than with croup.

PATIENT CARE Epiglottitis Emergency care for the pediatric patient with epiglottitis is as follows 1. Contact ALS. In most cases, the hospital is the closest source of ALS care. 2. Immediately transport the child, with the child sitting on the parent s lap. 3. Provide high-concentration oxygen from a humidified source. Do not increase the child’s anxiety If he or she resists the mask. let the parent hold it in front of the child’s face. Do not delay oxygen administration. 4. Constantly monitor the child for respiratory distress or arrest and be ready to resuscitate. 5. Do not place anything into the child’s mouth, including a thermometer, tongue blade, or oral airway doing so may set off spasms along the upper airway that will totally obstruct the airway.

The child will not want to lie down, and you should not force him to do so The child must be handled gently, since rough handling and stress could lead to a total airway obstruction from spasms of the larynx and swelling tissues. All respiratory disorders in children must be taken seriously. Respiratory disease is the primary cause of cardiac arrest not due to trauma. If you treat the respiratory system, the heart will also respond. The EMTs primary concern when caring for infants and children with respiratory problems, whether medical or trauma related, is to establish and maintain an open airway. About one-third of all pediatric trauma deaths are related to airway or respiratory compromise.

Other Pediatric Disorders Fever

Above-normal body temperature is one of the most important signs of an existing or impending acute illness. Fever usually accompanies infections (ear infections are common) as well as such childhood diseases as chicken pox, mononucleosis, pneumonia, epiglottitis, and meningitis. The fever also may be due to heat exposure, any infection, or some other non-infectious disease.

PATIENT ASSESSMENT Fever Never regard a fever as unimportant Fever can be the most important sign of a variety of serious conditions. Use relative skin temperature as a sign if you do not have a reliable means to obtain an accurate temperature Applying the un-gloved back of your hand to the patient’s forehead or to the abdomen beneath the clothing is another way to determine relative skin temperature. A high relative skin temperature is always enough reason to transport and seek medical opinion. Other signs are: • Fever with a rash is a sign of a potentially serious condition. • A seizure or seizures may accompany a high fever.

PATIENT CARE Fever

Children can tolerate a high temperature, and only a small percent will have a seizure due to fever (febrile seizure) It is the rapid rise in temperature rather than the temperature itself that causes seizures Cooling the child without bringing on hypothermia is an important care objective If you find an infant or child has a high fever, take the following steps:

1. Remove the child’s clothing, but do not allow him to be exposed to conditions that may bring on hypothermia If the child objects to having clothing removed, let the child keep on light clothing or underwear. 2. If the condition is a result of heat exposure, and if local protocols permit, cover the child with a towel soaked in tepid water. This will quickly cool the child. 3. Monitor for shivering and avoid hypothermia This may develop quickly in children. If shivering develops, stop the cooling activities and cover the child with a light blanket. 4. If local protocols permit, give the child fluids by mouth or allow him to suck on chipped ice. This may not prevent dehydration but will increase his comfort. 5. Be aware that a mild fever can quickly turn into a high fever that may indicate a serious, if not life-threatening, problem. If the infant or child feels very warm-to-hot to the touch, then prepare the patient for transport. Transport all children who have suffered a seizure as quickly as possible protecting the patient from temperature extremes. There are also some “do not’s” in treating an infant or child with fever: • Do not submerge the child in cold water, or cover with a towel soaked in ice water (which can rapidly cause hypothermia). • Do not use rubbing alcohol to cool the patient (It can be absorbed in toxic amounts and is a fixe hazard.)

Meningitis Meningitis is a potentially life-threatening infection of the lining of the brain and spinal cord (the meninges). It is caused by either a bacterial or a viral infection and commonly occurs between the ages of 1 month and 5 years. However, it is not uncommon to see meningitis in adolescents.

PATIENT ASSESSMENT The following are signs and symptoms of meningitis: • High fever • Stiff neck • Lethargy • Irritability • Headache • Sensitivity to light • In infants, bulging fontanelles unless the child is dehydrated • Painful movement during which the child does not want to be touched or held • Seizures • A rash if the infection is bacterial

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PATIENT CARE

It is most important to carefully take appropriate Standard Precautions Wear appropriate respiratory protection, since meningitis is an airborne disease When meningitis is suspected, provide the following care: 1. Monitor the patient’s airway, breathing, circulation, and vital signs. 2. Provide highMay mga uri ng meningitis concentration oxygen na sobrang nakakahawa. by nonrebreather Maging maingat sa pagsusuri mask. sa mga pasyente na meron nito. 3. Ventilate with a pediatric pocket mask May mga sitwasyon na ang mismong EMT ay sinusuri ng or bag-valve mask dojtor pagkatapos magbigay with supple-mental lunas sa pasyenteng may oxygen, if necessary. meningitis at ito 4. Provide CPR. if mismo ang necessary. binibigyan 5. Be alert for seizures. ng 6. Transport antibiotics. immediately. This is a true emergency. Do not delay.

