Test Bank For Paramedic Care Principles & Practice, Vols. 3 5th Edition by Bryan Bledsoe by QuentinAxel

MASTER TEACHING NOTES

Detailed Lesson Plan Chapter 1 Pulmonology 170–180 Minutes

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Teaching Tips Discussion Topics Class Activities Points to Emphasize Knowledge Application

Chapter 1 objectives can be found on text p. 1. These objectives, which form the basis of each chapter, were developed from the current National EMS Education Standards and the accompanying Paramedic Instructional Guidelines.

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Content Outline I.

Case Study

Master Teaching Notes Teaching Tips Have a student read the scenario. Tell students that the case will be reviewed after the lecture.

II. Introduction A. The respiratory system is a vital body system responsible for providing oxygen to the tissues and removing metabolic waste. B. Respiratory emergencies are among the most common emergencies EMS personnel are called upon to treat. C. Several risk factors increase the likelihood of developing respiratory disease. 1. Intrinsic risk factors are those that are influenced from within the patient. The most important intrinsic risk factor is genetic predisposition. 2. Extrinsic risk factors are those that are external to the patient. The most important extrinsic risk factor is cigarette smoking. III. Review of Respiratory System Anatomy and Physiology A. Upper Airway Anatomy 1. The upper airway is responsible for warming and humidifying incoming air. 2. The nasal cavity includes turbinates, which cause turbulence that facilitates the entrapment and removal of inhaled foreign particles. 3. The pharynx is a funnel-shaped structure that connects the nose and mouth to the larynx. 4. In addition to its role in speech, the larynx serves as a filtering device for the

Teaching Tips Respiratory emergencies are some of the most common responses for the EMS provider. It is important for students to understand the importance of managing respiratory emergencies.

Teaching Tips This is a review of material previously discussed. Revisit the previous topics concerning the anatomy of the respiratory system.

Class Activities Because this is review material, 1

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Content Outline digestive and respiratory tracts. a. The opening between the vestibule and the vocal cords is the glottic opening. b. The epiglottis closes during swallowing to divert food/liquids into the esophagus. B. Lower Airway Anatomy 1. The lower airway begins at the trachea and continues into the lungs. 2. The trachea is composed of a series of C-shaped cartilaginous rings and is lined with the same type of cells that line the nares. 3. At the carina, the trachea divides into the right and left bronchi. a. The right mainstem bronchus is almost a straight continuation of the trachea, whereas the left mainstem bronchus angles more acutely to the left. b. The mainstem bronchi divide into the secondary (lobar) bronchi. c. Secondary bronchi divide into tertiary bronchi, which ultimately divide into bronchioles or small airways. d. The bronchioles are approximately 1 mm thick and contain smooth muscle that can contract, thus reducing the diameter of the airway. 4. The respiratory bronchioles divide into alveolar ducts, although limited gas exchange may occur in the alveolar sacs. a. The alveolar wall consists of a thin layer of cells that lines the surface of the lung. b. In close proximity to the alveoli are the pulmonary capillaries, which carry carbon dioxide–rich blood from the lungs for return to the heart. c. The alveolar lining, supportive tissue, and capillaries make up the respiratory membrane. d. The alveoli are moistened and kept open because of the presence of surfactant. 5. The lungs are the main organs of respiration. a. The right lung contains three major divisions or lobes; the left lung has only two. b. The lungs are covered by connective tissue called pleura.

Master Teaching Notes have students split into groups, and have each group present a portion of the respiratory system to the rest of the class. Then you can gauge which content students most need to review.

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6. Blood is supplied to the lungs through the pulmonary and bronchial vessels. a. Pulmonary arteries transport deoxygenated blood, rich in carbon dioxide, from the heart to the lungs. b. The pulmonary veins transport the newly oxygenated blood from the lungs back to the heart. c. The bronchial arteries branching from the aorta provide blood supply to the lungs and the bronchial veins return it to the superior vena cava. C. Physiologic Processes 1. The major function of the respiratory system is to exchange gases with the environment. 2. Oxygen is taken in while carbon dioxide is eliminated, a process known as gas exchange. 3. Ventilation is the mechanical process of moving air into and out of the lungs. a. For ventilation to occur, several body structures must be intact, including the chest wall, nerve pathways, diaphragm, pleural cavity, and brainstem. b. During inspiration, air is drawn into the lungs, the diaphragm flattens, and the intercostal muscles contract, which expands the chest and decreases air pressure within the chest cavity, drawing air into the respiratory system. c. During expiration, air leaves the lungs by the chest wall and diaphragm recoiling to the resting state, driving air out of the lungs. d. Airway resistance and lung compliance also play a role in the amount of airflow into and out of the lungs. i. More airway resistance means less airflow into the chest cavity. a)Asthma results in bronchospasm, which reduces the diameter of the airways. ii. Lung compliance refers to the ease with which the chest expands. a)The more the chest wall expands, the greater the volume of air entering the chest cavity. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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Content Outline b)Loss of elasticity in the muscles of the chest wall with age decreases lung compliance. e. The volume of air entering the lungs varies on the basis of the metabolic needs of the patient f. Ventilation is controlled by the lower portion of the brainstem, specifically the medulla 4. Diffusion is the process by which gases move between the alveoli and the pulmonary capillaries. a. Gases flow from areas with high concentration to areas of low concentration. b. In the alveoli, oxygen flows from areas of high concentration to areas of low concentration in the pulmonary capillaries; conversely, carbon dioxide flows from the capillaries into the alveoli. c. High concentrations of oxygen can help to address problems with diffusion by increasing the amount available. 5. Perfusion is the circulation of blood through the lungs—specifically, through the pulmonary capillaries—and is dependent on three conditions. a. Adequate blood volume because of the concentration of hemoglobin in the blood b. Intact pulmonary capillaries where the gas exchange takes place c. Efficient pumping of blood by the heart for delivery of oxygen and elimination of carbon dioxide IV. Pathophysiology A. Disruption in Ventilation 1. Disruption of ventilation can occur when the normal conducting pathways are obstructed, the normal chest wall function is impaired, or there is an abnormality with the nervous system’s control 2. Disease states that affect the upper respiratory tract will result in obstruction of airflow to the lower structures. a. Upper airway trauma, infections, foreign bodies, and other structures (such as the tongue) are causes of obstruction. 3. The chest wall and diaphragm are essential components in ventilation, and

Master Teaching Notes

Class Activities Map a molecule of oxygen moving through the body, beginning with inhalation and ending with a target organ. Briefly discuss different areas where respiratory emergencies may affect its travel through the body.

Knowledge Application 4

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Content Outline traumatic injuries to these areas disrupt normal mechanics. a. Pneumothorax, hemothorax, flail chest, and diaphragmatic rupture are examples of traumatic injuries to these areas. 4. Any disease process that impairs the nervous system’s regulation of breathing may also alter ventilation. a. CNS depressants such as alcohol or barbiturates can alter the brain’s response. b. Certain abnormal respiratory patterns are produced by specific brain injury. i. Cheyne-Stokes respirations – seen in older patients with terminal illness or brain injury ii. Kussmaul’s respirations – result as a corrective measure against conditions such as diabetic ketoacidosis that produce metabolic acidosis iii. Central neurogenic hyperventilation – caused by strokes or injury to the brainstem iv. Ataxic (Biot’s) respirations – seen in patients with increased intracranial pressure v. Apneustic respirations – a result of stroke or severe central nervous system disease B. Disruption of Diffusion 1. Disruption of diffusion can be caused by many disease processes and situations, causing hypoxia 2. Changes in oxygen concentration affect diffusion. 3. Any disease that alters the structure or patency of the alveoli will limit diffusion. 4. Disease states that alter the thickness of the respiratory membrane will limit diffusion of gases. (The most common cause of this alteration is accumulation of fluid and inflammatory cells in the interstitial space.) 5. Changes in permeability of the pulmonary capillaries affect diffusion. C. Disruption in Perfusion 1. Disruption in perfusion is caused by alteration of blood flow through the

Master Teaching Notes Respiratory physiology is fundamental in the management of respiratory emergencies. It is important to be able to tie the concepts of respiratory emergencies to the functions and structures within the body they affect. For example, correlate the pulmonary circulation with the disorders that affect it.

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Content Outline pulmonary capillaries. 2. Any disease state that reduces the normal circulating blood volume will limit perfusion in the lungs. 3. If a portion of lung is without blood flow, it becomes unavailable for perfusion regardless of oxygenation. V. Assessment of the Respiratory System A. Scene Size-Up 1. When you first approach the scene, consider two major questions: a. Is the scene safe to approach the patient? b. Are there visual clues that might provide information regarding the patient’s medical complaint? B. Primary Impression 1. Take the following considerations and steps to help form your initial general impression of the patient’s respiratory status: a. Position of the patient b. Color c. Mental status d. Ability to speak e. Respiratory effort 2. Signs of respiratory distress include: a. Nasal flaring b. Intercostal muscle retraction c. Cyanosis d. Pursed lips e. Tracheal tugging 3. Airway assessment should be done immediately. a. Note whether the airway is open and patent and whether there are abnormal noises. b. If the airway is compromised, it must be corrected before you move on. 4. Breathing is the next step in respiratory assessment 5. The following signs suggest a possible life-threatening respiratory problem

Master Teaching Notes

Discussion Topics How does the assessment of a respiratory patient differ from that of other patients? What is important to consider when assessing respiratory patients?

Class Activities If possible, demonstrate the use of a pulse oximeter, capnogram, or other tools used to assess respiratory illnesses. Take some time for the class to become comfortable using them on one another.

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in adults: a. Alterations in mental status b. Severe central cyanosis c. Absent breath sounds d. Audible stridor e. One-to two-word dyspnea f. Tachycardia ≥130 beats per minute g. Pallor and diaphoresis h. Presence of intercostal and sternocleidomastoid retractions i. Use of accessory muscles C. Secondary Assessment 1. History should be directed at problem areas determined by the chief complaint or primary problem. a. Obtain a SAMPLE history. b. Ask the OPQRST questions, including questions about current symptoms. c. Ask whether the patient has had similar symptoms in the past. d. Ask whether the patient has a known respiratory disease. e. A good history of medication use is essential and may provide useful clues to the diagnosis. 2. The physical examination should focus on the respiratory system and address the patient’s head and neck and include the following: a. Inspection b. Palpation c. Percussion of the chest wall d. Auscultation i. Normal breath sounds are described as bronchial, bronchiovesicular, or vesicular. ii. Abnormal breath sounds include: a)Snoring b)Stridor c) Wheezing ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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Content Outline d)Rhonchi e)Crackles f) Pleural friction rub 3. The patient’s vital signs may also provide information regarding the severity of the respiratory complaints. 4. Three diagnostic measurements are of value in assessing the patient’s respiratory status: pulse oximetry, peak flow, and capnography. 5. Pulse oximetry offers a rapid and accurate means of assessing oxygen saturation. a. Most pulse oximeters cannot discern between hemoglobin saturated with oxygen and carbon monoxide. 6. Peak flow is used to determine a patient’s peak expiratory flow rate (PEFR). a. This requires a cooperative patient who understands the use of the device to get an accurate reading. 7. Capnography measures levels of carbon dioxide in the exhaled breath. a. Decreased carbon dioxide levels can be found in shock, cardiac arrest, pulmonary embolism, bronchospasm, and with incomplete airway obstruction. b. Increased carbon dioxide is found with hypoventilation, respiratory depression, and hyperthermia. VI. Management of Respiratory Disorders A. Management Principles 1. The airway always has the first priority. 2. Any patient with hypoxia should receive oxygen. 3. Any patient whose illness or injury suggests the possibility of hypoxia should receive oxygen until pulse oximetry is available. 4. If there is a question whether oxygen should be given, as in COPD, administer enough oxygen to maintain an adequate SpO2 level (typically ≥96%). Strive for normoxia in your patient to avoid both hypoxia and hyperoxia if possible. 5. Supplemental oxygen administration is the mainstay of respiratory emergency management.

Master Teaching Notes

Teaching Tips Don’t forget to focus on the importance of good basic skills of airway and breathing management, including ventilation. Points to Emphasize Oxygen should be treated like any other drug. You must be careful to provide just enough to treat hypoxia without causing hyperoxia. 8

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Content Outline VII. Specific Respiratory Diseases A. Upper Airway Obstruction 1. The most common cause of upper airway obstruction is the relaxed tongue. 2. Assessment of the patient with an upper airway obstruction varies depending on the cause of the obstruction and the history of the event. 3. Management of the obstructed airway is based on the nature of the obstruction. a. In a conscious adult, ask the patient whether he is choking; if the patient can speak, encourage him to cough the foreign body out. b. If obstruction is severe or the patient has poor air exchange, perform rapid abdominal thrusts. c. In the unconscious adult, open the airway using the headtilt/chin-lift or jaw-thrust without head extension maneuver in an attempt to open the airway. i. Begin CPR. ii. Each time you open the airway during CPR, look an object in the victim’s mouth and remove it. iii. If the obstruction persists and ventilation cannot be provided, visualize the airway with a laryngoscope. If you can see the foreign body, grasp it with the Magill forceps and remove it. iv. Once the obstruction has been removed, begin ventilation and administer supplemental oxygen. v. In cases of airway obstruction caused by laryngeal edema, supplemental oxygen and rapid airway management are necessary. B. Noncardiogenic Pulmonary Edema/Adult Respiratory Distress Syndrome (ARDS) 1. ARDS is a life-threatening condition that adversely affects gas

Master Teaching Notes Teaching Tips Specific respiratory diseases are treated on the basis of the underlying cause. It is more important to stress the priorities of care for airway and breathing rather than attempting to diagnose the respiratory problem.

Discussion Topics This chapter covers several different pathophysiologies. Assign groups to cover different topics and find unique ways to discuss them with the class. Perhaps students can build case studies around a patient and have the other students try to determine the cause of illness and treatment of each.

Class Activities Each respiratory complaint has different components of the history, physical exam, and treatment. Have students attempt to figure out the matching respiratory disease when given clues in pathophysiology, assessment, or management.

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exchange in the lungs. 2. It is a form of pulmonary edema that is caused by fluid accumulation in the interstitial spaces within the lungs. 3. It occurs in response to a wide variety of lung insults, including sepsis, aspiration, pneumonia, pulmonary injury, burns, inhalation injury, oxygen toxicity, drugs such as aspirin or opiates, high altitude, hypothermia, near drowning, head injury, emboli, tumor destruction, pancreatitis, procedures such as cardiopulmonary bypass or hemodialysis, and other insults such as hypoxia, hypotension, or cardiac arrest. 4. Increases in pulmonary capillary permeability, destruction of the capillary lining, and increases in osmotic force draw fluid into the interstitial space and contribute to interstitial edema. 5. Specific clinical symptoms are related to the underlying cause of ARDS. 6. Specific management of the underlying cause is the hallmark of treatment for ARDS. a. Use positive pressure ventilation to support any ARDS patient who demonstrates signs of respiratory failure. b. PEEP and CPAP will help to maintain patency of the alveoli. C. Obstructive Lung Disease 1. The most common lung diseases that are encountered in prehospital care are asthma, emphysema, and chronic bronchitis D. Emphysema 1. Emphysema results from destruction of the alveolar walls distal to the terminal bronchioles. 2. The major factor contributing to emphysema in our society is cigarette smoking. Significant exposure to environmental toxins is another contributing factor. a. Pathophysiology i. Continued exposure to noxious substances results in the gradual destruction of the walls of the alveoli, ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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lessening the area available for gas exchange. Pulmonary capillaries decrease in number, which leads to pulmonary hypertension and right heart failure. iii. Emphysema weakens the walls of the small bronchioles. b. Assessment i. The emphysema patient may report a history of recent weight loss, increased dyspnea on exertion, and progressive limitation of physical activity. ii. Physical examination usually reveals a barrel chest and a pink hue to the skin resulting from polycythemia. iii. Emphysema patients often involuntarily purse their lips to create continuous positive airway pressure. iv. Clubbing of the fingers is common. c. Management i. The primary goal of management is relief of hypoxia and reversal of bronchoconstriction. E. Chronic Bronchitis 1. Chronic bronchitis results from an increase in the number of goblet cells in the respiratory tree. a. Pathophysiology i. Unlike emphysema, the alveoli are not severely affected, and diffusion remains normal. ii. Gas exchange is decreased because of lowered alveolar ventilation secondary to chronic inflammation of the airways. iii. Increased PaCO2 causes pulmonary vasoconstriction, resulting in pulmonary hypertension, and eventually, cor pulmonale. b. Assessment ii.

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Patients will often have a history of heavy cigarette use, but the disease may also occur in nonsmokers. ii. There may also be a history of respiratory infections. iii. Patients tend to be overweight and cyanotic, leading to their being termed “blue-bloaters.” iv. ECG changes reflect increased right ventricular size. c. Management i. The primary goal is to relieve hypoxia and reverse any bronchoconstriction that might be present. ii. Fluid administration is suggested with signs of dehydration. iii. If ordered by medical direction, administer bronchodilators via small-volume nebulizer. 2. Asthma is a chronic inflammatory disorder of the airways. a. Pathophysiology i. Asthma may be induced by one of many different factors or triggers that vary from one individual to the next. ii. Within minutes of exposure to an offending trigger, a two-phase reaction occurs. a)The first phase is characterized by the release of chemical mediators such as histamine, resulting in bronchoconstriction and bronchial edema. b)The second phase begins 6–8 hours after exposure to the trigger and is characterized by inflammation of the bronchioles as cells of the immune system invade the mucosa of the respiratory tract. b. Assessment i. The most common presenting symptoms are dyspnea, wheezing, and cough. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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ii.

Other symptoms include a)One- to two-word dyspnea b)Pulsus paradoxus (a drop of systolic BP of 10 mmHg or more with inspiration) and tachycardia c) Decreased oxygen saturation on pulse oximetry iii. Determine whether this has happened previously, when the symptoms started, and what steps the patient has taken to correct symptoms already. iv. Note abnormal breath sounds such as wheezing. v. Patients will have low peak flow rates. vi. Capnogram will show a “shark fin” pattern, indicating bronchoconstriction. c. Management i. Treatment is designed to correct hypoxia, reverse any bronchospasm, and treat inflammatory changes associated with the disease. ii. Administer supplemental oxygen to correct hypoxia. iii. Establish intravenous access, and place the patient on an ECG monitor. iv. Administer beta-agonist preparations such as albuterol or levabuterol in conjunction with ipratropium bromide. v. Be prepared for the patient to fatigue and require aggressive airway management and ventilation d. Special Cases i. Status asthmaticus is a severe, prolonged asthma attack that cannot be broken with repeated doses of bronchodilators. a)Recognize that respiratory arrest is imminent, and be prepared for endotracheal ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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intubation. Asthma in children is common, and the pathophysiology and treatment are the same as in adults, with altered medication dosages. iii. Several additional medications are used in the treatment of childhood asthma (discussed in greater detail in “Pediatrics”: Volume 5, Chapter 4). F. Upper Respiratory Infection(URI) 1. Infections involving the upper airway and respiratory tract are among the most common infections for which patients seek medical attention. a. Pathophysiology i. Viruses cause the vast majority of URIs. ii. Most are self-limiting illnesses and resolve after several days of symptoms. b. Assessment i. The major symptoms of URI are determined by the portion of the upper respiratory tract that is predominantly affected. ii. Patients with URIs will often have accompanying symptoms such as fever, chills, myalgias, and fatigue. c. Management i. In most cases, diagnosis and treatment is based on history and physical findings. ii. Focus on the patient’s airway and ventilation. iii. Most URIs are treated symptomatically. G. Pneumonia 1. Pneumonia is an infection of the lungs and a common medical problem, especially in the aged and those infected with HIV. a. Pathophysiology i. Bacterial and viral pneumonias are the most ii.

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frequent, although fungal and other forms do exist. The infection begins in one part of the lung and often spreads to nearby alveoli. iii. Pneumonia is primarily a ventilation disorder. b. Assessment i. Patients will generally appear ill and report a fever and chills. ii. Many cases involve associated pleuritic chest pain. iii. Physical exam will commonly reveal fever, tachypnea, tachycardia, and cough. iv. Rales in the involved lung segment may be noted as well as egophony (“E” to “A” changes on auscultation). c. Management i. Place the patient in a position of comfort and use supplemental oxygen to correct hypoxia. H. Severe Acute Respiratory Syndrome (SARS) 1. SARS is a viral respiratory illness that is highly infectious. a. Pathophysiology i. SARS is caused by SARS-associated coronavirus and is spread by close person-to-person contact ii. The incubation period is generally 2–7 days, although some cases have had an incubation period of as long as 10–14 days. b. Assessment i. If a SARS outbreak has been identified, be sure to utilize strict personal protective equipment (PPE) protocol. ii. Look for altered mental status, dyspnea, cough, cyanosis, and hypoxia. iii. Associated symptoms include sore throat, rhinorrhea, chills or rigors, myalgias, headache, and ii.

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diarrhea. This can progress to cough, sputum production, respiratory distress, and eventual respiratory failure. c. Management i. Administer supplemental oxygen to correct hypoxia. ii. If the patient is wheezing, consider administration of a nebulized bronchodilator. iii. If SARS is suspected, notify the receiving hospital of your suspicions so that it can take appropriate measures for isolation of the patient and protection of health care workers. I. Middle East Respiratory Syndrome (MERS) 1. MERS is a viral respiratory infection that is new to humans. 2. It is caused by the Middle East respiratory syndrome coronavirus (MERS-CoV). 3. It is a very dangerous infection, causing death in 3–4 of every 10 patients infected. 4. It appears to be spread from person to person through close contact, including caring or living with a person who has the infection. 5. Primary signs include fever, cough, shortness of breath. 6. Some patients will develop nausea, vomiting, and diarrhea. 7. People with coexisting illnesses are more severely affected and can develop pneumonia and renal failure. 8. Currently, there is no vaccine for MERS. 9. Standard respiratory illness protection measures are recommended (similar to those employed for SARS). J. Lung Cancer 1. Lung cancer is the leading cause of cancer-related death in the United States. a. Pathophysiology i. The vast majority of lung cancers are caused by carcinogens. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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a)Adenocarcinoma, small cell carcinoma, epidermoid carcinoma, and large cell carcinoma are the four types. b. Assessment i. Patients with lung cancer will present with a variety of complaints depending on whether they are related to direct lung involvement. ii. Hoarseness, vague chest pain, and hemoptysis are common complaints. iii. Physical findings are nonspecific. c. Management i. Administer supplemental oxygen as needed to correct hypoxia/ ii. Be attentive for do not resuscitate (DNR) orders, advanced directives, or end-of life-care wishes. K. Toxic Inhalation 1. Inhalation of toxic substances into the respiratory tract can cause pain, inflammation, and destruction of the pulmonary tissues. a. Pathophysiology i. Causes include superheated air, toxic products of combustion, chemical irritants, and inhalation of steam. b. Assessment i. Determine the nature of the inhalant or combusted material. ii. During the physical examination, pay particular attention to the face, mouth, and throat. c. Management i. Remove the patient from the hazardous environment. ii. Establish and maintain an open airway. iii. Administer supplemental oxygen to correct hypoxia. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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iv.

Laryngeal edema is ominous and may require prompt endotracheal intubation. v. As a precaution, place a saline lock for venous access. vi. Transport promptly. L. Carbon Monoxide Inhalation 1. Carbon monoxide is an odorless, tasteless, colorless gas produced from the incomplete burning of fossil fuels and other carboncontaining compounds. 2. Carbon monoxide is the number one cause of poisoning in industrialized countries. a. Pathophysiology i. CO easily binds to the hemoglobin molecule and has an affinity for hemoglobin 200–250 times that of oxygen. ii. Hemoglobin with carbon monoxide bound is referred to as carboxyhemoglobin; it results in hypoxia at the cellular level and, ultimately, metabolic acidosis. b. Assessment i. After removing the patient to a safe environment, determine the source of exposure, its length, and the location. ii. Be alert for complaints of headache, nausea, vomiting, confusion, agitation, loss of coordination, chest pain, loss of consciousness, and seizures. iii. Cherry red skin is a very late finding. c. Management i. Remove the patient to a safe environment and administer supplemental oxygen to correct hypoxia. ii. Hyperbaric oxygen (HBO) therapy may be used in the treatment of severe cases, although the effectiveness of this treatment is questionable. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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M. Pulmonary Embolism (PE) 1. A pulmonary embolism is a blood clot (thrombus) or some other particle that lodges in a pulmonary artery, effectively blocking blood flow through the vessel. a. Pathophysiology i. Any condition that results in immobility of the extremities can increase the risk of thromboembolism, including recent surgery, longbone fractures (with immobilization), bedridden condition, and venous pooling that occurs during pregnancy. ii. Sources of PE include air embolism, fat embolism, amniotic fluid embolism, amniotic fluid embolism, and blood clots. iii. PE blocks blood flow through affected pulmonary arteries, which causes the heart to pump against increased resistance, leading to an increase in pulmonary capillary pressure. iv. The affected portion of the lung can no longer exchange gases, resulting in a perfusion and ventilation mismatch. b. Assessment i. Signs and symptoms will vary on the basis of the size and location of the obstruction. ii. Be alert for sudden, unexplained dyspnea; recent surgery; or prolonged immobilization. iii. Physical exam may reveal labored breathing, tachypnea, and tachycardia. iv. Right heart failure is a sign of a massive PE, resulting in jugular venous distention and falling blood pressure. v. Many cases exhibit a warm, swollen extremity with a ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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thick cord palpated along the medial thigh and pain on palpation or with extension of the calf. c. Management i. Your first priorities are always the airway, breathing, and circulation. ii. Administer supplemental oxygen at the highest possible concentration. iii. Endotracheal intubation may be required. iv. Place a saline lock. v. Carefully monitor the patient’s vital signs and cardiac rhythm. vi. Quickly transport the patient to a facility with the capabilities to care for the critical needs of the patient. N. Spontaneous Pneumothorax 1. A spontaneous pneumothorax occurs in the absence of blunt or penetrating trauma. a. Pathophysiology i. Ventilation is diminished as a result of loss of integrity of the pleural space. b. Assessment i. The patient presents with a sudden onset of sharp, pleuritic chest or shoulder pain. ii. Dyspnea is commonly reported. iii. Decreased breath sounds on the involved side may be difficult to note. c. Management i. Use the patient’s symptoms and pulse oximetry readings as guides to therapy. ii. Supplemental oxygen is usually all that is required. iii. Be careful when managing patients with positive pressure ventilation by mask or endotracheal tube, ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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as the increased pressure may cause a tension pneumothorax, which will require needle decompression. O. Hyperventilation Syndrome 1. Hyperventilation syndrome is characterized by rapid breathing, chest pains, numbness and other symptoms usually associated with anxiety or situational stress. a. Pathophysiology i. Hyperventilation frequently occurs in the anxious patient. ii. Hyperventilation in a purely anxious patient results in excess elimination of carbon dioxide, causing respiratory alkalosis. b. Assessment i. A history of fatigue, nervousness, dizziness, chest pain, and numbness and tingling around the mouth, hands, and feet may indicate hyperventilation. ii. The physical examination will reveal an anxious patient with tachypnea and tachycardia. iii. Spasm of the fingers and feet also may be present. iv. If the patient has a history of seizure disorder, the hyperventilation episode may precipitate a seizure. c. Management i. The primary treatment for hyperventilation syndrome is reassurance. ii. Instruct the patient to voluntarily reduce the respiratory rate. iii. Breath holding or breathing into a paper bag is discouraged. P. Central Nervous System (CNS) Dysfunction 1. CNS dysfunction, with the exception of drug overdose and massive stroke, is rarely a cause of respiratory emergencies but should be ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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considered in the dyspneic patient. a. Pathophysiology i. Head trauma, stroke, brain tumors, and various drugs can affect the respiratory control center in the brain, leading to difficulty breathing. b. Assessment i. Assessment should follow the same approach as for any respiratory emergency. ii. Be alert for nonrespiratory system problems, such as CNS trauma or drug ingestion c. Management i. Establish and maintain an open airway. ii. If respiratory depression is noted or if respirations are absent, initiate mechanical ventilation. iii. Administer supplemental oxygen if hypoxia is detected by pulse oximetry. iv. Establish a saline lock for venous access. v. Direct specific therapy at the underlying problem, if known. Q. Dysfunction of the Spinal Cord, Nerves, or Respiratory Muscles 1. Several disease processes can affect the spinal cord, nerves, and/or respiratory muscles. a. Pathophysiology i. Numerous disorders, including spinal cord trauma, polio, ALS, myasthenia gravis, Guillain-Barré syndrome, and certain tumors can interfere with respiratory function. b. Assessment i. Assessment should follow the same approach as with any respiratory emergency. ii. Be alert for subtle findings that may indicate a problem with the peripheral nervous system. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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Management i. Management of spinal cord and respiratory muscle dysfunction is purely supportive. ii. Establish an open airway and provide ventilator support. iii. If myasthenia gravis is present and if transport time is long, the physician may request the administration of one of several agents effective in treating such patients.

VIII.Summary A. Respiratory emergencies are commonly encountered in the prehospital setting. B. The primary treatment is to correct hypoxia. Necessary steps include establishing and maintaining the airway, assisting ventilations as required, and administering supplemental oxygen. Appropriate pharmacological agents may be subsequently ordered by local protocols. C. Use tools such as capnography, end tidal CO2, pulse oximetry, and carbon monoxide detectors to help in determining a respiratory patient’s status. IX. Case Study

Class Activities Discuss the case with students now that they are familiar with the chapter.

X. You Make the Call

Class Activities Read and discuss the call and questions as a group.

XI. Review Questions

Class Activities

Pass out review questions before the lesson starts. Have students answer them. Go over the questions again after the lecture to

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Master Teaching Notes assess students’ understanding of the information.

MASTER TEACHING NOTES

Detailed Lesson Plan Chapter 4 Endocrinology 90–110 Minutes

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Teaching Tips Class Activities Knowledge Application Decision Points

Chapter 4 objectives can be found on text p. 237. These objectives, which form the basis of each chapter, were developed from the current National EMS Education Standards and the accompanying Paramedic Instructional Guidelines.

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Content Outline I.

Case Study

Master Teaching Notes Teaching Tips Have a student read the scenario. Tell students that the case will be reviewed after the lecture.

II. Introduction A. The endocrine system is an important body system and is closely linked to the nervous system. B. It controls numerous physiological processes. 1. Specialized chemical messengers called hormones are utilized to control the body. 2. The fundamental structural units of the endocrine system are the endocrine glands. 3. Each endocrine gland produces one or more hormones. C. Endocrine glands differ from other glands in that they are ductless and secrete their hormones directly into capillaries to circulate in the blood throughout the body. D. The majority of glands are exocrine glands, which release their chemical products through ducts and tend to have a local effect. E. Many people have endocrine disorders involving excessive or deficient hormone function. F. Diabetes mellitus is commonly involved in medical emergencies encountered in the prehospital setting.

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Content Outline III. Anatomy and Physiology A. Hypothalamus 1. The hypothalamus is located deep within the cerebrum of the brain and is the junction between the central nervous system (CNS) and the endocrine system. a. In response to impulses from the autonomic nervous system (ANS), the hypothalamus and other organs of the endocrine system can release hormones that promote homeostasis. i. Growth hormone releasing hormone ii. Growth hormone inhibiting hormone iii. Corticotropin releasing hormone iv. Thyrotropin releasing hormone v. Gonadotropin releasing hormone vi. Prolactin releasing hormone vii. Prolactin inhibiting hormone B. Pituitary Gland 1. The posterior pituitary gland responds to nerve impulses from the hypothalamus and produces two hormones. a. Antidiuretic hormone (ADH) causes the kidneys to increase water reabsorption, resulting in increased circulating blood volume and decreased urine volume. b. Oxytocin (the natural form of the drug Pitocin) stimulates uterine contraction and lactation in women who have just delivered a baby. Oxytocin causes “letdown” of milk by stimulating contractile cells within the mammary glands. i. In both sexes, oxytocin has an antidiuretic effect. 2. The anterior pituitary gland regulates other endocrine glands and is rarely a factor in endocrine emergencies. a. Adrenocorticotropic hormone (ACTH) targets the adrenal cortexes. b. Thyroid-stimulating hormone (TSH) targets the thyroid. c. Follicle-stimulating hormone (FSH) targets the gonads. d. Lutenizing hormone (LH) targets the gonads. e. Prolactin (PRL) targets the mammary glands of women.

Master Teaching Notes Teaching Tips Anatomy and physiology should be a review for your students. When possible, have the class present some of the anatomic and physiologic traits of the endocrine system.

Knowledge Application If oxytocin is the natural form of Pitocin, how and why is it used in the emergency management of pregnant patients?

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f. Growth hormone (GH) targets almost all body cells. C. Thyroid Gland 1. The thyroid gland is located in the neck, anterior to and just below the cartilage of the larynx. 2. The thyroid produces three hormones. a. Thyroxine (T4), which stimulates cell metabolism b. Triiodothyronine (T3), which also stimulates cell metabolism c. Calcitonin, which lowers blood calcium 3. Disorders of excessive production of T4 and T3 result in hyperthyroidism and hypothyroidism. D. Parathyroid Glands 1. Normally, four parathyroid glands are located on the lateral surfaces of the thyroid gland, one pair above the other. 2. Parathyroid glands secrete parathyroid hormone (PTH), which increases blood calcium levels. E. Thymus Gland 1. The thymus is in the mediastinum just behind the sternum. 2. It is fairly large in childhood and shrinks into a small remnant of fat and fibrous tissue in adults. a. During childhood it secretes thymosin, which promotes maturation of T lymphocytes. F. Pancreas 1. The pancreas is located in the upper retroperitoneum behind the stomach and between the duodenum and spleen. 2. It is composed of both endocrine and exocrine tissues. a. Exocrine tissue in the pancreas is known as acini and it secretes digestive enzymes essential to digestion of fats and proteins. b. The microscopic clusters of endocrine tissue found within the pancreas are known as the islets of Langerhans. i. Alpha cells produce glucagon ,which stimulates the breakdown of glycogen into glucose when blood glucose levels fall. a)This is termed glycogenolysis. b)Glucagon stimulates liver breakdown of body proteins ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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and fats with subsequent conversion to glucose. i) This occurs from nonsugar sources and is called gluconeogenesis. Beta cells produce insulin, which decreases blood glucose levels by increasing the uptake of glucose by the cells. a)Insulin promotes energy storage in the body by increasing the synthesis of glycogen, protein, and fat Delta cells produce somatostatin, which inhibits secretion of glucagon and insulin.

G. Adrenal Glands 1. The paired adrenal glands are located on the superior surface of the kidneys. a. The inner portion of the adrenal glands called the adrenal medulla, and its cells behave both as nerve cells and gland cells. i. When sympathetic nerves carry an impulse to the adrenal medulla, its cells respond by secreting epinephrine or norepinephrine into the bloodstream. b. The outer portion of the adrenal gland is called the adrenal cortex, and it consists of endocrine tissue. c. The adrenal cortex secretes three classes of steroidal hormones that differ only slightly in chemical structure but have very distinct effects on the body. i. Glucocorticoids increase blood glucose levels by promoting gluconeogenesis and decreasing glucose utilization as an energy source ii. Mineralocorticoids contribute to salt and fluid balance in the body by regulating sodium and potassium excretion through the kidneys iii. Androgenic hormones have the same effect as those secreted by gonads H. Gonads 1. The ovaries, or female gonads, are paired organs about the size of an almond that are located in the pelvis on either side of the uterus. 2. Under the regulation of FSH and LH, the ovaries produce estrogen and ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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Content Outline progesterone. a. Estrogen promotes the development and maintenance of secondary female sexual characteristics. b. Progesterone is necessary for implantation of the fertilized egg and maintenance of the uterine lining throughout pregnancy. 3. Testes a. The male gonads, or testes, are located outside the abdominal cavity in the scrotum. b. Under the regulation of FSH and LH, the testes produce testosterone, which promotes the development and maintenance of secondary male sexual characteristics and plays a role in the development of sperm. I. Pineal Gland 1. The pineal gland is located in the roof of the thalamus in the brain. a. It releases the hormone melatonin in response to changes in light. i. Melatonin production is lowest during daylight hours and highest in the dark of the night. ii. The pineal gland is felt to help determine day-length and lunar cycles and plays a role in controlling the reproductive “biological clock.” J. Other Organs with Endocrine Activity 1. Many tissues that are not considered part of the endocrine system have important endocrine function and secrete hormones directly into the blood. a. The placenta b. Hormone-producing cells in the atrial walls of the heart c. Certain kidney cells will react to a decrease in blood volume or blood pressure by releasing the enzyme renin. d. In addition to renin, the kidneys secrete the hormone erythropoietin, which stimulates the production of red blood cells by the bone marrow. IV. Endocrine Disorders and Emergencies A. Disorders of the Pancreas 1. Diabetes mellitus is marked by inadequate insulin activity in the body. a. Diabetes mellitus

Master Teaching Notes

Teaching Tips Diabetes is prevalent in the United States and is a common reason to call for EMS providers. Remember to stress the importance of having 5

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ii.

Glucose is the only substance that brain cells can readily and efficiently use as an energy source.

More than 29.1 million Americans have been diagnosed with diabetes; nearly the same number of Americans may be living with undiagnosed diabetes. b. Glucose metabolism i. The building processes within a cell are collectively called anabolism. ii. Breakdown processes are collectively called catabolism. iii. When materials are abundant after meals and blood glucose is high, insulin enables cells to use glucose directly and to store energy as glycogen, protein, and fat. iv. Glucagon is the dominant hormone during periods of low blood glucose v. It stimulates catabolic pathways to produce usable energy from the body’s stores. vi. There must be sufficient insulin in the circulating bloodstream to satisfy cellular needs. vii. Insulin must be able to bind to body cells. viii. When insufficient insulin activities exist for glucose to be taken into the cell, diabetes occurs. ix. The body slowly switches from glucose to fat as the primary energy source. a)Adipose cells break down fat. b)Catabolism of fatty acids produces acetoacetic acid, which accumulates in the blood as ketones, leading to ketosis. c. Regulation of blood glucose i. The principal tissues involved in homeostasis are the alpha and beta cells of the islets of Langerhans and ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

Master Teaching Notes a grasp on the pathophysiology of diabetes and the changes it causes. Emphasize the portions of the population that are most likely to be affected by diabetes.

Class Activities Have a discussion with the class about the differences between type I and type II diabetes. How are they the same and how are they different?

Knowledge Application If insulin is important for glucose metabolism, how is it that patients who have little or no insulin have high blood sugar levels? How does this relate to treatment and pathophysiology? How does this affect a person with hypoglycemia?

Decision Points At what point do you decide to give oral glucose to your patient instead of IV dextrose? Once you have restored normal blood glucose, can your patient refuse transport to the hospital? How would you manage this situation?