Diarrhea and Vomiting

Diarrhea and vomiting are common in childhood illness. Either one can cause dehydration that worsens whatever other condition the child may have and may lead to life-threatening shock. Infants are more susceptible to the effects of dehydration because, compared to adults, a greater percentage of their body is water and their fluid maintenance needs are greater.

PATIENT ASSESSMENT

For any pediatric patient with diarrhea or vomiting: 1. Monitor the airway. 2. Monitor respiration. 3. Be alert for signs of shock.

PATIENT CARE

Emergency care for diarrhea and vomiting includes the following: 1. Maintain an open airway and be prepared to provide oral suctioning. 2. Provide oxygen if respirations are compromised. 3. If signs of shock are present, contact medical direction immediately and transport. 4. If your protocols or medical direction permits, offer the child sips of clear liquids or chipped ice if only diarrhea is present. Many physicians recommend nothing by mouth if there is nausea or vomiting. 630

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5. Some systems recommend that you save a sample of vomitus and rectal discharge e.g. a soiled diaper) Follow your local protocols.

Seizures Fever is the most common cause of seizures in infants and children. Epilepsy, infections, poisoning, hypoglycemia, trauma including head injury, or decreased levels of oxygen am also bring on seizures. Some seizures in children are idiopathic; that is, they have no known cause. They may be brief or prolonged. They are rarely life-threatening conditions in the children who frequently have them. However, the EMT should consider seizures, including those caused by fever, to be life threatening. Usually, you will arrive after the convulsion has passed.

PATIENT ASSESSMENT Interview the patient as well as family members and bystanders who saw the convulsion. Ask: • Has the child had prior seizures? • If yes, is this the child’s normal seizure pattern? (How long did the seizure last? What part of the body was seizing?) • Has the child had a fever? • Has the child taken any anti-seizure medication? Other medication? Assess the child for signs and symptoms of illness or injury, taking care to note any injuries sustained during the convulsion All infants and children who have undergone a seizure require medical evaluation The seizure itself may not be serious but it may be a sign of an underlying condition. Be aware that seizures may also be caused by a head injury.

PATIENT CARE

If the patient has a seizure in your presence, possibly during transport, provide the following care. 1. Maintain an open airway. Do not insert an oropharyngeal airway or bite suck. 2. Position the patient on his side if there is no possibility of spinal injury. 3. Be alert for vomiting. Suction as needed. 4. Provide oxygen If the patient is in respiratory arrest, provide artificial ventilations with supplemental oxygen. 5. Transport. 6. Monitor for inadequate breathing and/or altered mental status, which may occur following a seizure.

Altered Mental Status

Altered mental status may be caused by a variety of conditions, including hypoglycemia, poisoning, infection, head injury, decreased oxygen levels, shock, or the aftermath of a seizure.

PATIENT ASSESSMENT

Assessment of the patient with altered mental status focuses on life-threatening problems discovered during the primary assessment: • Be alert for a mechanism of injury that may have caused the altered mental status, such as head injury. • Be alert for signs of shock. • Look for evidence of poisoning from ingested, inhaled, or absorbed substances. • Attempt to quickly obtain a history of any seizure disorder or diabetes.

PATIENT CARE

Emergency care of a pediatric patient with altered mental status includes the following steps: 1. Ensure an open airway Be prepared to suction. 2. Protect the spine while managing the airway if a head injury or other trauma is present. 3. Administer high-concentration oxygen by pediatric nonrebreather mask or blow-by technique. Be prepared to perform artificial ventilations by pediatric pocket mask or bag-valve mask with supplemental oxygen. 4. Treat for shock. 5. Transport.

Poisoning Children are often the victims of accidental poisoning, often resulting from the ingestion of household products or medications. Certain poisons can quickly depress the respiratory system, cause respiratory arrest, and cause life-threatening conditions of the circulatory and nervous systems. The airway and gastrointestinal tract can also be burned by corrosive substances upon ingestion and with subsequent vomiting.

PATIENT ASSESSMENT

Some types of poisonings are not often associated with adult patients but are common to children. These special cases are: • Aspirin poisoning. Look for hyperventilation, vomiting, and sweating. The skin may feel hot Severe cases cause seizures, coma, or shock. • Acetaminophen poisoning. Many medications have

this compound, including Tylenol, Comtrex, Bancap, Excedrin PM, and Datril. Initially, the child may have no abnormal signs or symptoms Tho child may be restless (early) or drowsy Nausea, vomiting, and heavy perspiration may occur Loss of consciousness is possible. • Lead poisoning. This usually comes from ingesting chips of load-based paint it is often a chronic condition (building up over a long time). Look for nausea with abdominal pain and vomiting. Muscle cramps, headache, muscle weakness, and irritability are often present. • Iron poisoning. Iron compounds such as ferrous sulfate are found in some vitamin tablets and liquids As little as 1 gram of ferrous sulfate can be lethal to a child. Within 30 minutes to several hours, the child will show nausea and bloody vomiting, often accompanied by diarrhea Typically the child will develop shock, but this may be delayed for up to 24 hours as the child appears to be getting better. • Petroleum product poisoning. The patient will usually be vomiting with coughing or choking. In most cases, you will smell the distinctive odor of a petroleum distillate (e.g. gasoline, kerosene, heating fuel).

PATIENT CARE

Emergency care for a responsive poisoning patient includes the following steps: 1. Contact medical direction or the poison control center. 2. Consider the need to administer activated charcoal (where protocol allows). 3. Provide oxygen. 4. Transport. 5. Continue to monitor the patient The patient may become unresponsive. Emergency care for an unresponsive poisoning patient includes the following steps 1. Ensure an open airway. 2. Provide oxygen. 3. Be prepared to provide artificial ventilation. 4. Transport. 5. Contact medical direction of the poison control center. 6. Rule out trauma as a cause of altered mental status. Madalas na maging biktima ng pagkalason ang mga bata dahil sila ay kadalasan “curious” at mahilig mageksperimento. Sa loob ng bahay ay madaming uri ng kemikal at gamot na puwede nilang ikalason. Mahalagang makita ng EMT ang mga simtomas kung hindi nito alam ang pinagmulan ng pagkalason ng bata.

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Drowning Drowning is the process of experiencing respiratory impairment from submersion/ immersion in liquid, which may result in death, morbidity (illness or other adverse effects), or no morbidity. Water temperature may affect outcomes from drowning. Patients who have been submerged in cold water have been revived 30 minutes or more after submersion.

PATIENT ASSESSMENT Drowning

If the patient is unresponsive and you suspect he may be in cardiac arrest: 1. Establish unresponsiveness, breathlessness, and pulselessness. 2. If the patient is unresponsive, breathless, and pulseless, perform five cycles of compressions and ventilations (30:2 ratio) at a rate of 100 compressions per minute before activating the emergency response system if this has not already been done. 3. If trauma may have been a cause or result of the submersion incident (such as injury from a dive), maintain spinal stabilization and follow trauma assessment procedures. Remember, however, that resuscitation is your first priority. 4. Consider possible ingestion of alcohol as a cause of the drowning, especially in adolescents. 5. Consider the possibility of “secondary drowning syndrome”—deterioration after normal breathing resumes, minutes to hours after the event.

PATIENT CARE

For the drowning patient, provide the following care: 1. Provide artificial ventilation or CPR as necessary This is your first treatment priority. 2. Protect the airway Suction, if necessary. 3. Consider spinal immobilization. 4. Protect against possible hypothermia, especially if the patient has been in cool or cold water As soon as practical, remove wet clothing, dry the skin, and cover with a blanket 5. Treat any trauma, 6. Transport all drowning patients to the hospital, even if they seem to have recovered. 632