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the liver. A blood glucose level less than 80 mg/dL is hypoglycemia. iii. A blood glucose level greater than 140 mg/dL is hyperglycemia. iv. When blood is filtered through the glomeruli of the kidneys, the amount of glucose reabsorbed depends on the blood level of glucose. d. Type I diabetes mellitus is characterized by beta cell destruction with very low production of insulin by the pancreas. i. Also termed insulin-dependent diabetes mellitus (IDDM) due to insulin injections required for glucose homeostasis ii. Without adequate insulin, cells cannot use the circulating sugar, and catabolism of fat becomes the primary energy source. iii. Treatment almost always includes the periodic administration of insulin e. Type II diabetes mellitus is associated with a moderate decline in insulin production accompanied by a markedly deficient response to the insulin already present in the body. i. Type II is also called non-insulin-dependent diabetes mellitus (NIDDM), although some patients may require insulin. ii. Untreated type II diabetes typically presents with lower levels of hyperglycemia and fewer signs of major disruption. iii. Glucose is usually sufficient to keep the body from switching to fats as the primary energy source. iv. Initial therapy often consists of dietary changes and increased exercise. v. Oral hypoglycemic agents may be prescribed. ii.

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2. Diabetic ketoacidosis (diabetic coma) is a serious, potentially lifethreatening complication associated with type I diabetes. It occurs when there is profound insulin deficiency coupled with increased glucagon activity. a. Pathophysiology i. Profound hyperglycemia exists due to lack of insulin. ii. The loss of glucose in the urine accompanied by loss of water through osmotic diuresis produces significant dehydration. iii. As the body switches to fat-based metabolism, the blood levels of ketones rises. The ketone load accounts for the observed acidosis. b. Signs and symptoms i. Onset is slow, lasting from 12 to 24 hours. ii. The patient will complain of excessive hunger and thirst coupled with progression of general malaise. iii. Kussmal’s respirations ensue to attempt to compensate for acidosis. iv. Mental function declines. c. Assessment and management i. Sweet, fruity odor of ketones occasionally can be detected in the breath. ii. Blood glucose levels will exceed 500 mg/dL. iii. Manage ABCs and administer 1–2 liters of normal saline per protocol. 3. Hyperosmolar hyperglycemic state (HHS), sometimes called hyperglycemic hyperosmolar nonketotic coma (HHNK) is a serious complication associated with type II diabetes. a. Pathophysiology i. As sustained hyperglycemia develops, glucose spills into the urine, causing osmotic diuresis and dehydration. ii. Insulin activity prevents significant production of ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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ketone bodies. b. Signs and symptoms i. Onset is over several days. ii. Early signs include increased urination and increased thirst leading to orthostatic hypotension and tachycardia secondary to dehydration. iii. Kussmal’s respirations are rare. c. Assessment and management i. It is often difficult to differentiate between HHS coma and diabetic ketoacidosis. ii. Management of the two emergencies is identical.. 4. Hypoglycemia can occur when a patient takes too much insulin, eats too little to match an insulin dose, or overexerts and uses all available blood glucose. a. Pathophysiology i. Insulin causes almost all remaining blood glucose to be taken up by cells. b. Signs and symptoms i. In the earliest stages, the patient may appear restless or impatient or may complain of hunger. ii. If blood glucose falls to a critically low level, the patient may have a hypoglycemic seizure or become comatose. iii. Hypoglycemia can develop quickly. c. Assessment and management i. Perform an initial assessment quickly and determine blood glucose level. a)If less than 60 mg/dL, draw a red-top tube of blood and start an IV of normal saline. b)Next administer 50 to 100 mL (25 to50 g) of 50 percent dextrose intravenously. c) If the patient is conscious and able to swallow, glucose administration can be ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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completed with oral preparations. d)If an IV is unavailable, glucagon can be given IM, but it will be much slower acting and relies on adequate stores of glucagon. B. Disorders of the Thyroid Gland 1. Grave’s disease has an autoimmune origin and results in excessive amounts of thyroid hormones. a. Pathophysiology i. Antibodies are generated that stimulate thyroid tissue to produce excessive amounts of thyroid hormones. b. Signs and symptoms i. Agitation, emotional changeability, insomnia, poor heat tolerance, weight loss despite increased appetite, weakness, dyspnea, and tachycardia or new-onset atrial fibrillation without cardiac origin are common complaints. c. Assessment and management i. Cardiac dysfunction is probably the most likely context within which an emergency call may arise from thyrotoxicosis. ii. Use of adrenergic blockers may temporarily reduce cardiac stress. iii. Glucocorticoids are sometimes helpful in reducing the level of circulating T4. 2. Thyrotoxic crisis (thyroid storm) can be fatal in as few as 48 hours if untreated. a. Pathophysiology i. The mechanisms are poorly understood. ii. It is usually associated with severe psychological stress. iii. You may encounter thyroid storm secondary to overdose of thyroid hormone in a hypothyroid ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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individual. b. Signs and symptoms i. Reflected by hypermetabolic state and increased activity of the sympathetic nervous system ii. Characterized by high fever, irritability, delirium or coma, tachycardia, hypotension, vomiting, and diarrhea c. Assessment and management i. Field management is largely focused on supportive care, including oxygenation, ventilatory assistance, fluid resuscitation, and cardiac monitoring. 3. Hypothyroidism and myxedema a. Pathophysiology i. Hypothyroidism creates a low metabolic state, and early signs reflect poor organ function and poor response to challenges such as exercise or infection; if left untreated, results in myxedema ii. Thickening of connective tissue in the skin and other tissues including the heart b. Signs and symptoms i. Early signs may be subtle and may be as slight as fatigue and slowed mental function. ii. Typically, patients show lethargy, cold intolerance, constipation, decreased mental function, or decreased appetite with increased weight. c. Assessment and management i. Focus on maintenance of ABCs and close monitoring of cardiac activity and pulmonary status ii. Fluids should be limited due to electrolyte abnormalities. C. Disorders of the Adrenal Glands 1. Hyperadrenalism manifests as Cushing’s syndrome and is caused by high levels of cortisol in the blood. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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a. Pathophysiology i. Most commonly caused by long-term exposure to excess glucocorticoids ii. Causes sodium retention and increased blood volume as well as increased vascular sensitivity to catecholemines b. Signs and symptoms i. Regardless of the cause, presenting signs of Cushing’s syndrome are the same. ii. Weight gain through the trunk of the body, face, and neck and accumulation on the upper back iii. Mood swings and impaired memory or concentration are common. c. Assessment and management i. It is unlikely that you will see a patient with an acute hyperadrenal crisis. ii. Pay particular attention to skin preparation when starting IV lines. 2. Adrenal insufficiency, or Addison’s disease, occurs when the adrenal glands fail to produce adequate amounts of the steroid hormones. a. Pathophysiology i. Destruction of the adrenal cortex results in minimal production of glucocorticoids, mineralocorticoids, and androgens ii. Increased sodium excretion causes low blood volume, and potassium retention causes ECG changes. b. Signs and symptoms i. Addison’s disease is characterized by progressive weakness, fatigue, decreased appetite, and weight loss. c. Assessment and management i. Addison’s disease may be ascertained from the ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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history. Focus on management and maintenance of the ABCs and close monitoring of the ECG and oxygenation status. Be aggressive in fluid resuscitation.

V. Summary A. The vast majority of endocrine emergencies you encounter will involve complications of diabetes mellitus, such as hypoglycemia or ketoacidosis. B. In the field, always suspect diabetes when a patient presents with unexplained changes in mental status. C. Your primary responsibility for any diabetic emergency is to maintain a stable airway, oxygenate the patient, establish an IV line, and transport. VI. Case Study

VII. You Make the Call 5 VIII.Review Questions 5

Class Activities Discuss the case with students now that they are familiar with the chapter. Class Activities Read and discuss the call and questions as a group.

Class Activities Pass out review questions before the lesson starts. Have students answer them. Go over the questions again after the lecture to assess students’ understanding of the information.

MASTER TEACHING NOTES

Detailed Lesson Plan Chapter 5 Immunology 40–50 Minutes

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Teaching Tips Class Activities Knowledge Application

Chapter 5 objectives can be found on text p. 261. These objectives, which form the basis of each chapter, were developed from the current National EMS Education Standards and the accompanying Paramedic Instructional Guidelines.

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Content Outline I.

Case Study

Master Teaching Notes Teaching Tips Have a student read the scenario. Tell students that the case will be reviewed after the lecture.

II. Introduction A. An allergic reaction is an exaggerated response by the immune system to a foreign substance. 1. The first complete description of anaphylaxis was reported in 1902 by Porter and Richet, French immunologists who were attempting to immunize dogs against the deadly sea anemone. B. Anaphylaxis results from exposure to a particular substance that sets off a biochemical chain of events that can ultimately lead to shock and death. III. Pathophysiology A. The Immune System 1. The immune system is a complicated body system responsible for combating infection. 2. Components of the immune system can be found in the blood, bone marrow, and lymphatic system. 3. The immune response is a complex cascade of events that occurs following activation by an invading substance, or pathogen. a. Cellular immunity involves a direct attack on the foreign substance by specialized cells of the immune system.

Teaching Tips Refer to the anatomy and physiology section that involves the immune system and its components. Review with students any material that they have forgotten.

Knowledge Application Is it possible to have a significant 1

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Content Outline b. Humoral immunity is a chemical attack of the invading substance by antibodies (also called immunoglobulins). i. The humoral response begins with exposure of the body to an antigen (any substance capable of inducing an immune response). ii. Antibodies are released from cells of the immune system. iii. The initial response to an antigen is called the primary response and requires several days before the cellular and humoral components of the immune system respond. iv. The cells develop a memory of the particular antigen. If the body is exposed to the same antigen again, the immune system responds much faster (secondary response). c. Immunity may be natural or acquired. d. Natural immunity, also called innate immunity, is genetically predetermined and present at birth. e. Acquired immunity develops over time and results from exposure to antigens. f. Naturally acquired immunity normally begins to develop after birth and is continually enhanced by exposure to new pathogens and antigens throughout life. g. Induced active immunity, also called artificially acquired immunity, is designed to provide protection from exposure to an antigen at some time in the future. h. Active immunity occurs following exposure to an antigen and results in the production of antibodies specific for the antigen. i. The administration of antibodies is referred to as passive immunity. a) Natural passive immunity – occurs when antibodies cross the placental barrier from the mother to the

Master Teaching Notes allergic reaction or anaphylaxis with the first exposure to an antigen? Why or why not?

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infant to provide protection against embryonic or fetal infections b) Induced passive immunity – the administration of antibodies to an individual to help fight infection or prevent disease B. Allergies 1. The initial exposure of an individual to an antigen is referred to as sensitization. 2. Delayed hypersensitivity is a result of cellular immunity and therefore does not involve antibodies. a. It most commonly results in a skin rash and is often due to exposure to certain drugs and chemicals. 3. Immediate hypersensitivity (usually called allergy) reactions include hay fever, drug allergies, food allergies, eczema, and asthma. 4. Common allergens include drugs; food and food additives; animals; insects; fungi and molds; and radiology contrast materials. a. Following exposure to a particular allergen, large quantities of IgE antibodies are released. These antibodies attach to basophils and mast cells that assist in the immune response. i. These cells release histamine, heparin, and other substances into the surrounding tissue, which causes what people call an “allergic reaction.” ii. Histamine is a potent substance that causes bronchoconstriction, increased intestinal motility, vasodilation, and increased vascular permeability. a)Histamine acts by activating specialized histamine receptors present throughout the body. C. Anaphylaxis 1. Anaphylaxis usually occurs when a specific allergen is injected directly into the circulation. a. The allergen interacts with both basophils and mast cells, ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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Content Outline resulting in the massive dumping of histamine and other substances associated with anaphylaxis. b. The principal body systems affected are the cardiovascular, respiratory, and gastrointestinal systems and the skin, c. People sustaining anaphylaxis can actually die from circulatory shock. IV. Assessment Findings in Anaphylaxis A. The signs and symptoms of anaphylaxis begin within 30–60 seconds following exposure to the offending allergen. 1. The severity of the reaction is often related to the speed of onset. 2. A rapid and focused assessment is crucial to the early detection and treatment of anaphylaxis. 3. Quickly evaluate the patient’s level of consciousness and upper airway. a. Upper airway problems, including laryngeal edema, may result in the patient being unable to speak. 4. A common manifestation of anaphylaxis is angioneurotic edema, involving the face and neck. 5. Initially the patient will become tachypneic and later, as lower airway edema and bronchospasm develop, respirations will become labored. a. Ultimately, anaphylaxis can result in diminished lung sounds, which reflect decreased air movement and hypoventilation. 6. As histamine is released, fluid will diffuse from leaky capillaries, resulting in urticaria (hives). 7. As cardiovascular collapse and dyspnea progress, the patient will become diaphoretic. 8. Vital signs will vary based on the severity and stage of the reaction. 9. As airway and edema occur, the respiratory rate can fall, which is an ominous finding. 10. Blood pressure will fall when significant capillary leakage and peripheral vasodilation occur.

Master Teaching Notes

Teaching Tips Spend some extra time reviewing the signs and symptoms of anaphylaxis. By becoming more aware of these presentations, students can be better prepared to recognize and respond to anaphylaxis.

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Content Outline V. Management of Anaphylaxis A. Protect the Airway 1. Position the patient and protect the airway. 2. Administer oxygen via a nonrebreather mask if the patient is hypoxic. 3. Initiate ventilator assistance if the patient is hypoventilating or apneic. 4. If an airway problem is detected, first apply basic airway maneuvers, such as head positioning or the modified jaw-thrust maneuver. 5. Use oropharyngeal and nasopharyngeal airways with caution, as they can cause laryngospasm 6. Consider early endotracheal intubation to prevent complete occlusion of the airway. a. The larynx will be irritable, and any manipulation of the airway may lead to laryngospasm. b. Have equipment available for placement of a surgical airway. 7. Establish an IV as soon as possible with a crystalloid solution. B. Administer Medications 1. The primary treatment for anaphylaxis is pharmacological. a. Oxygen is always the first drug administered. b. Epinephrine can reverse some of the bronchospasm associated with anaphylaxis, reverses some of the bronchoconstriction and capillary permeability, and increases the strength of the cardiac contractile force. i. Administer epinephrine 1:10,000 IV 0.1–0.35 mg in adults or 0.01 mg/kg in children. ii. Repeat boluses may be necessary. c. Antihistamines are second-line agents in the treatment of anaphylaxis and should follow epinephrine. iii. Diphenhydramine 25–50 mg IV or IM in adult or 1–2 mg/kg in children d. Corticosteroids are of little benefit in the initial stages of treatment; however, they help to suppress the inflammatory

Master Teaching Notes Teaching Tips Airway management is an important part of early intervention. Have students practice intubation using simulators that can provide laryngeal edema. If you don’t have a simulator available, use external manipulation or inserts in the airway to make intubation more difficult.

Class Activities Have the class practice airway management. Revisit IM injections and discuss the medications used for treatment of anaphylaxis and why they work.

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Content Outline response. e. Use vasopressors for severe and prolonged anaphylactic reactions to support blood pressure. f. Beta agonists can be useful to reverse bronchospasm and laryngeal edema. iv. Albuterol inhaled 2.5 mg in adult or 0.2–0.5 mL in children g. Other medications have been identified as potentially beneficial for anaphylaxis: vasopressin, atropine, and glucagon. C. Offer psychological support 1. Provide the patient with emotional support, and explain the treatment regimen. 2. Caution patients about the potential side effects of administered medication. VI. Assessment Findings in Allergic Reactions A. An allergic reaction, as contrasted with an anaphylactic reaction, will have a more gradual onset with milder signs and symptoms, and the patient will have a normal mental status. B. Management of Allergic Reactions 1. Common manifestations of mild allergic reactions include itching, rash, and urticaria. 2. Any patient suffering an allergic reaction who exhibits dyspnea or wheezing should receive supplemental oxygen followed by intramuscular epinephrine 1:1,000. 3. Lesser allergic reactions that are not accompanied by hypotension or airway problems can be adequately treated with epinephrine 1:1,000 administered intramuscularly. 4. The intramuscular route should not be used in severe anaphylaxis, for which IV epinephrine should be used.

Master Teaching Notes

Teaching Tips Integrate allergy patients into the practice with anaphylactic patients. Change the presentations, and keep students guessing, much as if they were in the field. Some patients start out stable and quickly deteriorate, whereas others are very easy to manage.

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Patient Education A. People with a history of anaphylactic reactions should be educated about recognition and treatment. 1. Many patients can initiate emergency anaphylactic treatment at home with epinephrine delivery systems such as the EpiPen. 2. The severity of an allergic reaction can be diminished in certain cases through desensitization. a. In these cases, physicians begin therapy by administering an extremely small amount of the allergen that causes the patient’s allergic reaction. b. The quantity of the allergen present in the injection is gradually increased to a point at which the body’s immune system to the allergen is blunted and anaphylactic reactions are averted.

VIII.Summary A. Luckily, severe allergies and anaphylaxis are uncommon; however, when they do occur, they can progress quickly and result in death in minutes. B. The central physiologic reaction in anaphylaxis is the massive release of histamine and other mediators. C. The primary and most important drug used in the treatment of anaphylaxis is epinephrine. Following the administration of epinephrine, potent antihistamines should be used. D. Intravenous fluid replacement is crucial in preventing hypovolemia and hypotension. E. The key to successful prehospital management of anaphylaxis is prompt recognition and treatment. IX. Case Study

Class Activities Discuss the case with students now that they are familiar with the chapter.

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X. You Make the Call

Class Activities Read and discuss the call and questions as a group.

XI. Review Questions

Class Activities

Pass out review questions before the lesson starts. Have students answer them. Go over the questions again after the lecture to assess students’ understanding of the information.

MASTER TEACHING NOTES

Detailed Lesson Plan Chapter 6 Gastroenterology 80–90 Minutes

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Teaching Tips Discussion Topics Class Activities Knowledge Application

Chapter 6 objectives can be found on text p. 275. These objectives, which form the basis of each chapter, were developed from the current National EMS Education Standards and the accompanying Paramedic Instructional Guidelines.

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Master Teaching Notes Teaching Tips Have a student read the scenario. Tell students that the case will be reviewed after the lecture.

II. Introduction A. Gastrointestinal (GI) emergencies account for over 500,000 emergency visits and hospitalizations every year. 1. Of that number, more than 300,000 are due to GI bleeding. 2. In the past few years, the number of patients over 60 years of age included in these statistics has risen from approximately 3% to more than 455. III. General Pathophysiology, Assessment, and Treatment A. General Pathophysiology 1. Pain is the hallmark of the acute abdominal emergency. 2. Visceral pain originates in the walls of hollow organs, in the capsules of solid organs, or in the visceral peritoneum. a. Three separate mechanisms can produce this pain: inflammation, distention, and ischemia. i. Inflammation, distention, and ischemia transmit pain signals from visceral afferent neural fibers back to the spinal column.

Teaching Tips General pathophysiology and treatment will cover most abdominal emergencies. It is important to remember that most of the illnesses presented cannot be diagnosed in the field. Stress the importance of a thorough exam and history and prompt transport of patients who are 1

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Because the nerves enter the spinal column at various levels, visceral pain is usually not localized to any one specific area. iii. Pain is often described as vague, dull, or crampy. b. Somatic pain is a sharp type of pain that travels along definite neural routes, or tissue blocks, to the spinal column i. Pain can be localized to a particular region or area. ii. Bacterial and chemical irritations of the abdomen are commonly the cause of somatic pain. c. Referred pain is not a true pain-producing mechanism; the term refers to pain originating from a region other than where it is felt. i. Many neural pathways from various organs pass through or over regions where the organ was formed during embryonic development, leading to referral of pain. B. General Assessment 1. Scene Size-Up and Primary Assessment a. As you approach, look for mechanisms of injury to help determine whether the call is medical or trauma. b. In the vast majority of medical patients, you can check responsiveness and airway patency by asking his name and chief complaint. c. Evaluate the rate, depth, and quality of the patient’s respirations. 2. Secondary assessment a. After you conduct the SAMPLE history, you can take a more through history, exploring the chief complaint, the history of the present illness, the past medical history, and the current health status. b. Your OPQRST-ASPN history for GI patients should include: i. Onset ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

Master Teaching Notes acutely ill.

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ii. iii. iv. v. vi. vii. viii.

Provocation/palliation Quality Region/radiation Severity Time Associated symptoms Pertinent negatives a)Not all abdominal emergencies result in abdominal pain. c. Past medical history d. You can begin the physical examination while conducting the history. i. Your patient’s general appearance and posture strongly suggest the apparent state of health and severity of his complaint. ii. Take a complete set of vital signs to establish a baseline for further evaluation and treatment. iii. Visually inspect the abdomen before palpating it, auscultating it, or moving the patient. iv. Distention of the abdomen may be an ominous sign. v. Auscultating the abdomen usually provides little helpful information. vi. Before palpating, ask the patient to point to where he is experiencing the most discomfort, then work in reverse order, palpating that area last. a)Palpate the abdomen with gentle pressure, feeling for muscle tension or its absence, as well as for masses, pulsations, and tenderness beneath the muscle. 3. General Treatment a. The highest priority is to secure and maintain the patient’s airway, breathing, and circulation. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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b. Supplemental oxygen and aggressive airway management may be indicated, depending on the patient’s status. c. Establish a large-bore IV if emergency blood transfusion becomes necessary. d. Place the patient in a position of comfort and provide emotional reassurance based on your field assessment, any conversation with hospital staff or family, and knowledge of estimated transport time. e. Persistent abdominal pain lasting longer than 6 hours is classified as a surgical emergency and always requires transport. f. In all cases, be sure to maintain monitoring of mental status and vital signs and to give nothing by mouth. g. Bring vomitus to the emergency department for evaluation. 45

IV. Specific Illnesses A. Upper Gastrointestinal Diseases 1. Upper GI bleeding can be defined as bleeding within the GI tract proximal to the ligament of Treitz (at the point where the first two sections of small intestine meet). 2. The six major identifiable causes of upper GI bleed are (in descending order of frequency): a. Peptic ulcer disease b. Gastritis c. Variceal rupture d. Mallory-Weiss syndrome e. Esophogitis f. Duodenitis 3. Most cases of GI bleeding are chronic irritations or inflammations that cause minimal discomfort and minor hemorrhage. 4. Upper GI bleeds may be obvious or quite subtle, and most patients will complain of some type of abdominal discomfort ranging from vague burning sensations to tearing pain in the upper quadrants.

Class Activities Once you have discussed signs and symptoms of the various illnesses, have students get into small groups. Have them perform focused histories and assessments on one another. The student being assessed should use the signs and symptoms specific to one of the illnesses. See whether students can figure out a diagnosis based on the complaints presented.

Knowledge Application Many abdominal issues involve internal hemorrhage. What are some ways to determine if the 4

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Content Outline 5. Patients may experience hematemesis or melena (if blood passes through the lower GI tract). a. Blood in emesis may be bright red (new, fresh blood) or look like coffee grounds (old, partially digested blood). b. Bleeding can be light or brisk and life threatening. c. Hypotension suggests a decreased circulating volume and hypovolemia, 6. The patient’s general appearance is the best indicator of his condition’s severity. 7. Abdominal inspection may show symmetric distention or bulging in one region of the abdomen. 8. Ecchymosis may be present if much blood has been lost into the abdominal cavity. 9. Prehospital treatment centers on maintaining a patent airway, oxygenation, and circulatory status. 10. Esophageal varices a. An esophogeal varix is a swollen vein of the esophagus. i. The cause of esophageal varices usually is an increase in portal pressure. a)Damage to the liver can impede circulation, causing blood to back up into the left gastric vein and, from there, into the esophageal veins. b. The primary causes of varices are the consumption of alcohol and ingestion of caustic substances.. c. Patients suffering from leaking or ruptured esophageal varices often present initially with painless bleeding and signs of hemodynamic instability. i. The patient may exhibit the classic signs of shock. d. Care should focus on aggressive airway management, IV fluid resuscitation, and rapid transport to the emergency department.

Master Teaching Notes patient has a significant hemorrhage? How will that impact your fluid resuscitation options?

Discussion Topics Many abdominal issues are resolved surgically. How does this affect your treatment priorities? How does this affect your destination decision?

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Acute gastroenteritis a. Acute gastroenteritis is defined as inflammation of the stomach and intestines associated with sudden-onset vomiting and/or diarrhea. i. Pathologic inflammation causes hemorrhage and erosion of the mucosal and submucosal layers of the GI tract. ii. Volume replacement is the major prehospital prevention strategy to minimize the likelihood of hypovolemia. b. The onset is rapid and usually severe. c. Diarrhea is almost always associated with this condition. i. The GI tract expels the fluid that would normally be absorbed, leading to dehydration and possibly hypovolemia, especially in pediatric, geriatric,, and previously compromised patients. d. The patient may complain of widespread and diffuse abdominal pain that is not specific to any one region. e. Treatment is mainly supportive and palliative. i. Maintain adequate oxygenation. ii. Rehydrate your patient with IV fluids. iii. Pharmacologic treatment can involve antiemetics. Chronic gastroenteritis a. Chronic gastroenteritis is inflammation of GI mucosa marked by long-term mucosal changes or permanent mucosal damage. i. Unlike acute gastroenteritis, chronic gastroenteritis is primarily due to microbial infection b. Patients present with nausea and vomiting, fever, diarrhea, abdominal pain, cramping, anorexia, lethargy, and, in severe cases, shock. c. Prehospital treatment involves protecting yourself and the

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d. e.

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patient from further contamination, monitoring the ABCs, and transport. Peptic ulcers Peptic ulcers are erosions caused by gastric acid. They can occur anywhere in the GI tract and are termed based on the portion of the GI tract affected. Pain usually increases after eating or with a full stomach. i. There is usually no pain at night. ii. Patients with duodenal ulcers commonly have pain at night and on empty stomachs. Nonsteroidal anti-inflammatories (NSAIDS), acid-stimulating products, and Helicobacter pylori are the most common causes of peptic ulcers. A blocked pancreatic duct can also contribute to duodenal ulcers. Findings on clinical examinations can vary. i. Pain may be localized or diffuse. ii. Some patients experience pain relief after coating the GI tract with a liquid such as milk. iii. Bouts of nausea and vomiting due to irritation of the mucosa are common. iv. Most patients will lie still to decrease the pain. Treatment for peptic ulcers depends on the severity of the pain. Common medications to reduce mucosal irritation include histamine blockers, proton-pump inhibitors, and antacids. Clinical vomiting syndrome (CVS) CVS is an increasingly common disorder characterized by repeated sudden attacks, called episodes, of severe nausea, vomiting, and physical exhaustion without apparent cause. Episodes last from several hours to several days. Four distinct cycles:

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i. Prodrome phase ii. Vomiting phase iii. Recovery phase iv. Well phase d. CVS can result in dehydration, esophagitis, tearing of the upper GI tract, and decay and damage from the frequent and excessive exposure to gastric acids. e. It appears to be more common in children than adults. f. Treatment can be challenging. IV hydration is typically indicated, and the patients may require pain medication. g. It is often worthwhile to try a different antiemetic from the one that the patient typically takes. h. Prevention is often the best treatment. B. Lower Gastrointestinal Diseases 1. Lower GI bleeding occurs in the GI tract distal to the ligament of Treitz. It most frequently occurs in conjunction with chronic disorders and anatomic changes associated with advanced age. a. The most common cause is diverticulosis. b. Other causes are colon lesions, rectal lesions, and inflammatory bowel disorders. c. Assessment will be identical to those with upper GI bleeding. d. Frequent complaints include cramping, nausea and vomiting, and changes in stool. i. Melenic stool usually indicates a slow GI bleed. ii. If bright red blood is noted in the stool, consider significant hemorrhage or that it has occurred in the distal colon. e. Check for signs of early shock. f. Management of these patients will depend on their physiologic status. i. Administer high-concentration oxygenation via a nonrebreather mask or positive pressure ventilation. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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ii.

Establish IV access and fluid resuscitation based on your patient’s hemodynamic status. 2. Ulcerative colitis a. Ulcerative colitis is classified as an idiopathic inflammatory bowel disorder that creates a continuous length of chronic ulcers in the mucosal layer of the colon. i. As ulcers heal, granular tissue replaces the ulcerations, thickening the mucosa. b. Acute ulcerative colitis is difficult to differentiate from other causes of lower GI bleeding. c. The severity of the signs and symptoms is usually directly related to the extent and severity of current inflammation in the colon. d. Typically it presents as a recurrent disorder with occasional bloody diarrhea or stool containing mucous. i. Accompanying stool abnormalities are colic , nausea and vomiting, and occasionally fever or weight loss. ii. Patients will typically appear restless as a result of abdominal discomfort but will not show signs of hemodynamic instability. iii. More severe cases present with bloody diarrhea and intense colicky abdominal pain, electrolyte derangements, and eventually perforation of the bowel. e. Management of the patient will depend on his physiologic status. 3. Crohn’s disease a. Crohn’s disease can occur anywhere from the mouth to the rectum and causes a variety of problems ranging from diarrhea to intestinal and perianal abscesses and fistulas. i. Complete intestinal obstruction can occur, causing a surgical emergency. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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ii. Significant bleeding is rare. b. Inflammation damages the mucosa. c. The affected section of intestinal wall eventually becomes rubbery and nondistensible because of hypertrophy and fibrosis of the muscles underlying the submucosa. d. Formation of granulomas, fibrosis, and hypertrophy also decreases the intestine’s internal diameter, resulting in fissures in the mucosa and possibly deeper into the submucosa as food boluses pass through. e. Clinical presentation of Crohn’s patients can vary drastically as the disease progresses, and prehospital diagnosis is difficult or next to impossible. i. Common signs and symptoms include GI bleeding, recent weight loss, intermittent abdominal cramping/pain, nausea and vomiting, diarrhea, and fever. f. Physical exam is nonspecific and nonlocalized, with diffuse tenderness the most commonly found sign. g. Because the vast majority of patients with this disease are hemodynamically stable, prehospital treatment is largely palliative and will depend on the patient’s physiologic status. 4. Diverticulitis a. Diverticulitis is a relatively common complication of diverticulosis, which is characterized by the presence of diverticula in the intestine. i. Small outpouchings of mucosal and submucosal tissue push through the outermost layer of the intestine, the muscle. ii. Stool passes sluggishly through the colon, and the colon responds with muscle spasms that increase bulk movement by raising pressure on the contents within. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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iii.

Nerves and blood vessels enter the colon through small openings within the teniae coli that become weakened with age, allowing the mucosa and submucosa to be herniated through them. a)These diverticula commonly trap small amounts of fecal material. b)The entrapped feces allow bacteria and other abnormal flora to grow, causing infection and inflammation. b. The most common presentation of diverticulitis is a colicky pain associated with low-grade fever, nausea, and vomiting, with tenderness on palpation of the lower left quadrant (as the sigmoid colon is involved in 95% of cases). i. Bleeding diverticuli can also result in hematochezia. ii. The patients may feel that he cannot empty his rectum even after defecation. c. Prehospital treatment is mainly supportive, and measures to combat hypovolemic shock are necessary only when significant hemorrhage has occurred. i. Antiemetics may comfort the patient 5. Hemorrhoids a. Hemorrhoids are small masses of swollen veins that occur in the anus (external) or rectum (internal). i. Most are idiopathic but can be caused by pregnancy or portal hypertension. a)External hemorrhoids often result from lifting of heavy objects. b. Hemorrhoids rarely cause significant hemorrhage. c. Physical assessment usually reveals a hemodynamically stable patient with relatively normal appearance who bleeds with defecation. d. Most frequently, emotional reassurance and transport are all ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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that is needed. 6. Irritable bowel syndrome (IBS) a. IBS, sometimes called spastic colon, is a GI disorder that is characterized by the presence of common signs and symptoms that include: i. Abdominal pain ii. Cramping iii. Increased gas iv. Altered bowel habits v. Food intolerance vi. Abdominal distention (bloating) b. IBS is defined as a functional issue rather than a structural issue. c. It can occur in both children and adults. d. The exact cause is uncertain but may be due to food sensitivities, hypersensitivity to the pain that occurs with gaseous distention, abnormal peristalsis, hormonal imbalances, hereditary factors, and psychological conditions such as depression or anxiety. e. In a prehospital setting, IBS should be treated as any other abdominal complaint. 7. Rectal foreign body a. Sometimes patients present with foreign bodies in their rectum. b. Some may show signs of infection or frank shock. c. Prehospital treatment is supportive and analgesia may be required. 8. Bowel obstruction a. Bowel obstructions are blockages of the hollow space within the small and large intestines and can be partial or complete. b. The most common site for obstructions is the small intestine because of its diameter, greater length, flexibility, and ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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mobility. Obstructions may be chronic, as with tumor growth or adhesion progression, or acute, as with a foreign body. i. Chronic obstructions usually result in decreased appetite, fever, malaise, nausea and vomiting, weight loss, and, if rupture occurs, peritonitis. ii. Patients with bowel obstruction may vomit an emesis that looks and smells like feces. iii. These patients present with diffuse visceral pain, usually poorly localized. iv. You may see signs and symptoms of shock. v. Palpation will reveal tenderness. a)Palpate gently, as additional pressure may result in rupture. vi. Prehospital management is based on physiological and psychological support during expedited transport to an appropriate facility. 9. Mesenteric ischemia a. Mesenteric ischemia occurs when one of the mesenteric arteries becomes occluded or narrowed. b. When blood flow is stopped or reduced, abdominal pain occurs. c. Nausea, vomiting, and diarrhea are common. d. Over time, if untreated, the bowel will become ischemic and die, causing infection. e. Prehospital treatment should include hydration, pain control, and antiemetics. f. The treatment is usually surgical. C. Accessory Organ Diseases 1. Appendicitis a. Appendicitis is inflammation of the vermiform appendix, which is located at the junction of the large and small c.

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intestine. i. If untreated, the inflamed appendix can rupture, spilling its contents into the peritoneal cavity, resulting in peritonitis. ii. Inflammation also causes the internal diameter to expand, which can block the appendicular artery, causing thrombosis and leading to necrosis. b. Mild appendicitis causes diffuse, colicky pain associated with nausea and vomiting and sometimes a low-grade fever. i. Often the pain is located in the periumbilical region. ii. As the appendix continues to dilate, the pain will localize in the right lower quadrant. iii. Once the appendix ruptures, the pain becomes diffuse due to the development of peritonitis. c. Physical assessment will find a patient who appears to be in discomfort. d. The abdominal exam will reveal tenderness or guarding around the umbilicus or right lower quadrant. e. Prehospital care includes placing the patient in a position of comfort, giving psychological support, diligently managing the airway to prevent aspiration, establishing IV access, and transporting the patient. f. Monitor as you would for bowel obstruction, and treat any complications such as tachycardia or other signs of shock as they arise. 2. Cholecystitis a. Cholecystitis is an inflammation of the gallbladder. i. It is caused by gallstones and can be chronic or acute. b. An inflamed gallbladder usually causes an acute attack of upper right quadrant pain. i. The inflammation can irritate the diaphragm, causing ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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referred pain in the right shoulder. c. Often the pain occurs after a meal high in fat content. d. Nausea and vomiting are common. e. Palpation may reveal either diffuse right-side tenderness or point tenderness under the right costal margin (positive Murphy’s sign). f. Prehospital treatment is mainly palliative. 3. Pancreatitis a. Pancreatitis is an inflammation of the pancreas. i. Frequently, gallstones leaving the common bile duct become lodged at the ampulla of Vater and obstruct the pancreatic duct. ii. The obstruction backs up pancreatic digestive enzymes, causing inflammation. b. Chronic pancreatitis occurs secondary to acinar tissue destruction caused by chronic alcohol intake, drug toxicity, ischemia, or infectious diseases. c. Pain is intense and localized to the left upper quadrant or may radiate to the back or epigastric region. d. Most patients experience nausea and uncontrolled vomiting and retching. e. Patients appear acutely ill with diaphoresis, tachycardia, and possibly hypotension if massive hemorrhage is involved. f. Prehospital treatment is supportive and aimed at maintaining ABCs by providing high-concentration oxygen (if the patient is hypoxic) and establishing intravenous access. 4. Hepatitis a. Hepatitis involves any injury to hepatocytes (liver cells) associated with inflammation or infection. i. Changes to the liver secondary to hepatocyte injury cause hypertrophy, fatty changes, loss of architecture, and appearance of lesions and ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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spontaneous hemorrhages. Symptoms can range from mild to complete liver failure. b. Patients commonly present with symptoms relative to the severity of the disease. i. Usually, they complain of upper right quadrant tenderness not relieved by antacids, food, or positioning. ii. Increased bilirubin retention causes jaundice and scleral icterus. a)Other signs and symptoms include severe nausea and vomiting, general malaise, photophobia, pharyngitis, and coughing. iii. The physical exam reveals a sick patient with a jaundiced appearance. iv. Inspection is typically nonspecific; however, palpation may reveal an enlarged liver. c. Prehospital treatment is mainly palliative. i. Carefully consider any pharmacologic administration because the liver breaks down many active drug metabolites. ii.

V. Summary A. Abdominal pain can originate from a wide variety of causes, either from the abdominal organs or from areas outside the abdominal cavity. B. Generally, the patient’s description of the pain (sharp, dull, burning, tearing cramping) may help narrow the differential diagnosis; however, prehospital management priorities for the abdominal patient are to establish and maintain the patient’s airway, breathing, and circulation. C. Airway management is of paramount importance, as patients frequently suffer from bouts of nausea and vomiting. D. Prompt recognition, treatment, and rapid transport to the hospital are the keys to successful treatment.

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VII. You Make the Call 5 VIII. Review Questions 5

Master Teaching Notes Class Activities Discuss the case with students now that they are familiar with the chapter. Class Activities Read and discuss the call and questions as a group.

Class Activities Pass out review questions before the lesson starts. Have students answer them. Go over the questions again after the lecture to assess students’ understanding of the information.

MASTER TEACHING NOTES

Detailed Lesson Plan Chapter 7 Urology and Nephrology 65–75 Minutes

    

Teaching Tips Class Activities Points to Emphasize Knowledge Application Decision Points

Chapter 7 objectives can be found on text p. 300. These objectives, which form the basis of each chapter, were developed from the current National EMS Education Standards and the accompanying Paramedic Instructional Guidelines.

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Case Study

Master Teaching Notes Teaching Tips Have a student read the scenario. Tell students that the case will be reviewed after the lecture.

II. Introduction A. The urinary system performs a number of vital functions. 1. It maintains blood volume and proper balance of water, electrolytes, and pH. 2. It plays a major role in arterial blood pressure regulation. 3. It controls the development of erythrocytes (red blood cells). B. Renal and urologic disorders are common, affecting about 20 million Americans. 1. More than 50,000 Americans die annually from kidney disease. a. More than 250,000 Americans suffer from the most severe form of long-term kidney failure, end-stage renal failure. III. Anatomy and Physiology A. Kidneys 1. Gross and microscopic anatomy of the kidney a. The renal artery and vein, as well as nerves, lymphatic vessels, and ureter, pass into the kidney at the hylum. b. The outer region of the kidney is the cortex. c. The inner region of the kidney is the medulla. i. Medullary tissue is divided into fan-shaped regions

Teaching Tips The renal system is one of the most complicated systems in the human body. Have diagrams of the kidneys and their associated structures available during lectures so that you have a visual aid while discussing the anatomy and 1

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Content Outline called pyramids, which end in the papilla and project into the hollow space of the renal pelvis. d. The nephron is the functional unit of the kidney and forms urine. i. Blood flows into the renal artery and into the glomerulus, a cluster of capillaries surrounded by Bowman’s capsule. a)Water and chemical substances enter the tubule through Bowman’s capsule. ii. Water then flows successively through the proximal tubule, descending loop of Henle, ascending loop of Henle, and the distal tubule; urine drips into the collecting duct before entering the renal pelvis and ureter. 2. Kidney physiology a. Overview of nephron physiology i. The first step in the formation of urine is filtration of blood through the glomerulus. a)The rate at which blood is filtered is called the glomerular filtration rate (GFR) and averages 180 L/day. b)Filtration is a nonselective process based primarily on molecular size and is essential to urine formation. ii. Reabsorption and secretion are highly selective and involve simple diffusion, osmosis, facilitated diffusion, and active transport. a)Active transport is vital because it allows for a precise balance of reabsorption and secretion that results in independent homeostatic handling of electrolytes and other substances such as glucose. b. Tubular handling of water and electrolytes

Master Teaching Notes physiology of the renal system.

Knowledge Application Some medications given by paramedics directly affect the kidney and reabsorption. Loop diuretics are used in emergency management. Given their mechanism of action, what portion of the kidney do they affect, and how does this benefit our patients?

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Under normal conditions, about 65% of filtered sodium and chloride is reabsorbed in the proximal tubule, along with osmotic reabsorption of about the same percentage of filtered water. ii. As filtrate moves through the next part of the nephron, the loop of Henle, its volume and composition change further. iii. By the time filtrate has moved through the descending limb of the loop, roughly another 20% of the filtrate’s original water has been reabsorbed. a)Healthy kidneys can produce urine with osmolarity as low as one-sixth the osmolar concentration of blood plasma, an action termed diuresis. b)Antidiuresis can form a very concentrated urine with an osmolarity as high as four times that of plasma, Tubular handling of glucose and urea i. Glucose is freely filtered into Bowman’s capsule as an element of filtrate. ii. The body’s absolute retention of glucose is usually maintained until the blood glucose level reaches about 180 mg/dL; above that level, it begins to be lost in urine. iii. Urea is also freely filtered into Bowman’s capsule. iv. Urea is passively reabsorbed throughout most of the tubule, and about half of the filtered load will remain in urine. a)If the GFR remains adequate, the net result of filtration and reabsorption will keep the blood level of urea from rising to a toxic level. b) The blood urea nitrogen (BUN) test 3

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measures blood concentration of urea and indicates GFR. d. Control of arterial blood pressure i. Juxtaglomerular cells, specialized cells adjacent to glomerular capillary cells, respond to low blood pressure by releasing the enzyme renin. a)Renin produces significant amounts of the active hormone angiotensin I, which flows through the lungs and is converted to angiotensin II by angiotensin-converting enzyme (ACE). b)Angiotensin II is a powerful vasoconstrictor that immediately raises arterial blood pressure. e. Control of erythrocyte development i. The kidneys produce 90% of the body’s erythropoietin, a hormone that regulates the rate at which erythrocytes mature in bone marrow. ii. The exact mechanism that produces erythropoietin is unclear. B. Ureters 1. Urine drains from the renal pelvis into the ureter, the long duct that runs from the kidney to the urinary bladder. 2. A thin, muscular layer in the ureters’ walls limits their ability to distend in response to internal pressure. 3. The microscopic structure of the ureters and the nature of their nerve supply are important in understanding the symptoms caused by kidney stones. C. Urinary Bladder 1. The urinary bladder is the anteriormost organ in the pelvis of both men and women and stores urine. 2. In women, connective tissue loosely attaches the bladder’s posterior wall to the anterior vaginal wall. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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3. In men, the bladder wall is structurally continuous with the prostate gland. Urethra 1. The urethra is the duct that carries urine from the bladder to the exterior of the body. 2. In women, the urethra is only about 3–4 cm long and opens to the external environment via a small orifice just anterior to that of the vagina. a. This is probably one reason the female urinary system is more vulnerable to bacterial infection from environmental (largely skin) sources. 3. In men, the urethra is about 20 cm long and ends at the tip of the penis. Testes 1. Testes are the primary male reproductive organs. 2. They produce both the hormones that are responsible for sexual maturation and sperm cells. Epididymis and Vas Deferens 1. Sperm cells pass from the testes into the epididymis, where they are stored. 2. Sperm are channeled from the epididymis to the vas deferens, a muscular duct that carries them into the pelvis and through the substance of the prostate gland to its opening into the urethra. Prostate Gland 1. The prostate gland surrounds the male urinary bladder neck, and the first part of the urethra runs through its tissue. 2. The prostate gland is a major source of the fluid that combines with sperm to form semen, the ejaculated male reproductive fluid. 3. Enlargement of the prostate that narrows or obstructs the urethra can block urine flow and create a possible medical emergency. Penis 1. The penis is the male organ of copulation. 2. Internal spongy tissues fill with blood to produce penile erection.

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Content Outline IV. General Mechanisms of Nontraumatic Tissue Problems A. Both traumatic and nontraumatic problems can affect the urinary system, particularly the kidneys. B. Notraumatic renal and urologic disorders result from four general mechanisms: 1. Inflammatory or immune-mediated disease 2. Infectious disease 3. Physical obstruction 4. Hemorrhage V. General Pathophysiology, Assessment, and Management A. Pathophysiologic Basis of Pain 1. Causes of pain a. Bacterial infection damages the epithelial tissue that lines structures such as the urethra and urinary bladder. i. This damage causes pain that often worsens when urine flows over the affected tissue during urination. b. Distention of a ureter by a renal calculus (kidney stone) causes a sharp pain that may ease or worsen when the stone shifts position inside the ureter. 2. Types of pain c. Visceral pain is a characteristic aching or crampy pain felt deep within the body and poorly localized owing to the relatively low numbers of nerve fibers in the involved areas. d. Referred pain is felt in a location other than its site of origin and occurs when afferent nerve fibers carrying the pain message merge with other pain-carrying fibers at the junction with the spinal cord. B. Assessment and Management 1. The assessment steps are the same for all abdominal emergencies. a. Do not attempt to pinpoint the cause of abdominal pain in the field; diagnosis is often difficult even in the hospital setting. 2. Scene Size-Up a. During the scene size-up, look for evidence of traumatic

Master Teaching Notes

Class Activities Urologic and nephrologic emergencies have many complaints in common with abdominal emergencies. When practicing abdominal assessment, include urologic complaints and have students differentiate the symptoms from those of abdominal emergencies.

Knowledge Application The kidneys play an important role in the regulation of fluids and electrolytes. Dialysis patients rely on machines to help with this function. Many of these patients can have significant complications. What types of complications do you expect to see in a patient who has not been dialyzed recently? What about a patient who has just had dialysis? How will this affect your care and treatment plan? 6

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Content Outline versus medical causes and for signs of a life-threatening situation. 3. Primary and Secondary Assessments a. Primary assessment of the patient concentrates on the ABCs as well as on patient disability. b. Secondary assessment includes the history, physical exam, and vital signs. 4. History a. Information about pain should be elicited using OPQRST. i. Onset ii. Provocation/palliation iii. Quality iv. Region/radiation v. Severity vi. Time b. Ask about previous history of a similar event c. Presence of nausea or vomiting d. Changes in bowel habits and stool e. Weight loss f. Last oral intake g. Presence of chest pain 5. Physical examination includes forming an overall impression as well as examination of the abdomen. a. Appearance b. Posture c. Level of consciousness d. Apparent state of health e. Skin color f. Examination of the abdomen i. Always inspect the abdomen first. ii. Auscultation rarely produces a positive finding. iii. Pain induced by percussion of the flanks, especially when accompanied by fever, suggests

Master Teaching Notes Decision Points Patients receiving dialysis can have serious consequences based on their dialysis status. How will this affect your transport decision? Additionally, the kidneys are responsible for fluid management; how does this affect your use of IV fluids for hypovolemia? What are your options for treatment in these cases?

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pyelonephritis or kidney infection. Pain on percussion just above the pelvic rim, especially when accompanied by fever and an increased urge to void, suggests a bladder infection. Constant, sharp pain increased by percussion of the affected flank may indicate where a kidney stone has lodged in a ureter. Palpation of the lower abdomen may help diagnose acute urinary obstruction in older men who have prostatic enlargement. The male abdominal exam should also include inspection of the penis and scrotum.

6. Vital Signs a. Temperature is important because fever suggests an infectious process. 7. Management and treatment plans a. Management includes general and case-specific elements. b. Management always begins with ABCs. c. Consider placing a large-bore IV for volume replacement or drug administration. i. Nausea is common and should be treated with antiemetics. ii. Pain should be treated, preferably with an opiate. d. Each patient with abdominal pain of greater than 6 hours is considered a surgical emergency until hospital evaluation proves otherwise. e. Rapidly, yet gently, transport patients. f. Talk quietly to the patient during transport both to calm him and to keep him informed of transport time.

VI. Renal and Urologic Emergencies A. Acute Kidney Injury 1. Acute kidney injury (AKI), also called acute renal failure (ARF), is a

Points to Emphasize Refer students again to the renal system diagrams that you 8

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Content Outline sudden drop in urine output to less than 400 to 500 mL per day (oliguria). 2. Pathophysiology a. Prerenal ARF begins with dysfunction before the level of the kidney typically due to hypoperfusion. i. Problems that can trigger prerenal ARF are hemorrhage, heart failure (MI or CFH), sepsis, and shock. ii. These triggers decrease renal blood supply through a drop in blood volume, blood pressure, or both. iii. If hypoperfusion is prolonged or worsens in degree, GFR decreases, and less filtrate means less urine formation, iv. The nephron tubular cells become ischemic and active reabsorption and secretion decrease or cease. b. Renal AKI is caused within the kidney or renal parenchyma. i. Microangiopathy and glomerular injury result in obstruction of the minute vessels that are a vital part of the blood vessel–tubule structure of the nephron. ii. Tubular cell death or acute tubular necrosis can follow prerenal AKI or can develop directly due to toxin deposition. iii. Interstitial nephritis, a chronic inflammatory process also commonly due to toxic compounds, can also result in renal AKI. c. Postrenal AKI originates in a structure distal to the kidney – the ureters, bladder, or urethra. i. Both ureters must be blocked simultaneously for postrenal AKI to develop. 3. Assessment a. The focused history will often provide clues to the severity and duration of AKI.

Master Teaching Notes previously used to discuss anatomy and physiology. Explain to students that renal emergencies often deal with multiple systems. Go over the conditions and risk factors that will likely appear with renal emergencies.

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b. The focused physical exam may be helpful in assessing the degree of AKI present, the antecedent condition, and any immediate life threats. c. If shock triggered the AKI or has developed more recently, profound hypotension may be present, accompanied by tachycardia and hyperkalemia. d. Examination of the abdomen will reveal very different findings depending on the cause of AKI. 4. Management a. Because AKI can lead to life-threatening metabolic derangements, monitoring and supporting the ABCs is vital. b. Initial fluid resuscitation may be required if hypovolemia is present. c. Monitor ECG readings closely, and adjust support per local protocol or discussion with medical direction. d. The chief prevention strategies are protecting fluid volume and cardiovascular function and eliminating or reducing exposure to nephrotoxic agents or medications. B. Chronic Kidney Disease 1. Chronic kidney disease (CKD), also called chronic renal disease (CRD), is inadequate kidney function due to permanent loss of nephrons. 2. Pathophysiology a. The three pathologic processes that initiate nephron damage of CKD are the same as those underlying renal AKI: microangiopathy, glomerular capillary injury, tubular cell injury, and inflammation or infection in interstitial tissue b. Physiologically, each of the kidney’s major functions is highly disturbed or absent depending on the degree of renal failure. i. Active transport in the tubules decreases significantly or ceases. Filtrate simply passes through the tubules, leading to characteristic isosthenuria, the inability to concentrate or dilute ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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iv. v.

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urine. Retention of sodium and water increases, causing a high-volume stress on the cardiovascular system Retention of potassium can lead to dangerous hyperkalemia, and retention of acids can lead to metabolic acidosis. Glucose and other substances that normally are actively reabsorbed are lost in urine as filtrate flows passively through the nephron. The wastes urea and creatinine accumulate in the blood almost in direct proportion to the number of nephrons lost. The renin–angiotensin loop is disrupted, and even small amounts of renin lead to severe hypotension. Because erythropoietin is no longer produced in normal quantities, chronic anemia develops.

3. Assessment a. During the focused history and exam, you will probably find many characteristics of uremia in CKD patients and endstage disease. b. The focused history will typically show GI symptoms such as anorexia and nausea, sometimes with vomiting. c. Skin will be pale, moist, and cool. i. Uremic frost appears when excessive amounts of urea are eliminated through sweat. d. Either hypotension or hypertension may occur depending on the degree of fluid retention. e. ECG findings may include arrhythmia secondary to hyperkalemia, and metabolic acidosis compounds the effects. f. Your abdominal exam will reveal many abnormalities, and the challenge is to begin separating chronic findings from those of recent onset or aggravated by the emergency that ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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led to your call. 4. Management a. Immediate management i. Supporting ABCs is vital. ii. Provide supplemental oxygen. iii. Consider a small IV fluid bolus if hypovolemia is evident. iv. Monitor the ECG readings closely, and adjust supports according to local protocol or discussion with medical direction. v. Chief prevention strategies are (1) regulation of fluid volume and cardiovascular function and major electrolyte disturbances and (2) elimination of exposure to nephrotoxic agents or medications. vi. Err on the side of conservative treatment except for clearly life-threatening complications. vii. Expedite transportation to an appropriate facility in the same manner appropriate for patients with AKI. b. Long-term management i. Renal dialysis, the artificial replacement of some of the kidney’s most critical functions, is a fact of life for most CKD patients. a)Hemodialysis occurs when the patient’s blood is passed through a machine that contains an artificial membrane and a dialysate solution. b)A superficial internal fistula is created surgically by anastamosing an artery and a vein. ii. Chronic ambulatory peritoneal dialysis (CAPD) uses the peritoneal membrane within the patient’s abdomen as the semipermeable dialysis membrane, and dialysate solution is introduced and removed ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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from the abdominal cavity via an indwelling catheter. a)Peritoneal dialysis avoids some of the risks of fluid shift and electrolyte shifts seen during hemodialysis, but its success requires additional physical characteristics, such as healthy vasculature around the peritoneum. Both forms of dialysis have complications in common that are not related to vascular access, including hypotension, shortness of breath, chest pain, and neurologic complaints.

C. Renal Calculi 1. Pathophysiology a. Stones may form in metabolic disorders such as gout and primary hypothyroidism, which produce excessive amounts of uric acid and calcium. b. Most often, they occur when the general balance between water conservation and dissolution of relatively insoluble substances, such as mineral ions and uric acid, is lost and excessive amounts of the insolubles aggregate into stones. 2. Assessment a. The focused history almost always centers on pain. Typically, the patient first notes discomfort as a vague, visceral pain in one flank. b. Within 30–60 minutes, it progresses to an extremely sharp pain that may remain in the flank or migrate downward and anteriorly toward the groin. c. Fever is typically not present unless there in an infection. d. The physical exam will almost always reveal someone who is very uncomfortable. The patient may be agitated, restless, and walking to reduce the pain. e. Vital signs will vary with level of discomfort. f. Abdominal examination may be difficult, depending on the ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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patient’s ability to remain still. 3. Management a. As always, management begins with the ABCs. b. Positioning should center on comfort, but be prepared for vomiting due to severe pain. c. Consider analgesia en route to the hospital according to local protocols and your perception of the patient’s condition. d. Nausea and vomiting are common, and antiemetics should be considered. e. If kidney function is adequate, IV fluid promotes urine formation and movement through the system. D. Priapism 1. Priapism is a painful and prolonged erection of the penis. a. It is associated with certain disease processes, trauma, envenomation, and carbon monoxide poisoning. b. It is a medical emergency and requires prompt intervention by a urologist to prevent permanent damage. E. Testicular Torsion 1. Testicular torsion is the twisting of the spermatic cord that cuts off blood supply to the testicle and surrounding tissues within the scrotum. 2. Certain men are predisposed; however, it can also result from trauma to the scrotum. 3. It is characterized by sudden onset of severe testicular pain (usually limited to one side) and edema. 4. Nausea, vomiting, and dizziness are common. 5. Prehospital treatment includes identification of the condition and pain control. F. Urinary Tract Infection (UTI) 1. Pathophysiology a. UTIs are generally divided into those of the lower tract and those of the upper tract. i. Uretrhitis affects the urethra and is typically coupled ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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with cystitis. ii. Cystitis is infection of the bladder. iii. Prostatitis involves inflammation of the prostate gland. iv. Pyelonephritis is an infectious inflammation of the renal parenchyma, which includes the nephrons, interstitial tissues, or both. It is an upper UTI. b. Community-acquired infections are predominantly Gramnegative enteric bacteria. c. Nosocomial infections are acquired in an inpatient setting or related to catheterization, and are typically caused by Proteus, Klebsiella and Pseudomonas. 2. Assessment a. The focused history of lower UTI typically centers on painful urination, frequent urge to urinate, and difficulty in beginning and continuing to void. b. Pain begins as visceral discomfort that progresses to severe, burning pain, particularly during and just after urination. c. Pain is localized to the pelvis. d. Patients with pyelonephritis are more likely to feel generally ill or feverish; they typically complain of constant moderate or severe flank pain. e. On physical exam, patients appear restless and uncomfortable. f. Vital signs will vary with the degree of illness and pain, but in an otherwise healthy individual, they should not be far from the norms. 3. Management a. UTI management should center on the ABCs and circulatory support. b. If pain is severe, help the patient to a comfortable position, but consider the risk of aspiration during vomiting. c. The best prevention technique is hydration to increase blood ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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flow through the kidneys and to produce a more dilute urine. In many cases, this is best accomplished by IV administration. 5

VII. Summary A. Renal and urologic emergencies typically present as an acute abdomen. B. The most common emergencies you will see are acute renal injury (ARI), chronic kidney disease (CKD), and renal calculi. C. Because renal function is often lowered in the elderly and in persons with hypertension or diabetes, consider it potentially impaired in all these patients. D. The best prevention strategies are to minimize the likelihood of prerenal failure by protecting blood volume and blood pressure and to investigate possible postrenal urinary tract obstruction. VIII. Case Study

IX. You Make the Call 5 X. Review Questions 5

Class Activities Discuss the case with students now that they are familiar with the chapter. Class Activities Read and discuss the call and questions as a group.

Class Activities Pass out review questions before the lesson starts. Have students answer them. Go over the questions again after the lecture to assess students’ understanding of the information.

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Detailed Lesson Plan Chapter 8 Toxicology and Substance Abuse 190–200 Minutes

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Teaching Tips Discussion Topics Class Activities Knowledge Application

Chapter 8 objectives can be found on text p. 325. These objectives, which form the basis of each chapter, were developed from the current National EMS Education Standards and the accompanying Paramedic Instructional Guidelines.

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Case Study

Master Teaching Notes Teaching Tips Have a student read the scenario. Tell students that the case will be reviewed after the lecture.

II. Introduction A. Toxicology is the study of toxins, their antidotes, and their effects on living organisms. B. Toxicologic emergencies result from the ingestion, inhalation, surface absorption, or injection of toxic substances that exert their adverse effects on the body’s metabolic tissues and mechanisms. 1. Poisoning describes exposure to nonpharmacologic substances. 2. Overdose describes exposure to pharmacologic substances. III. Epidemiology A. The American Association of Poison Control Centers estimates that more than 3.1 million poisonings occur annually. B. 10% of all emergency department visits and EMS responses involve toxic exposures. C. 50% of accidental poisonings occur in children under the age of 6 years. D. A child who has experienced an accidental ingestion has a 25% chance of another, similar ingestion within one year. E. 80% of all attempted suicides involve drug overdose. F. Adult poisonings and overdoses account for 90% of hospital admissions for

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toxic substance exposure, and account for 95% of the fatalities in this category.

IV. Poison Control Centers A. Poison control centers have been set up across the United States and Canada to assist in the treatment of poison victims and to provide information on new products and new treatment recommendations. 1. They are usually based in major medical centers and teaching hospitals and serve a large population. 2. Poison control centers are usually staffed by physicians, toxicologists, pharmacists, nurses, or paramedics with special training in toxicology. 3. Poison control centers can help you immediately determine potential toxicity based on the type of agent, amount and time of exposure, and physical condition of the patient, B. The most current, definitive treatment can sometimes be started in the field. C. The poison control center can also notify the receiving hospital of current treatment and recommendations even before arrival of the patient. V. Routes of Toxic Exposure A. Ingestion 1. Ingestion is the most common route of entry for toxic exposure. 2. Immediate toxic effects of corrosive substances can involve burns to the lips, tongue, throat, and esophagus. a. Delayed effects result from absorption of the poison from the GI tract. B. Inhalation 1. Inhalation of a poison results in rapid absorption of the toxic agent through the alveolar–capillary membrane in the lungs. 2. When toxins are absorbed, wider systemic effects can occur. C. Surface Absorption

Class Activities Discuss the poison control center and the number used to contact your local center. If time permits and resources are available, arrange a visit to the poison control center.

Knowledge Application Given the route of exposure, what do you think are the initial complaints? Which route provides the quickest symptoms? Are there emergency medications we use that are given by the same routes?

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Content Outline 1. Surface absorption is the entry of a toxic substance through the skin or mucous membranes. 2. This most frequently occurs from contact with poisonous plants or organophosphates. D. Injection 1. Injection of a toxic agent under the skin, into muscle, or into a blood vessel results in both immediate and delayed effects. a. An allergic or anaphylactic reaction can also appear. b. Later, as the toxin is distributed throughout the body by the circulatory system, delayed systemic reactions can occur. VI. General Principles of Toxicologic Assessment and Management A. Scene Size-Up 1. Always begin assessment with a thorough evaluation of the scene, taking note of where you are and who is around you. a. Patients who are suicidal may have potential for violence. b. Chemical spills and hazardous materials emergencies can quickly incapacitate any individuals who are nearby. B. Primary Assessment 1. Perform the standard primary assessment, form a general impression, and quickly assess mental status. 2. ABC assessment is critical because airway and respiratory compromise are common complications. C. Secondary Assessment 1. For responsive patients, start by obtaining a history. a. It is important to find out not only what toxin the patient was exposed to but when the exposure took place, because toxic effects develop over time. b. Never delay supportive measures or transport to the hospital based on a delay in contacting or obtaining information from poison control. c. A detailed physical exam can be performed en route if time and the patient’s condition permit.

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Discussion Topics Given that some of patients may want to harm themselves and others, how does that affect your treatment plan? What resources are available to you locally, and how are they accessed? Does this affect where you transport your patient? Why and how does it affect your destination decision?

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Content Outline D. Treatment 1. Decontamination is the process of minimizing toxicity by reducing the amount of toxin absorbed into the body. a. Reduce the intake of the toxin. b. Reduce absorption of the toxin once in the body. i. This usually occurs with ingested toxins. ii. Use of syrup of ipecac is no longer recommended. iii. Gastric lavage has been found to be of limited use. iv. The most effective and widely used method of reducing absorption of toxins is activated charcoal. c. Enhance the elimination of the toxin. i. Cathartics increase gastric motility, thereby shortening the amount of time toxins stay in the GI tract to be absorbed. 2. If indicated, the appropriate antidote should be administered. a. Most poisonings will not require the administration of an antidote. E. Suicidal Patients and Protective Custody 1. Always involve law enforcement personnel in these cases and involve them early. 2. Only law enforcement personnel can place a patient in protective custody and ultimately consent to treatment. VII. Ingested Toxins A. Poisoning by ingestion is the most common route of poisoning you will encounter in prehospital care. 1. Assessment a. You need to find out not only what was ingested, but also when it was ingested. b. Begin your history by trying to determine the type of toxin, quantity, time elapsed since ingestion, and whether the patient also took any alcohol or other potentiating substance. 2. The physical examination is extremely important because it will

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Teaching Tips Because ingestion is the most common route of poisoning, integrate the history and physical exam elements into your medical patient assessment. When you practice patient assessment with your students, use examples of overdose patients both critical and noncritical so that students get a 4

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Content Outline provide physical evidence of intoxication and help to find any underlying illnesses that may affect the outcome of the poisoning. a. Pay attention to the following patient features: i. Skin ii. Eyes iii. Mouth iv. Chest v. Circulation vi. Abdomen b. You will frequently encounter patients who have ingested more than one toxin, making assessment even more difficult. 3. Management a. Prevent aspiration i. Early airway management may be required, including rapid sequence intubation (RSI). b. Administer fluids and drugs i. Establish an IV. ii. Treatment should be guided by objective patient information obtained on scene. iii. If narcotic intoxication is suspected (respiratory depression or pinpoint pupils), give 1–2 mg of naloxone IV push. c. Decontamination is performed in the emergency department rather than on scene or during transport. d. Do not induce vomiting.

VIII. Inhaled Toxins A. Toxic inhalations can be self-induced or the result of accidental exposure from such sources as house fires or industrial accidents. 1. Assessment a. Look for the presence of pain on the upper or lower lip, which can indicate inhalant abuse. b. Central nervous system signs and symptoms: dizziness,

Master Teaching Notes feel for the range of symptoms and complaints these patients present with.

Knowledge Application What are some of the sources of inhaled toxins? Are there major sources of these types of poisons in your area?

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headache, confusion, seizures, hallucinations, coma Respiratory system signs and symptoms: tachypnea, cough, hoarseness, stridor, dyspnea, retractions, wheezing, chest pain or tightness, crackles (rales), or rhonchi d. Cardiac system signs and symptoms: arrhythmias 2. Management a. Your first priority is to safely remove the patient from the poisonous environment. b. Wear protective clothing. c. Use appropriate respiratory protection. d. Remove the patient’s contaminated clothing. e. Perform the primary assessment, history, and physical exam. f. Initiate supportive measures. g. Contact the poison control center and medical direction according to local protocols. IX. Surface-Absorbed Toxins A. Many poisons, including organophosphates, cyanide, and other toxins, can be absorbed through the skin and mucous membranes. 1. Assessment and management a. Safely remove the patient from the poisonous environment. b. Wear protective clothing. c. Use appropriate respiratory protection. d. Remove the patient’s contaminated clothing. e. Perform the primary assessment, history, and physical exam. f. Initiate supportive measures. g. Contact the poison control center and medical direction according to local protocols. c.

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Content Outline X. Specific Ingested, Inhaled, and Absorbed Toxins A. Carbon monoxide (CO) is the number-one cause of poisoning in industrialized countries. 1. Sources a. Endogenous b. Exogenous c. Methylene chloride 2. Pathophysiology a. CO competes with oxygen for the oxygen-binding sites on hemoglobin. i. CO will bind to hemoglobin with an affinity that is approximately 200 to 250 times that of oxygen. ii. The binding of CO to hemoglobin results in the formation of carboxyhemoglobin, which prevents oxygen from binding to hemoglobin. iii. Once CO binds to hemoglobin and forms carboxyhemoglobin, it can be removed only slowly or via degradation. a)The normal half-life is 4–6 hours. b)100% oxygen reduces the half-life to 80 minutes. c) Hyperbaric oxygen therapy reduces the halflife to 22 minutes. iv. Inhibits oxygen transfer v. Causes tissue inflammation vi. Causes reduced cardiac function vii. Increases activation of nitric oxide viii. Causes vasodilation ix. Induces free-radical formation 3. Signs and symptoms a. Signs and symptoms are vague and nonspecific and closely resemble those of other diseases.

Master Teaching Notes Teaching Tips Revisit oxygen and its transport throughout the body. Diagram a red blood cell and the hemoglobin molecule.

Class Activities Many prescription medications are regularly advertised on television. Take some of them as examples and research their uses. What are the side effects? How would you manage an overdose?

Knowledge Application Many prescription cardiac medications have various side effects. What are some of the commonly prescribed medications? What would be the results of an overdose of the cardiac medications we give?

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b. As a rule, the signs and symptoms of acute CO poisoning worsen with increasing levels of carboxyhemoglobin. 4. CO detection a. Until recently, detection of CO relied upon hospital-based arterial blood gas sampling. b. CO oximetry functions similar to pulse oximetry but can detect deoxyhemoglobin, oxyhemoglobin, carboxyhemoglobin, and methemoglobin. 5. Management a. It is important to maintain a low threshold of suspicion for treating victims of CO exposure. b. The CDC has established diagnostic categories for CO poisoning: suspected, probable, and confirmed. c. Treatment should be based on the severity of symptoms. d. Begin the administration of high-concentration oxygen. e. Treatment and monitoring of the patient with CO exposure should continue on scene and en route to the hospital. B. Cyanide 1. Cyanide is a colorless gas that has a faint, bitter-almond smell. a. Hydrogen cyanide is a gaseous product of combustion. b. Most accidental cyanide exposures result from inhalation of cyanide gas. c. Cyanide is a cellular toxin that causes the cells to shift from aerobic metabolism to anaerobic metabolism. i. Energy production by the cell is markedly reduced. d. Cyanide can enter the variety by a variety of routes. e. It is present in many household and commercial items that can be ingested or absorbed. f. The incidence of cyanide poisoning in conjunction with CO poisoning is higher than once thought. g. Cyanide, like CO, results from the combustion of selected materials, and the effects of CO and cyanide are cumulative. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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2. Signs and symptoms a. Burning sensation in the mouth and throat b. Headache, confusion, combative behavior c. Hypertension and tachycardia followed by hypotension and further arrhythmias d. Seizures and coma e. Pulmonary edema f. Elevated serum lactate 3. Management a. First, safely remove the patient from the source of exposure. b. Always wear breathing equipment when entering the scene of a fire. c. Initiate supportive measures immediately. d. Lilly or Pasadena cyanide antidote kit e. If dual CO and cyanide poisoning is suspected, hydroxocobalamin should be the preferred antidote. C. Cardiac Medications 1. Signs and symptoms a. In overdose quantities, signs and symptoms of cardiac medications include: i. Nausea and vomiting ii. Headache, dizziness, confusion iii. Profound hypotension iv. Cardiac arrhythmias (usually bradycardia) v. Heart conduction blocks vi. Bronchospasm and pulmonary edema (especially with beta blockers) 2. Management a. Initiate standard toxicologic emergency assessment and treatment immediately. b. Be aware that severe bradycardia may not respond to well to atropine; therefore, you may need to use an external pacing ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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device. Caustic Substances 1. Caustic substances are either acids or alkalis that are found in both the home and industrial workplace. a. Strong caustics can produce severe burns at the site of contact and, if ingested, can cause tissue destruction at the lips, mouth, esophagus, and other areas of the GI tract. b. Strong acids have a pH less than 2 and are found in plumbing liquids. Contact usually produces immediate and severe pain as a result of tissue coagulation and necrosis. c. 2. Strong alkaline agents typically have a pH greater than 12.5 and can be in solid or liquid form. 3. These agents are routinely found around the house. a. They cause injury by inducing liquefaction necrosis. b. Pain is often delayed, which allows for longer tissue contact and deeper tissue injury. 4. Signs and symptoms include: a. Facial burns b. Pain in the lips, tongue, throat, or gums c. Drooling, trouble swallowing d. Hoarseness, stridor, or shortness of breath e. Shock from bleeding, vomiting 5. Management a. Assessment and intervention must be aggressive and rapid to minimize morbidity and mortality. b. Take precautions to prevent injury to rescuers. c. Initiate standard toxicologic emergency assessment and treatment, but pay particular attention to establishing an airway. d. Rapid transport to the emergency department is essential. E. Hydrofluoric Acid (HF) D.

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1. Hydrofluoric acid is extremely toxic and can be lethal despite the appearance of only moderate burns on skin contact. a. HF acid penetrates deeply into tissues and is activated only when it comes into contact with cations such as calcium ion (Ca++). b. Death has been reported from exposure of less than 2.5% body surface area to a highly concentrated solution. 2. Signs and symptoms a. Burning at site of contact b. Trouble breathing c. Confusion d. Palpitations e. Muscle cramps 3. Management a. Ensure the safety of rescue personnel. b. Initiate supportive measures. c. Remove exposed clothing. d. Thoroughly irrigate the affected area with water. e. Immerse the affected limb in iced water with magnesium sulfate, calcium salts, or benzothonium chloride. f. Transport immediately for definitive care. F. Alcohol 1. See the section on alcohol abuse later in the chapter. G. Hydrocarbons 1. Hydrocarbons are organic compounds of mostly carbon and hydrogen and include kerosene, naphtha, turpentine, mineral oil, chloroform, toluene, and benzene. a. Toxicity from hydrocarbons can occur through any route, including ingestion, inhalation, or surface absorption. 2. Signs and symptoms a. Burns due to local contact b. Wheezing, dyspnea, hypoxia, and pneumonitis from ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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aspiration or inhalation Headache, dizziness, slurred speech, ataxia, and obtundation d. Foot and wrist drop with numbness and tingling e. Cardiac arrhythmias 3. Management a. Recent studies have shown that very few poisonings with hydrocarbons are serious, and less than 1 percent require physician intervention. b. Any patient who is symptomatic, does not know what he has taken, or has taken a hydrocarbon that requires GI decontamination must be treated using standard toxicologic emergency procedures. H. Tricyclic Antidepressants 1. Tricyclic antidepressants were once commonly used to treat depression. 2. Close monitoring was required because these medications have a narrow therapeutic index. 3. Signs and symptoms of antidepressant tricyclic toxicity include: a. Dry mouth b. Blurred vision c. Urinary retention d. Constipation 4. Late into an overdose, more severe toxicity may produce: a. Confusion b. Hyperthermia c. Respiratory depression d. Seizures e. Tachycardia and hypotension f. Cardiac arrhythmias (heart block, wide QRS, torsades de pointes) 5. Management c.

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a. Toxicity from tricyclic antidepressants requires immediate initiation of standard toxicologic emergency procedures,. b. Cardiac monitoring is critical. c. If you suspect a mixed overdose with benzodiazepines, do not use flumazenil because it may precipitate seizures. d. If significant cardiac toxicity occurs, sodium bicarbonate can be used as an additional therapy. I. MAO Inhibitors 1. These drugs inhibit the breakdown of neurotransmitters such as norepinephrine and dopamine while increasing the availability of the components needed to make even more neurotransmitters. 2. Signs and symptoms of MAOI overdose include: a. Headache, agitation, restlessness, tremor b. Nausea c. Palpitations d. Tachycardia e. Severe hypertension f. Hyperthermia g. Eventually bradycardia, hypotension, coma, and death 3. Management a. No antidote exists for MAOI overdose. b. Institute standard toxicologic emergency procedures as soon as possible. c. If necessary, give symptomatic support for seizures using hyperthermia using benzodiazepines. d. If vasopressors are needed, use norepinephrine. J. Newer Antidepressants 1. In recent years, several new agents have been developed to treat depression that have a high safety profile in therapeutic and overdose amounts. 2. Signs and symptoms a. When the newer antidepressants are taken in overdose, ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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usually the signs and symptoms are mild. b. More commonly, the symptoms may include: i. Drowsiness ii. Tremor iii. Nausea and vomiting iv. Sinus tachycardia 3. Serotonin syndrome is a clinical syndrome that manifests as autonomic instability, altered mental status, seizures, extrapyramidal syndrome including muscle rigidity, hyperthermia, and, rarely, death. a. Onset is within 6 hours of ingestion. b. The symptoms of serotonin syndrome are diverse. i. Mild symptoms may include tachycardia, shivering, diaphoresis, mydriasis, intermittent tremor or myoclonus, and overactive or hyperactive reflexes. ii. Moderate symptoms include abnormalities such as hypertension and hyperthermia. Mental status changes include hypervigilance and agitation. iii. Severe symptoms include severe hypertension and tachycardia that may eventually lead to shock, agitated delirium, muscular rigidity, and high muscular tension. iv. A triad of cognitive effects, autonomic effects, and somatic effects is indicative of serotonin syndrome. c. Management i. Treat overdoses with the standard toxicologic emergency procedures. ii. Have the patient discontinue all serotonergic drugs. iii. Implement supportive measures. iv. Benzodiazepines occasionally are used to improve patient comfort but are rarely given in the field. 4. Lithium a. In the treatment of bipolar disorder, no other drug has proven ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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to be more effective than lithium; however, it has a narrow therapeutic index that results in toxicity during normal use and in overdose situations. b. Signs and symptoms of lithium overdose include: i. Thirst and dry mouth ii. Tremor, muscle twitching, increased reflexes iii. Confusion , stupor, seizures, and coma iv. Nausea, vomiting, and diarrhea v. Bradycardia, arrhythmias c. Management i. Treat lithium overdose with mostly supportive measures. ii. Use standard toxicologic emergency procedures. iii. Remember that activated charcoal will not bind lithium and need not be given. K. Salicylates 1. Salicylates are some of the more common drugs taken in overdose, largely because that they are readily available over the counter. a. About 300 mg/kg is required to cause toxicity; in such amounts, salicylates inhibit normal energy production and acid buffering in the body. This results in metabolic acidosis, which further injures other organ systems. 2. Signs and symptoms include: a. Rapid respirations b. Hyperthermia c. Confusion, lethargy, coma d. Cardiac failure, arrhythmias e. Abdominal pain, vomiting, hematemesis f. Pulmonary edema, acute respiratory distress syndrome (ARDS) 3. Management a. In all cases, salicylate poisoning should be treated using ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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standard toxicologic emergency procedures. b. Activated charcoal reduces drug absorption and should be used. c. Most symptomatic patients will require generous IV fluids, and severe cases may require dialysis. L. Acetaminophen 1. In doses greater than 150 mg/kg, acetaminophen is considered toxic and may result in death due to liver injury. a. When large amounts enter the system, the detoxification system is overwhelmed and gradually depleted, leaving the toxic metabolite in the circulation, causing hepatic necrosis. 2. Signs and symptoms a. Stage 1 (half hour to 24 hours) includes nausea, vomiting, weakness and fatigue b. Stage 2 (24 to 48 hours) includes abdominal pain, decreased urine, and elevated liver enzymes c. Stage 3 (72 to 96 hours) includes liver function disruption d. Stage 4 (4 to 14 days) includes gradual recovery or progressive liver failure 3. Management a. Treat acetaminophen overdose with standard toxicologic emergency procedures. b. Find out the time of ingestion, as blood levels taken at the right time can predict the potential for injury. M. Other Nonprescription Pain Medications 1. Non-steroidal anti-inflammatories (NSAIDs) are another group of medications that are readily available and often overdosed. 2. Signs and symptoms a. Headache b. Tinnitus c. Nausea, vomiting, abdominal pain d. Swelling of the extremities ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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e. Mild drowsiness f. Dyspnea, wheezing, pulmonary edema g. Rash, itching 3. Management a. There is no specific antidote for NSAID toxicity. b. Use general overdose procedures, including supportive care, as soon as possible. c. Transport the patient to the emergency department for observation and any necessary symptomatic treatment. N. Theophylline 1. Theophylline belongs to a group of medications called xanthines. 2. It is occasionally used for patients with asthma or COPD. a. It has a narrow therapeutic index and high toxicity and has become less popular recently. 3. Signs and symptoms a. Agitation b. Tremors c. Seizures d. Cardiac arrhythmias e. Nausea and vomiting 4. Management a. Theophylline can cause significant morbidity and mortality. b. In overdose situations, it is essential that you institute toxicologic emergency procedures immediately. c. Multiple doses of activated charcoal over time will continuously remove more and more of the drug from the body. O. Metals 1. With the exception of iron, overdose of heavy metals is a rare occurrence. 2. All metals affect numerous enzyme systems within the body and therefore present with a variety of symptoms. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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3. Iron overdose symptoms occur when more than 20 mg/kg of elemental iron are ingested. a. Signs and symptoms of excess iron i. Vomiting (often hematemesis), diarrhea ii. Abdominal pain and shock iii. Liver failure iv. Metabolic acidosis with tachypnea v. Eventual bowel scarring and possible obstruction b. Management i. It is essential to initiate standard toxicologic emergency procedures immediately. ii. Activated charcoal will not bind iron (or any metals) and should not be used. iii. Deforoxamine, a chelating agent, may be used in iron overdose as an antidote, as it binds to iron so that less is moved into cells and tissues to cause damage. P. Lead and Mercury 1. Lead and mercury are heavy metals found in varying amounts in the environment. 2. Lead was often used in glazes and paints before toxic potential of such exposure became apparent. 3. Mercury is a contaminant from industrial processing but is also found in thermometers and temperature-control switches in most homes. 4. Chronic and acute exposures are possible with both metals. a. Signs and symptoms i. Headache, irritability, confusion, coma ii. Memory disturbance iii. Tremor, weakness, agitation iv. Abdominal pain b. Management i. It is essential to initiate standard toxicologic ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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emergency procedures immediately. Activated charcoal will not bind heavy metals, but various chelating agents are available and may be used in definitive management in the hospital.