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PEDIATRIC EMERGENCIES

Sudden Infant Death Syndrome In the United States, sudden infant death syndrome (SIDS)—the sudden, unexplained death during sleep of an apparently healthy baby in its first year of life—occurs in 2.000 to 2.500 babies each year. These babies were usually receiving proper care and frequently have passed physical examinations within days of their sudden death. Many possible causes for this syndrome have been investigated but are not well understood. The problem is not caused by external methods of suffocation or by vomiting or choking. The problem may possibly be related to nerve cell development in the brain or the tissue chemistry of the respiratory system or the heart. Some relationships have been drawn to family history of SIDS and respiratory problems, but there is still no accepted reason why these babies die. When asleep, the typical SIDS patient will show periods of cardiac slowdown and temporary cessation of breathing known as sleep apnea. Eventually, the infant will stop breathing and will not start again on its own. Unless reached in time, the episode can be fatal. The baby’s condition is most commonly discovered in the early morning when the parents go to wake the baby. It is not up to you, as an EMT, to diagnose SIDS. All you or the parents will know is that the baby is in respiratory or cardiac arrest. You will treat the baby as you would any patient in this condition: 1. Unless there is rigor mortis (stiffening of the body after death), provide resuscitation. 2. Be certain that the parents receive emotional support and that they understand that everything possible is being done for the child at the scene and during transport. Parents who lose a child to SIDS often suffer intense feelings of guilt from the moment they find the child. Whether or not the parents express such guilt, remind them that SIDS occurs to apparently healthy babies who are receiving the best of parental care. Do not speak with a suspicious tone or ask inappropriate questions. Do not be embarrassed to express your sorrow for their loss.

PEDIATRIC TRAUMA EMERGENCIES

Trauma is the number one cause of death in infants and children. Blunt trauma far exceeds penetrating trauma in this age group. Much of this trauma occurs because children are curious and learning about their environment. Exploring often leads to injury from accidental falls (or things falling on them), burns, entrapment, crushing, and other mechanisms of injury, emergencies When providing emergency care for the injured child, always tell him what you are going to do before you do it.

Injury Patterns

Injury management is basically the same for children as for adults. However, their anatomic and physiologic differences cause children to have different patterns of injury.

During motor-vehicle collisions: • Unrestrained child passengers (those without seat belts or restraint in a child safety seat) tend to have head and neck injuries. • Restrained passengers may have abdominal and lower spine injuries. Children who are struck by motor vehicles while bicycle riding often have head, spinal, and abdominal injuries. The child who has been struck by a vehicle may present with the following triad of injuries: • Head injury • Abdominal injury with possible internal bleeding • Lower extremity injury (possibly a fractured femur)

Iba’t ibang injuries ang puwedeng makuha ng isang bata. Puwede itong ma-injure habang naglalaro, habang nasa beach at lumalangoy, o habang nasa eskuwelahan at kasali sa sports. Puwede rin itong maging biktima ng child abuse. Bilang EMT, importante na malaman mo kung papaano bibigyan ng lunas ang lahat ng injuries na ito.

Head

Recall that the head is proportionately larger and heavier in the small child. This leads to head injury when the head is propelled forward in a collision. This is often combined with internal injuries. Suspect internal injuries whenever a child with a head injury presents with shock, since head injury itself is seldom a cause of shock. Respiratory arrest is a common secondary effect of head injury, so be alert to this possibility. Although the most frequent sign of head injury is an altered mental status, nausea and vomiting also often occur.

Chest

The less-developed respiratory muscles of the chest and the more elastic ribs make the pediatric chest more easily deformed, the immature respiratory muscles make breathing slightly less efficient than in adults. The more elastic ribs rarely fracture: however, there is more likely to be injury to the structures beneath the ribs. You must suspect internal chest injuries when the mechanism of injury is significant, despite the absence of external signs of chest injury.

Abdomen

Infants and young children are abdominal breathers; that is, they rely on their diaphragms for breathing more than adults do. Thus, they may not have significant movement of their chest while breathing. Therefore, watch the abdomen to evaluate breathing. In addition, abdominal muscles are immature and therefore provide less protection to internal organs than do adult abdominal muscles. The abdomen can be a site of “hidden” injuries. You must suspect an internal abdominal injury when the patient deteriorates even without evidence of external injury. In addition, air in the stomach can distend the abdomen and interfere with artificial ventilation. This may also lead to vomiting. Be prepared to suction the patient.

Extremities

Despite the more flexible bones in the pediatric patient, their extremity injuries are managed the same way as extremity injuries in adults.

Burns

Burns are a common pediatric injury. Review the pediatric differences in the “rule of nines” as it applies to estimating the extent of burns in children and infants. Follow these guidelines when managing patients with burns: • Identify candidates for transportation to burn centers. Local protocols should guide your determination. • Cover the burn with sterile dressings. Nonadherent dressings are the best, but sterile sheets may be used. Moist dressings should be used with caution in the pediatric patient. Remember that the child’s body surface area is larger proportionately to their body mass, making them more prone to heat loss. Burned patients who become hypothermic have a higher death rate. You must keep the infant or child covered to prevent a drop in body temperature.