Q. Contaminated Food 1. Food poisoning is caused by a spectrum of different factors. a. Bacterial food poisonings range in severity. b. A variety of seafood poisonings are a result of specific toxins found in contaminated shellfish, which can lead to respiratory arrest in addition to GI complaints. 2. Signs and symptoms a. Nausea, vomiting, diarrhea, abdominal pain b. Facial flushing, respiratory distress (with some seafood poisonings) 3. Management a. Except for botulism, food poisoning is rarely life threatening. b. Treatment is largely supportive. c. In suspected cases, contact poison control and medication direction. d. Perform the necessary assessment. e. Collect samples of the suspected contaminated food source. f. Establish and maintain the airway. g. Administer high-concentration oxygen initially. h. Establish venous access. i. Consider antihistamines (especially in seafood poisonings) and antiemetics. R. Poisonous Plants and Mushrooms 1. The vast majority of plants and mushrooms are nontoxic, and it can be difficult to identify the offending material. a. Examine the patient’s mouth and throat for redness, blistering, or edema. 2. Signs and symptoms ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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Content Outline a. Excessive salivation, lacrimation, diaphoresis b. Abdominal cramps, nausea, vomiting, diarrhea c. Decreasing levels of consciousness, eventually progressing to coma 3. Management a. For guidance on the treatment of plant poisonings, call the poison control center. b. If contact cannot be made, use the procedures outlined as described for treatment of food poisoning. XI. Injected Toxins A. General Principles of Management 1. General principles of management include a. Protect rescue personnel. b. Remove the patient from danger of repeated injection, especially in the case of yellow jackets, wasps, or hornets. c. If possible, identify the insect, reptile, or animal that caused the injury and bring it to the emergency department along with the patient (if it can be done safely). d. Perform a primary assessment and rapid physical exam. e. Prevent or delay further absorption of the poison. f. Initiate supportive measures as indicated. g. Watch for anaphylactic reaction. h. Transport the patient as rapidly as possible. i. Contact the poison control center and medical direction according to local protocols. B. Bites and Stings 1. Insect stings a. In most cases of insect bite, local treatment is all that is necessary. b. Unless an allergic reaction occurs, most patients will tolerate the isolated Hymenoptera sting. c. Signs and symptoms

Master Teaching Notes

Teaching Tips Provide the class with pictures of the various animals and insects discussed in this section. Concentrate on those that are local.

Knowledge Application What are some common insects and venomous animals in your area? Is it possible to experience a patient who is exposed to an animal not native to your area?

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i. ii. iii. iv. v.

Localized pain Redness Swelling Skin wheals The major problem resulting from a Hymenoptera sting is an allergic reaction or anaphylaxis. d. Management of Hymenoptera stings: i. Wash the area. ii. Gently remove the stinger, if present, by scraping without squeezing the venom sac. iii. Apply a cool compress to the injection site. iv. Observe and treat allergic reactions and/or anaphylaxis. 2. Africanized Honeybees a. These bees acquired the name “killer bees” because they will viciously attack people and animals that unwittingly stray into their territory, and the stings often result in serious injury or death. b. Only a minimal disturbance is necessary to cause an AHB attack. c. ABHs pose a particular risk for firefighters and EMS personnel. d. Heavy turnout gear can provide good protection as long as a properly fitting bee veil is also used. e. Hazardous material suits can also be used. f. AHBs can be immobilized and killed with wetting agents, including commercial dishwashing detergents. 3. Brown recluse spider bites a. Brown recluse spider bites are usually painless. b. Initially, a small erythematous macule surrounded by a white ring forms at the site. c. Over the next 8 hours, localized pain, redness, and swelling ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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develop. d. Tissue necrosis at the site occurs over days to weeks, e. Other symptoms include chills, fever, nausea and vomiting, joint pain, and, in severe situations, bleeding disorders. f. Treatment is mostly supportive. g. Emergency department treatment consists of antihistamines to reduce systemic reactions and possible surgical excision of necrotic tissue. 4. Black widow spider bites a. Signs and symptoms start as immediate localized pain, redness, and swelling. b. Progressive muscle spasms of all large muscle groups can occur and are usually associated with severe pain. c. Other systemic symptoms include nausea, vomiting, sweating, seizures, paralysis, and decreased level of consciousness. d. Prehospital treatment is mostly supportive; however, IV muscle relaxants may be necessary for severe spasms. i. Physicians may order diazepam (2.5 to 10 mg IV) or calcium gluconate (0.1–0.2 mg/kg of 10% solution IV). 5. Scorpion stings a. The bark scorpion’s venom acts on the nervous system, producing a burning and tingling effect without much evidence of injury initially. b. Gradually, this progresses to numbness. c. Begin treatment by reassuring the patient. d. Apply a constricting band above the wound site no tighter than a watchband to occlude lymphatic flow. e. Avoid the use of analgesics, which may increase toxicity and potentiate the venom’s effect on airway control. C. Snakebites ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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1. Signs and symptoms of snakebites depend on the snake, the location of the bite, and the type and amount of venom injected. 2. Pit viper bites a. Pit viper venom contains hydrolytic enzymes that are capable of destroying proteins and most other tissue components. b. These enzymes may produce destruction of red blood cells and other tissue components and may affect the body’s blood clotting system within the blood vessels. c. This will produce infarction and tissue necrosis, especially at the site of the bite. d. A severe pit viper bite can result in death from shock within 30 minutes. e. Most deaths from pit viper bites occur from 6 to 30 hours after the bite, with 90 percent occurring within the first 48 hours. f. Signs and symptoms i. Fang marks ii. Swelling and pain at the wound site iii. Continued oozing at the wound site iv. Weakness, dizziness, or faintness v. Sweating and/or chills vi. Thirst vii. Nausea and vomiting viii. Diarrhea ix. Tachycardia and hypotension x. Bloody urine and gastrointestinal (GI) hemorrhage (late) xi. Ecchymosis xii. Necrosis xiii. Shallow respirations, progressing to respiratory failure ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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xiv.

Numbness and tingling around face and head (classic) g. Management i. The primary goal of treatment is to slow absorption of the venom. ii. Antivenin should be considered only for severe cases where marked envenomation has occurred, evidenced by severe systemic symptoms. iii. Keep the patient supine. iv. Immobilize the limb with a splint. v. Maintain the extremity in a neutral position. Do not apply constricting bands. vi. Initiate supportive care, including oxygenation, IV fluids, and transport. vii. Do not apply ice, cold packs, or Freon spray to the wound. viii. Do not apply an arterial tourniquet. ix. Do not apply electrical stimulation from any device in an attempt to retard or reverse venom spread. 3. Coral snake bites a. Coral snake venom contains some of the same enzymes found in pit viper venom; however, it also contains a neurotoxin that primarily affects nervous tissue. b. Signs and symptoms i. Localized numbness, weakness, and drowsiness ii. Ataxia iii. Slurred speech and excessive salivation iv. Paralysis of the tongue and larynx v. Drooping of eyelids, double vision, dilated pupils vi. Abdominal pain vii. Nausea and vomiting viii. Loss of consciousness ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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ix. Seizures x. Respiratory failure xi. Hypotension c. Management i. Wash the wound with copious amounts of water. ii. Apply a compression bandage, and keep the extremity at the level of the heart. iii. Immobilize the limb with a splint. iv. Start an IV using crystalloid. v. Transport the patient to the emergency department for administration of antivenin. vi. Do not apply ice, cold pack, or Freon spray to the wound. vii. Do not incise the wound. viii. Do not apply electrical stimulation from any device in an attempt to retard or reverse venom spread. D. Marine Animal Injection 1. Marine animal injections can present as stings from jellyfish and corals or as punctures from the bony spines of urchins and stingrays. 2. They produce pain out of proportion to the size of the injury. 3. Signs and symptoms a. Intense local pain and swelling b. Weakness c. Nausea and vomiting d. Dyspnea e. Tachycardia f. Hypotension or shock (severe cases) 4. Management a. Establish and maintain the airway. b. Apply a constricting band between the wound and the heart no tighter than a watchband to occlude lymphatic flow only. c. Apply heat or hot water (110°–113°F). ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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Content Outline d. Inactivate or remove any stingers. E. Ciguatera Poisoning 1. Ciguatera poisoning is an illness caused by eating fish that contains toxins produced by Gambierdiscus toxicus. 2. It generally presents with GI syndrome consisting of nausea, vomiting, diarrhea, and abdominal pain with an onset ranging from 2 to 30 hours after ingestion. 3. It is often associated with signs of cardiovascular dysfunction such as hypotension, bradycardia, or arrhythmia. 4. There is no cure and treatment is supportive. 5. Some studies have demonstrated a benefit with administration of mannitol. 6. Symptoms usually go away in days or weeks but can last for years; people can be treated for their symptoms. XII. Substance Abuse and Overdose A. Substance abuse is the use of a pharmacologic substance for purposes other than medically defined reasons. 1. Abusers begin to crave the feelings the drugs give them and develop dependence on the drug (called addiction). 2. Becoming accustomed to the use of the drug is called habituation. 3. With continued use of the drug, tolerance develops. 4. Attempts to stop the drug can trigger a psychological or physical reaction known as withdrawal. a. It can be severe enough to cause death. 5. Drug overdose refers to poisoning from a pharmacologic substance, either legal or illegal. It can occur intentionally or accidentally. a. It is imperative to remain nonjudgmental. b. The presentation of the overdose will vary on the basis of the substance used. c. Management should be the same as for any ingested, inhaled, or injected poison. d. Contact poison control for additional direction.

Master Teaching Notes

Teaching Tips Substance abuse and overdose are important subjects to discuss, as it is common for medical providers to have known someone who has been in an abuse situation or to have been in such a situation themselves. EMS providers are not immune to substance abuse based on the stressful nature of our work. Provide information about counseling programs and peer groups that help to identify and treat the unique problems we face in our careers.

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Content Outline B. Commonly Abused Drugs 1. Drugs of abuse are both common and dangerous. a. Alcohol – May require thiamine and D50W for hypoglycemia b. Amphetamines/stimulants – Use benzodiazepines for seizures and in combination with haloperidol for hyperactivity. c. Barbiturates – Forced diuresis and alkalization of the urine improve elimination of barbiturates from the body. d. Benzodiazepines – Use Flumazenil to counteract adverse effects. Be careful not to trigger a withdrawal syndrome with seizures. e. Cocaine – Benzodiazepines may be needed to sedation and to treat seizures. Beta blockers are absolutely contraindicated because unopposed alpha-receptor stimulation can cause cardiac ischemia, hypertension, and hyperthermia. f. Hallucinogens – Use benzodiazepines for seizures and in combination with haloperidol for hyperactivity g. Narcotics/ opiates – Naloxone is effective in reversing respiratory depression and sedation, but be careful, as it may trigger a withdrawal reaction in chronic opiate abusers. 2. Drugs used for sexual purposes a. These drugs are used to stimulate and enhance the sexual experience but without medically approved indications for such use. i. Ecstasy (also called MDMA) is one such drug, and it causes anxiety, nausea, tachycardia, and elevated blood pressure, followed by relaxation, euphoria, and feelings of enhanced emotional insight. a)No specific treatment exists. b)Standard supportive measures should be initiated.

Master Teaching Notes You will encounter many patients suffering from substance abuse. How can your attitude affect not only your care, but also the outcome of the patient? As medical professionals, we are supposed to do what is best for the patient. How does that translate to the drug or alcohol addict whom we see on a regular basis? What are some methods of separating our personal feelings from that of our responsibilities as care providers?

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Rohypnol is a strong benzodiazepine and is commonly called “the date rape drug.” a)Treatment is the same as for any benzodiazepine, but be alert for signs and symptoms of sexual assault.

XIII. Alcohol Abuse A. Physiologic Effects 1. Alcohol depresses the CNS potentially to the point of stupor, coma, and death. a. At low doses, alcohol has excitatory and stimulating effects that depress inhibitions/ b. At higher doses, the depressive effects are more obvious. c. Alcohol is completely absorbed from the stomach and intestinal tract in 30–120 minutes and is distributed to all body tissues and fluids, the concentration in the brain rapidly approaching that in the blood. d. Alcohol has a peripheral vasodilator effect on the cardiovascular system, resulting in flushing and a feeling of warmth. e. The diuretic effect is due to inhibition of vasopressin, which is responsible for conservation of body fluids. B. General Alcoholic Profile 1. Alcoholism is characterized by impaired control over drinking, preoccupation with ethanol despite adverse consequences, and distortions in thinking, such as denial. C. Consequences of Chronic Alcohol Ingestion 1. Alcohol has many deleterious effects on the body. Some of the more common effects include: a. Poor nutrition b. Alcohol hepatitis c. Liver cirrhosis with subsequent esophogeal varices d. Loss of sensation in hands and feet

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Discussion Topics Consider that alcohol and drug abuse affects people in every walk of life. How would you manage a partner who you suspect may have a problem? What can you do if you have a problem with substance abuse? There are many resources available. What is the best way to treat not only your patients, but also your peers, family, friends, or mentors who may have a problem?

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e. Loss of cerebellar function (balance and coordination) f. Pancreatitis g. Upper GI hemorrhage (often fatal) h. Hypoglycemia i. Subdural hematoma (due to falls) j. Rib and extremity fractures (due to falls) 2. Alcohol withdrawal syndrome a. The alcoholic may suffer a withdrawal reaction either from abrupt discontinuation after prolonged use or from a rapid fall in blood alcohol after acute intoxication. i. Withdrawal symptoms can be fatal and can occur within the first few hours and last up to 5–7 days. ii. Delirium tremens usually develops on the second or third day and are characterized by a decreased level of consciousness in which the patient hallucinates and misinterprets nearby events. b. Signs and symptoms i. Coarse tremors of hands, tongue, and eyelids ii. Nausea and vomiting iii. General weakness iv. Increased sympathetic tone v. Tachycardia vi. Sweating vii. Hypertension viii. Orthostatic hypotension ix. Anxiety x. Irritability or a depressed mood xi. Hallucinations xii. Poor sleep c. Management i. Whether acute or chronic, withdrawal should not be underestimated ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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Establish and maintain the airway. Determine whether other drugs are involved. Start an IV using lactated Ringer’s or normal saline. Chemstrip, and administer 25 g of D50W if the patient is hypoglycemic. Consider benzodiazepines. Maintain a sympathetic attitude, and reassure the patient of help. Transport to the emergency department for further care.

XIV. Summary A. Because toxicologic emergencies can vary greatly, consider following these rules: 1. Recognize and identify the poisoning promptly. 2. Be thorough in your primary assessment and evaluation of the patient. 3. Initiate the standard treatment procedures required for all toxicologic emergencies. 4. Contact poison control and/or medical direction for toxin-specific treatment instructions. 5. Administer an antidote if one exists for the particular toxin. XV. Case Study

XVI.

You Make the Call

XVII.

Review Questions

Class Activities Discuss the case with students now that they are familiar with the chapter. Class Activities Read and discuss the call and questions as a group.

Class Activities Pass out review questions before the lesson starts. Have students answer them. Go over the questions again after the lecture to 30

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MASTER TEACHING NOTES

Detailed Lesson Plan Chapter 9 Hematology 110–110 Minutes

   

Teaching Tips Discussion Topics Class Activities Knowledge Application

Chapter 9 objectives can be found on text p. 369. These objectives, which form the basis of each chapter, were developed from the current National EMS Education Standards and the accompanying Paramedic Instructional Guidelines.

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Case Study

Master Teaching Notes Teaching Tips Have a student read the scenario. Tell students that the case will be reviewed after the lecture.

II. Introduction A. Hematology is the study of the blood and the blood-forming organs. 1. Hematologic disorders are common and include: a. Red blood cell disorders b. White blood cell disorders c. Platelet disorders d. Coagulation problems B. Rarely are hematologic disorders the primary cause of a medical emergency. C. Patients with hematologic problems often complain of signs and symptoms that do not point directly to a specific disease process; therefore, careful examination and history taking may be necessary to further clarify the diagnosis.

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Content Outline III. Anatomy, Physiology, and Pathophysiology A. The hematopoietic system consists of blood (both cells and plasma), bone marrow, the liver, the spleen, and the kidneys. B. Components of Blood 1. Plasma is a thick, pale yellow fluid that is 90–92% water and 6–7% proteins. a. Plasma transports the cellular components of blood and dissolved nutrients throughout the body and, at the same time, transports waste products from cellular metabolism to the liver, kidneys, and lungs, where they can be removed from the body. b. Most plasma components can move back and forth across the capillary membrane. i. Plasma proteins such as albumin are large molecules that remain in the plasma to help retain water in the capillaries. c. Electrolytes and carbohydrates (generally in the form of glucose) are also found in plasma. 2. Red blood cells a. The primary function of blood is to transport oxygen from the lungs to the tissues. b. The red blood cell (RBC), or erythrocyte, is a biconcave disc that does not have a nucleus when mature. c. It contains hemoglobin molecules that transport oxygen. i. Each hemoglobin molecule can transport up to four oxygen molecules. ii. The effectiveness of oxygen transport depends on: a)RBC mass (number present) b)Hemoglobin’s affinity for oxygen i) The higher the temperature, the more readily hemoglobin releases oxygen. ii) The lower the pH, the more readily hemoglobin will release oxygen. iii) The greater a substance’s affinity for

Master Teaching Notes Teaching Tips It is helpful to review the immune system and its components before discussing the hematopoietic system, as they have many components that are shared.

Class Activities Have students diagram the clotting cascade. Have them demonstrate how it progresses and at which point each component is involved.

Knowledge Application Some areas allow paramedics to give blood infusions. If your area allows paramedics to perform this task, how does it affect your treatment of bleeding disorders and trauma? What are the methods of storing the blood? What blood type is used?

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the binding sites, the more readily the substance will bind (think carbon monoxide). iii. Erythropoiesis is RBC production and occurs when erythropoietin (EPO) is released from the kidney . a)EPO stimulates bone marrow to produce RBCs and is released when the renal cells sense hypoxia. iv. RBCs live approximately 120 days. a)Hemorrhage, hemolysis, or sequestration by the liver or spleen significantly reduce the life span. b)Macrophages in the liver and spleen remove damaged or abnormal RBCs from the circulation. v. RBC count is the number of RBCs in millions per cubic millimeter. vi. The hematocrit is the packed cell volume of RBCs per unit of blood. 3. White blood cells (WBCs), also called leukocytes, circulate through the bloodstream and tissues and provide protection from foreign invaders. a. Healthy people have 5,000–9,000 WBCs per microliter of blood. i. Infections can increase that number to more than 16,000 WBCs. ii. An increase in the number of WBCs is a classic sign of a bacterial infection. b. WBCs are classified as granulocytes, monocytes, or lymphocytes. i. Granlulocytes contain granules and can be classified as basophils, eosinophils, or neutrophils. ii. Monocytes are released into the circulation and remain there or migrate to distant sites to further mature into free or fixed tissue macrophages. iii. Lymphocytes are the primary cells involved in the body’s immune response. a)T cells mature in the thymus and are responsible for cell-mediated immunity. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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b)B cells produce antibodies to fight infection and are responsible for humoral immunity. i) Autoimmune diseases occur when the body makes antibodies against its own tissues. iv. Several factors can alter the body’s immune response. v. The inflammatory process is a nonspecific defense mechanism that wards off damage from microorganisms or trauma by attempting to localize the damage while destroying the source and facilitating repair of the tissue. 4. Platelets, or thrombocytes, are small fragments of cells that form a plug at an initial bleeding site and secrete factors important in clot formation. a. Platelets are activated when they contact injured tissue, which stimulates an enzyme within the platelet and causes them to become “sticky.” C. Hemostasis 1. Hemostasis is the term used to describe the combined three mechanisms that work to prevent or control blood loss. a. Vascular spasms b. Platelet plugs c. Stable fibrin clots (coagulation) 2. When a blood vessel tears, the smooth muscle fibers in the vessel walls contract. 3. At any tear in a blood vessel, platelets aggregate and adhere to collagen, forming a platelet plug that is unstable and requires formation of a stable clot. 4. Damage to cells or the vessel lining starts the coagulation cascade. a. The intrinsic pathway begins when platelets release substances that lead to the formation of prothrombin activator. b. The extrinsic pathway begins when tissue damage causes platelet aggregation and the formation of prothrombin activator. c. The common pathway involves prothrombin converted to thrombin in the presence of calcium. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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d. Thrombin converts fibrinogen to a stable fibrin that traps blood cells and more platelets to form a clot. i. Once a clot is formed, it releases plasminogen, which is converted to plasmin and is then capable of lysing a clot through fibrinolysis. ii. Thrombosis occurring within a coronary or cerebral artery may lead to heart attack or stroke. D. Blood Products and Blood Typing 1. Someone with A antigen on the RBC would have anti-B antibodies and would have blood type B. 2. Someone with B antigen on the RBC would have anti-A antibodies and would have blood type B. 3. Someone with both antigens but neither antibody would have blood type AB. a. They can receive any type blood and are called universal recipients. 4. Others have neither antigen but both antibodies and are blood type O. a. They can give blood to anyone and are called universal donors. 5. Crossmatching blood involves checking samples from both donor and recipient to ensure the greatest compatibility. a. If a person has the Rh factor, he is Rh positive; if he does not have the Rh factor, he is Rh negative. E. Transfusion Reactions 1. A hemolytic reaction occurs when a donor’s and recipient’s blood are not compatible. a. Signs and symptoms include i. Facial flushing ii. Hyperventilation iii. Tachycardia iv. Sense of dread v. Hives may appear on the skin vi. Patient may develop chest pain, wheezing, fever, chills, and cyanosis vii. Flank pain may occur as small clots begin to clog the ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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Content Outline microvasculature of the kidneys b. If you are caring for a patient receiving a transfusion and a reaction occurs, stop the infusion immediately, change all tubing, and initiate IV therapy with maintenance of perfusion and blood pressure. i. If you observe evidence of an allergic reaction, give diphenhydramine, and in extreme cases administer epinephrine. 2. The most common transfusion reaction is the febrile nonhemolytic reaction. a. Signs and symptoms include headache, fever, and chills. b. Stop the transfusion before attempting to treat it, and initiate IV therapy. IV. General Assessment and Management A. In general, patients with disorders of the hematopoietic system may present with a variety of complaints and physical findings. 1. Patients with infection, WBC abnormalities (immunocompromised and prone to infection), or transfusion reactions may present with febrile symptoms. 2. Most hematopoietic disorders are chronic conditions that present with acute exacerbation when the patient is exposed to additional stress such as infection or trauma. 3. Treatment in most cases is supportive. B. Scene Size-Up 1. Assessment begins as it would for any other patient. 2. Perform scene size-up, and take standard precautions. 3. During your approach, form a general impression of the patient. C. Primary Assessment 1. Complete a primary assessment for all life threats. 2. Determine responsiveness and ABCs. a. Alterations in the hematopoietic system may present as a life-threatening bleeds or overwhelming infections with septic shock.

Master Teaching Notes

Teaching Tips Patients with disorders of the hematopoietic system should be integrated into your medical patient assessment practices.

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D. Secondary Assessment 1. Use your general impression to choose a format for a responsive or unresponsive medical patient or trauma patient. 2. Obtain a SAMPLE history, and perform a physical exam. 3. Any changes in the blood’s ability to deliver oxygen will appear in the cardiovascular and respiratory systems, so note dyspnea, palpitations, and dizziness with changes in the patient’s position. 4. Make note of surgeries such as splenectomy, heart valve replacement, or placement of long-term venous access devices. 5. Ask about bloodborne infections such as HIV or hepatitis B or C. E. The physical exam should evaluate each system methodically, as you would with any other patient 1. Always evaluate the nervous system. 2. Note the patient’s skin color. 3. The lymphatic system is affected early in hematopoietic diseases, especially those of the immune system. 4. The GI effects can be quite varied. a. Bleeding of the gums is one of the earliest findings. b. Abdominal pain is common in persons with hematological disease. 5. Many hematopoietic diseases are autoimmune in nature and affect the musculoskeletal system. 6. The effects on the cardiorespiratory system are varied. 7. Genitourinary problems are typically due to bleeding disorders or infection. F. General Management of Hematopoietic Emergencies 1. Pay close attention to airway and ventilation status, and place the patient on high-concentration supplemental oxygen. 2. Consider volume replacement, but remember that crystalloids cannot carry oxygen. 3. Be alert for arrhythmias and treat accordingly. 4. Transport the patient to the appropriate facility, provide comfort measures, including analgesia, and provide psychological support to ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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both the patient and his family.

V. Managing Specific Patient Problems A. Diseases of the Red Blood Cells 1. Anemias are typically classified by a hematocrit less than 37 percent in women and less than 40% in men. a. Most patients will be asymptomatic until hematocrit falls below 30%. b. Anemia can be a self-limiting disease or a lifelong illness requiring periodic transfusions. c. Anemias resulting from destruction of RBCs are called hemolytic anemias. i. Acquired hemolytic anemias can result from immune system disorders, drug effects, or environmental effects. d. Anemia is a sign, not a disease process in itself. e. The signs and symptoms vary, depending on the rapidity of onset, the patient’s age, and underlying general health. f. If anemia develops rapidly, the body does not have time to compensate for the change. i. Signs and symptoms of shock may be present, including postural hypotension and decreased cardiac output. g. Prehospital treatment is primarily symptomatic. 2. Sickle cell disease a. Sickle cell anemia is a disorder of RBC production. i. Sickle hemoglobin has a C shape when oxygen levels are low. ii. Blockage of blood flow to various tissues and organs is common and usually follows a period of stress.

Knowledge Application Many of the disorders discussed are nonacute and secondary to other, more life-threatening problems. How do these problems compound other issues your patient might have? Which patients are more likely to become very unstable?

Discussion Topics Do any of these particular problems affect your transport decisions? What types of local facilities can manage these types of patients?

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iii.

Adult patients often have multiple organ problems, including cardiopulmonary disease, renal disease, and neurologic disorders. iv. Vasoocclusive crises cause musculoskeletal pain, abdominal pain, priapism, pulmonary problems, renal crises, and central nervous system (CNS) crises. v. Hematologic crises consist of a fall in hemoglobin level, sequestration of RBCs in the spleen, and problems with bone marrow function. vi. Infectious crises arise owing to the patient being immunocompromised secondary to loss of splenic function. b. Prehospital care is primarily supportive. i. Begin high-concentration oxygen (if hypoxic), and initiate IV therapy. ii. Start analgesics for pain, if possible. iii. Often, these patients will require large amounts of narcotics for pain control. iv. Always consult medical direction if there is a question regarding management. v. Transport is indicated. 3. Polycythemia a. Polycythemia is an abnormally high hematocrit due to excess production of RBCs. b. It is a relatively rare disorder and typically occurs in adults 50 years of age or older. i. Most deaths occur due to thrombosis. c. Signs and symptoms vary, but the principal finding is a hematocrit of 50% or greater. i. Epistaxis, spontaneous bruising, and gastrointestinal (GI) bleeding can result. ii. Patients may complain of headache, dizziness, ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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blurred vision, itching and GI disease. Severe cases can result in congestive heart failure (CHF). d. Prehospital treatment is supportive and centers on adequate ABCs, oxygen administration, and IV therapy. B. Diseases of the White Blood Cells 1. Leukopenia/neutropenia a. A decrease in the number of WBCs indicates a problem with WBC production in the marrow or destruction of WBCs. b. The prehospital treatment of leucopenia/neutropenia is supportive c. Pay special attention to preventing infection in these patients, as the immune system is overstressed. 2. Leukocytosis a. Leukocytosis is an increase in the number of circulating WBCs and occurs when the body is exposed to an infectious agent or is particularly stressed. i. During stress, immature neutrophils may be released into the circulation; they are called “bands” or “segs” and indicate significant bacterial infection. ii. Viral infections tend to have little effect on WBC and may even cause a decrease in number. 3. Leukemia a. Leukemias are cancers of hematopoietic cells and are classified by the type of cell or the cells involved. b. Medicine has made significant advances in the treatment of leukemia, resulting in the curing of some types. c. Infections are a common complication of leukemia resulting from the low circulating numbers of neutrophils. d. Deaths are typically secondary to infection or bleeding. e. Signs and symptoms vary, and most patients will have a moderate to severe anemia. i. Patients will appear acutely ill, febrile, and weak and iii.

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have various lymph node, liver, and spleen enlargement, resulting in abdominal pain. ii. Patients have a history of weight loss and anorexia. iii. The sternum may be tender, secondary to the increased bone marrow activity. iv. Fatigue is a common complaint. f. Prehospital treatment is primarily supportive and centers on position of comfort, oxygen administration, and IV fluids for dehydration. 4. Lymphomas a. Lymphomas are cancers of the lymphatic system and are classified as Hodgkin’s lymphoma or non-Hodgkin’s lymphoma. b. Malignant lymphoma is classified by the cell type involved . c. The most common sign of non-Hodgkin’s lymphoma is painless swelling of the lymph nodes. d. The majority of patients with Hodgkin’s lymphomas typically have no related symptoms. e. Some lymphoma patients report fever, night sweats, anorexia, weight loss, fatigue, and pruritus. f. Treatment patients symptomatically. C. Diseases of the Platelets/Blood Clotting Abnormalities 1. Thrombocytosis a. Thrombocytosis is an increase in the number of platelets, usually due to increased platelet production. b. Most patients are asymptomatic. c. Prehospital treatment is supportive. 2. Thrombocytopenia a. Thrombocytopenia is an abnormal decrease in the number of platelets and is due to decreased production, sequestration of platelets in the spleen, destruction of platelets, or any combination of the three. b. It is characterized by easy bruising, bleeding, and falling ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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platelet count. c. Prehospital treatment is supportive. 3. Hemophilia a. Hemophilia is a blood disorder in which one of the proteins necessary for blood clotting is missing or defective. i. A deficiency of factor VIII is hemophilia A and is more common. ii. A deficiency of factor IX is hemophilia B (Christmas disease). b. Bleeding takes longer to stop because the body cannot form stable fibrin clots. c. It is a sex-linked, inherited bleeding disorder carried on the X chromosome and expressed on the Y chromosome. d. Signs and symptoms include numerous bruises, deep muscle bleeding characterized as pain or a “pulled muscle,” and hemarthrosis. e. Treatment is provided in the hospital with infusions of factor VIII or blood transfusions. f. Prehospital treatment should be comprehensive with attention paid to prolonged bleeding. 4. Von Willebrand’s disease a. Von Willebrand’s disease involves a component of factor VIII being deficient. b. In addition to clotting problems, patients also have abnormal platelet function. c. Signs are typically excessive bleeding, primarily after surgery or injury. d. Prehospital treatment is supportive. e. Aspirin is generally contraindicated. f. Definitive treatment is the administration of von Willebrand's factor. D. Other Hematopoietic Disorders 1. Disseminated intravascular coagulation (DIC) ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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a. DIC is a disorder of coagulation caused by systemic activation of the coagulation cascade. b. Circulating thrombin cleaves fibrinogen to form fibrin clots throughout the circulation. i. This causes widespread thrombosis and, occasionally, end-organ ischemia. ii. Bleeding is the most frequent sign of DIC and is due to the reduced fibrinogen level, consumption of coagulation factors, and thrombocytopenia. c. DIC most commonly results from sepsis, hypotension, obstetric complications, severe tissue injury, brain injury, cancer, and major hemolytic transfusion reactions. d. Prehospital care is symptomatic. i. The patient may be hemodynamically unstable and require IV fluids. ii. Definitive treatment includes the administration of fresh-frozen plasma and platelets. 2. Multiple myeloma a. Multiple myeloma is a cancerous disorder of plasma cells. i. Cancerous cells crowd out healthy cells and lead to a reduction in blood cell production. ii. The patient becomes anemic and prone to infections. b. The first sign is often pain in the back or ribs. c. The resulting anemia leads to fatigue, and reduced platelet production places the patient at risk for bleeding. d. Treatment includes chemotherapy, radiation, and bone marrow transplants. e. Prehospital care is supportive; consider analgesics if pain is severe. 5

VI. Summary A. Hematology is the study of blood and blood-forming organs. B. Hemostasis is the body’s way of preventing or controlling blood loss.

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C. Numerous conditions and diseases affect the hematologic system, with varying and sometimes disastrous outcomes. D. As a paramedic, you must understand hematology because breakdowns in the hematologic system can complicate patient assessment and care. VII. Case Study 5

VIII.You Make the Call 5 IX. Review Questions 5

Class Activities Discuss the case with students now that they are familiar with the chapter. Class Activities Read and discuss the call and questions as a group.

Class Activities Pass out review questions before the lesson starts. Have students answer them. Go over the questions again after the lecture to assess students’ understanding of the information.

MASTER TEACHING NOTES

Detailed Lesson Plan Chapter 10 Infectious Diseases and Sepsis 170–180 Minutes

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Teaching Tips Class Activities Knowledge Application Decision Points

Chapter 10 objectives can be found on text pp. 391–392. These objectives, which form the basis of each chapter, were developed from the current National EMS Education Standards and the accompanying Paramedic Instructional Guidelines.

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Case Study

Master Teaching Notes Teaching Tips Have a student read the scenario. Tell students that the case will be reviewed after the lecture.

II. Introduction A. Infectious diseases are illnesses caused by infestation of the body by biological organisms such as bacteria, viruses, fungi, protozoans, and helminthes (worms). 1. Most infectious disease states are not life threatening, and patients recover completely. B. All health care professionals must maintain a strong working knowledge of public health principles; this is especially true for paramedics, who are often the first to encounter patients with communicable diseases. 1. Early recognition and management of these patients may make a difference in how the patient is treated and may also ensure that care providers take necessary precautions to prevent the spread of the disease to others. III. Public Health Principles A. Paramedics should be alert to specific illness patterns related to infectious diseases. 1. When dealing with infectious diseases, you must consider the impact of the disease process on the community as well as on the infected patient.

Teaching Tips Getting students to practice disease prevention and Standard Precautions is important. It should be practiced with every patient assessment and skill practice throughout the class.

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Content Outline 2. To track the progress of infection within a population, epidemiologists work backward through the chain of infection to determine the index case. 3. To gauge a disease’s potential impact on the community, paramedics must evaluate the host, what they believe to be the infectious agent, and the environment. IV. Public Health Agencies A. Local agencies are the first line of defense in disease surveillance and outbreak. B. At the state level, a designated agency (health department or board of health, for instance) generally monitors infectious diseases and may set policies requiring vaccinations and regulate or implement various control programs. C. A number of federal agencies are involved in tracking the morbidity and mortality of infectious diseases. 1. The U.S. Department of Health and Human Services (DHHS) Centers for Disease Control and Prevention (CDC) is the most visible federal agency. 2. The CDC monitors national disease data and disseminates the information to all health care providers; it sends personnel nationally and internationally to assist with studying, characterizing, and managing serious disease outbreaks and is involved in researching infectious diseases. 3. The National Institute for Occupational Safety and Health (NIOSH), also under the aegis of DHHS, works with the U.S. Department of Labor’s Occupational Safety and Health Administration (OSHA) in setting standards and guidelines for workplace and worker controls to prevent infectious diseases in the workplace. V. Microorganisms A. Most disease-causing organisms are microscopic and are called pathogens. 1. Microorganisms that reside in our bodies without ordinarily causing disease are part of the host defenses known as normal flora. 2. Opportunistic pathogens are ordinarily nonharmful bacteria that

Master Teaching Notes

Knowledge Application Many employers require yearly competencies that include bloodborne pathogens and OSHA requirements. Why do you think it is important to begin good practices now? How will this affect your career?

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cause disease only under unusual circumstances. a. Patients who have a weakened immune system or who are under unusual stress become susceptible to diseases caused by opportunistic organisms. B. Bacteria 1. Bacteria are microscopic single-celled organisms that range in length from 1 to 20 micrometers. 2. Bacteria do not have a distinct nuclear membrane. a. Bacteria that turn purple in Gram stain are Gram-positive, and bacteria that turn red are Gram-negative. 3. Pathogenic bacteria harm their human hosts in a number of ways. a. Indirect damage is caused by releasing toxic chemicals that have localized or systemic effects. i. Exotoxins are poisonous proteins shed by bacteria during bacterial growth. ii. Endotoxins consist of proteins, polysaccharides, and lipids that are shed when the bacterial cell is destroyed. 4. Most bacterial infections respond to treatment with antibiotics that are bactericidal (kill bacteria) or bacteriostatic (inhibit growth or reproduction). a. The more a type of bacterium is exposed to an antibiotic, the greater the likelihood of its developing resistance. 5. Antimicrobial treatment alters the normal flora of the skin, mouth, mucosa, and gastrointestinal tract and often results in colonization of those areas by new microorganisms that resist antibiotics. C. Viruses 1. Viruses are much smaller than bacteria and can be seen only with an electron microscope. a. They cannot reproduce and carry on metabolism by themselves. b. They are obligate intracellular parasites that can only grow ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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and reproduce within a host cell. They resist antibiotic treatment because they hide within a host cell. d. Most viral diseases are mild and self-limiting. e. Once a person’s immune system develops active immunity against a virus, it becomes attuned to similar viruses and will destroy them. D. Other Microorganisms 1. Prions are protein particles that accumulate in nervous system and brain tissue, destroying them and giving them a spongy appearance on gross examination. 2. Fungi are plantlike microorganisms, most of which are not pathogenic. a. Although they may compose a large part of the body’s natural flora, they may become pathogenic in patients with compromised immune function. 3. Protozoa are single-celled parasitic organisms with flexible membranes and the ability to move. a. They are rarely the cause of disease in humans. 4. Pinworms are common in the United States and in other civilized countries. a. These tiny worms (3–10 mm long) live in the distal colon and crawl onto the anal mucosa to lay their eggs, usually when the host is asleep. b. Although the disease is asymptomatic, it is a common cause of anal pruritus and infection and is easily spread among children, especially in day care centers. c. Treatment involves a single dose of antibiotic; all family members must be treated simultaneously to avoid reinfection. 5. Hookworms are found in moist, warm climates. a. The disease is most commonly contracted when a barefoot c.