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High-Risk Mechanisms of Injury and Pediatric Injury Patterns Transport to a trauma center with pediatric care capabilities if any of the following are identified:

HIGH-RISK MECHANISM

TYPE OF INJURY TO PEDIATRIC PATIENT

FALLS Over age 15: 20 feet (one story = 10 feet) Under age 15: fall > 10 feet or two to three times child’s height Note: Seriousness depends on: 1. height of fall, 2. surface on which child fell, and 3. child’s age. (Infants may have serious head injury from falls of 5-4 feet from a changing table.)

Head and upper neck injury and fractures to upper and lower extremities from moderate falls. 5-15 feet Head, neck, spine injury, abdominal and chest injury, and fractures of upper and lower extremities from high falls over 15 feet

AUTO CRASH Improperly restrained/unrestrained passenger

Serious head and neck injury, facial abrasions, and lacerations. Soft-tissue injury of the neck from shoulder belt used without lap belt or shoulder belt used on a too-small child. Internal abdominal injury from lap belt used without shoulder belt or lap bell improperly positioned over abdomen. Fracture of lower vertebrae and spinal cord damage from violent flexion at waist when lap belt is used without shoulder belt.

Child struck by deployed air bag

Severe head and neck injury. Burns to the eye and face caused by the caustic powder released when air bag deploys.

Pedestrian or bicyclist struck with significant (> 20 mph) Impact Child thrown onto hood/windshield or minimal distance on Impact

Severe head injury, especially if thrown any distance, by force of high speed at impact. Multiple head, chest, abdominal, and leg injuries. Fracture of long bones, especially the femur. Internal injury and bleeding of the liver and/or spleen. (Kidney, liver— blows to right upper quadrant; spleen— blows to flank and torso.)

Child run over by car

Internal chest injury, often without obvious external damage. Internal abdominal injury, often without obvious external damage. Fractures of upper and lower extremities and the pelvis.

PATIENT CARE Trauma

Emergency care steps for the pediatric trauma patient should include the following 1. Ensure an open airway Use the jaw-thrust maneuver. 2. Suction as necessary, using a rigid suction catheter. 3. Provide high-concentration oxygen 4. Ventilate with a pediatric pocket mask or bag-valve mask as needed. 5. Provide spinal immobilization. 6. Transport immediately. 7. Continue to reassess en route. 8. Assess and treat other injuries en route if time permits.

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Immobilizing a Child Using a KED Although many pediatric immobilization devices are available, an adult Kendrick Extrication Device (KED) can also be used successfully to immobilize a child if adjusted to suit the child’s size and anatomy. Manually stabilize the child’s neck and spine throughout, and apply a cervical spine immobilization collar before securing the child to the KED. 1. Open the KED and place padding on it to properly position and align the child’s head and body. Log roll the child onto the KED. 2. Fold the side pieces inward to provide side padding and support and to allow visualization of the chest and abdomen. Since the torso straps will be rolled to the inside, secure the torso with tape. Fold the head flaps securely against the child’s head and tape across the head and chin.

CHILD ABUSE AND NEGLECT Although the number of known child abuse cases is large, the real number may be even larger than the statistics indicate. Experts believe that for every abused child seen by the emergency department or family physician, there are many more unreported cases who never receive care. Child abusers are mothers, fathers, sisters, brothers, grandparents, stepparents, baby-sitters and other caregivers, white-collar workers, bluecollar workers and those who are unemployed, rich, or poor. There is no distinction as to race, creed, ethnicity, or economic background. Child abuse can take several different forms, often occurring in combination; • Psychological (emotional) abuse • Neglect • Physical abuse • Sexual abuse What constitutes neglect is a serious legal question. If a child goes without proper food, shelter, clothing, supervision, treatment of injuries and illnesses, a safe environment, and love, the effects surely will be seen but will seldom directly trigger an emergency call. Physical and sexual abuse are the problems likely to be seen by EMTs. If signs of neglect are observed in the course of a call, they should also be reported to the proper authorities.

Physical and Sexual Abuse Abusers inflict almost every imaginable kind of injury and maltreatment. Physically abused children—often called “battered” children—are beaten with fists, hair brushes, electric cords, pool cues, pots and pans, and almost any other object that can be used as a weapon. They are intentionally burned by hot water, steam, open flames, cigarettes, and other thermal sources. Battered children may be severely shaken, thrown into their cribs or down steps, pushed out of windows and over railings, and even pushed from moving cars. Sexual abuse ranges from adults exposing themselves to children to sexual intercourse or sexual torture. Often, cases in which sexual abuse results in serious physical injury are reported to the authorities However, some cases, especially those in which emotional injury or minor physical injury were done, are not reported, and therefore they are difficult to estimate.

PATIENT ASSESSMENT Physical Abuse In child physical abuse cases, you will find: • Slap marks, bruises, abrasions, lacerations, and incisions of all sizes and with shapes matching the item used. You may see wide welts from bolts, a looped shape from cords, or the shape of a hand from slapping You may find swollen limbs, split lips, black eyes, and loose or broken teeth Often the injuries are to the back. legs, and arms • Broken bones are common and all types of fractures are possible Many battered children have multiple fractures, often in various stages of healing, or have fractureassociated complications. • Head injuries are common. with concussions and skull fractures being reported. Closed head injuries occur, to many infants and small children who have been severely shaken • Abdominal injuries include ruptured spleens, livers and lungs lacerated by broken ribs, internal bleeding from blunt trauma and punching. and lacerated and avulsed genitalia • Bite marks showing the teeth size and pattern of the adult mouth may be present. • Burn marks that are small and round from cigarettes, “glove”* or “stocking” burn marks from dipping in hot water: burns on buttocks and legs (creases behind the knees and at the thighs are protected when flexed). and demarcation burns in the shape of an iron, stove burner, or other hot utensil are frequently found • Indications of shaking an infant include a bulging fontanelle due to increased intracranial pressure from the bleeding of torn blood vessels in the brain, unconsciousness, and typical signs and symptoms of head and brain injury. Injuries to the central nervous system from “the shaken baby syndrome” are among the most lethal child abuse injuries. Sometimes you will treat an injured child and never consider that he has been abused, especially if the child relates well with the parents and there appears to be a strong bond between them. However, there can be certain indications that abuse may be occurring in or outside the home, with the family feeling they must not admit to the problem Be on the alert for: • Repeated responses to provide care for the same child or children in a family. Remember that in areas with many hospitals, you may see the child more frequently than any one hospital. • Indications of past injuries This is one reason why you must do a physical examination and why you must remove articles of clothing Pay special attention to the child’s back and buttocks • Poorly healing wounds or improperly healed fractures It is extremely rare for a child to receive a fracture, be given proper orthopedic care, and then show angulations and large

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Day 24 “bumps” and “knots” of bone at the “healed” injury site. • Indications of past burns or fresh bilateral burns. Children seldom put both hands on a hot object or touch the same hot object again (true, some do—this is only an indication, not proof) Some types of burns are almost always linked to child abuse, such as cigarette burns to the body and burns to the buttocks and lower extremities that result from the child being dipped in hot water. • Many different types of injuries to both sides, or to tho front and back, of the body. This gains even more importance if the adults on the scene keep insisting that the child “falls a lot”. • Fear on the part of the child to tell you how the injury occurred. The child may seem to expect no comfort from the parents and may have little or no apparent reaction to pain. • The parent or caregiver at the scene who does not wish to leave you alone with the child, tells conflicting or changing stories, overwhelms you with explanations of the cause of the injury, or faults the child. These should arouse your suspicions and cause you to more carefully assess the situation. Pay attention to the adults as you treat the child: • Do they seem inappropriately unconcerned about the child? • Do they have trouble controlling their anger? • Do you feel that at any moment there may be an emotional explosion? • Do any of the adults appear to be in a deep state of depression? • Are there indications of alcohol or drug abuse? • Do any of the adults speak of suicide or seeking mercy for their unhappy children? Although parents or caregivers may call for help for the child, they may be reluctant to provide a history of the injury and refuse transport. Take note of any parent who refuses to have his child sent to the nearest hospital or to a hospital where the child has been seen before. This may indicate fear of the staff remembering or seeing a record of past injuries. You cannot transport without parental consent; however, you may be able to convince the parents the child needs to be seen by a doctor because of certain signs and symptoms that are “difficult to determine” in the field. Be the child’s advocate, but do not accuse the parent.

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PEDIATRIC EMERGENCIES

PATIENT ASSESSMENT Sexual Abuse Rearrange or remove clothing only as necessary to determine and treat injuries. This will help preserve evidence where possible. Examine the genitalia only if there is obvious injury or the child tells you of a recent injury. The child may be hysterical, frightened, or withdrawn and unable to give you a history of the incident. Be calm and as reassuring as possible The following are common signs of sexual abuse: • Obvious signs of sexual assault, including burns on wounds to the genitalia. • Any unexplained genital injury such as bruising, lacerations, or bloody discharge from genital orifices (openings). • Seminal fluid on the body or clothes or other discharges associated with sexually transmitted diseases. • In rare cases, the child may tell you that he was sexually assaulted. Remain professional and control your emotions Protect the child from embarrassment. Say nothing that may make the child believe that he is to blame for the sexual assault. (Many believe that they are.)