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child walks in a contaminated area. b. The larvae enter through the skin and migrate to the intestines, where they grip and irritate the intestinal wall and feed on blood. c. Epigastric pain and anemia are possible. d. Prevention involves wearing shoes. e. Treatment is similar to that for pinworms. 6. Trichinosis may be contracted by eating raw or inadequately cooked pork products, most commonly sausage a. Diagnosis is made by finding encrusted worms during examination of muscle biopsy. b. Mebendazole is the antibiotic of choice. 7. Other types of worms, such as tapeworms and flukes, are rarely encountered in the United States. VI. Contraction, Transmission, and Stages of Disease A. Infectious agents may invade hosts through one of two basic mechanisms. 1. The more common is direct transmission is from person to person through a cough, sneeze, kiss, or sexual contact. 2. Indirect transmission can spread organisms in a number of ways and can be transmitted by contact with contaminated surfaces, via food products, water, or even through the soil. a. Bloodborne diseases are transmitted by contact with the blood or body fluids of an infected person. b. Some infectious diseases may be transmitted through the air on droplets expelled during a productive cough or sneeze via the airborne route. c. Some infectious diseases are transmitted orally (primarily by eating) or by the fecal–oral route. 3. In the prehospital setting, the unpredictable environment and behavior of patients increase the risk of exposure. 4. Not all exposures to microorganisms from body fluids or infected patients will result in transmission of those agents.

Master Teaching Notes

Teaching Tips Remind students of the immunology section, and consider how the body responds to activation of the immune system.

Knowledge Application How does mode of transmission and entry affect the paramedic? How can we limit exposure when we are unsure whether the patient is infectious? What additional measures can be taken in the ambulance in the closed environment?

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a. Exposure may result in contamination (agent exists on the surface without entering). b. Penetration of the host implies that infection has occurred, but infection should never be equated with disease. c. Factors that affect the likelihood that an exposed individual will become infected and then actually develop disease include: i. Correct mode of entry ii. Virulence iii. Number of organisms transmitted (dose) iv. Host resistance v. Other host factors, including the tendency of the host to travel or be in contact with other potential hosts, the age and socioeconomic status of the host, and the characteristics of other hosts within the population of which the infected host is a member all affect the likelihood of contracting disease. B. Phases of the Infectious Process 1. Once infected with an infectious agent, the host goes through a latent period when he cannot transmit the agent to someone else. 2. Following the latent period is a communicable period, when the host may exhibit signs of clinical disease and transmit the infectious agent to another host. 3. The time between exposure and presentation is called the incubation period and may range from a few days to months or years. a. Most viruses and bacteria have surface proteins (antigens) that stimulate the body to produce antibodies. i. Seroconversion occurs when a person develops antibodies after exposure to a disease. ii. The time between exposure and seroconversion is called the window phase. 4. The disease period is the duration from the onset of signs and ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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symptoms until the resolution of the symptoms or death occurs.

VII. The Body’s Defenses Against Disease A. The Immune System 1. The immune system fights disease by protecting the body from foreign invaders. 2. It must be able to differentiate self from “nonself.” a. Once it identifies a material as nonself, it starts a series of actions to eliminate the foreign material. b. This series of mechanisms is initiated by the inflammatory response, which results from local tissue injury. 3. Cell-mediated immunity does not result in the formation of antibodies a. It generates various forms of T lymphocytes that react against specific antigens. 4. Humoral immunity results in the formation of antibodies. a. B lymphocytes are antibodies formed in the lymph nodes and bone marrow. b. Humoral immunity can result in autoimmunity, which causes the body to form antibodies against itself. B. The Complement System 1. The complement system provides an alternative pathway to react quickly to foreign bodies, 2. It responds by recognizing surface endotoxins from Gram-negative bacteria, C. The Lymphatic System 1. The lymphatic system is a secondary circulatory system that compromises the spleen, thymus, lymph nodes, and lymphatic ducts. a. It collects overflow fluid from the tissue spaces and returns it to the circulation after filtering it through the lymph nodes.

Teaching Tips Review the immune system and its components.

Class Activities Have students describe the differences in immunity and how the body prevents antigens from attacking the body.

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The leftovers, cell fragments and amino acids, are returned to the circulatory system to be used in cellular metabolism. 2. The spleen is an essential lymphatic organ. a. B and T lymphocytes are generated in the white pulp, and the red pulp removes unwanted particulate matter such as old or damaged red blood cells (RBCs). D. Individual Host Immunity 1. An individual is said to have acquired passive immunity if he has received antibodies from the maternal circulation or from inoculation. 2. Active immunity is humoral immunity and generally lasts for years or the lifetime of the individual. VIII. Infection Control in Prehospital Care A. Preparation for Response 1. Establish and maintain written standard operating procedures (SOPs) for infection control, and monitor employee compliance. 2. Prepare an infection control plan that includes a schedule of when and how to implement OSHA. NIOSH, and CDC pathogen standards and guidelines. 3. Provide adequate original and ongoing infection control training to all personnel, including engineering and work practice controls. 4. Ensure that all employees are provided with personal protective equipment (PPE) and that it is fitted appropriately, checked regularly, maintained properly, and can be easily located. 5. Ensure that all EMS personnel treat and bandage all personnel wounds before any emergency response. 6. Use disposable supplies and equipment when possible. 7. Ensure that all EMS personnel have access to the facilities and supplies needed to maintain a high level of personal hygiene. 8. Do not allow EMS personnel to deliver patient care if they exhibit signs or symptoms of an infectious disease. 9. Monitor all EMS personnel for compliance with vaccinations and

Master Teaching Notes

Knowledge Application What is your school’s exposure plan and where is it located? Do you know what to do if you are exposed during your education? Is this adequate, or do students think changes need to be made?

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appropriate diagnostic tests. 10. Appointed a designated infectious disease control officer (IDCO) to serve as a contact person for personnel exposed to an infectious disease and monitor the infection control program. 11. Identify specific job classifications and work processes in which the possibility of exposure exists. 12. Provide hazmat education for employees, including how to locate and interpret safety data sheets (SDS) regarding chemicals or chemical mixtures with information on the associated health hazards. B. Response 1. When responding to an EMS call, take the following control measures: a. Obtain as much information as possible from dispatch regarding the nature of the patient’s illness or injury. b. Prepare for patient contact. Put on gloves and don eye and face protection before contact when practical. c. Prepare mentally for the call. Think infection control! C. Patient Contact 1. Your contact with a patient, especially at an emergency scene, poses the highest risk for acquiring an infectious disease. a. Isolate all body substances and avoid contact with them. b. Take Standard Precautions. Wear appropriate PPE. c. Allow only necessary personnel to make patient contact. d. Use airway adjuncts such as a pocket mask or bag-valvemask unit to minimize exposure. e. Properly dispose of biohazardous waste. f. Use extreme caution with sharp instruments. g. Dispose of all contaminated sharps in properly labeled puncture-resistant containers. h. Never smoke, eat, or drink in the patient compartment of the ambulance. i. Do not apply cosmetics or lip balm, or handle contact lenses, ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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when a likelihood of exposure exists 2. Standard Precautions a. All healthcare workers should routinely use appropriate barrier precautions to prevent exposure of the skin and mucous membranes to any contact with blood, or other bodily fluids, from any patient. b. Wash your hands and other skin surfaces thoroughly with soap and warm water after removal of gloves, especially after contamination with blood and other bodily fluids. c. Take precautions to prevent injuries caused by needles, scalpels, or other sharp instruments or devices when performing procedures, cleaning instruments, or disposing of instruments. d. Use mouthpieces with one-way valves or filters, bag-valve mask devices, and other ventilation devices to avoid mouthto-mouth contact. e. Do not put gloved hands close to your mouth, and avoid wiping your forearms or the backs of your gloved hands. Use clean towels to deal with perspiration. f. If you have exudative or weeping skin lesions, refrain from direct patient care and from handling patient care equipment until the condition resolves. g. Pregnant health care workers should be especially familiar with, and strictly adhere to, precautions to minimize the risk of HIV transmission. h. Disinfection of diagnostic or therapeutic equipment and supplies is mandatory. 3. Enhanced Precautions a. The occurrence of Ebola virus disease (EVD) in 2014 in the United States resulted in the CDC issuing recommendations for enhanced protection of EMS personnel when exposure to EVD or a similar highly contagious disease was possible. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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Patient assessment Safety and PPE Patient management Prehospital care considerations Additional considerations

D. Recovery 1. Infection control does not end when you deliver the patient to the emergency department. a. Wash hands immediately after patient contact. b. If you sustain a wound and are exposed, vigorously wash the wound with soap and warm water. c. Dispose of all biohazardous waste in accordance with local laws and regulations. d. Place potentially infectious waste in leak-proof biohazard bags. e. Decontaminate all contaminated clothing and reusable equipment. f. Handle uniforms in accordance with the agency’s standard procedures for personal protective equipment. 2. Decontamination methods and procedures a. Decontaminate according to protocol and SOPs. i. Low-level disinfection destroys most bacteria and some viruses and fungi. ii. Intermediate level destroys Mycobacterium tuberculosis and most viruses and fungi. iii. High level destroys all forms of microorganisms except certain bacterial spores. iv. Sterilization destroys all microorganisms and is required for all contaminated invasive instruments. E. Infectious Disease Exposures 1. Immediately report exposures of EMS personnel to the designated IDCO, according to local protocol. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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a. This permits immediate medical follow-up, including counseling for the EMS provider and identification of the infectious agent b. Employers are required to provide medical evaluation and treatment for any provider exposed to an infectious disease 2. The Ryan White Act is a federal law, originally passed in 1990, that outlines the rights and responsibilities of agencies and health care workers when an infectious disease exposure occurs. 3. Employers are required to provide a medical evaluation and treatment for any paramedic or other EMS provider who has been exposed to an infectious disease. a. After a paramedic has been exposed to an infectious disease, he has the option to submit a blood sample for baseline testing. 4. The IDCO will maintain records of all exposures as required by law. IX. Assessment of the Patient with Infectious Disease A. When assessing a patient, always maintain a high index of suspicion that an infectious agent may be involved. B. Past Medical History(PMH) 1. PMH may provide valuable clues to the patient’s illness. 2. Conditions that increase the risk for developing infectious diseases include AIDS, diabetes, alcoholism, malnutrition, IV drug abuse, malignancy, splenectomy, and artificial heart valves or joints. 3. Thoroughly investigate the patient’s chief complaint and any history of the present illness. C. The Physical Examination 1. Physical examination of the patient who is suspected of having an infectious disease follows the standard format for assessing a medical patient. a. Skin for temperature, hydration, color, or rash b. Sclera (white of eye) for icterus c. Reaction to neck flexion

Master Teaching Notes

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Lymph nodes for swelling or tenderness Breath sounds Hepatomegaly Purulent lesions

X. Specific Infectious Diseases A. Diseases of Immediate Concern to EMS Providers 1. Human immunodeficiency virus/AIDS a. AIDS poses a significantly lower occupational risk to health care workers in developed countries than other infectious agents. b. HIV specifically targets T lymphocytes with the CD4 marker. c. AIDS can now be treated, and patients can be expected to live a relatively normal life and have a relatively normal life span. d. HIV is transmitted through contact with blood, blood products, and body fluids. i. Persons most at risk for HIV exposure in the United States are men who have sex with men, African Americans, and urban dwellers. ii. Infection of health care workers is exceedingly rare. iii. Accidental needle sticks are the most frequent source of infection. e. The AIDS patient may first develop a mononucleosis-like syndrome with nonspecific signs such as fatigue, fever, sore throat, fatigue, lymphadenopathy, splenomegaly, rash, and diarrhea. f. Many patients develop Kaposi’s sarcoma. g. As the disease progresses, it involves the central nervous system. h. Dementia, psychosis, encephalopathy, and peripheral neurologic disorders may develop.

Master Teaching Notes

Decision Points Although many of these diseases are not immediately life threatening, they can cause longterm issues for patients and providers. How does this affect how you treat these patients? How should you approach not only these patients but also all patients?

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i. j.

There is no cure or vaccine for AIDS. After exposure to a confirmed HIV patient, the health care worker should seek immediate evaluation and postexposure therapy. 2. Hepatitis a. Hepatitis is an inflammation of the liver caused by viruses, bacteria, fungi, parasites, excessive alcohol consumption, or medications. b. Signs and symptoms include headache, fever, weakness, joint pain, anorexia, nausea and vomiting, and right upper quadrant abdominal pain. i. As it progresses the patient may become jaundiced. c. Hepatitis A is transmitted by the fecal–oral route and has an incubation period of 15–30 days. d. Hepatitis B is transmitted through direct contact with contaminated body fluids and therefore presents a substantial risk to EMS providers. i. The effectiveness of the vaccination is 90%. ii. The incubation period is 8–24 weeks. iii. Joint pain and rash are more common with hepatitis B infection than with other types of hepatitis. e. Hepatitis C is transmitted primarily by IV drug abuse and sexual contact and causes liver fibrosis that progresses to cirrhosis. f. Hepatitis D infection seems to exist only with a coexisting HBV infection; cases in health care workers are extremely rare. No vaccine exists for hepatitis D. g. Hepatitis E is transmitted like hepatitis A and seems to be associated with contaminated drinking water 3. Tuberculosis (TB) a. TB is the most common preventable adult infectious disease in the world. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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b. It primarily affects the respiratory system, including a highly contagious form in the larynx. c. It is commonly transmitted through airborne respiratory droplets but may also be contracted through direct inoculation through mucous membranes and broken skin or by drinking contaminated milk. i. Coughing and other expiratory actions create bacteria-containing droplets, which susceptible individuals inhale into the alveoli. ii. Purified protein derivative (PPD) skin tests identify candidates for prophylactic drug therapy in health care workers. d. TB’s incubation period is 4 to 12 weeks, and development of the disease usually occurs in the 6 to 12 months after infection. i. If the macrophages in the lungs do not destroy them, they lie dormant and are distributed throughout the body until depression of the immune system triggers their reactivation. e. Signs and symptoms can be nonspecific i. Chills ii. Fever iii. Fatigue iv. Productive or nonproductive cough v. Weight loss vi. Night sweats vii. Hemoptysis f. Protecting yourself from TB is the most important step in preventing the disease. g. Place a mask on a patient who is suspected of having TB when it does not create dyspnea. h. Nebulized medications may be administered more safely ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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with a nebulization mask. Use appropriate respiratory precautions while performing CPR and intubation. j. Don a protective respirator. k. Masks effectively prevent the transmission of many airborne pathogens, especially when both provider and patient wear them. l. Early identification of exposure and drug prophylaxis, if deemed necessary, is the key to effective prevention in health care workers. 4. Pneumonia a. Pneumonia, an acute lung inflammation, is not a single disease but a family of diseases resulting from respiratory infection by viruses, bacteria, or fungi. b. Those at highest risk are immunocompromised patients. c. Signs and symptoms in previously healthy individuals include i. Chills ii. High-grade fever iii. Dyspnea iv. Pleuritic chest pain worsened by deep inspiration v. Productive cough vi. Adventitious breath sounds d. The absence of fever does not rule out pneumonia. e. Management is aimed at supporting adequate ventilation and oxygenation. f. Routine vaccination for EMS workers is not necessary. 5. Severe acute respiratory syndrome (SARS) a. SARS is a viral respiratory illness caused by the SARSassociated coronavirus. i. Coronaviruses may survive in the environment for several days and are spread by close person-toperson contact. i.

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b. Incubation is generally 2–7 days but can be as long as 10– 14 days. c. If a SARS outbreak has been identified, all personnel should use appropriate personal protective equipment (PPE) on every call or as directed by local authorities. d. Signs and symptoms include sore throat, rhinorrhea, chills, rigors, myalgias, headache, and diarrhea. e. Any patient who is suspected of having SARS should be treated as any patient with suspected pneumonia or other respiratory illness. 6. Middle East respiratory syndrome a. This syndrome is caused by the Middle East respiratory syndrome coronavirus (MERS-CoV), which is similar to the SARS virus. b. It primarily affects the respiratory system, has a fatality rate that ranges from 30% to 40%, and has affected persons from 1 to 99 years of age. c. The incubation period is usually 5– 6 days but can range from 2 days to 2 weeks. d. Clinical findings include fever, cough, and shortness of breath. e. Some patients report nausea, vomiting, and diarrhea. f. Most related deaths are caused by pneumonia and acute renal failure. 7. Ebola virus disease (EVD) a. EVD is a disease of humans and other primates that is caused by the Ebolavirus, of which there are four types. b. EVD is transmitted between people via direct contact through broken skin and mucous membranes of blood or other body fluids (saliva, mucus, vomit, feces, sweat, tears, urine, semen, and breast milk) of a person who is infected with the virus. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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c. EVD can also be found in fruit bats and in other primates such as gorillas, monkeys, and chimpanzees. d. Signs and symptoms vary somewhat, depending on the stage of infection, and include: i. Fever ii. Severe headache iii. Loss of appetite iv. Joint and muscle pain v. Weaknesses vi. Fatigue vii. Vomiting viii. Diarrhea ix. Abdominal pain x. Unexplained hemorrhage e. Any patient with signs or symptoms that are suggestive of EVD should be approached with extreme caution. f. Recovery from EVD depends on several factors, including the quality of supportive care that incorporates hydration, maintenance of oxygen saturation and blood pressure, and the treatment of concomitant infections. g. The patient’s immune system is also a factor in recovery from EVD. 8. Zika virus a. Zika virus disease (ZVD) is caused by the Zika virus. b. Signs and symptoms include fever, rash, joint pain, headache, and conjunctivitis. c. The illness is mild and usually lasts several days to a week. d. Many people (80%) who contract the disease remain asymptomatic. e. Deaths are rare, and no specific treatment is available. f. Maternal–fetal transmission of the disease has been associated with some birth defects (e.g., microcephaly) and ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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fetal deaths. g. There has been a reported association between ZVD and Guillain-Barré syndrome. 9. Chikungunya disease a. Chikungunya disease is caused by the Chikungunya virus and is spread by the Aedes species of mosquitoes. b. Symptoms usually begin 3–7 days after being bitten by an infected mosquito. c. The most common signs and symptoms are fever and joint pain. d. Many suffer headaches, muscle pain, joint swelling and/or rash. e. It is more severe in newborns and older adults as well as those who have hypertension, diabetes, or heart disease. f. There is no specific treatment, and most patients recover uneventfully. 10. Chickenpox (varicella) a. Chickenpox is caused by the varicella zoster virus (VZV). b. Chickenpox usually occurs in clusters during winter and spring and presents with respiratory symptoms, malaise, low-grade fever, and a rash that starts on the face and trunk and progresses to the rest of the body. c. The incubation period is 10–21 days, d. Most people develop lifelong immunity after recovery from childhood chickenpox infections. e. Observe Standard Precautions, and place masks on all patients. i. A patient with chickenpox should remain isolated or home until lesions are crusted and dry. 11. Meningitis a. Meningitis is an inflammation of the meninges and cerebrospinal fluid (CSF) caused by bacterial and viral ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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infections. b. Vaccines have proven very effective, especially in children. c. Neisseria meningitis asymptomatically colonizes the upper respiratory tract of healthy individuals and is then transmitted by droplets. i. Almost every human has been a carrier at some point in his life. d. The disease peaks at midwinter months with low temperature and humidity. e. Incubation period ranges from 2 to 4 days but may last as long as 10 days. f. Signs and symptoms develop rapidly and include fever, chills, headache, nuchal rigidity with flexion, arthralgia, lethargy, malaise, altered mental status, vomiting, and seizures. i. A characteristic rash may appear and develop into petechiae. ii. Newborns or infants may seem slow or inactive, vomit, appear irritable, or feed poorly. g. The meningococcal vaccine is not currently recommended for routine immunization of healthcare workers. h. Travelers to endemic areas and children younger than 2 years old and who are asplenic or have a certain deficiency in their complement system are candidates for vaccination. i. Observing Standard Precautions and using a mask on yourself and/or your patients with suspected meningococcal meningitis will adequately protect you against all the infectious agents of meningitis. Other job-related airborne diseases a. Influenza, the common cold, measles, mumps, rubella, respiratory syncytial virus (RSV), and pertussis are viral infections that may be contracted in the EMS environment.

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These diseases are transmitted by direct inhalation of infected droplets or through exposed mucosal surfaces. ii. Effective, vigorous hand washing with soap and warm water after patient contact is the most important personal precaution against disease transmission. b. Influenza is the leading cause of respiratory disease and is characterized by the sudden onset of fever, chills, malaise, muscle aches, nasal discharge, and cough and is most serious in the very young or old. i. Management is primarily supportive. c. The common cold or viral rhinitis has over 100 serotypes, and its course is mild, often without fever and generally without muscle aching. i. It is often difficult to differentiate from influenza and management is supportive. d. Most avian influenza viruses do not infect humans except in cases of prolonged contact. i. The reported symptoms in humans have ranged from typical influenza-like symptoms to eye infections, pneumonia, acute respiratory distress, viral pneumonia, and other severe and lifethreatening complications. e. Measles is a systemic disease that is highly communicable; immunity is lifelong following transmission. i. Symptoms present like a severe cold with fever, conjunctivitis, swelling of the eyelids, photophobia, malaise, cough, and nasopharyngeal congestion. ii. In otherwise healthy children or adults, uncomplicated measles has a very low mortality rate. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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iii.

Potential complications include pneumonia, eye damage, and myocarditis. iv. Unimmunized or previously unexposed paramedics should mask their measles patients and be vigilant about handling linens and touching their face during and after the call. v. Postexposure handwashing is critical. f. Mumps is a virus transmitted through respiratory droplets and saliva of infected patients, and is characterized by painful enlargement of the salivary glands. i. Most cases resolve spontaneously within one week without intervention. g. Rubella is a systemic viral disease transmitted by inhalation of infected droplets, and is characterized by sore throat and low-grade fever accompanied by a fine pink rash on the face, trunk, and extremities. i. There is no specific treatment. ii. It is devastating to a developing fetus. iii. The vaccine is combined with that for measles, mumps, and rubella. h. Respiratory syncytial virus (RSV) is a common cause of pneumonia and bronchiolitis in infants and young children and is associated with outbreaks of lower respiratory infections from November to April. i. It commonly begins as an upper respiratory infection and may be misdiagnosed as a simple cold. ii. Children with RSV will initially develop a runny nose and nasal congestion that later spreads to lower airway involvement, as evidenced by wheezing, tachypnea, and respiratory distress. iii. High-risk patients are treated with the antiviral agent ribavirin. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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13.

Pertussis (whooping cough) affects the oropharynx after an incubation period of 6–20 days. i. It begins with symptoms similar to those of a common cold lasting 1–2 weeks. ii. The patient develops a mild cough that quickly develops into a severe and violent cough followed by deep, high-pitched inspiration. iii. The cough often produces large amounts of thick mucus. iv. EMS treatment will typically be oxygen administration and supportive care; however, anticipate airway management, and remember that these patients are highly contagious a)Transmission occurs via respiratory secretions or in an aerosolized form. b)Mask the patient, and observe Standard Precautions, including postexposure hand washing. Viral diseases transmitted by contact a. Mononucleosis is caused by the Epstein-Barr virus (EBV) and affects the oropharynx, tonsils, and reticuloendothelial system. i. After a 4- to 6-week incubation period, fatigue, sore throat, oral discharges, and enlarged, tender lymph nodes are common. ii. Treatment is typically supportive, and corticosteroids have been shown to reduce tonsillar swelling. b. Herpes simplex virus type 1 is transmitted by saliva and infects the oropharynx, face, lips, skin, fingers, and toes. i. After 2–2 days of incubation, fluid-filled vesicles develop in the oral cavity, and fever and malaise follow.

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ii.

Standard Precautions, primarily gloves, are essential. iii. Treatment is supportive and may include acyclovir. B. Other Infectious Conditions of the Respiratory System 1. Epiglottitis a. Epiglottitis is an inflammation of the epiglottis and may also involve the areas just above and below. b. It is caused by Haemophilus influenzae and has an abrupt onset without any history of upper respiratory disease. c. Patients present with one or more of the following: drooling, dysphonia, dysphagia, or distress. 2. Croup is a common cause of acute upper airway obstruction in children and is a viral illness characterized by inspiratory and expiratory stridor and a seal-bark-like cough. a. The child commonly awakens with acute respiratory distress, tachypnea, and retractions. b. Total airway obstruction is rare. 3. Pharyngitis is a common infection of the pharynx and tonsils and may be caused by a bacteria or virus. a. It is characterized by sudden-onset fever and sore throat. b. Antibiotics are an effective treatment. 4. Sinusitis is an inflammation of the paranasal sinuses and occurs when mucus and pus cannot drain and become trapped in the sinus. a. It is usually preceded by a viral upper respiratory infection or exposure to allergens causing nasal congestion. b. Management includes corticosteroids, decongestants, and supportive care. c. Apply a heat pack directly over the affected sinus to relieve pain and facilitate drainage. 5. Hantavirus is a family of viruses carried by rodents such as the deer mouse, and most cases occur in the southwestern United States, particularly in the Four Corners region. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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a. Transmission is primarily by inhalation of aerosols created by stirring up the dried urine, saliva, and fecal droppings of these rodents. b. Initial symptoms are fatigue, fever, and muscle aches, especially of large muscle groups. c. Headache, nausea, vomiting, diarrhea, and abdominal pain are also common, whereas sore throat and rash are uncommon. d. After 4–10 days, pulmonary edema occurs and can progress to myocardial depression. e. The only specific treatment is intensive supportive care, and no immunization is available. C. GI System Infections 1. Gastroenteritis a. Gastroenteritis is manifested by nausea, vomiting, GI cramping or discomfort, anorexia, and diarrhea. b. In otherwise healthy persons, gastroenteritis is generally self-limiting and benign but can be fatal in the very young or old and those who have preexisting disease. c. Prolonged vomiting and/or diarrhea may result in dehydration and electrolyte disturbances. d. Consider IV fluids and antiemetics. e. Comply with Standard Precautions and hand washing to avoid exposure. 2. Food poisoning a. Food poisoning is a nonspecific term that is often applied to gastroenteritis. b. It occurs suddenly and is caused by eating. c. It is characterized by diarrhea, vomiting, and GI discomfort. d. Most cases are caused by bacteria and their toxic products. e. In the majority of cases, only the GI system is affected. f. Initiate standard ALS protocols, including assessment of ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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airway and ventilator status, oxygenation, initiation of IV, and cardiac monitoring. g. Fluid resuscitation is often required. h. Consider antiemetics for severe vomiting or diarrhea. i. Constant reassessment of ventilator status is essential. j. Observe Standard Precautions. k. No immunization against these agents or their toxins exists. D. Nervous System Infections 1. Encephalitis a. Encephalitis is an inflammation caused by infection of the brain and its structures, usually by viruses. b. Clinical presentation is similar to that of meningitis, as they often coexist. c. Signs and symptoms include decreased level of consciousness, fever, headache, drowsiness, coma, tremors, and a stiff neck and back. d. Seizures may occur in patients of all ages but are most common in infants. e. Treatment is difficult, even when the virus is known. f. Despite the severity of illness, many patients suffer no longterm neurologic deficits. 2. Rabies a. Rabies is transmitted by the rabies virus and affects the nervous system. b. Humans are especially susceptible when bitten by an infected animal. c. The highly variable incubation period is usually 3–8 weeks but can be as short as 9 days (rare) or as long as 10 years i. It is believed to be dependent on the bite site, bites to the head and neck generally being followed by shorter incubation periods. d. Rabies is characterized by a nonspecific prodrome of ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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malaise, headache, fever, chills, sore throat, myalgias, anorexia, nausea, vomiting, and diarrhea. e. The encephalitic phase begins with periods of excessive motor activity, excitation, and agitation, which is followed by confusion, hallucinations, combativeness, bizarre aberrations of thought, muscle twitches and tetany, and seizures. f. Inspect the site of the wound for a bite pattern and the presence of saliva, and then rinse the wound with copious amounts of normal saline to remove saliva and blood. i. Do not bandage the wound, but allow it to drain freely during transport. 3. Tetanus a. Tetanus is an acute bacterial infection of the CNS. b. The incubation period is variable (usually 3–21 days, sometimes from 1 day to several months) and depends on the wound’s severity and location. i. Generally, a shorter incubation period leads to a more severe illness. c. Localized symptoms include rigidity of muscles in close proximity to the injury site. Subsequent generalized symptoms of pain and stiffness in the jaw muscles may progress to muscle spasm and rigidity of the entire body. d. EMS responders will rarely encounter this disease, much less recognize its signs and symptoms until they are advanced to the point of tetany. e. Immunizations, which generally begin in childhood, include boosters before entering elementary school and every ten years thereafter. f. Standard Precautions should provide adequate protection. 4. Lyme disease a. Lyme disease is a recurrent inflammatory disorder accompanied by skin lesions, polyarthritis, and involvement ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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of the heart and nervous system. b. The EMS response to Lyme disease will probably be to treat its clinical consequences, especially those of the disseminated and late stages. c. Adhere to Standard Precautions. E. Sexually Transmitted Diseases 1. Gonorrhea is caused by Neisseria gonorrhoeae, a Gram-negative bacterium, and presents with painful urination and a purulent urethral discharge. It commonly leads to pelvic inflammatory disease. 2. Syphilis is caused by a spirochete and is characterized by lesions that may involve any organ or tissue. 3. Genital warts are caused by the human papillomavirus (HPV) and appear as cauliflower-like fleshy growths on the penis, anus, and mucosa of the anal canal. In women, they appear on the labial surfaces. 4. Herpes simplex virus type 2 presents as lesions on the penis, rectum, anus, and mouth of the male, depending on sexual activity. a. Females are sometimes asymptomatic but can display lesions on the vagina, vulva, perineum, rectum, mouth, and cervix. 5. Chlamydia is a genus of intracellular parasites similar to Gramnegative bacteria and presents much like gonorrhea. 6. Trichomoniasis is a common cause of vaginitis and causes a greenish-yellow discharge, irritation of the perineum and thighs, and dysuria. 7. Chancroid is a highly contagious ulcer that appears on the penis, anus, urethra, or vulva and can spread to other sites such as breasts, fingers, and thighs. F. Diseases of the Skin 1. Impetigo is a very contagious infection of the skin that begins as a single vesicle that ruptures and forms a thick, honey-colored crust with a yellowish-red center. Lesions most commonly occur on the ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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Content Outline extremities and joints. 2. Lice are a parasitic infestation of the skin, scalp, trunk, or pubic area that causes severe itching. a. Treatment is through several nonprescription agents. 3. Scabies is caused by infestation of a mite that is barely visible without magnification, and causes intense itching, usually at night. 4. Bed bugs are small, flat, parasitic insects that feed solely on the blood of people and animals while they sleep. G. Nosocomial Infections 1. Especially virulent strains of microorganisms may cause nosocomial (hospital-acquired) diseases. 2. VRE and MRSA have become especially alarming. a. Both organisms rapidly colonize patients in whom broadspectrum antibiotics have eliminated normal flora. XI. Patient Education A. Prevention is without question the most effective intervention in preventing transmission of infectious diseases. B. The key to effective prevention is education; however, because these diseases are less “glamorous” than other illnesses, attracting public attention is difficult. C. Many of the diseases covered in this chapter are not emergencies and may not require emergency treatment. XII. Preventing Disease Transmission A. Preventing or limiting exposure to infectious or communicable diseases cannot be overemphasized. B. Do not go to work if you: 1. Have diarrhea. 2. Have a draining wound or wet lesion. 3. Are jaundiced. 4. Have mononucleosis. 5. Have been exposed to lice or scabies and have not been treated. 6. Have strep throat and have not been taking antibiotics for at least 24

Master Teaching Notes

Class Activities The class should be familiar with all personal protective equipment and how to don it appropriately. Have the class use the proper precautions for every practice and assessment.

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Content Outline hours. 7. Have a cold. C. Keep MMR, hepatitis A, hepatitis B, DPT, polio, chickenpox, influenza, and rabies vaccinations current. D. Always approach the scene cautiously, with a high index of suspicion. E. Use Standard Precautions. F. Wear personal protective equipment. G. After a call, wash your hands first. H. Decontaminate your equipment, and disinfect your equipment and the interior of the ambulance. XIII. Sepsis/Systemic Inflammatory Response Syndrome (SIRS) A. Sepsis is the tenth most common cause of death in the world and the most common cause of death in debilitated patients in hospital intensive care units. 1. Septicemia is a life-threatening medical condition caused by a wholebody inflammatory state called systemic inflammatory response (SIRS). a. The original site of infection can be anywhere in the body, and the infection usually spreads to the vascular system or other sterile areas. b. Sepsis can also result from medical interventions and devices, including IV lines, surgical wounds and drains, decubitus ulcers, urinary catheters, and others. 2. Sepsis a. The diagnosis is made when the patient has an infection and at least two of the following signs and symptoms: i. Heart rate > 90 beats per minute ii. Abnormal body temperature (>100.4°F [>38.°C] or <96.8°F [<36°C]) iii. Tachypnea (>20 breaths/minute or a PaCO2 < 32 mmHg) iv. Abnormal white blood cell count (<4,000 or >12,000

Master Teaching Notes

Knowledge Application Sepsis kills many patients after we have corrected the original problem. How can we diminish the incidence of sepsis? Are there things we can do to help prevent sepsis?

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cells/microliter) on a complete blood count (CBC) 3. Severe sepsis a. Severe sepsis includes the presence of sepsis and evidence of hypoperfusion: i. Mottled skin ii. Delayed capillary refill (>3 seconds) iii. Decreased urine output (<0.5 mL/kg/hr) iv. Lactate > 1 mmol/L v. Altered mental status vi. Abnormal findings in EEG vii. Platelet count < 100,000 cells/mL viii. Disseminated intravascular coagulation (DIC) ix. Acute lung injury or acute respiratory distress syndrome (ARDS) x. Cardiac dysfunction, shown on echocardiography or direct measurement of cardiac output 4. Septic shock a. Septic shock is defined as severe sepsis associated with one or both of the following conditions: i. Mean systemic blood pressure below 60 mmHg (or less than 80 mmHg if the patient has known hypertension) ii. The maintenance of mean arterial pressure above 60 mmHg (or greater than 80 mmHg, if there is prior history of hypertension) requires vasopressor therapy. 5. Management a. Early recognition and aggressive treatment for sepsis is necessary for the best outcome. b. Supplemental oxygen (if the patient is hypoxic) with or without intubation and mechanical ventilation. c. Fluid resuscitation ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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d. Maintenance of blood pressure > 90 mmHg with vasopressors e. Administration of broad spectrum antibiotics 5

XIV. Summary A. EMS can have a significant impact on the incidence of infectious disease if providers remain knowledgeable, are leaders in public education, and are considerably alert in protecting themselves and their patients. B. EMS personnel deal with few infectious disease emergencies; however, when we do respond to such emergencies, we are often unaware of the disease’s presence until after the call. Constant vigilance and personal accountability are the keys to reducing these risks. XV. Case Study

XVI.

You Make the Call

XVII.

Review Questions

Class Activities Discuss the case with students now that they are familiar with the chapter. Class Activities Read and discuss the call and questions as a group.

Class Activities Pass out review questions before the lesson starts. Have students answer them. Go over the questions again after the lecture to assess students’ understanding of the information.

MASTER TEACHING NOTES

Detailed Lesson Plan Chapter 11 Psychiatric and Behavioral Disorders 120–130 Minutes

    

Teaching Tips Critical Thinking Questions Class Activities Knowledge Application Decision Points

Chapter 11 objectives can be found on text pp. 444–445. These objectives, which form the basis of each chapter, were developed from the current National EMS Education Standards and the accompanying Paramedic Instructional Guidelines.

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Content Outline I.

Case Study

Master Teaching Notes Teaching Tips Have a student read the scenario. Tell students that the case will be reviewed after the lecture.

II. Introduction A. Behavioral and psychological emergencies are not as clear cut as the many topics discussed thus far that have had objective diagnostic criteria. 1. The assessment of behavioral and psychiatric conditions will rely on your people skills. 2. You evaluate the psychiatric patient by observing his behavior, by gathering information from his family and bystanders, and by interviewing him. 3. Your care consists of support, calming reassurance, and occasionally patient restraint. 4. Your care requires interpersonal skills more than diagnostic equipment.

Teaching Tips Behavioral emergencies are some of the situations EMS personnel face that are very unpredictable. It is important to stress the importance of safety when dealing with these and all patients.

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III. Behavioral Emergencies A. Behavior is a person’s observable conduct and activity. 1. A behavioral emergency is a situation in which a patient’s behavior becomes so unusual, bizarre, threatening, or dangerous that it alarms the patient or another person and requires the intervention of emergency service and/or mental health personnel. 2. Differentiation between normal and abnormal behavior is largely subjective. a. Objective factors that may indicate a behavioral or psychological condition include actions or situations that: i. Interfere with core life functions. ii. Pose a threat to the life or well-being of the patient or others. iii. Significantly deviate from society’s expectations or norms.

Knowledge Application

IV. Pathophysiology of Psychiatric Disorders A. Biological 1. Biological factors result from disease processes such as infections and tumors or structural changes in the brain. a. Never assume a patient with an altered mental status or unusual behavior is suffering a purely psychological condition or disease until you have completely ruled out medical conditions and substance abuse. B. Psychosocial 1. Psychosocial conditions are related to a patient’s personality style, dynamics of unresolved conflict, or crisis management methods. 2. Environment plays a large part in psychosocial development. a. Traumatic childhood incidents b. Parents or other persons in position of authority c. Dysfunctional families d. Abusive parents e. Alcohol or drug abuse by parents f. Neglect

Critical Thinking Questions

Because behavior is subjective, patients may be acting abnormally but feel that their actions are completely normal. How does this affect the way you approach your behavioral patient?

Sometimes it is impossible to rule out medical issues with our patients. How do behavioral situations alter our decisions regarding transport and refusal or transport and destination? What are some tools to help with our evaluation?

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Content Outline C. Sociocultural 1. Sociocultural causes of behavioral disorders are related to the patient’s actions and interactions within society and to factors such as socioeconomic status, social habits, and values. a. They are usually attributable to events that change the patient’s social space, social isolation, or otherwise have an impact on socialization. V. Assessment of Behavioral Emergency Patients A. Scene Size-Up 1. As with any call, determining scene safety is of the utmost importance. a. If the situation warrants EMS, it is most likely significant enough to also warrant law enforcement. 2. The scene size-up also includes making observations that relate to patient care, such as evidence of substance use or abuse or therapeutic medications that may indicate an underlying medical problem, and signs of violence or property destruction. B. Primary Assessment 1. Because many behavioral emergencies are caused by or concurrent with medical conditions, you should be acutely suspicious of lifethreatening emergencies. 2. Be cautious of any overt behavior such as posture or hand gestures. 3. Note any emotional response such as rage, fear, anxiety, confusion, or anger. 4. Control the scene as soon as possible. 5. Remove anyone who agitates the patient or adds confusion to the scene. 6. Observe the patient’s affect in greater detail. 7. Stay alert for signs of aggression. C. Secondary Assessment 1. Your examination of a patient who is experiencing a behavioral emergency is largely conversational.