PATIENT CARE Physical or Sexual Abuse Emergency care for physical or sexual abuse includes the following steps: 1. Dress and provide other appropriate care for injuries as necessary. 2. Preserve evidence of sexual abuse if it is suspected: Discourage the child from going to the bathroom (for both defecation and urination) Give nothing to the patient by mouth. Do not have the child wash or change clothes. 3. Transport the child. Bilang EMT, kailangan mong i-report nang malinaw at direkta sa medical director mo kung may suspetsa ka na biktima ng physical o sexual abuse ang iyong pasyente.

Role of the EMT in Cases of Suspected Abuse or Neglect Remember that you are charged with providing emergency care for an injured child. You are not a police officer, court investigator, social worker, or judge. Gather information from the parents or caregiver away from the child without expression of disbelief or judgment. Talk with the child separately about how an injury occurred. As you assess the patient and provide appropriate care, control your emotions and hold back accusations. Do not indicate to the parents or other adults at the scene that you suspect child abuse or neglect. Do not ask the child if he has been abused. Doing so when others are around could produce stress too great for the injured child to handle. If you are suspicious about the mechanism of injury, transport the child even though the severity of injury may not warrant such action. In some cities, EMTs are mandated reporters; that is, they are required by law to report suspicions of child abuse or neglect. Commonly, reporting means contacting your state’s child abuse reporting hotline. Often just notifying hospital personnel about your suspicions is not enough. Be familiar with your state laws. Even if reporting possible child abuse or neglect is not a legal requirement in your state, it is a professional obligation. As an EMT,

you may be the only advocate an abused child has. Be conscientious. Past responses can be checked and future responses noted in case a pattern develops to indicate possible abuse. However, even when talking to your partner, the hospital staff, the police, and your superiors, use the terms suspected and possible Always be objective and report only the facts. Avoid generalizations and assumptions. Do not call someone a child abuser. Keep in mind that the courts can deal harshly with those who provide patient care and then violate the confidentiality of the patient, the family, and the home. Rumors about abuse may, in the long run. cause mental or physical harm to your child patient. It may be difficult, but remember that the parent or caregiver needs help as well. Your actions, response, and concern directed toward suspected abusers can help them recognize their problem and may encourage them to seek therapy and rehabilitation. Also bear in mind that your suspicions may be unfounded. Not every injury to a child is the result of child abuse. Suspicions should be aroused not by individual injuries but by patterns of injuries and behavior.

INFANTS AND CHILDREN WITH SPECIAL CHALLENGES Over the years, medical expertise has improved significantly, allowing many children who would formerly have died to live. The following are some common groups of children with special challenges: • Premature infants with lung disease • Infants and children with heart disease • Infants and children with neurological disease • Children with chronic disease or altered function from birth Often these children are able to live at home with their parents. This means that you may receive calls to care for children who have complicated medical problems and are dependent on various technologies. In fact, children with special challenges living at home constitute a significant percentage of the relatively small number of pediatric emergency calls. The children’s parents will be familiar with the various devices used and can serve as a valuable resource. Common devices include tracheostomy tubes, home artificial ventilators, central intravenous lines, gastrostomy tubes and gastric feeding tubes, and shunts. Emergency care of children with special challenges has often been complicated by the lack of information that EMTs and emergency department staff are able to quickly obtain about the children’s medication, condition, history, precautions needed, and special management plans

Sa ibang bansa, partikular na sa US, pinagsusuot ng bracelet ang mga bata na may special needs para malaman agad kung ano ang mga medical needs nila. Pero sa Pilipinas, hindi pa ito uso. Kung meron kang pasyente na bata na may special needs, tingnan mo kung meron siyang medical ID o bracelet. Makakatulong iyon sa iyo para malaman ang dapat mong gawin.

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PEDIATRIC EMERGENCIES

Tracheostomy Tubes Tracheostomy tubes are tubes that have been placed into the child’s trachea to create an open airway. They are often used when a child has been on a ventilator for a prolonged Pangunahin mong time. Although there are tungkulin ay ang various types of tubes the tulungan ang pasyente na potential complications are makahinga nang maayos identical. You may be called to hanggang makarating siya help when there is: sa ospital. • Obstruction • Bleeding from the tube or around the tube • Air leaking around the tube • Infection • Dislodged tube

Home Artificial Ventilators Artificial ventilators in the home are becoming more common. Although the parents will be trained in the ventilator’s use. they will call EMS when there is trouble. Regardless of the problem, your emergency care will include: • Maintaining an open airway • Artificially ventilating with a pocket mask or bag-valve mask with oxygen • Transporting the patient

Central Intravenous Lines Central lines are intravenous lines that are placed close to the heart. Unlike most peripheral IV lines, central lines may be left in place for long-term use. Possible complications of the use of central lines are: • Infection • Bleeding • Clotting-off of the line • Cracked line

Gastrostomy Tubes and Gastric Feeding Gastrostomy tubes, tubes placed through the abdominal wall directly into the stomach, are used when a patient is not able to be orally fed. The most dangerous potential problem associated with their use involves respiratory distress. The emergency care will include the following steps: • Being alert for altered mental status in diabetic patients. They may become hypoglycemic quickly when unable to eat. 638

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• Ensuring an open airway. • Suctioning the airway as needed. • Providing oxygen, if needed. • Transporting the patient in cither a sitting position or lying on the right side with the head elevated to reduce the risk of aspiration.

Shunts

A shunt is a drainage device that runs from the brain to the abdomen to relieve excess cerebrospinal fluid. There will be a reservoir on the side of the skull. If the shunt malfunctions, pressure inside the skull will rise, causing an altered mental status. An altered mental status may also be caused by an infection. These patients are prone to respiratory arrest. Your emergency care will include the following steps; • Maintaining an open airway • Ventilating with a pocket mask or bag-valve mask and high-concentration oxygen, if needed • Transporting the patient

THE EMT AND PEDIATRIC EMERGENCIES Many types of pediatric illnesses and injuries have been discussed in this chapter. The focus has been on the patient. Now we will look at the psychological responses of the EMT. It is well known that pediatric calls can be among the most stressful for the EMT. Even when they are uneventful. EMTs who have children often identify their patients with their own children. Other EMTs have no experience with children and feel anxiety about communicating with them and treating them—even about estimating their ages. However, the skills of communicating with and treating children can be learned and applied. Often, the EMT who starts out “knowing nothing about children” turns out to have a real knack for dealing with them. Child care mostly consists of applying what you have learned about the care of adult patients and combining it with knowledge of the key differences in developmental characteristics, anatomy, and physiology of children. Often the most serious stresses an EMT faces result from pediatric calls that involve a very sick, injured, or abused child, or a child who has died or who dies during or after emergency care. Fortunately, such calls are rare and can be prepared for with advance training. When you have had an experience like this, talk with other EMTs. If your squad or service has a counsellor, see this person for advice. You may think that you can handle the stress or sorrow by yourself, but experienced EMTs know better. Unless you resolve the impact of stressful events, the problems created may compound and could lead to “burnout.”

Lifeline in Action

A CASE OF HYPOGLYCEMIA By Jon Ignatius lacsina

As an EMT, I often ask our Giver of Life for an exciting case where our skills will be challenged and tested. In my 250 hours of on the job training with Lifeline, I never had such case. But in one case, we were dispatched to patient who lost consciousness. When we arrived at the scene, we found the patient already conscious. However, our assessment revealed that the patient was confused, incoherent and somewhat delirious. We asked her relatives what happened, and we were told WHEN WE REACHED that the patient experienced hypoglycemia. According to the relatives, the patient had diabetes mellitus, and she exhibited THE HOSPITAL, THE symptoms like diaphoresis (excessive sweating) and cold, EMERGENCY ROOM clammy skin. During assessment, it was found that the patientâ&#x20AC;&#x2122;s blood NURSE ASSESSED sugar level was a very low 33mg/dL (normal is 80-100mg/ THE PATIENT AND dL). The patient was given chocolate drink and she craved for more. We then rechecked her blood sugar and it increased to DECLARED THAT HER 42mg/dL. My team leader gave the patient some water with STATE OF HEALTH sugar in it, but the patient still seemed to be disoriented. So my team leader opted to do an intravenous treatment. At the WAS ALREADY same time, he decided to immediately transport the patient to the designated hospital. IMPROVING In the ambulance, we rechecked the patientâ&#x20AC;&#x2122;s blood sugar once again and it now increased to 64mg/dL. When we reached the hospital, the emergency room nurse assessed the patient and declared that her state of health was already improving.

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