Master Teaching Notes

Teaching Tips Safety should be stressed, and these types of patients should be integrated into patient assessment practice.

Class Activities Listening is an important skill in the assessment and management of behavioral patients. Have students practice evaluating psychological patients and encourage them to pay special attention to their listening skills and providing reassurance.

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2. Remove the patient from the crisis area, and limit interruptions. 3. Focus your questioning and assessment on the immediate problem. 4. Follow these guidelines: a. Listen. b. Spend time, don’t rush. c. Be assured. d. Do not threaten. e. Do not fear silence. f. Place yourself at the patient’s level. g. Keep a safe and proper distance. h. Appear comfortable. i. Avoid appearing judgmental. j. Never lie to the patient. D. Mental Status Examination(MSE) 1. General appearance 2. Behavioral observations 3. Orientation 4. Memory 5. Sensorium 6. Perceptual processes 7. Mood and affect 8. Intelligence 9. Thought processes 10. Insight 11. Judgment 12. Psychomotor E. Psychiatric Medications 1. The patient’s use of psychiatric medications can provide clues to the underlying condition. 2. If a patient is not compliant, the condition may deteriorate.

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Content Outline VI. Specific Psychiatric Disorders A. Almost all psychiatric disorders have at least two diagnostic elements: symptoms of the disease or disorder and indications that the disease has impaired major life function. B. Cognitive Disorders 1. Psychiatric disorders with an organic cause, such as brain injury or disease, are known as cognitive disorders. a. Delirium is characterized by a relatively rapid onset of widespread disorganized thought and may be reversible. i. Confusion is a hallmark of delirium. b. Dementia may be due to several medical problems and involves memory impairment, cognitive disturbance, and pervasive impairment of abstract thinking and judgment. i. Dementia usually develops over months and, in many cases, is irreversible. c. Schizophrenia is a common mental health problem, affecting an estimated 1% of the population. d. Its hallmark is a significant change in behavior and a loss of contact with reality. i. Symptoms include hallucinations, delusions, disorganized speech, catatonia, and flat affect ii. Diagnosis requires that two or more symptoms must each be present for a significant portion of each month over the course of 6 months iii. Major types include paranoid, disorganized, catatonic, and undifferentiated C. Anxiety and Related Disorders 1. These are characterized by dominating apprehension and fear. a. Panic attacks are characterized by extreme periods of anxiety resulting in great emotional distress. i. Signs and symptoms include a)Palpitations, pounding heart, or accelerated

Master Teaching Notes Knowledge Application Mental health professionals diagnose the disorders listed according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), but students still need to know how each disorder is differentiated from the others. Go over each of the disorders, and highlight how the presentation of each differs. Is the care for each different, or can we follow a common theme?

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heart rate b)Sweating c) Trembling or shaking d)Sensations of shortness of breath or smothering e)Chest pain or discomfort f) Nausea or abdominal distress g)Feeling dizzy, unsteady, lightheaded, or faint h)Fear of losing control or going crazy i) Fear of dying j) Parasthesia k) Chills or hot flashes ii. Management is generally simple and supportive, iii. Show empathy. iv. Patients with severe or incapacitating symptoms may benefit from sedatives. b. Phobias occur when fear becomes excessive and interferes with functioning. i. Management is supportive. c. Post-traumatic stress disorder (PTSD) is a reaction to an extreme, usually life-threatening stressor, and is characterized by a desire to avoid similar situations, recurrent intrusive thoughts, depression, sleep disorders, nightmares, and persistent symptoms of increased arousal. i. Treat any patient with PTSD with respect, empathy, and support, and transport the patient to an appropriate facility for evaluation. D. Mood Disorders 1. The DSM-5 defines mood as a pervasive and sustained emotion that colors a person’s perception of the world. a. Depression is characterized by a profound sadness or feeling of melancholy. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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A major depressive episode is a prolonged or severe depression and is characterized by: a)Depressed mood most of the day, nearly every day, as indicated by subjective report or observation by others b)Markedly diminished interest in pleasure in all, or almost all, activities most of the day nearly every day c) Significant weight loss (without dieting) or weight gain; a 5% change in body weight is considered significant d)Insomnia or hypersomnia nearly every day e)Psychomotor agitation or retardation every day (observable by others, not just the subjective feeling of the patient) f) Feelings of worthlessness or excessive inappropriate guilt (may be delusional) nearly every day g)Diminished ability to concentrate, or indecisiveness nearly every day h)Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or specific plan for committing suicide ii. Depression may occur as an isolated condition but is often accompanied by other disorders. b. Bipolar disorder is characterized by one or more manic episodes with or without subsequent or alternating periods of depression. i. Manic-depressive episodes begin suddenly and escalate over a few days. ii. Management includes maintaining a calm, protective ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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environment. a)Overtly psychotic patients may require antipsychotic medications. E. Substance-Related Disorders 1. Many patients you encounter will be under the influence of one or many substances. 2. Any psychiatric patient should be screened for substance use and/or abuse. a. Repetitive use of a mood-altering chemical may lead to dependence or addiction. F. Somatoform Disorders 1. Somatoform disorders are characterized by physical symptoms that have no apparent physiological cause and are believed to be attributed to psychological factors. a. Somatization disorder – patients are preoccupied with physical symptoms. b. Conversion disorder – patients sustain a loss of function, usually involving the nervous system. c. Hypochondriasis is an exaggerated interpretation of physical symptoms as a serious illness. d. Body dysmorphic disorder causes a patient to believe that he has a defect in appearance. e. Pain disorder – the patient suffers from pain, usually severe, that is unexplained by a physical ailment. 2. Never attribute physical symptoms to a behavioral disorder until medical conditions have been ruled out. G. Factitious Disorder 1. Factitious disorders are sometimes confused with somatoform disorders. 2. They are characterized by an intentional production of physical or psychological symptoms; motivated by assuming the role of patient; and external incentives for the behavior are absent. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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3. Patients will often voluntarily produce symptoms and present with a very plausible history, and they often have an extensive knowledge of medical terminology. H. Dissociative Disorders 1. Dissociative disorders are attempts to avoid stressful situations while still gratifying needs. 2. The individual dissociates from his core personality. a. Psychogenic amnesia is a total inability to recall or identify past events. b. Fugue state causes a patient to flee as a defense mechanism. c. Multiple personality disorder causes the patient to react to an unidentifiable stress by manifesting two or more complete systems of personality, d. Depersonalization causes a patient to experience a loss of the sense of one’s self. I. Eating Disorders 1. Eating disorders generally occur between adolescence and the age of 25. a. Anorexia nervosa is a disorder marked by excessive fasting. i. Patients suffer from weight loss, refusal to maintain body weight, and often a cessation of menstruation from severe malnutrition. b. Bulimia nervosa is recurrent episodes of uncontrollable binge eating with compensatory self-induced vomiting or diarrhea, excessive exercise, or dieting and with a full awareness of the behavior’s abnormality. c. Starvation and attempts to purge can have drastic consequences, such as anemia, dehydration, vitamin deficiencies, hypoglycemia, and cardiovascular problems. J. Personality Disorders 1. Personality disorders stem largely from immature and distorted ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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personality development and result in maladaptive ways of perceiving, thinking, and relating to the world. 2. Personality disorder clusters a. Cluster A patients often act odd or eccentric. b. Cluster B patients often appear dramatic, emotional, or fearful. c. Cluster C patients often appear anxious or fearful. K. Impulse Control Disorders 1. Recurrent impulses and the patient’s failure to control them characterize these disorders. a. Kleptomania b. Pyromania c. Pathological gambling d. Trichotillomania e. Intermittent explosive disorder L. Suicide 1. Suicide is the ninth leading cause of death overall and the third leading cause in 15- to 24-year age group. 2. Assessing potentially suicidal patients a. In cases of attempted suicide, many focus on whether the patient really wanted to kill himself. b. Perform an appropriate focused history and exam concurrently with providing sound psychological care. 3. Risk factors a. Previous attempts b. Depression c. Age (ages 15–24 and over 40) d. Alcohol or drug abuse e. Divorce or widowhood f. Giving away personal belongings g. Living alone or increased isolation h. Presence of psychosis with depression ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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i. Homosexuality j. Major separation trauma k. Major physical stresses l. Lack of independence m. Suicide of same-sex parent or other family member n. Expression of a plan for committing suicide o. Possession of the mechanism for suicide M. Age-Related Conditions 1. Crises in the geriatric patient a. Elderly patients often experience depression that is mistaken for dementia. b. When assessing an elderly patient in crisis, perform the following: i. Assess the patient’s ability to communicate. ii. Provide continual reassurance. iii. Compensate for the patient’s loss of sight and hearing with reassuring physical contact. iv. Treat the patient with respect, and call the patient by title and name. v. Avoid administering medication. vi. Describe what you are going to do before you do it. vii. Take your time. viii. Allow family members and friends to remain with the patient, if possible. 2. Crises in the pediatric patient a. Behavioral emergencies are not limited to adults. b. When assessing a child in crisis, perform the following: i. Avoid separating a young child from his parents. ii. Attempt to prevent him from seeing things that will increase his distress. iii. Make all explanations brief and simple, and repeat them often. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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iv. v.

Be calm and speak slowly. Identify yourself by giving both your name and your function. vi. Be truthful with the child. vii. Encourage the child to help with his care. viii. Reassure the child by carrying out all interventions gently. ix. Do not discourage the child from crying or showing emotion. x. If you must be separated from the child, introduce the person who will assume responsibility for his care. xi. Allow the child to keep a favorite blanket or toy. xii. Do not leave the patient alone, even for a short period. N. Excited Delirium Syndrome 1. Also called agitated delirium, excited delirium is a mental and physical arousal that results from increased dopamine levels in the brain and is caused by drug intoxication psychiatric illness, or a combination of both. 2. Patients suffering from excited delirium may have: a. Abnormal tolerance of pain (100%) b. Tachypnea (100%) c. Sweating (95%) d. Agitation (95%) e. Skin that feels hot to the touch (95%) f. Noncompliance toward police (90%) g. Lack of tiring (90%) h. Unusual strength (90%) i. Inappropriate clothing (70%) 3. Beware of the patient who suddenly becomes tranquil after frenzied activity, as this is often followed by cardiac collapse and death. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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4. Excited delirium must always be suspected when a patient is restrained.

VII. Management of Behavioral Emergencies A. Take the following measures when you treat a patient who is experiencing a behavioral emergency: 1. Ensure scene safety, and use Standard Precautions. 2. Provide a supportive and calm environment. 3. Treat any existing medical conditions. 4. Do not allow the suicidal patient to be alone. 5. Do not confront or argue with the patient. 6. Provide realistic reassurance. 7. Respond in a direct, simple manner. 8. Transport to an appropriate receiving facility. B. TASERed Patients 1. A TASER is a nonlethal (sometimes called less-lethal) weapon used by law enforcement officers to subdue subjects. 2. A TASER uses an electrical current to disrupt voluntary control of the skeletal muscles and cause pain. 3. The TASER fires two dart-like electrodes that make contact with the skin. 4. An electrical current is sent through wires attached to the probes. a. Generally speaking, the darts will work virtually anywhere on the body and do not need to penetrate or contact the skin to function properly. b. Direct injuries generally result from the impact of the probe. c. Secondary injuries can result from the muscle contraction that occurs with the electrical pulse. d. Although the device is high voltage, the wattage is very low at approximately 0.36 joules.

Teaching Tips When practicing patient assessment, provide clues that require students to question whether the scene is safe. Utilize multiple people on scenes to demonstrate the importance of each person on the scene and the possibility of violence.

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5. Ensure that the scene is safe. 6. Patients should have the following findings before being released to law enforcement: a. Glasgow Coma Score of 15 b. Heart rate less than 100/minute c. Respiratory rate greater than 12/minute d. Normal pulse oximetry (greater than 94%) e. Systolic BP greater than 100 mmHg f. The dart must not have penetrated the eye, face, neck, breast (females), axilla, or genitalia. g. The patient has no other acute medical condition, including trauma, hypoglycemia, and/or acute psychiatric disturbances such as excited delirium syndrome. 7. To remove the dart: a. Ensure that the TASER is no longer active and has been secured. b. Use scissors to cut the wire at the base of each dart. c. While wearing gloves, grasp the cylinder of the TASER between your thumb and index finger, and remove the dart with a quick, firm hold directed perpendicular to the skin surface. Dispose of the dart in a sharps container, being careful not to sustain an injury with the device. d. Clean each dart wound with an appropriate antiseptic solution. e. Cover each wound with a bandage or other sterile dressing. f. Offer the patient transport to the hospital if necessary. g. Document your findings, and obtain appropriate releases. h. Encourage the patient to seek follow-up care if he develops signs of infection around on or both of the punctures. C. Medical Care 1. Patients who are experiencing apparent behavioral emergencies often have concurrent medical conditions, some of which may be ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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Content Outline responsible for the problem. D. Psychological Care 1. Be calm and reassuring while you interview your patient. 2. Visualize your patients on a continuum ranging from agitated and out of control to introverted and depressed. 3. Note how the patient reacts to you, and adjust your strategy. 4. Your approach requires excellent people skills, especially listening and observing. a. Some patients will not respond favorably, regardless of the approach. 5. Never play along with a patient who is having delusions or hallucinations, or you will lose credibility. VIII. Violent Patients and Restraint A. Providing medical care in the prehospital environment often places paramedics in harm’s way. 1. It’s important to remember that medical and trauma conditions can result in agitation and combativeness. B. Methods of Restraint 1. Always ensure that law enforcement personnel secure the scene before EMS enters. a. Be alert for unexpectedly agitated patients or those with escalating emotions. b. The chosen method should be the least restrictive method that ensures the safety of the patient and EMS personnel. 2. Verbal deescalation a. The application of verbal techniques to calm a patient is usually the first method paramedics should be employ. b. Avoid direct eye contact and encroachment on the patient’s “personal space,” which may create added stress and anxiety. c. Always attempt to have equally open escape routes for both the patient and paramedics.

Master Teaching Notes

Teaching Tips Discuss local protocols for chemical restraint and how they apply in your area.

Class Activities Practice the various methods of restraint (verbal and physical), and stress the importance of safety for your patient and the rescuers.

Decision Points It is not always possible to have multiple personnel on the scene for restraint. What are some methods of utilizing other personnel? Who should be included when restraining a patient? Who should be excluded?

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3. Physical restraint a. When physically restraining a patient, paramedics must make every effort to avoid injuring the patient. i. Avoid the use of hard restraints. b. Ideally, a minimum of five people should be present to safely apply physical restraint to a violent patient, which allows for control of the head and each limb. c. Four-point restraints are preferred over two-point restraints. d. Patients should not be transported while restrained in the prone position, as it has been associated with positional asphyxia. e. A patient should never be hobbled or “hog-tied.” f. Never leave the patient unattended after restraint. g. Perform and document frequent neurovascular assessment of the restrained extremities to ensure adequate circulation. h. A patient should not be allowed to continually struggle against the restraints, which can cause acidosis and fatal arrhythmia. 4. Chemical restraint a. Chemical restraint is defined as the administration of specific pharmacological agents to decrease agitation and increase cooperation of patients who require medical care and transportation. b. The goal is to subdue excessive agitation and struggling against physical restraints. c. Butyrophenones (haloperidol and droperidol) and/or benzodiazepines are the medications most commonly used for chemical restraint in emergency departments and in prehospital care. i. Droperidol has been associated with problems in patients who have a prolonged QT interval on their ECG, which makes it undesirable in the prehospital ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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setting. d. When considering the use of chemical restraint, weigh the risk of struggle against the side effect profile of the medications being considered for sedation of the agitated patient. 5

IX. Summary A. Once you have determined that the patient is experiencing a purely behavioral emergency, your compassion and communication skills, rather than medications and procedures, will benefit him most. B. Emergency medical service providers routinely encounter patients who are violent or combative as a result of behavioral illness, a medical condition, or trauma. C. EMS personnel and their medical directors should ensure that their systems are prepared to treat violent or combative patients responsibly by providing appropriate training, policies, and protocols to deal with these situations. X.

Case Study

XI. You Make the Call 5 XII. Review Questions 5

Class Activities Discuss the case with students now that they are familiar with the chapter. Class Activities Read and discuss the call and questions as a group.

Class Activities Pass out review questions before the lesson starts. Have students answer them. Go over the questions again after the lecture to assess students’ understanding of the information.

MASTER TEACHING NOTES

Detailed Lesson Plan Chapter 12 Diseases of the Eyes, Ears, Nose, and Throat 80–90 Minutes

   

Teaching Tips Class Activities Knowledge Application Decision Points

Chapter 12 objectives can be found on text p. 465. These objectives, which form the basis of each chapter, were developed from the current National EMS Education Standards and the accompanying Paramedic Instructional Guidelines.

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Content Outline I.

Case Study

Master Teaching Notes Teaching Tips Have a student read the scenario. Tell students that the case will be reviewed after the lecture.

II. Introduction A. The head and neck contain many of the body’s essential sensory organs and other important structures. B. Numerous medical conditions can affect the head and neck and its associated structures. 1. This is particularly true in the case of the pediatric patient.

Teaching Tips

III. Eyes

Class Activities A. Anatomy of the Eye 1. External anatomy of the eye a. They eyes are well protected by a group of bones that form the ocular orbit. b. Movement of the eyes is controlled by six extraocular muscles. c. They eyelids protect the eyes from the environment. d. The eyelashes function as sensors to cause rapid closure of the eyelids when a foreign substance approaches the eyes. e. A membrane called the conjunctiva covers and protects the

Have diagrams and models of the structures available when reviewing the anatomy and physiology of the eyes, ears, nose, and throat.

Review the anatomy of the eye.

Knowledge Application Although many conditions are not life threatening, vision is an important sense for patients. Why is it important to treat these cases as emergencies and provide appropriate and compassionate care? 1

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exposed surface of the eye. Tears are manufactured in the lacrimal glands and then spread across the eye laterally to medially, where they drain through the lacrimal ducts into the nose. 2. Internal anatomy of the eye a. The posterior cavity is the portion behind the lens and contains the vitreous humor. b. The anterior cavity is in front of the lens and contains the aqueous humor surrounding the iris, pupil, and lens. c. The sclera is a tough, fibrous protective tissue. d. The choroid is a highly vascular tissue that provides essential nutrients to the tissues of the eye, and contains both the iris and the pupil. e. The retina contains the nerve endings that receive and interpret incoming the incoming image. It also contains the rods and cones. B. Medical Conditions of the Eye 1. A sty is an infection of the eyelid that results from blockage of the oil glands associated with an eyelash. 2. A chalazion is inflammation or an infection that results from blockage of one of the meibomian glands in the tarsal plate of the eyelid. 3. Conjunctivitis is an infection or inflammation of the conjunctiva. a. Bacterial conjunctivitis is called “pink eye.” b. Viral conjunctivitis is similar to bacterial, except that the cause is viral. c. Allergic conjunctivitis is a common condition related to exposure to pollen and other antigens to which the patient is allergic. d. A pterygium is a conjunctival condition characterized by a raised, wedge-shaped growth of the conjunctiva. e. Iritis, also called uveitis, is a swelling and irritation of the middle layer of the eye. f.

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Herpes simplex virus (HSV) keratitis is an infection and inflammation of the cornea that results from the herpes simplex virus. g. Herpes zoster opthalmicus is a condition in which herpes zoster (shingles) affects they eye. h. Corneal ulcers are typically caused by an infectious agent that breaks through the epithelial border of the cornea. i. Cellulitis results in infection of the soft tissues surrounding the eye. i. Periorbital cellulits has not breached the orbital septum. ii. Orbital cellulitis is a serious infection that involves the structures behind the orbital septum. j. A hyphema is a collection of blood in the anterior chamber of the eye. k. Glaucoma is a group of eye conditions that threaten sight and are characterized by an increase in the pressure within the eye (intraocular pressure [IOP]). i. Angle-closure glaucoma occurs when the outflow of aqueous humor is suddenly blocked and IOP acutely increases. ii. Open-angle glaucoma is the most common type of glaucoma encountered. Although the cause is unknown, the IOP to increase slowly over time, placing pressure on the optic nerve and retina. This can lead to blindness. l. A cataract is a clouding of the lens of the eye. m. Optic neuritis is an inflammation of the optic nerve and typically occurs as a result of autoimmune disease, infection, drug toxicity, and multiple sclerosis. n. Papilledema is swelling of the optic disc secondary to increased IOP. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

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o. Central retinal artery occlusion is a blockage of one of the small arteries that supply the retina. p. Central retinal vein occlusion is a blockage of the small veins that drain the retina. q. A retinal detachment is separation of the retina from the supporting structures. It can be seen in trauma, diabetes, and similar disorders. IV. Ear 15

Class Activities A. Anatomy of the Ear 1. The external ear a. The major portion of the external ear is called the pinna or auricle. It collects sound waves and directs them to the external auditory canal through the external auditory meatus to contact the tympanic membrane. 2. The middle ear a. The middle ear contains the auditory ossicles, which are three small bones that are joined together and function to amplify sound waves received by the tympanic membrane. 3. The inner ear a. The inner ear is separated from the middle ear by the oval window. b. Hearing and equilibrium are provided by specialized receptors within the inner ear. c. These receptors are well protected by the bony labyrinth. i. The membranous labyrinth is filled with endolymph and surrounds the bony labyrinth. B. Medical Conditions of the Ear 1. Foreign bodies are not uncommon, especially in children. a. They are typically not an emergency but can be quite painful and disturbing to the patient. 2. Impacted cerumen can block the external auditory canal and

Review the anatomy of the ear.

Knowledge Application Inner ear issues can cause significant problems with balance and severe bouts of nausea and vomiting. Why is this significant, and how can we diminish these problems?

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interfere with hearing. 3. Infections of the ear are common. a. Otitis externa (swimmer’s ear) is an infection of the outer ear and/or external auditory canal. b. Otitis media is common in children and is caused by blockage of the Eustachian tube, causing increased fluid pressure in the middle ear. c. Perforated tympanic membrane is caused by rupture or tearing of the tympanic membrane. d. Mastoiditis is an infection of the mastoid bone at the base of the skull, typically after an infection has spread from the middle ear to the mastoid. e. Labyrinthitis is a swelling and irritation of the inner ear, and can cause vertigo, involuntary eye movements, dizziness, loss of balance, nausea and vomiting, hearing loss, and tinnitus. f. Meniere’s disease affects the inner ear, causing balance and hearing issues, and occurs when the labyrinths within the inner ear become swollen. V. Nose 10

Class Activities A. Anatomy and Physiology of the Nose 1. The sense of smell originates from receptors in the olfactory region of the upper part of the nasal cavity. 2. The nerves that arise from the olfactory receptors are a part of the first cranial nerve and enter the brain through the cribriform plate. 3. The structures of the nose are highly vascular. 4. There are four sinuses: maxillary, frontal, ethmoid, and sphenoid. B. Medical Conditions of the Nose 1. Epistaxis is a nosebleed. a. The vast majorities of nose bleeds are anterior bleeds. b. Posterior bleeds arise farther back and tend to be arterial in origin and more profuse than arterial bleeds.

Review the anatomy and physiology of the nose.

Decision Points Epistaxis can cause significant bleeding and even vomiting if the patient swallows blood. How does this affect your decision to transport these patients or not? Are there significant medical problems that can cause epistaxis? 5

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2. Nasal foreign bodies are common, especially in pediatric patients. 3. Rhinitis is an inflammation of the nose and is most commonly associated with an upper respiratory infection or allergies. 4. Sinusitis is an infection or inflammation of the sinuses and can result from infections as well as allergies. VI. Throat 15

Class Activities A. Anatomy and Physiology of the Mouth and Throat 1. The mouth is the opening to the oral cavity and is the entrance to the gastrointestinal tract. 2. The many structures within the oral cavity include: a. Labia or lips b. Palate, both soft and hard c. Tongue d. Pharynx e. Uvula f. Tonsils and adenoids g. Teeth h. Salivary glands i. Esophagus j. Larynx B. Medical Conditions of the Mouth and Throat 1. Pharyngitis and tonsillitis are common infections that often occur together. a. There may be enlargement and tenderness of the anterior cervical lymph nodes. 2. Oral candidaisis, commonly called thrush, is a fungal yeast infection of the mouth and is common in immunocompromised patients. 3. A peritonsillar abscess is a collection of infected material (pus) in the area around the tonsils. a. Swollen tissues may block the airway, which is a lifethreatening medical emergency. 4. Ludwig’s angina is a type of oral bacterial cellulitis, or inflammation,

Review the anatomy and physiology of the throat.

Knowledge Application Issues with the throat and mouth can cause significant airway problems. Why is it important to thoroughly assess these patients early? What additional types of things should you assess if you anticipate airway management?

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that involves the floor of the mouth under the tongue; it develops quickly and can occlude the airway. a. This causes great concern for airway management and may require a surgical airway. 5. Dentalgia and dental abscess are caused by injury or infection. 6. Foreign bodies can lodge in the mouth or throat, sometimes creating an emergency situation. 7. Epiglottitis is an inflammation or infection of the epiglottis and can be a life-threatening emergency. a. It is relatively uncommon. Besides fever and a sore throat, the patient may have drooling, stridor, hoarseness, difficulty breathing, and even cyanosis. 8. Laryngitis is a swelling and inflammation of the larynx and is most commonly caused by a viral infection or draining from an upper airway or sinus infection. 9. Tracheitis is an inflammation or infection of the trachea usually caused by a bacterial infection and is limited to the trachea below the level of the larynx. a. The primary concern in the prehospital setting is prevention of airway obstruction and ventilation of the patient. 10. Temporomandibular joint syndrome (TMJ) disorders result from problems with the joint between the temporal bone and mandible (jaw). 5

VII. Summary A. In many instances, treatment of the conditions discussed in this chapter is symptomatic. B. Many nontraumatic conditions involving the ears, eyes, nose, mouth, and throat can be true emergencies. Prompt recognition and treatment are essential. VIII. Case Study

Class Activities Discuss the case with students now that they are familiar with the chapter. 7

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IX. You Make the Call

Class Activities Read and discuss the call and questions as a group.

X. Review Questions

Class Activities

Pass out review questions before the lesson starts. Have students answer them. Go over the questions again after the lecture to assess students’ understanding of the information.

MASTER TEACHING NOTES

Detailed Lesson Plan Chapter 13 Nontraumatic Musculoskeletal Disorders 70–80 Minutes

  

Teaching Tips Class Activities Knowledge Application

Chapter 13 objectives can be found on text p. 485. These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

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Content Outline I.

Case Study

Master Teaching Notes Teaching Tips Have a student read the scenario. Tell students that the case will be reviewed after the lecture.

II. Introduction A. From the standpoint of emergency services, most musculoskeletal complaints are secondary to trauma. B. There are numerous nontraumatic conditions that affect the musculoskeletal system, and many are inflammatory or autoimmune in nature. C. Although these conditions are generally chronic and non-life-threatening conditions, during acute exacerbations, the patient may summon EMS for emergency medical care. III. Anatomy and Physiology Review A. Skeletal System 1. The human skeletal system consists of 206 bones, which are typically are classified on their shape. 2. Long bones are generally found in the extremities, whereas short bones are found in the wrists and ankles. 3. Bones are joined together by ligaments to form the joints. a. Gliding joints b. Hinge joints c. Saddle joints d. Pivot joints

Teaching Tips This is a review of previously discussed material. Revisit the previous topics concerning the anatomy of the musculoskeletal system. It helps to have diagrams and models for discussion of anatomy and physiology.

Class Activities Because this is review material, 1

Chapter 13 objectives can be found on text p. 485. These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

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Content Outline e. Ellipsoidal joints f. Ball-and-socket joints 4. Joints also contain cartilage, which is a flexible connective tissue that provides support and structure as well as a cushioning effect. a. Hyaline cartilage b. Elastic cartilage c. Fibrocartilage B. Muscular System 1. The muscular system allows for movement of the organism. 2. There are approximately 700 skeletal muscles in humans. These perform multiple functions, including: a. Allowing movement of the skeleton b. Supporting the soft tissues c. Maintaining posture and body position d. Protecting the entrances and exits of the digestive and urinary tracts e. Maintaining body temperature 3. The muscular system consists of muscles and tendons. a. The muscles are the contractile units . b. Tendons are located at the ends of the muscle and form a fibrous bundle that connects the muscle to bone. 4. Skeletal muscles are controlled by the voluntary nervous system via the neuromuscular junctions. IV. Assessment and Findings A. Most patients with nontraumatic musculoskeletal disorders will present with pain or tenderness. 1. Physical examination findings will be as varied as the patients. 2. Your assessment techniques and strategies will be the same as for a patient with any other complaint, including assessment of the ABCs. 3. Secondary assessment should include a fairly focused and detailed history of the illness, and you should pay particular attention to the body region involved. a. If a joint is involved, examine the joint for tenderness,

Master Teaching Notes have students split into groups, and have each group present a portion of the musculoskeletal system to the rest of the class.

Teaching Tips Patients with nontraumatic musculoskeletal disorders should be integrated into your assessment of the medical patient practice sessions.

Knowledge Application What are some of the basic skills we can use to diminish some of 2

Chapter 13 objectives can be found on text p. 485. These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

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Content Outline swelling, erythema, and restrictions in the range of motion. b. For muscular disorders, look for restrictions in range of motion as well as particular tender points and muscle spasm. c. The examination of the patient with back pain should include examination of the affected area and a neurologic exam including deep tendon reflexes as well as the search for sensory or motor deficits. 4. For the most part, treatment is supportive and symptomatic. a. Pain management can be provided with opiate analgesics and NSAIDs. b. In some cases, nonpharmacological treatments, such as splinting, application of cold or heat packs, and similar strategies, may be beneficial. V. Nontraumatic Musculoskeletal Conditions A. Overuse/Repetitive-Motion Disorders 1. Overuse and repetitive-motion disorders are a form of trauma; however, because they tend to be chronic they are often considered medical conditions. 2. Repetitive-motion injuries are quite common and are due to microscopic tears of affected muscles or tendons. a. Most are related to a vocation or avocation, and the patient often must or will continue to use the affected body part. i. Tendinitis is an inflammation of the tendon. a) Tennis elbow (lateral epicondylitis) is an inflammation of the common extensor tendon on the lateral aspect of the elbow. b) Golfer’s elbow (medial epicondylitis) involves the common tendinous sheath that inserts into the medial epicondyle. ii. Tenosynovitis is an inflammation of the lining of the sheath that surrounds the tendon. iii. Bursitis is inflammation of the bursae. iv. Myalgia means muscle pain and is not a condition as

Master Teaching Notes the effects of musculoskeletal complaints? Do they always require pain control or ALS measures?

Class Activities Splinting and immobilization are some of the basic modalities we can provide to patients with nontraumatic musculoskeletal conditions. Have students practice splinting each other’s extremities and incorporate these disorders into the assessment portion. Some may require nothing more than a splint, whereas others may require analgesia, which should be discussed in the treatment.

Chapter 13 objectives can be found on text p. 485. These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

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much as it is a symptom. Carpal tunnel syndrome is a condition caused by pressure on the median nerve in the wrist. B. Degenerative Conditions 1. Osteoarthritis is a common condition caused by wear and tear on the joints. a. It includes pain and stiffness upon rising in the morning and typically improves with movement and activities of daily living. 2. Osteoporosis is the most common form of bone disease and is a thinning of bone tissue and loss of bone density that occurs over time. a. It occurs when the body fails to produce enough new bone to replace bone that is resorbed or used. b. The primary cause is the loss of estrogen in women and occurs in men following a drop in testosterone . 3. Degenerative disk disease is one of the most common causes of low back pain. a. As we age, the disks in the vertebrae become dehydrated and stiff and begin to rupture or bulge. C. Inflammatory Conditions 1. Rheumatoid arthritis (RA) is a chronic disease that leads to inflammation and injury to the joints and surrounding tissues. a. It is considered to be an autoimmune disorder, as the immune system attacks the synovium and surrounding tissues, causing inflammation and damage. b. The joints of the wrists, fingers, knees, ankles, and feet are most commonly affected. c. RA is a chronic condition that cannot be cured but can be treated with medications. d. In severe or untreated cases, RA can cause significant joint damage and deformity. 2. Ankylosing spondylitis (AS) is a form of inflammatory arthritis that v.

Chapter 13 objectives can be found on text p. 485. These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

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affects the spine, causing inflammation of the joints between the vertebrae and the sacroiliac joints in the pelvis. a. As the condition worsens and the inflammation persists, new bone forms as part of the healing process, causing the spine to become inflexible b. As the disease progresses, the spine becomes fused into a single unit incapable of flexion, extension, or lateral movement, forcing patients to walk bent over. i. Because most AS patients have chronic spinal flexion, it is important to adequately pad underneath the patient’s head, neck, and upper back with sheets or pillows.. 3. Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that can affect the skin, joints, kidneys, and other organs. a. The immune system attacks otherwise healthy cells and tissues, causing chronic inflammation. 4. Gout is a form of inflammatory arthritis that occurs when uric acid accumulates in the joints. a. An abnormal amount of uric acid in the body causes swelling and erythema of the affected joints, often the joint between the foot and great toe (first metatarsal). b. Pain can be so severe that even the presence of a sheet resting on the joint is unbearable. D. Infectious Conditions 1. Soft tissue infections a. Cellulitis is an infection of the skin and often involves the associated soft tissues. b. Fasciitis is an inflammation and infection of the fascia. i. Necrotizing fasciitis is a bacterial infection that can rapidly destroy the skin, muscles, and surrounding tissues and is often due to multiple bacteria. c. Tenosynovitis refers to inflammation of the fibrous sheath that surrounds the tendon. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

Chapter 13 objectives can be found on text p. 485. These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

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d. Gangrene is the death of tissue in the affected part of the body and usually occurs when the blood supply in the affected tissue is interrupted. e. The diabetic foot is a common soft tissue condition that affects the feet in diabetics. i. Diabetes adversely affects peripheral blood vessels and nerves, resulting in decreased blood supply and decreased sensation. ii. A minor injury, such as a laceration or ulcer, may go unnoticed, and this can lead to the development of a serious foot infection that often spreads to bone, causing osteomyelitis. 2. Bone and joint infections a. Osteomyelitis is an infection of the bone that is either acute or chronic, based on the duration of the infection. i. The most common cause is a bacterial infection, and it generally results from a spread of infection from the skin, muscles, and/or tendons to the affected bone. b. A septic joint is an infection of a joint by various microorganisms, primarily bacteria but possibly, to a lesser degree, viruses and fungi. c. Surgical procedures and the presence of a prosthetic joint place the patient at increased risk for developing a septic joint. E. Neoplastic Processes 1. A neoplasm is an abnormal growth of body tissue and is often called a tumor. a. A primary musculoskeletal tumor is one that arises from muscle, bone, or an associated tissue. b. A secondary musculoskeletal tumor is one that spreads to the muscle or bone from another site or tissue type. c. Most malignant bone tumors are sarcomas arising from ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

Chapter 13 objectives can be found on text p. 485. These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

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bone, cartilage, muscle, fat, and similar tissues. F. Chronic Pain Syndrome 1. Pain persisting longer than typically seen in others with the same condition and typically lasting 3–6 months is chronic pain syndrome (CPS). a. CPS often has associated psychological syndromes, including depression, anxiety, and hypochondriasis. b. CPS is often characterized by the presence of the six D’s:: i. Dramatization of complaints ii. Drug misuse iii. Dysfunction/disease iv. Depression v. Disability c. Some treatments, including short-acting opiates, can worsen CPS. 2. Fibromyalgia (central sensitivity syndrome) is characterized by widespread pain in the muscles and soft tissues throughout the body. a. Signs and symptoms include pain in the muscles and soft tissues of the neck and back. b. It is associated with chronic fatigue and difficulty sleeping. c. Many patients have an overlay of anxiety and depression that can worsen the condition. 3. Reflex sympathetic dystrophy (RSD) is a chronic pain condition characterized by diffuse pain, swelling, and limitation of movement that follows an injury to an arm or leg. a. The symptoms are significantly out of proportion to the severity of the injury and may continue long after the injury has healed. G. Pediatric Conditions 1. Although most nontraumatic musculoskeletal conditions occur in adults, some conditions occur in children. 2. Osgood-Schlatter disease is a painful swelling of the anterior tibial ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

Chapter 13 objectives can be found on text p. 485. These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.

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tubercle and is thought to be caused by repetitive injuries before growth is complete. 3. Slipped capital femoral epiphysis is a separation of the ball of the hip joint from the femur and occurs in children at the growth plate in the proximal femur. 5

VI. Summary A. Most musculoskeletal problems you will encounter as a paramedic will be traumatic in origin. However, there are some nontraumatic conditions that can become emergent. B. In most cases, the patient’s primary complaint will be pain. C. Pain should be treated appropriately using the medications recommended for the condition and by r local EMS protocols. D. The role of the paramedic is to address the immediate problem and provide needed treatment, even if only symptomatic and supportive care. VII. Case Study

VIII.You Make the Call 5 IX. Review Questions 5

Class Activities Discuss the case with students now that they are familiar with the chapter. Class Activities Read and discuss the call and questions as a group.

Class Activities Pass out review questions before the lesson starts. Have students answer them. Go over the questions again after the lecture to assess students’ understanding of the information.

Chapter 1 Pulmonology

Student’s Name ________________

HANDOUT 1-1 SKILLS

ADMINISTERING NEBULIZED MEDICATIONS Charting Student Progress: 1. Learning skill 2. Performs skill with direction 3. Performs skill independently Procedure 1. Complete the primary assessment. 2. Place the patient on an ECG monitor. 3. Select the desired medication(s). 4. Add medication to the nebulizer. 5. Assemble the nebulizer. 6. Determine pretreatment pulse rate. 7. Administer the medication. 8. Determine posttreatment pulse rate. 9. Reassess breath sounds. Comments:

Student’s Name ________________

HANDOUT 1-2 EVALUATION

CHAPTER 1 QUIZ Write the letter of the best answer in the space provided. ______1.

Which one of the following is NOT a function of the upper airway? a. Purifying incoming air b. Separation of gases in incoming air c. Warming incoming air d. Humidifying incoming air

______2.

The purpose of the turbinates is to: a. warm the incoming air. b. vibrate and create sound. c. cause turbulence in the nose. d. create mucus to remove foreign debris.

______3.

The fingerlike projections that line the respiratory tract and assist in removing entrapped particles are called: a. cilia. c. tonsils. b. sinuses. d. flagella.

______4.

Nerve fibers important to the sense of smell are derived from the ________ cranial nerve: a. first c. third b. second d. fourth

______5.

The carina is the point at which the ________ divides into the right and left mainstem bronchi. a. larynx c. esophagus b. vocal cords d. trachea

______6.

The respiratory bronchioles divide into the: a. right and left mainstem bronchi. c. primary bronchi. b. alveolar ducts. d. alveolar sacs.

______7.

The alveoli are moistened and kept open because of the presence of a chemical called: a. surfactant. c. visceral pleura. b. alveolar fluid. d. capillary endothelium.

______8.

The total number of lobes in the lungs is: a. two. c. five. b. four. d. seven.

______9.

The total amount of air moved into and out of the lungs during a quiet respiration is referred to as the ________ volume. a. inspiratory c. minute b. parietal d. tidal

______10. The portion of the brain that controls ventilation is the: a. medulla. c. dura mater. b. cerebellum. d. cerebral cortex. ______11. Regulation of ventilation in patients with COPD is based on the: a. carbon dioxide level in arterial blood. b. oxygen level in arterial blood. c. decrease in pH in cerebrospinal fluid. d. increase in pH in cerebrospinal fluid. ______12. Lung perfusion is dependent on three conditions, one of which is: a. adequate blood volume. b. controlled body temperature. c. adequate humidity of the air. d. adequate atmospheric pressure. ______13. The greatest portion of CO2 produced during metabolism in cells is converted into: a. bicarbonate. c. plasma. b. hemoglobin. d. enzymes. ______14. ______ respirations are characterized by repeated episodes of gasping ventilations separated by period of apnea. a. Ataxic b. Kussmaul’s c. Central neurogenic d. Cheyne-Stokes ______15. Confusion due to excess carbon dioxide is called: a. hyperdiox. c. hyperoxia. b. hypercarbon. d. hypercarbia. ______16. One sign of a possible life-threatening respiratory problem in an adult patient is: a. audible wheezing. b. tachycardia ≥ 130 beats per minute. c. pursed lips. d. six- to seven-word dyspnea. ______17. Which one of the following is NOT a normal breath sound? a. Loud and high-pitched over the trachea b. Soft and medium-pitched over mainstem bronchi c. Harsh and high-pitched on inspiration d. Soft and low-pitched in the lung periphery ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

______18. A form of pulmonary edema that is caused by fluid accumulation in the interstitial space within the lungs is called: a. adult respiratory distress syndrome. c. cor pulmonale. b. positive end-expiratory pressure. d. polycythemia. ______19. Clubbing of the fingers suggests long-standing: a. hypercarbia. c. hypoxemia. b. hyperventilation. d. hypocarbia. ______20. _____________ is the visual representation of the expired CO 2 waveform. a. Capnography c. Capnogram b. Capnograph d. Capnometry ______21. ARDS is a disorder of lung diffusion that results from increased fluid in the: a. intravascular space. c. intrapulmonary space. b. interstitial space. d. terminal bronchi. ______22. Your assessment of a patient with emphysema may reveal: a. a frequent, productive cough. b. recent weight gain. c. a barrel chest. d. Cheyne-Stokes respirations. ______23. Unlike emphysema, in chronic bronchitis, diffusion: a. remains normal. c. is decreased. b. is increased. d. is initially normal, then increases. ______24. With asthma, a common sign is: a. persistent cough. b. snoring respirations. c. narrowing pulse pressure. d. gradually decreasing respiratory rate. ______25. Pneumonia is primarily a(n): a. metabolic disorder. b. ventilation disorder. c. perfusion disorder. d. oxygenation disorder. ______26.

A patient with SARS is considered contagious: a. until the patient is asymptomatic. b. for 2–7 days after the onset of symptoms. c. for 10–14 days after the onset of symptoms. d. for 10 days after the patient is asymptomatic.

______27. Carbon monoxide has an affinity for hemoglobin that is _________ times that of oxygen. a. 5 to 10 c. 200 to 250 b. 50 to 100 d. 500 to 600 ______28. A pulmonary embolism is a blood clot that lodges in a: a. pulmonary vein. c. coronary artery. b. pulmonary artery. d. coronary vein. ______29. Risk factors for spontaneous pneumothorax include all of the following EXCEPT: a. age 20 to 40. b. cigarette smoking. c. COPD. d. short stature. ______30. Carpopedal spasms, seen in hyperventilation, are due to: a. hypocalcemia. b. hypercalcemia. c. hypocarbia. d. hypercarbia.

Student’s Name ________________

HANDOUT 1-3 EVALUATION

CHAPTER 1 SCENARIO Review the following real-life situation. Then answer the questions that follow. The school nurse, frustrated by the apparent lack of progress in treating a child’s asthma attack, calls 911. The child has a long-standing history of asthma. He makes numerous visits to her office for his inhaler, especially in the spring. But today’s visit is different. The child looks exhausted. You arrive and immediately assess the patient’s airway while auscultating his lungs. You look at your partner quizzically and report, “I don’t hear any wheezing.” Without hesitation, you open the endotracheal roll and put it at the patient’s head. You then start an IV of normal saline. The patient is simultaneously given 100% oxygen via a nonrebreather mask. Vital signs are obtained, and the ECG is monitored. The patient is started on an albuterol treatment via small-volume nebulizer and transported immediately to the closest emergency department. While en route, the patient is not able to hold the nebulizer in his mouth. You elect to nasally intubate the patient and ventilate him before arrival at the hospital. 1. This child did not respond well to the nebulized treatments. Why?

2. What would be the next course of action in the emergency department? 3. How could you detect an improvement in this patient’s status?

Student’s Name ________________

HANDOUT 1-4 REINFORCEMENT

CHAPTER 1 REVIEW Write the word or words that best complete each sentence in the space(s) provided. 1. The three divisions of the pharnyx include the ____________, the ____________, and the ______________. 2. The point at which the trachea bifurcates into the right and left mainstem bronchi is the ________________. 3. A compound secreted by the lungs that contributes to the elastic properties of the pulmonary tissues is __________________. 4. __________________ is the mechanical process of moving air into and out of the lungs. 5. ___________________ resistance and ______________________ compliance govern the amount of air that flows into the lungs. 6. The _________________ ____________________ is the amount of air that is measured from a full inspiration to a full expiration. 7. Located on the visceral pleura and on the walls of the bronchi and bronchioles, the __________________ _________________ provide input to the medulla’s respiratory center. 8. ____________ is the movement of molecules through a membrane from an area of greater concentration to an area of lesser concentration. 9. The circulation of blood through the capillaries is called ___________. 10. ______________ is the transport protein that carries oxygen in the blood. 11. Hemoglobin with oxygen bound is referred to as _______________. 12. Hemoglobin without oxygen is called _________________. 13. Hemoglobin with carbon dioxide bound is called ____________________. 14. Lung perfusion is dependent on three conditions: adequate _________________ volume, intact pulmonary __________________, and efficient pumping of the blood by the _____________________. 15. The exchange of gasses between a living organism and its environment is called ______________. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

16. A common condition, ___________ _____________ _____________, occurs when the tongue (or adjoining tissues) blocks the airway during deep sleep. This results in periods of apnea that usually awakens the patient. 17. _____________ ___________ respiration is characterized by progressively increasing tidal volume, followed by a declining volume, separated by periods of apnea at the end of expiration. 18. When an area of lung tissue is appropriately ventilated but no capillary perfusion occurs, available oxygen is not moved into the circulatory system, which is referred to as _______________ _____________. 19. _________ ____________ is a colorless and odorless gas that may be present in quantities large enough to overcome unsuspecting emergency care personnel. 20. When assessing your patient’s respiratory status during your general impression, you should consider: __________, ______________, _________ _______, ________ ____ ______, and _____________ ___________. 21. As you form your general impression, you should also make specific note of any of the following signs of respiratory distress: __________ ______, ______ _________ ___________, ___ __ ____ ___________ ________ ________, _________, _____ ______, _______ ______. 22. When performing a physical examination of the respiratory system, you should palpate the trachea for _________ _________, which is suggestive of a ______________ __________. 23. Abnormal breath sounds include _________, __________, __________, ____________, ___________, and __________ ___________ ____. 24. A drop in the systolic blood pressure of 10 mmHg or more with each respiratory cycle is called ______________ ___________. 25. Three diagnostic measurements are of value in assessing the patient’s respiratory status: ___________ _____________, ____________ _________, and ____________. 26. ____________ provides a noninvasive measure of CO2 levels. 27. _______________ of the capnogram is the respiratory upstroke, and reflects the appearance of CO2 in the alveoli. 28. When determining whether or not to provide oxygen to your patient, you should strive for ____________ in your patient and avoid both hypoxia and _____________ if possible.

29. As the disease process of emphysema progresses, __________ decreases, which may lead to increased red blood cell production and ___________________. 30. __________ is a chronic inflammatory disorder of the airways in which the airway becomes ___________________. 31. A severe, prolonged asthma attack that cannot be broken by repeated doses of bronchodilators is called ____________ _____________. 32. The four major types of lung cancers are: ____________________, ________ ______ __________, ______________ __________, and ____________ __________ _____________. 33. Hyperventilating patients require oxygen, and mechanisms that will assist in increasing the PCO2, such as breath ______________ or breathing ___________ __ _______ _______, are discouraged in prehospital care. 34. Two conditions that can exhibit symptoms similar to hyperventilation syndrome are ____________ __________ and __________ ________ __________. 35. Disorders that can interfere with respiratory function include __________ ______ ______, ______, ___________ _________ ___________, and ____________ __________.

Student’s Name ________________

HANDOUT 1-5 REINFORCEMENT

RECOGNIZING RESPIRATORY PROBLEMS Match the terms with the statements that best describe them. a. Emphysema b. Chronic bronchitis c. Asthma d. Pulmonary embolism e. Hyperventilation syndrome ______

______ ______

______

______ ______ ______ ______

______

f. Carbon monoxide poisoning g. Cor pulmonale h. Pneumonia i. Status asthmaticus j. Central nervous system dysfunction

1. Results from an increase in the number of mucus-secreting cells in the respiratory tree; usually associated with a productive cough and copious sputum production. 2. An infection of the lungs that causes fluid and inflammatory cells to collect in the alveoli. 3. Chronic inflammatory disorder of the airway, causing symptoms usually associated with widespread but variable airflow obstruction and airway hyperresponsiveness. 4. Exposure to a gas that has an affinity for hemoglobin 200 times that of oxygen; results in hypoxia at the cellular level and, ultimately, metabolic acidosis. 5. A blood clot (thrombus) or some other particle that lodges in a pulmonary artery, effectively blocking blood flow. 6. Hypertrophy of the right ventricle resulting from disorders of the lung. 7. Results from continued exposure to noxious substances that gradually destroy the alveolar walls. 8. Characterized by rapid breathing, chest pains, numbness, and other symptoms usually associated with anxiety or a situational reaction; must be considered indicative of a serious medical problem until proven otherwise. 9. Except in the cases of drug overdose and massive stroke, this condition is rarely the cause of a respiratory emergency but must always be considered. 10. Signs include a greatly distended chest from continued air trapping, severe acidosis, exhaustion, and dehydration.

Student’s Name ________________

HANDOUT 1-6 REINFORCEMENT

CAUSES OF HYPERVENTILATION Write the possible causes of hyperventilation in the spaces provided. 1. _________________________ 2. _________________________ 3. _________________________ 4. _________________________ 5. _________________________ 6. _________________________ 7. _________________________ 8. _________________________

9. _________________________ 10. _________________________ 11. _________________________ 12. _________________________ 13. _________________________ 14. _________________________ 15. _________________________

Student’s Name ________________

HANDOUT 1-7 REINFORCEMENT

BASIC RULES OF CAPNOGRAPHY Write the possible causes of symptoms associated with the use of capnography.

SUDDEN DROP OF ETCO2 TO ZERO 1. ______________________________________________ 2. _____________________________________________ 3. ______________________________________________

SUDDEN DECREASE OF ETCO2 (NOT TO ZERO) 4. _____________________________________ 5. _____________________________________ 6. _____________________________________

EXPONENTIAL DECREASE OF ETCO2 7. ___________________________________ 8. ___________________________________ 9. ___________________________________ 10. ___________________________________ CHANGE IN CO2 BASELINE 11. __________________________________ 12. __________________________________ 13. __________________________________ SUDDEN INCREASE IN ETCO2 14. ____________________________________ 15. ____________________________________ 16. ____________________________________ GRADUAL LOWERING OF ETCO2 17. ______________________________________ 18. ______________________________________ 19. ______________________________________ GRADUAL INCREASE IN ETCO2 20. _______________________________________ 21. _______________________________________ 22. _______________________________________ 23. _______________________________________ ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed.

Chapter 1 Answer Key Handout 1-2: Chapter 1 Quiz 1. b 9. d 2. c 10. a 3. a 11. b 4. a 12. a 5. d 13. a 6. b 14. a 7. a 15. d 8. c 16. b

17. c 18. a 19. c 20. c 21. b 22. c 23. a

24. a 25. b 26. a 27. c 28. b 29. d 30. a

Handout 1-3: Chapter 1 Scenario 1. The child may be experiencing status asthmaticus. He has progressed past the initial phase of an asthma attack and is in the second phase. The second phase typically will not respond to inhaled beta-agonist drugs. 2. The emergency department would continue the same course and add an anti-inflammatory drug such as a corticosteroid. Therefore, the prehospital establishment of an IV access will expedite the patient’s care. 3. An increase in wheezing would actually indicate an improvement in aeration and ventilation. A higher oxygen saturation as observed through pulse oximetry also would be an indication of improvement. Handout 1-4: Chapter 1 Review 1.

nasopharynx, oropharynx, layngopharynx.

carina

surfactant

Ventilation

Airway, lung

vital capacity

stretch receptors

Diffusion

perfusion

10.

Hemoglobin

11.

oxyhemoglobin

12.

deoxyhemoglobin

13.

carbaminohemoglobin

14.

blood, capillaries, heart

15.

respiration

16.

obstructive sleep apnea

17.

Cheyne-Stokes

18.

pulmonary shunting

19.

Carbon monoxide

20.

position, color, mental status, ability to speak, respiratory effort

21.

nasal flaring, intercostal muscle retraction, use of the accessory respiratory muscles, cyanosis, pursed lips, tracheal tugging

22.

tracheal deviation, tension pneumothorax.

23.

snoring, stridor, wheezing, rhonchi, crackles, pleural friction rub

24.

pulsus paradoxus

25.

pulse oximetry, peak flow, capnography

26.

Capnometry

27.

Phase II

28.

normoxia, hyperoxia

29.

PaO2, polycythemia

30.

Asthma, hyperresponsive

31.

status asthmaticus

32.

adenocarcinoma, small cell carcinoma, epidermoid carcinoma, large cell carcinoma

33.

holding, into a paper bag

34.

pulmonary embolism, acute myocardial infarction

35.

spinal cord trauma, polio, amyotrophic lateral sclerosis, myasthenia gravis

10.

Handout 1-6: Causes of Hyperventilation (ANY 15 OF) 1.

Acidosis

Beta-adrenergic agonists

Bronchial asthma

Cardiovascular disorders

Central nervous system infection or tumors

Congestive heart failure

Drugs

Fever, sepsis

Hepatic failure

10. High altitude 11. Hypotension 12. Hypoxia 13. Interstitial pneumonitis, fibrosis, edema 14. Metabolic disorders 15. Methylxanthine derivatives

16. Neurologic disorders 17. Pain 18. Pneumonia 19. Pregnancy 20. Progestrone 21. Psychogenic or anxiety hypertension 22. Pulmonary disease 23. Pulmonary emboli, vascular disease 24. Salicylate Handout 1-7: Basic Rules of Capnography 1.

Esophageal intubation

Ventilator disconnection or defect in ventilator

Defect in CO2 analyzer

Leak in ventilator system; obstruction

Partial disconnect in ventilator circuit

Partial airway obstruction (secretions)

Pulmonary embolism

Cardiac arrest

Hypotension (sudden)

10. Severe hyperventilation 11. Calibration error 12. Water droplet in analyzer 13. Mechanical failure (ventilator) 14. Accessing an area of lung previously obstructed 15. Release of tourniquet 16. Sudden increase in blood pressure

17. Hypovolemia 18. Decreasing cardiac output 19. Decreasing body temperature; hypothermia; drop in metabolism 20. Rising body temperature 21. Hypoventilation 22. CO2 absorption 23. Partial airway obstruction (foreign body); reactive airway disease

Chapter 2 Cardiology

Student’s Name ________________

HANDOUT 2-1 SKILLS

ECG MONITORING Charting Student Progress: 1 Learning skill 2. Performs skill with direction 3. Performs skill independently Procedure 1. Turn on the machine. 2. Prepare the skin. 3. Apply the electrodes. 4. Ask the patient to relax and remain still. 5. Check the ECG. 6. Obtain a tracing. 7. Examine the ECG strip. 8. Continue ALS care. Comments:

Student’s Name ________________

HANDOUT 2-2 SKILLS

DEFIBRILLATION Charting Student Progress: 1. Learning skill 2. Performs skill with direction 3. Performs skill independently Procedure 1. Begin CPR while the defibrillator is being readied. 2. Continue CPR for at least 2 minutes while the defibrillator pads are being applied. 3. Charge the defibrillation paddles. 4. Reconfirm the rhythm on the cardiac monitor. 5. Verbally and visually clear everybody, including yourself, from the cardiac patient. 6. Check the rhythm. If a shockable rhythm is detected, administer a shock by pressing both buttons simultaneously. 7. Resume CPR immediately after the shock without a pulse check. Administer appropriate medications. After 2 minutes of CPR, check the rhythm again. Apply next shock if indicated. 8. Reconfirm the rhythm on the cardiac monitor. Begin CPR or other appropriate care based on cardiac rhythm. Comments:

Student’s Name ________________

HANDOUT 2-3 SKILLS

TRANSCUTANEOUS CARDIAC PACING Charting Student Progress: 1. Learning skill 2. Performs skill with direction 3. Performs skill independently Procedure 1. Establish an IV line. 2. Place ECG electrodes. 3. Carefully assess vital signs and place appropriate monitors. 4. If transcutaneous cardiac pacing is indicated, apply the pacing electrodes according to the manufacturer’s recommendations. Consider sedation or analgesia. 5. Connect the electrodes. 6. Select the desired pacing rate and current. 7. Monitor the patient’s response to treatment. Comments:

Student’s Name ________________

HANDOUT 2-4 SKILLS

CAROTID SINUS MASSAGE Charting Student Progress: 1. Learning skill 2. Performs skill with direction 3. Performs skill independently

Procedure 1. Initiate IV, oxygen (if patient is hypoxic) and ECG monitoring. 2. Position patient on his back, slightly hyperextending the head. 3. Listen to both carotids for the presence of bruits. Do not perform carotid sinus massage if bruit is present. 4. Tilt the patient’s head to either side. Place your index and middle fingers over one artery, below the angle of the jaw and as high up on the neck as possible. 5. Firmly massage the artery by pressing it against the vertebral body and rubbing. 6. Monitor the ECG and obtain a continuous readout. Terminate massage at the first sign of slowing or heart block. 7. Maintain pressure no longer than 15–20 seconds. 8. If the massage is ineffective, you may repeat it, preferably on the other side of the patient’s neck.

Comments:

Student’s Name ________________

HANDOUT 2-5 SKILLS

12-LEAD PREHOSPITAL ECG MONITORING Charting Student Progress: 1. Learning skill 2. Performs skill with direction 3. Performs skill independently Procedure 1. Prep the skin. 2. Place the four limb leads according to the manufacturer’s recommendations. 3. Place lead V1. 4. Place lead V2. 5. Place lead V4. 6. Place lead V3. 7. Place lead V5. 8. Place lead V6. 9. Ensure that all leads are attached. 10. Turn on the machine. 11. Check the quality of the tracing being received from each channel. 12. Record the tracing. 13. Examine the tracing. Do not completely rely on the machine’s interpretation of the tracing. 14. Transmit the tracing to the receiving hospital, if appropriate. Comments:

Student’s Name ________________

HANDOUT 2-6 EVALUATION

CHAPTER 2 QUIZ, PART 1 Write the letter of the best answer in the space provided. ______1.

______2.

______3.

______4.

______5.

______6.

______7.

______8.

______9.

The cardiovascular system’s two major components are the heart and: a. veins. b. central blood vessels. c. peripheral blood vessels. d. arteries. The heart consists of three tissue layers, including the: a. epithelium. c. subcardium. b. endocardium. d. parathelium. The ______ consists of the visceral and parietal layers. a. epicardium c. pericardium b. endocardium d. intracardium Which of the following statements about the four chambers of the heart is CORRECT? a. Atria are the inferior chambers of the heart. b. Ventricles are separated by the interventricular septum. c. Atria are the two largest chambers of the heart. d. Ventricles receive incoming blood from the body. The heart contains the ______ valves. a. atrioventricular and semilunar c. chordae and papillary b. epicardial and pericardial d. arterial and ventricular After blood circulates through the lungs and becomes oxygenated, it returns to the heart by way of the: a. pulmonary arteries. c. pulmonary veins. b. myocardial arteries. d. superior and inferior vena cava. Which of the following statements about the circulation of blood is TRUE? a. Intracardiac pressures are higher on the right side of the heart. b. The left atrium sends oxygenated blood into the left ventricle. c. Pulmonary arteries are the only arteries that carry oxygenated blood. d. The right myocardium is thicker than the left myocardium. The heart receives its nutrients from the: a. anterior great cardiac vein. c. coronary arteries. b. blood within its chambers. d. aorta. The term “collateral circulation” refers to: a. both sides of the heart receiving blood at the same time.

b. blood being sent from the atria into the ventricles. c. an alternative path for blood flow in case of blockage. d. blood flow to the lungs and heart at the same time. ______10. Stroke volume depends on three factors: preload, cardiac contractility, and: a. afterload. c. papillary contractitlity. b. circumflexion. d. atrial response. ______11. The connection points between the arterial and venous systems are called: a. lumens. c. venules. b. capillaries. d. tunica. ______12. Which of the following statements about arteries is TRUE? a. They always carry oxygenated blood. b. They carry blood away from the heart. c. They carry blood under low pressure. d. They cannot change the size of their lumen. ______13. The period of time from the end of one cardiac contraction to the end of the next is called the cardiac: a. fraction. c. systole. b. diastole. d. cycle. ______14. Pressure in the filled ventricle at the end of diastole is called: a. afterload. c. cardiac output. b. preload. d. stroke volume. ______15. The equation used to determine cardiac output is: a. stroke volume × heart rate. b. systolic pressure × heart rate. c. preload × stroke volume. d. preload × afterload. ______16. Which of the following statements about the nervous system’s control of the heart is TRUE? a. In the heart’s normal state, the sympathetic system is dominant. b. During sleep, the parasympathetic and sympathetic systems balance. c. In stressful situations, the sympathetic system becomes dominant. d. In the heart’s normal state, the parasympathetic system is dominant. ______17. A positive chronotropic agent will: a. increase the heart rate. b. increase the respiratory rate. c. strengthen cardiac contraction. d. speed impulse conduction. ______18. Repolarization is influenced by: a. calcium. b. sodium. c. potassium. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed

d. magnesium. ______19. The return of a cardiac muscle cell to its preexcitation resting state is called: a. resting potential. c. action potential. b. depolarization. d. repolarization. ______20. The term automaticity refers to a cell’s capability of: a. responding to electrical stimuli. b. propagating an electrical impulse from one cell to another. c. self-depolarization. d. contraction or shortening. ______21. The AV node has an intrinsic rate of self-excitation, which is _________ beats per minute. a. 20 to 40 c. 60 to 80 b. 40 to 60 d. 80 to 100 ______22. Muscle tremors, shivering, and loose electrodes can cause deflections on the ECG called: a. anomalies. c. aberrant conduction. b. artifacts. d. FLBs. ______23. The three types of ECG leads include: a. augmented. c. triangle. b. quadripolar. d. paradoxical. ______24. Leads I, II, and III form: A. Starling’s triad. c. Einthoven’s triangle. b. Cushing’s quadrant. d. circle of Willis. ______25. Leads I, II, and III are considered ______ leads. a. unipolar c. precordial b. bipolar d. anterior ______26. Leads designated aVR, aVL, and aVF are known as __________ leads. a. unipolar c. precordial b. bipolar d. anterior ______27. A single monitoring lead can indicate a. the presence or location of an infarct. b. axis deviation or chamber enlargement. c. right-to-left differences in impulse formation. d. the time it takes to conduct an impulse through the heart. ______28. One small box on ECG graph paper equals: a. 0.20 seconds. c. 0.04 seconds. b. 0.02 seconds. d. 0.40 seconds. ______29. Time interval markings on ECG paper are placed at ______second intervals. a. 1 c. 3 b. 2 d. 6 ______30. Which of the following statements about the P wave is TRUE? a. It is a negative deflection in lead II. b. It is a rounded wave appearing after the QRS complex. c. It corresponds to atrial depolarization. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed

d. It follows the T wave on normal ECGs. ______31. The QRS complex reflects: a. atrial depolarization. b. ventricular depolarization. c. ventricular repolarization. d. atrial repolarization. ______32. Waves that are associated with electrolyte abnormalities but that may be a normal finding are the _______ waves. a. P b. U c. T d. P, U, and T ______33. A prolonged PR interval: a. is 0.12–0.20 seconds. b. indicates a delay in the AV node. c. may indicate a bundle branch block. d. is related to an increased risk of sudden death. ______34. The interval of time in the cardiac cycle when a sufficiently strong stimulus may produce depolarization is called the ______ refractory period. a. absolute c. relative b. comparative d. prolonged ______35. The ST segment may be: a. affected by myocardial infarction. b. positive and rounded. c. invisible in the normal ECG. d. isoelectric in the presence of ischemia. ______36. The five-step procedure for interpreting ECG rhythm strips includes analyzing all of the following EXCEPT: a. QRS complex. c. PR interval. b. rhythm. d. ST segment. ______37. A nonpacemaker heart cell that automatically depolarizes is called a(n) ______ focus. a. ectopic c. ischemic b. irritable d. reentry ______38. Dysrhythmias are defined as: a. rhythms resulting in chest pain. c. rhythm absence. b. myocardial infarctions. d. heart rhythm abnormalities. ______39. Dysrhythmias that originate in the SA node include: a. asystole. c. sinus tachycardia. b. accelerated junctional rhythm. d. atrial fibrillation. ______40. An ectopic focus in the atrium resulting in an early P wave is called: a. atrial fibrillation. c. atrial tachycardia. b. premature atrial contractions (PACs). d. atrial flutter.

______41. Which of the following may be used in the treatment of symptomatic paroxysmal supraventricular tachycardia (PSVT)? a. Lidocaine c. Defibrillation b. Epinephrine d. Vagal maneuvers ______42. Which of the following statements about first-degree AV blocks is TRUE? a. The rhythm is irregularly irregular. b. The pacemaker site is the AV node. c. The PR interval is greater than 0.20 seconds. d. It is usually a life-threatening dysrhythmia. ______43. The absence of conduction between the atria and the ventricles is called ______ AV block. a. first-degree c. type II second-degree b. type I second-degree d. third-degree ______44. Ventricular escape rhythms: a. should be treated with lidocaine. b. serve as safety mechanisms to prevent cardiac standstill. c. look identical to a normal QRS complex. d. cause an ST segment elevation. ______45. Since PVCs do not usually depolarize the SA node: a. the pause following the PVC is fully compensatory. b. the PVCs will appear as inverted QRS complexes. c. each PVC will appear to be from a different focus. d. increasing the heart rate will eliminate them. ______46. PVCs are considered malignant when more than ______ occur(s) per minute. a. 1 c. 4 b. 2 d. 6 ______47. Ventricular fibrillation should be treated with immediate: a. intubation. b. antidysrhythmics. c. synchronized cardioversion. d. defibrillation. ______48. ________ has a prognosis for resuscitation that is very poor. a. Asystole c. Complete AV block b. Ventricular fibrillation d. Ventricular tachycardia ______49. The “P” in PEA stands for: a. pneumothorax. c. pericardiocentesis. b. postdefibrillation. d. pulseless. ______50. A kind of interventricular heart block in which conduction through either the right or the left bundle branch is blocked or delayed is called a: a. third-degree AV block. b. bundle branch block. c. type II second-degree AV block. d. junctional block. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed

HANDOUT 2-7

Student’s Name ________________

EVALUATION

CHAPTER 2 QUIZ, PART 2 Write the letter of the best answer in the space provided. ______1. The letter “P” in OPQRST stands for: a. provocation. b. past medical history. c. pain. d. provocation/palliation. ______2. The “feeling of impending doom” is caused by massive stimulation of the: a. parasympathomimetic system. b. sympatholoytic system. c. sympathetic nervous system. d. parasympathetic nervous system. ______3. All of the following can be a cause of poor ECG tracings EXCEPT: a. dry skin. b. excessive hair. c. poor electrode placement. d. loose electrodes. ______4. Which of the following statements about a precordial thump is TRUE? a. There is little risk of causing rib fractures or other problems. b. It is most effective immediately after the onset of ventricular fibrillation. c. Strike the midsternum from a distance of no more than 6 inches. d. It stimulates polarization of ventricular cells, causing a resumption of an organized rhythm. ______5. The parasympatholytic agent used to treat symptomatic bradycardias is: a. adenosine. c. atropine sulfate. b. verapamil. d. amiodarone. ______6. Stable and unstable narrow-complex tachycardias are managed by: a. amiodarone. c. lidocaine. b. adenosine. d. bretylium. ______7. Sympathomimetic agents are similar to naturally occurring hormones, one of which is: a. atropine sulfate. c. verapamil. b. lidocaine. d. epinephrine. ______8. The drug used in cardiac arrest resuscitation that acts on both alpha- and beta-adrenergic receptors is: a. dopamine. c. isoproterenol. b. epinephrine. d. atropine sulfate. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed

______9. Dopamine stimulates: a. alpha receptors. b. beta receptors. c. both alpha and beta receptors. d. neither alpha nor beta receptors. ______10. Which of the following statements about nitrous oxide is TRUE? a. It is used to treat MI because of its hemodynamic effects. b. It can be used to increase myocardial oxygen supply. c. Its effects subside within 10–15 hours. d. You may give it to intoxicated patients. ______11. Morphine sulfate is important in managing MI because it: a. increases myocardial oxygen demand. b. has few side effects, none of which are toxic. c. increases sympathetic nervous system discharge. d. acts directly on the central nervous system. ______12. Aspirin is used in the treatment of myocardial ischemia because it: a. is a thrombolytic. b. has analgesic effects. c. inhibits the aggregation of platelets. d. can cause gastric upset and bleeding. ______13. When using alteplase, a potent fibrinolytic, an important point to remember is that: a. it must be administered within 3 hours after the onset of coronary ischemia. b. the typical dose is a single 10-unit bolus given IV push over 2 minutes. c. complications include potentially life-threatening arrhythmias. d. unlike other fibrinolytics, hemorrhage is not a complication. ______14. The purpose of defibrillation is to: a. deliver an electric shock to jump-start the heart. b. depolarize the cells and allow them to repolarize uniformly. c. deliver a regular impulse to pace a bradycardic heart. d. suppress ectopic beats, such as PVCs. ______15. Several factors influence the success of defibrillation, including: a. duration of ventricular fibrillation. c. antidysrhythmic drugs. b. age of the patient. d. previous medical history. ______16. Steps in performing defibrillation include: a. making sure the defibrillator paddles are clean and dry. b. using firm downward pressure on the paddles to decrease transthoracic resistance. c. verifying that the synchronizer is turned on. d. charging the defibrillator to 100 joules for all shocks. ______17. Indications for emergency synchronized cardioversion of an unstable patient include: a. pulseless ventricular tachycardia. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed

b. ventricular fibrillation. c. rapid atrial fibrillation. d. pulseless electrical activity. ______18. The procedure for synchronized cardioversion is the same as that for defibrillation EXCEPT that: a. the button on only one paddle is pressed. b. the energy used is much less. c. the electrodes are placed in different positions. d. clearing the patient before delivery is unnecessary. ______19. Symptomatic patients in atrial fibrillation with a slow ventricular response may be treated with: a. defibrillation. b. synchronized cardioversion. c. external cardiac pacing. d. none of the above. ______20. ________ occurs when the heart’s blood supply is transiently exceeded by myocardial oxygen demands. a. Myocardial infarction c. Prinzmetal’s angina b. Heart failure d. Angina pectoris ______21. The major difference between stable and unstable angina is that unstable angina: a. occurs at rest. b. responds more readily to treatment. c. indicates that the patient’s condition is improving. d. causes cardiac muscle cell death. ______22. Which of the following statements about angina pectoris is TRUE? a. It results from underlying coronary artery disease. b. For relief, angina pain requires morphine. c. With angina, peripheral pulses are typically unequal. d. Blood pressure will decrease during the episode. ______23. Myocardial infarction: a. is the death of a portion of the heart muscle. b. can result from coronary artery spasm. c. may be caused by hypotension. d. is all of the above. ______24. The MOST common complication of myocardial infarction is/are: a. heart failure. c. ventricular aneurysm. b. arrhythmias. d. pulmonary edema. ______25. To determine specifics about chest pain, use ______ to help you. a. SAMPLE c. DCAP-BTLS b. AVPU d. OPQRST ______26. Rapid transport of a patient with chest pain is indicated if: a. the patient has a cardiac history. b. pathological Q waves are present on the 12-lead. c. the ST segment has no changes. d. the patient is over 35 years of age. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed

______27. The clinical syndrome in which the heart’s mechanical performance is compromised so cardiac output cannot meet the body’s needs is called: a. angina pectoris. c. heart failure. b. pneumothorax. d. cardiac tamponade. ______28. The condition in which the heart’s reduced stroke volume causes an overload of fluid in the body’s other tissues is called: a. congestive heart failure. c. Prinzmetal’s angina. b. myocardial infarction. d. angina pectoris. ______29. Management of the responsive adult patient with a history congestive heart failure who presents with respiratory distress, respiratory rate of 32, and SpO2 of 88% includes: a. placing the patient supine position with legs slightly raised. b. administration of furosemide. c. use of continuous positive airway pressure. d. establishing an IV and administering large boluses of fluid. ______30. Your patient is extremely hypertensive with a diastolic reading of over 130 mmHg. He complains of a severe headache, vomiting, and dizziness. You should suspect: a. noncardiogenic pulmonary edema. b. hypertensive encephalopathy. c. dissecting aortic aneurysm. d. meningitis. ______31. Sudden death is defined as death: a. immediately after the onset of symptoms. b. without any signs or symptoms. c. within 1 hour after the onset of symptoms. d. that is unexpected for any reason. ______32. Return of spontaneous circulation (ROSC) occurs when resuscitation results in: a. survival. b. sudden death. c. a spontaneous pulse and respirations. d. a spontaneous pulse, with or without breathing. ______33. According to the MOST recent science of cardiac arrest: a. airway has priority over circulation. b. circulation has priority over breathing. c. breathing has priority over circulation. d. defibrillation has priority over circulation. ______34. The thickening, loss of elasticity, and hardening of the walls of the arteries from calcium deposits are called: a. arteriosclerosis. c. claudication. b. atherosclerosis. d. an aneurysm. ______35. Which of the following statements about an abdominal aortic aneurysm is TRUE? a. It is more common in women than in men. b. It is most prevalent between the ages of 60 and 70. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed

c. It occurs most frequently above the renal arteries. d. Signs and symptoms include pain in the calf muscles.

Student’s Name ________________

HANDOUT 2-8 EVALUATION

CHAPTER 2 QUIZ, PART 3 Write the letter of the best answer in the space provided. ______1. Passage of an electrical current away from the positive electrode will cause ______ deflection on the recorder. a. no c. a negative b. a positive d. an upward ______2. The frontal plane leads consist of leads: a. I, II, III, aVR, aVL, and aVF. c. I, II, and III. b. V1, V2, V3, V4, V5, and V6. d. aVR, aVL, and aVF. ______3. Leads I, II, and III are: a. unipolar. c. precordial. b. bipolar. d. pericardial. ______4. When the electrical current moves through the heart from the right arm toward the left arm, lead I will record a: a. negative deflection. c. biphasic deflection. b. positive deflection. d. deflection that depends on the placement. ______5. In lead II, the negative electrode is placed on the: a. left arm, and the positive electrode is placed on the left leg. b. right arm, and the positive electrode is placed on the left arm. c. right arm, and the positive electrode is placed on the left leg. d. right leg, and the positive electrode is placed on the right arm. ______6. Leads I, II, and III form: a. Cushing’s triad. c. Einthoven’s triangle. b. Starling’s triad. d. Brewster’s islet. ______7. The precordial leads provide a look at the ______ plane of the heart. a. vertical c. parallel b. horizontal d. diagonal ______8. The heart’s normal electrical axis is 59 degrees. In the normal tracing, which lead will have the most positive deflection? a. Lead I c. Lead III b. Lead II d. Lead aVF ______9. Any time the axis equals or exceeds +105 degrees, the patient is said to have a(n): a. normal electrical axis. c. right axis deviation. b. left axis deviation. d. indeterminate axis. ______10. Which quadrant of the frontal plane is considered normal? a. 0 to +90 degrees c. 0 to −90 degrees b. +90 to +180 degrees d. −90 to −180 degrees ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed

______11. An infarction that affects only the deeper levels of the myocardium is a(n) ______ infarction. a. transmural c. endocardial b. subepicardium d. subendocardial ______12. ST segment elevation, T wave inversion, and the development of significant Q waves in the ______ leads indicate myocardial infarction involving the anterior surface of the heart. a. V5 and V6 c. I, V2, V3, and V4 b. II, III, and aVF d. I and aVL ______13. True posterior infarctions can be diagnosed by looking: a. for reciprocal changes in V1 and V2. b. at leads II, III, and aVF. c. at leads V5 and V6. d. for none of the above. ______14. The dysrhythmia that is characterized by each impulse arriving at the AV junction being progressively delayed until, eventually, AV conduction is completely blocked is called ______ AV block (Mobitz I). a. first-degree c. partial b. second-degree d. third-degree ______15. Your patient’s ECG shows a broad S wave in lead I and an R-S-R prime complex in lead V1. This indicates a: a. third-degree AV block. c. right bundle branch block. b. hemiblock. d. chamber enlargement.

Student’s Name ________________

HANDOUT 2-9 EVALUATION

CHAPTER 2 SCENARIO 1 Review the following real-life situation. Then answer the question that follow. You are called to the local shopping center, where a 70-year-old woman has collapsed while shopping. Her daughter called the ambulance. The daughter states that the patient weighs approximately 110 pounds and that she had been experiencing substernal chest pains for approximately 20 minutes when she suddenly “passed out. ” The patient has not responded to verbal stimuli in the past 5 minutes. Bystanders inform you that the patient was breathing on her own until a few minutes before your arrival. The store manager, who has recently been trained in CPR, initiated rescue breathing but has not begun chest compressions because he “thought he felt a pulse.” You immediately connect the patient to the cardiac monitor and note the rhythm to be sinus tachycardia, with frequent PVCs. You note at this time that the patient has resumed spontaneous respirations. 1. What steps would you take in the management of this patient?

Student’s Name ________________

HANDOUT 2-10 EVALUATION

CHAPTER 2 SCENARIO 2 Review the following real-life situation. Then answer the questions that follow. You and your partner are called to the scene of a rural residence where you find a 57-year-old male who is complaining of chest pain. The patient reports a history of recent surgery that was performed to repair a fractured pelvis. Approximately 2 hours ago, he began to experience “tightening in his chest,” chest discomfort, and shortness of breath. He now reports that he feels nauseated. 1. What would be your initial assessment considerations with this patient? Your partner records the patient’s vital signs as follows: blood pressure, 180/120; heart rate, 140; and respirations, 32. When you connect the patient to the ECG, you see a wide-complex tachycardia (uncertain type). When you contact the base hospital, your medical direction physician instructs you to follow the ACLS algorithm for wide-complex tachycardia and to keep her informed of the patient’s status. 2. Before initiating drug therapy, what questions would you ask the patient?

3. What is the most important step in the initial management of this patient?

4. Five minutes into your management of this patient, his blood pressure drops to 130/74, and he exhibits a decreased level of consciousness. What should you do next?

Student’s Name ________________

HANDOUT 2-11 REINFORCEMENT

CHAPTER 2 REVIEW Write the word or words that best complete each sentence in the space(s) provided. 1. The heart consists of three tissue layers: the ____________________, ________________, and ________________. 2. The two superior chambers of the heart are the ________________. The larger, inferior chambers are the ________________. 3. The heart contains two pairs of valves, the ________________ valves and the ________________ valves. 4. The ________________ ________________ ________________ receives deoxygenated blood from the head and upper extremities. The ________________ ________________ ________________ receives blood from the areas below the heart. 5. The only veins in the body that carry oxygenated blood are the ________________ veins. 6. ________________ law states that blood flow through a vessel is directly proportional to the radius of the vessel to the fourth power. 7. The period of time from the end of one cardiac contraction to the end of the next is called the ________________ ________________. 8. The period of time when the myocardium is relaxed and cardiac filling and coronary perfusion occur is called ________________. 9.

________________ is the period of the cardiac cycle when the myocardium is contracting.

10. The ratio of blood pumped from the ventricle to the amount of blood remaining at the end of diastole is called the ________________ ________________. 11. The term ________________ refers to the pressure within the ventricles at the end of diastole. 12. The term ________________ refers to the resistance against which the heart must pump. 13. The amount of blood pumped by the heart in one minute is called the ________________ ________________. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed

14. The term ________________ ________________ refers to the amount of blood ejected by the heart in one cardiac contraction. 15. The term chronotropy pertains to heart ________________. 16. The term inotropy pertains to cardiac ________________ ________________. 17. The term ________________ pertains to the speed of impulse transmission. 18. A reversal of charges at a cell membrane so that the inside of the cell becomes positive in relation to the outside is called cardiac ________________. 19. The normal electrical state of cells is called ________________ ________________. 20. The stimulation of myocardial cells that subsequently spreads across the myocardium is called the ________________ ________________. 21. The return of a muscle cell to its preexcitation resting state is called ________________. 22. The term ________________ pertains to cells being able to respond to an electrical stimulus. 23. The term ________________ pertains to cells being able to propagate the electrical impulse from one cell to another. 24. The pacemaker cells’ capability of self-depolarization is called ________________. 25. A deflection on the ECG produced by factors other than the heart’s electrical activity is called a(n) ________________. 26. Leads I, II, and III are known as ________________ limb leads. 27. Leads V1 through V6 are called the ________________ leads. 28. Unipolar limb leads are also called ________________ limb leads. 29. On ECG graph paper, one small box is equal to ________________ seconds. 30. On ECG graph paper, one large box is equal to ________________ seconds. 31. The P wave corresponds to ________________ depolarization. 32. The QRS complex reflects ________________ depolarization. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed

33. ________________ waves may be associated with electrolyte abnormalities. 34. The normal duration of the PR interval is ________________ to ________________ seconds. 35. The normal QRS complex is ________________ to ________________ seconds. 36. The period of time when myocardial cells have not yet completely repolarized and cannot be stimulated again is called the ________________ ________________ period. 37. The ________________ ________________ ________________ is the period of the cardiac cycle when a sufficiently strong stimulus may reproduce depolarization. 38. A heart rate greater than ________________ beats per minute is called tachycardia. 39. A heart rate less than 60 beats per minute is called ________________. 40. Any deviation from the normal electrical rhythm of the heart is called ________________. 41. The absence of cardiac electrical activity is called ________________. 42. A nonpacemaker cell that automatically depolarizes is called a(n) ________________ focus. 43. Forced expiration against a closed glottis is called a ________________ maneuver. 44. The sound of turbulent blood flow through a vessel is called a(n) ________________. 45. A uniform delay in conduction at the level of the AV node is called a(n) ________________-degree AV block. 46. An intermittent block at the level of the AV node is called a(n) ________________-degree AV block. 47. The absence of conduction between the atria and the ventricles resulting from complete electrical block at or below the AV node is called a(n) ________________-degree AV block. 48. A single ectopic impulse arising from an irritable focus in either ventricle that occurs earlier than the next expected beat is called a(n) ________________ ________________ ________________.

49. PVCs are termed as malignant if there are more than ________________ per minute. 50. ________________ ________________ is a chaotic ventricular rhythm usually resulting from the presence of many reentry circuits within the ventricles. 51. The dysrhythmia in which there are electrical complexes but no accompanying mechanical contractions of the heart is called ________________ ________________ ________________. 52. Conduction of the electrical impulse through the heart’s conductive system in an abnormal fashion is called ________________ conduction. 53. A(n) ________________ ________________ ________________ is a kind of interventricular heart block in which conduction through either the right or the left bundle branches is blocked or delayed. 54. ________________ ________________ is the most common presenting symptom in cases of cardiac disease. 55. Use the ________________ acronym to help you obtain the patient’s description of pain. 56. Systematic, thorough physical examinations involve three components: ________________, ________________, and ________________. 57. ________________ life support is the primary skill for managing serious cardiovascular problems. 58. Having the patient bear down as if attempting to have a bowel movement is called a(n) ________________ maneuver. 59. Atropine, lidocaine, adenosine, amiodarone, and diltiazem are all ________________ medications. 60. ________________ ________________ is a parasympatholytic agent used to treat symptomatic bradycardia. 61. ________________ is a medication used to manage supraventricular tachydysrhythmia. 62. ________________ is a first-line antidysrhythmic used to treat and prevent life-threatening ventricular dysrhythmia. 63. ________________, the mainstay medication of cardiac arrest resuscitation, acts on both alpha- and beta-adrenergic receptors. 64. ________________ ________________ is a medication that reduces myocardial oxygen demand by reducing preload and afterload. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed

65. ________________ is a medication that inhibits the aggregation of platelets. 66. The process of passing a current through a fibrillating heart to depolarize the cells is called ________________. 67. The term ________________ ________________ refers to the passage of an electrical current through the heart during a specific part of the cardiac cycle to terminate certain kinds of dysrhythmia. 68. Chest pain that results when myocardial oxygen demands exceed the heart’s blood supply is called ________________ ________________. 69. A variant of angina pectoris caused by vasospasm of the coronary arteries is called ________________ angina. 70. Ischemia and subsequent necrosis of the heart muscle caused by inadequate blood supply take place in ________________ ________________. 71. ________________ ________________ is the clinical syndrome in which the heart’s mechanical performance is compromised such that cardiac output cannot meet the body’s needs. 72. A blood clot in one of the pulmonary arteries is called a pulmonary ________________. 73. In ________________ ________________ ________________, the heart’s reduced stroke volume causes an overload of fluid in the body’s other tissues. 74. A sudden episode of difficult breathing that occurs after lying down is called ________________ ________________ ________________. 75. The accumulation of excess fluid inside the pericardium is called ________________ ________________. 76. A cerebral disorder of hypertension indicated by severe headache, nausea, vomiting, and altered mental status is called ________________ ________________. 77. The inability of the heart to meet the metabolic needs of the body, resulting in inadequate tissue perfusion, is called ________________ shock. 78. The absence of any ventricular contraction is called ________________ ________________. 79. ________________ death is death within 1 hour after the onset of symptoms. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed

80. The thickening, loss of elasticity, and hardening of the walls of the arteries from calcium deposits are known as ________________. 81. Severe pain in the calf muscle due to inadequate blood supply is called ________________. 82. The condition in which the ballooning of an arterial wall results from a defect or weakness in the wall is called a(n) ________________. 83. ________________ ________________ ________________ is the death or degeneration of a part of the wall of an artery. 84. ________________ ________________ ________________ is a blockage that occurs when a blood clot or other particle lodges in a pulmonary artery. 85. Sudden occlusion of arterial blood flow is called ________________ ________________ occlusion. 86. Leads I, II, and III are called ________________ limb leads. 87. Leads aVR, aVL, and aVF are called ________________ limb leads. 88. Leads V1 through V6 are known as the ________________ leads. 89. A force that has both magnitude and direction is called a(n) ________________. 90. The reduction of all the heart’s electrical forces to a single vector represented by an arrow moving in a single plane is called the ________________ axis. 91. A calculated axis of the heart’s electrical energy that equals or exceeds +105° is known as ________________ ________________ ________________. 92. A calculated axis of the heart’s electrical energy that equals or exceeds −30° is known as ________________ ________________ ________________. 93. Deprivation of oxygen and other nutrients to the myocardium is called ________________ ________________. 94. ________________ ________________ is the death of myocardial tissue. 95. Myocardial infarction that affects only the deeper levels of the myocardium is called ________________ infarction. 96. Myocardial infarction that affects the full thickness of the myocardium is called ________________ infarction. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed

97. A mirror image seen typically on the opposite wall of the injured area is said to be ________________. 98. ________________ is enlargement without any additional cells. 99. Myocardial ischemia occurs ________________ ________________ following loss of blood supply. 100. If myocardial ischemia is allowed to progress untreated, ________________ ________________ will result.

Student’s Name ________________

HANDOUT 2-12 REINFORCEMENT

ECG ANALYSIS

List the five-step procedure for ECG analysis.

1. ___________________________________________________________ 2. ___________________________________________________________ 3. ___________________________________________________________ 4. ___________________________________________________________ 5. ___________________________________________________________

Student’s Name ________________

HANDOUT 2-13 REINFORCEMENT

DYSRHYTHMIA MATCHING Write the letter of the term in the space provided next to the appropriate description. a. sinus bradycardia

r. third-degree AV block

b. sinus tachycardia

s. premature junctional contractions

c. sinus dysrhythmia d. sinus arrest e. sinus block f. sinus pause g. wandering atrial pacemaker h. multifocal atrial tachycardia

t. junctional escape complexes and rhythm u. junctional bradycardia v. accelerated junctional rhythm

i. premature atrial contractions

w. ventricular escape complexes and rhythms

j. paroxysmal supraventricular tachycardia

x. accelerated idioventricular rhythm

k. supraventricular tachycardia

y. premature ventricular contraction

l. atrial flutter m. atrial fibrillation n. first-degree AV block

z. ventricular tachycardia aa. torsades de pointes bb.

ventricular fibrillation

o. type I second-degree AV block

cc. asystole

p. type II second-degree AV block

dd. artificial pacemaker rhythm

q. 2:1 AV block ______

______

______ ______

1. Polymorphic ventricular tachycardia that differs in appearance and cause from ventricular tachycardia in general. It is more common in women than in men. 2. Intermittent block characterized by P waves that are not conducted to the ventricles but without associated lengthening of the PR interval before the dropped beats. 3. Results from slowing of the SA node. 4. Delay in conduction at the level of the AV node rather than an actual block. This is a condition superimposed on another rhythm.

______

5. Single ectopic impulse arising from an irritable focus in either ventricle that occurs earlier than the next expected beat. ______ 6. Results from an increased rate of SA node discharge. ______ 7. Passive transfer of pacemaker sites from the sinus node to other latent pacemaker sites in the atria and AV junction. ______ 8. Chaotic ventricular rhythm usually resulting from the presence of many reentry circuits within the ventricles. ______ 9. Results from regular cardiac stimulation by an electrode implanted in the heart and connected to a power source. ______ 10. Occurs when the sinus node fires on time but the impulse is blocked before it exits the sinus node. This results in a pause that varies in length depending on how many sinus beats are blocked. ______ 11. Often results from a variation of the R-R interval. ______ 12. Results from a single electrical impulse originating in the atria outside the SA node, which in turn causes a premature depolarization of the heart before the next expected sinus beat. ______ 13. Accelerated junctional rhythm resulting from increased automaticity in the AV junction, causing the AV junction to discharge faster than its intrinsic rate. ______ 14. Dysrhythmia with a heart rate less than the intrinsic rate of the AV node. ______ 15. Refers to tachycardias that originate above the ventricles. The pacemaker site is often difficult to determine because of the heart rate. ______ 16. Wandering pacemaker rhythm with a rate greater than 100. ______ 17. Results from multiple areas of reentry within the atria or from multiple ectopic foci bombarding an AV node that physiologically cannot handle all of the incoming impulses. ______ 18. Intermittent block at the level of the AV node. It produces a characteristic cyclic pattern in which the PR intervals become progressively longer until an impulse is blocked (not conducted). ______ 19. Results from a rapid atrial reentry circuit and an AV node that physiologically cannot conduct all impulses through to the ventricles. ______ 20. Absence of conduction between the atria and the ventricles resulting from complete electrical block at or below the AV node. The atria and ventricles subsequently pace the heart independently of each other. ______ 21. Single electrical impulse originating in the AV node that occurs before the next expected sinus beat. ______ 22. Dysrhythmia that results when the rate of the primary pacemaker, usually the SA node, is slower than that of the AV node. The AV node then becomes the pacemaker. ______ 23. Type of second-degree AV block in which there are two P waves for each QRS complex. The first P wave of each pair of P waves is blocked. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed

______ 24. Occurs when rapid atrial depolarization overrides the SA node. It often occurs in paroxysm with sudden onset, may last minutes to hours, and terminates abruptly. ______ 25. Results either when impulses from higher pacemakers fail to reach the ventricles or when the discharge rate of higher pacemakers becomes less than that of the ventricles. ______ 26. Abnormally wide ventricular dysrhythmia that usually occurs during an acute myocardial infarction. Typically, the rate is 60 to 110 beats per minute. ______ 27. Occurs when the sinus node fails to discharge for a brief period, resulting in missing a single PQRST complex. ______ 28. Three or more ventricular complexes in succession at a rate of 100 beats per minute or more. ______ 29. Sinus node fails to discharge for a brief period, resulting in short periods of cardiac standstill. One or more of the subsequent PQRST complexes will be missing. ______ 30. Absence of all cardiac electrical activity.

Chapter 2 Answer Key Handout 2-6: Chapter 2 Quiz, Part 1 1. c 2. b 3. c 4. b 5. a 6. c 7. b 8. c 9. c 10. a 11. b 12. b 13. d

14. b 15. a 16. c 17. a 18. c 19. d 20. c 21. b 22. b 23. a 24. c 25. b 26. a

27. d 28. c 29. c 30. c 31. b 32. b 33. b 34. c 35. a 36. d 37. a 38. d 39. c

40. b 41. d 42. c 43. d 44. b 45. a 46. d 47. d 48. a 49. d 50. b

Handout 2-7: Chapter 2 Quiz, Part 2 1. d 2. c 3. a 4. b 5. c 6. b 7. d 8. b 9. c

10. b 11. d 12. c 13. c 14. b 15. a 16. b 17. c 18. b

19. c 20. d 21. a 22. a 23. d 24. b 25. d 26. b 27. c

28. a 29. c 30. b 31. c 32. d 33. b 34. a 35. b

Handout 2-8: Chapter 2 Quiz, Part 3 1. c 2. a 3. b 4. b

5. c 6. c 7. b 8. b

9. c 10. a 11. d 12. c

13. a 14. b 15. c

Handout 2-9: Chapter 2 Scenario 1 1. Steps in the management of this patient would include the following: a. Immediately reassess the patient’s level of consciousness and ABCs. b. Place the patient on 100% oxygen via nonrebreather mask. c. Obtain baseline vital signs and contact medical direction. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed

d. Establish an IV per protocols or medical direction. e. Consider an IV bolus of lidocaine per protocols or medical direction. Handout 2-10: Chapter 2 Scenario 2 1. As with all patients who are ill or injured, the initial assessment considerations include immediate assessment of the patient’s level of consciousness, airway, breathing, and circulatory status. 2. Do you have any allergies? Have you ever experienced this type of pain before? What medications are you currently taking? 3. Administration of high-flow oxygen (100% at 15 L/min) via nonrebreather mask. 4. An IV NS would have been established. Administer amiodarone 150 mg IV over 10 minutes. Repeat as needed to a maximum dose of 2, 2 g over 24 hours. If SVT with aberrancy is suspected, administer adenosine, 6 mg rapid IV push. Adenosine can be repeated in one to two minutes if necessary at 12 mg rapid IV push. Consider synchronized cardioversion with sedation as well. Carefully monitor the patient en route to the hospital, maintaining contact with medical direction. Handout 2-11: Chapter 2 Review 1. endocardium, myocardium, pericardium 2. atria, ventricles 3. atrioventricular, semilunar 4. superior vena cava, inferior vena cava 5. pulmonary 6. Poiseuille’s 7. cardiac cycle 8. diastole 9.

Systole

12. afterload 13. cardiac output 14. stroke volume 15. rate 16. contractile force 17. dromotropy 18. depolarization 19. resting potential 20. action potential 21. repolarization 22. excitability 23. conductivity 24. automaticity 25. artifact 26. bipolar 27. precordial 28. augmented 29. 0.04 30. 0.20 31. atrial 32. ventricular 33. Q 34. 0.12, 0.20 35. 0.08, 0.12 36. absolute refractory 37. relative refractory period ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed

38. 100 39. bradycardia 40. dysrhythmia 41. arrhythmia 42. ectopic 43. vagal (or Valsalva) 44. bruit 45. first 46. second 47. third 48. premature ventricular contraction (PVC) 49. six 50. Ventricular fibrillation 51. pulseless electrical activity 52. aberrant 53. bundle branch block 54. Chest pain 55. OPQRST 56. inspection, auscultation, palpation 57. Basic 58. vagal (or Valsalva) 59. antidysrhythmic 60. Atropine sulfate 61. Adenosine 62. Amiodarone 63. Epinephrine ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed

64. Morphine sulfate 65. Aspirin 66. defibrillation 67. synchronized cardioversion 68. angina pectoris 69. Prinzmetal’s 70. myocardial infarction 71. Heart failure 72. embolism 73. congestive heart failure 74. paroxysmal nocturnal dyspnea 75. cardiac tamponade 76. hypertensive encephalopathy 77. cardiogenic 78. cardiac arrest 79. Sudden 80. arteriosclerosis 81. claudication 82. aneurysm 83. Cystic medial necrosis 84. Acute pulmonary edema 85. acute arterial 86. bipolar 87. unipolar 88. precordial 89. vector ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed

90. QRS 91. right axis deviation 92. left axis deviation 93. myocardial ischemia 94. Myocardial infarction 95. subendocardial 96. transmural 97. reciprocal 98. Hypertrophy 99. almost immediately 100. myocardial injury

Handout 2-12: ECG Analysis 1. Rate 2. Rhythm 3. P waves 4. PR interval 5. QRS complex Handout 2-13: Dysrhythmia Matching 1. aa 2. p 3. a 4. n 5. y 6. b 7. g 8. bb ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed

9. dd 10. e 11. c 12. i 13. v 14. u 15. k 16. h 17. m 18. o 19. l 20. r 21. s 22. t 23. q 24. j 25. w 26. x 27. f 28. z 29. d 30. cc

Chapter 3 Neurology Student’s Name ________________

HANDOUT 3-1 EVALUATION

CHAPTER 3 QUIZ Write the letter of the best answer in the space provided. ______ 1.

The part of the nervous system that extends throughout the body is called the ______ nervous system. a. peripheral c. somatic b. ventral d. afferent

______ 2.

The sympathetic nervous system is also known as the ______ division. a. feed-or-breed c. slow-or-go b. fight-or-flight d. stand-or-draw

______ 3.

The division of the autonomic nervous system that is responsible for controlling vegetative functions is the ______ nervous system. a. somatic c. sympathetic b. afferent d. parasympathetic

______ 4.

The fundamental unit of the nervous system is the: a. axon. c. synaptic terminals. b. soma. d. nerve cell, or neuron.

______ 5.

The axon is the portion of a nerve cell that: a. comes into physical contact with another nerve cell. b. conducts nerve impulses toward the soma. c. conducts nerve impulses away from the soma. d. contains most of the metabolic machinery.

______ 6.

The membranes covering the brain and spinal cord are collectively called the: a. dura mater. c. pia mater. b. meninges. d. arachnoid membranes.

______ 7.

The portion of the brain that governs all sensory and motor actions is the: a. cerebellum. c. cerebrum. b. medulla oblongata. d. pons.

______ 8.

The middle layer of the meninges is called the: a. mid mater. c. pia mater. b. dura mater. d. arachnoid membrane.

______ 9.

Involuntary actions such as temperature regulation, sleep, water balance, stress response, and emotions are the responsibility of the: a. cerebellum. c. corpus callosum. b. midbrain. d. diencephalon.

______ 10. A portion of the brain that is NOT considered part of the brainstem is the: a. mesencephalon. c. medulla oblongata. b. pons. d. cerebellum. ______ 11. The reticular activating system is responsible for: a. maintaining consciousness and the ability to respond to stimuli. b. posture, equilibrium, and muscle tone. c. respiratory, cardiac, and vasomotor activity. d. motor coordination and eye movement. ______ 12. One of the two systems that join at the circle of Willis is the ______ system. a. venous sinus c. vertebrobasilar b. internal jugular d. reticular activating ______ 13. The ______ fibers transmit impulses to the central nervous system from the body. a. afferent c. dermerent b. efferent d. reflexerent ______ 14. The 12 pairs of ______ nerves originate in the brain and supply nervous control to the head, neck, and certain thoracic and abdominal organs. a. cranial c. anterolateral b. arachnoid d. hexaxial ______ 15. When stimulated, the sympathetic nervous system: a. causes a rise in blood glucose. b. causes an increase in digestive activity. c. is mediated by the neurotransmitter acetylcholine. d. is responsible for controlling vegetative functions. ______ 16. A mechanism that is capable of producing alterations in mental status is a structural lesion. One cause of structural lesions is: a. hepatic failure. c. brain tumor (neoplasm). b. hypoglycemia. d. anoxia. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed

______ 17. Any malfunction of or damage to the peripheral nerves is called peripheral: a. neuropathy. c. diaphoresis. b. cyanosis. d. encephalopathy. ______ 18. You can quickly assess a patient’s mental status by using the ______ method. a. SAMPLE c. AEIOU-TIPS b. AVPU d. OPQRST ______ 19. Abnormal pupils can be an early indicator of increasing intracranial pressure that is compressing cranial nerve: a. I. c. III. b. II. d. IV. ______ 20. The breathing pattern characterized by a period of apnea that lasts 10–60 seconds, followed by gradually increasing depth and frequency of respirations, is called: a. Kussmaul’s respiration. b. Guillian-Barré respiration. c. apneustic respiration. d. Cheyne-Stokes respiration. ______ 21. Ataxic respirations are: a. intercostal muscle dysfunctions. b. poor respirations due to CNS damage. c. prolonged inspirations unrelieved by expirations. d. lesions caused by hyperventilation. ______ 22. Your patient opens his eyes only when you pinch his shoulder. He has no verbal responses and withdraws from pain. His Glasgow Coma Score total is: a. 2. c. 4. b. 3. d. 7. ______ 23. On the Glasgow Coma Scale, a patient with a total score of ______ or better has an estimated 94% favorable outcome. a. 8 c. 6 b. 7 d. 5 ______ 24. Cushing’s traid is associated with increasing intracranial pressure and: a. decreased blood pressure c. irregular respirations. b. increased pulse. d. decreased temperature. ______ 25. The words ______ and ______ are assigned to the letter “A” in the mnemonic AEIOU-TIPS. a. airway, altered c. abdomen, acute ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed

b. alert, awake

d. acidosis, alcohol

______ 26. Studies have proven that ______ and other thrombolytic agents used in the treatment of heart attack are also effective in treating certain occlusive strokes. a. epinephrine c. morphine sulfate b. tPa d. lidocaine ______ 27. A stroke caused by the gradual development of a blood clot in a cerebral artery is called a(n): a. thrombotic stroke. c. hemorrhagic stroke. b. embolic stroke. d. aneurysm. ______ 28. The prehospital stroke scoring system that assesses blood glucose levels, facial droop, grip strength, and arm drift is the: a. Cincinnati Prehospital Stroke Scale. b. New York Prehospital Stroke Screen. c. Los Angeles Prehospital Stroke Screen. d. North American Prehospital Stroke Scale. ______ 29. Symptoms from a transient ischemic attack (TIA) generally resolve within: a. 6 hours. c. 24 hours. b. 12 hours. d. 48 hours. ______ 30. When caring for a patient suffering from a nervous system condition or disease, your first priority in patient care is to: a. administer thrombolytic therapy. b. assess for any neurologic deficits. c. establish and maintain an adequate airway. d. apply high-concentration oxygen by nonrebreather mask. ______ 31. A generalized motor seizure that produces a loss of consciousness is known as a(n): a. absence seizure. c. hysterical seizure. b. tonic-clonic seizure. d. complex partial seizure. ______ 32. The phases of a generalized seizure include all of the following EXCEPT: a. aura. c. postictal. b. loss of consciousness. d. absence. ______ 33. Management of the seizure patient includes: a. inserting an oral airway while the patient is seizing. b. protecting the patient from hitting nearby objects. c. establishing an IV containing a dextrose solution. d. holding a tongue blade in the patient’s mouth. ______ 34. The term “status epilepticus” refers to a: ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed

a. chronic seizure patient taking anticonvulsant medication regularly. b. generalized seizure lasting more than one minute. c. two or more seizures with no intervening periods of consciousness. d. patient experiencing a seizure for the first time. ______ 35. Management of the adult patient in status epilepticus includes administration of: a. 5–10 mg diazepam IV push. b. oral glucose if hypoglycemia is present. c. dextrose, Narcan, and thiamine IV push. d. sumatriptan and prochlorperazine. ______ 36. A series of one-sided headaches that are sudden and intense and that may continue for 15 minutes to 4 hours is referred to as: a. syncope headaches. c. organic headaches. b. migraine headaches. d. cluster headaches. ______ 37. Consider a headache a potentially serious condition if the patient describes it as: a. sudden in onset and “the worst headache of my life.” b. lasting for more than 24 hours. c. being accompanied by nausea and photosensitivity. d. dull or achy pain with a feeling of forceful pressure. ______ 38. The term ______ is used to desribe the new growth of a tumor. a. malignant c. benign b. metastasized d. neoplasm ______ 39. The disease that involves inflammation of certain nerve cells followed by demyelination is called: a. dystonia. c. multiple sclerosis. b. muscular dystrophy. d. Alzheimer’s disease. ______ 40. A neural defect that results from the failure of one or more of the fetal vertebrae to close properly during the first month of pregnancy is called: a. myoclonus. c. poliomyelitis. b. amyotrophic lateral sclerosis (ALS). d. spina bifida. ______41.

Inflammation of the interspinous bursae will cause pain at the level of: a. C-1, C-2, C-3, C-4, and C-5 b. T-1, T-2, T-3, T-4, T-5, and T-6 c. L-3, L-4, L-5, and S-1 d. S-1, S-2, S-3, S-4, and S-5

Student’s Name ________________

HANDOUT 3-2 EVALUATION

CHAPTER 3 SCENARIO Review the following real-life situation. Then answer the questions that follow. Your crew has just finished lunch when your pagers go off. It is a call for an unconscious patient at 1324 Amsterdam Avenue. After a relatively short trip, the ambulance pulls up to the address given by the dispatcher. A man meets you at the front door of the house and says that his wife has just had a seizure. As you enter the residence, you see three small children standing in the spotless living room. The children and the husband are all very upset and concerned about the patient, who is a well-dressed, 32-year-old woman who appears to be sleeping on the couch. You begin to assess the patient while another paramedic obtains a history. The paramedic student, who is riding with your crew today, prepares to hook the patient up to oxygen and the cardiac monitor. When you speak to the patient, she opens her eyes for a moment, mumbles something unintelligible, and goes back to sleep. She is breathing normally (rate 16 and regular), and her breath sounds are clear bilaterally. The pulse is strong and regular at the wrist, but the rate is slightly elevated at 105. She can move all extremities and responds to pain. Her pupils are equal and reactive (although sluggishly) to light. Blood glucose is 100, and the ECG shows a sinus tachycardia. The husband reports that his wife has a history of epilepsy. She takes Tegretol as directed by her physician (three times a day), but she ran out after last night’s dose. They were getting ready to go to the drugstore to pick up the refill when she began to seize. Her epilepsy is fairly well controlled, and she has not had a seizure for a couple of months. The seizure appeared to be typical for the patient: tonic–clonic twitching for about 1 minute followed by a postictal phase. The patient has no other health problems, her recent health has been good, and the only medication she takes is Tegretol. She is allergic to codeine, and her last meal was lunch, about 45 minutes ago. The patient wakes and starts speaking to you. She states that she does not want to go to the hospital. If she gets her medicine, she will be okay, and there is nothing the hospital can do for her. You ask some questions to determine whether she is alert and oriented. Not only does she pass all the tests, but she even manages to make a small joke when asked who the president is. The patient and her husband thank you and your crew profusely but insist that no further services are required. A refusal form is signed by the patient and witnessed before you return to the station. 1. Why did the crew pay attention to the condition of the house and the dress and appearance of the patient?

2. What are some considerations the crew should raise before allowing this patient to refuse transportation?

3. Was the crew right to let the patient refuse treatment? 4. Who should witness the patient’s refusal, and what information should be relayed to the patient?

Student’s Name ________________

HANDOUT 3-3 REINFORCEMENT

CHAPTER 3 REVIEW Write the word or words that best complete each sentence in the space(s) provided. 1. The central nervous system is made up of the _____________ and _____________ __________________. 2. The _______________ nervous system extends throughout the body. 3. Voluntary bodily functions are controlled by the __________________ nervous system. 4. The _______________ nervous system controls involuntary bodily functions. 5. The _______________ nervous system is the division of the autonomic nervous system that prepares the body for stressful situations. 6. The _______________ nervous system is the division of the autonomic nervous system that controls vegetative functions. 7. A(n) _______________ is a substance that is released from the axon terminal of a presynaptic neuron on excitation. 8. The membranes covering and protecting the brain and spinal cord are called the __________________. 9. The portion of the brain lying beneath the cerebrum and above the brain stem is called the ______________________. 10. The __________________ ________________ is the lower portion of the brain stem, connecting the pons and the spinal cord. It contains major centers for control of _______________, ___________________, and __________________ activity. 11. The system responsible for consciousness is the ____________ ________________ system. 12. ___________________ fibers transmit impulses to the central nervous system from the body, while ___________________ fibers carry impulses from the central nervous system to the body. 13. There are 12 pairs of _________________ nerves that extend from the lower surface of the brain. 14. The ________________ nervous system is often referred to as the “fight-or-flight” system, and the __________________ nervous system is referred to as the “feed-and-breed” system. 15. The parasympathetic nervous system is mediated by the neurotransmitter _________________. 16. Brain tumor, intracranial hemorrhage, parasites, and trauma are among the causes of ________________ _________________, which are capable of producing alterations in mental status. 17. Any malfunction or damage of the peripheral nerves is called ______________ _________________. 18. The “A” in the mnemonic ____________________ means that the patient is alert and aware of his or her surroundings. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed

19. Hyperventilation caused by a lesion in the CNS, often characterized by rapid, deep, noisy respirations, is called _______________ ______________ ___________. 20. Poor respirations due to CNS damage, causing ineffective thoracic muscular coordination, are called __________________. 21. A(n) _______________ posture is one in which the patient presents with the arms flexed, fists clenched, and legs extended. 22. A(n) ______________ posture is one in which the patient presents with stiff and extended extremities and retracted head. 23. A collective change in vital signs associated with increasing intracranial pressure is called _______________ triad. 24. _______________ syndrome is a condition characterized by loss of memory and disorientation and is associated with chronic alcohol intake and a diet that is deficient in thiamine. 25. Hemorrhagic strokes are usually categorized as being within the brain (__________) or in the space around the outer surface of the brain (____________). 26. The Cincinnati Prehospital Stroke Scale (CPSS) evaluates __________________ ________________, _______________ __________________, and ___________________. 27. Seizures that begin as an electrical discharge in a small area of the brain but spread to involve the entire cerebral cortex, causing widespread malfunction, are called __________________ seizures. 28. In the ________________ phase of a generalized seizure, the patient may awaken confused and fatigued. 29. _________ __________ are idiopathic disorders of early childhood and rarely occur after age 20. 30. A series of two or more generalized motor seizures without any intervening periods of consciousness is called _____________ _______________. 31. A neurologic condition characterized by the sudden, temporary loss of consciousness caused by insufficient blood flow to the brain, with recovery of consciousness almost immediately on becoming supine, is known as _______________. 32. ________ _________ is a sudden, unilateral weakness or paralysis of the facial muscles, due to a dysfunction of the seventh cranial nerve. 33. Alzheimer’s disease, muscular dystrophy, and multiple sclerosis are all examples of _________________ _________________ disorders. 34. Lou Gehrig’s disease, or _______________ _________________ ______________, is a progressive degeneration of specific nerve cells that control voluntary movement. 35. Thousands of survivors of _______________, an infectious, inflammatory viral disease of the CNS that can result in permanent paralysis, require supportive care. 36. ________ _________ refers to the vertebrae themselves breaking down.

HANDOUT 3-4

Student’s Name ________________

REINFORCEMENT TREATMENT IN NERVOUS SYSTEM EMERGENCIES A number of treatments are performed for the patient with CNS problems. For each one described here, give a brief rationale of why the treatment is beneficial. 1. Administration of oxygen 2. Initiating IV normal saline or lactated Ringer’s solution (not 5% dextrose) 3. Determining the blood glucose level 4. Protecting the airway 5. Providing reassurance to the patient 6. Monitoring cardiac rhythm

HANDOUT 3-5

Student’s Name ________________

REINFORCEMENT NERVOUS SYSTEM ANATOMY AND PHYSIOLOGY Write the word or words that best complete each sentence in the space(s) provided. 1. The fundamental unit of the nervous system is the nerve cell, or _______________. The nerve cell includes the cell body, which contains the _______________; the ___________________, which carry nervous impulses to the cell body; and the ____________________, which transmit nervous impulses away from the cell body. 2. The transmission of impulses in the nervous system resembles the conduction of electrical impulses through the _________________. When stimulated, __________________ rapidly enters the cell and _____________________ rapidly leaves it, producing a positive charge at the entry site. This positive charge, which is called the ___________________________ ___________________________, is subsequently transmitted down the neuron at extremely high velocity. The neuron joins with other neurons at junctions called ___________________________. The neurons do not come into direct contact with each other. Instead, on reaching the junction, the cell causes the release of a chemical ___________________________. The chemical associated with the parasympathetic and voluntary nervous systems is ___________________________. The chemical found at the terminals of sympathetic nerves is ___________________________. 3. The entire central nervous system is covered in protective membranes called the ___________________________. The outermost layer is called the ___________________________ ___________________________. The middle layer is known as the ___________________________ membrane. The innermost layer, directly overlying the central nervous system, is called the ___________________________ ___________________________. Both the brain and the spinal cord are bathed in ___________________________ fluid. 4. Of the six main divisions of the brain, the largest one is called the ___________________________. It consists of ___________________________ hemispheres and is the seat of ___________________________ and the center of the higher mental functions. 5. The superior most portion of the brainstem is called the ___________________________. It contains the thalamus, the ___________________________, and the limbic system. This area is responsible for many involuntary actions, such as ___________________________. 6. The _____________________, or the midbrain, controls ___________________________ ___________________________ and ___________________________ ___________________________. The ___________________________ is located between the midbrain and the ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed

medulla oblongata and contains connections between the brain and the spinal cord. The ___________________________ ___________________________ is the lower portion of the brainstem, connecting the pons and the spinal cord. The ___________________________ is located in the posterior fossa of the cranial cavity.

Chapter 3 Answer Key Handout 3-1: Chapter 3 Quiz 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

a b d d c b c d d d

11. 12. 13. 14. 15. 16. 17. 18. 19. 20.

a c a a a c a b c d

21. 22. 23. 24. 25. 26. 27. 28. 29. 30.

b d a c d b a c c c

31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41.

b d b c a d a d c d c

Handout 3-2: Chapter 3 Scenario 1. If a patient is taking care of the living environment and personal appearance, she may exercise similar care about personal health and adherence to a physician’s orders. 2. The patient cannot drive to the drugstore in her condition, and the husband should not leave her alone with three small children. The paramedics have an obligation to ensure that these considerations are brought up and resolved reasonably. 3. The patient was alert and oriented. Additionally, the patient is familiar with her seizure pattern and can make a reasonable assessment of her need for transport. 4. Ideally, the refusal should be witnessed by the woman’s husband. As part of the refusal process, the patient should be informed of the risks of refusing treatment (another seizure) and other possible causes of the seizure (hypoxia, diabetes, and so on) that the paramedics cannot rule out. The family should also be informed that if the patient has another seizure, they are to call 911 without hesitation. Finally, the patient should be advised to inform her private physician that she had a seizure. Handout 3-3: Chapter 3 Review 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.

brain, spinal cord peripheral somatic autonomic sympathetic parasympathetic neurotransmitter meninges diencephalon medulla oblongata, respiratory, cardiac, vasomotor reticular activating Afferent, efferent

13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36.

cranial sympathetic, parasympathetic acetylcholine structural lesions peripheral neuropathy AVPU central neurogenic hyperventilation ataxic decorticate decerebrate Cushing’s Wernicke’s intracerebral, subarachnoid facial droop, arm drift, speech generalized postictal Absence seizures status epilepticus syncope Bell’s palsy degenerative neurologic amyotrophic lateral sclerosis poliomyelitis Vertebral spondylolysis

Handout 3-4: Treatment in NervousSystem Emergencies 1. The brain is very sensitive to hypoxia. Administration of oxygen is important for minimizing further CNS damage. 2. An IV is needed for vascular access. Saline or lactated Ringer’s solution is used because they are isotonic solutions, which should not contribute significantly to cerebral edema. In addition, the emergency department staff may have to administer phenytoin, which is incompatible with dextrose solutions. 3. Hypoglycemia may be the cause of the CNS problems. 4. The patient cannot protect his airway on his own. Also, in a CNS emergency patient, the risk of vomiting is increased. 5. Often, the patient cannot communicate and may not understand what is happening. 6. Cardiac rhythm disturbances may be causing the CNS problem, or damage to the cardiac and respiratory centers of the brain may result in dysrhythmias. Handout 3-5: Nervous System Anatomyand Physiology 1. neuron, nucleus, dendrites, axons 2. heart, sodium, potassium, action potential, synapses, neurotransmitter, acetylcholine, norepinephrine 3. meninges, dura mater, arachnoid, pia mater, cerebrospinal fluid 4. cerebrum, two, consciousness ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed

5. diencephalon, hypothalamus, (any of the following) temperature regulation, sleep, water balance, stress response, emotions 6. mesencephalon, motor coordination, eye movement, pons, medulla oblongata, cerebellum

Chapter 4 Endocrinology Student’s Name ________________

HANDOUT 4-1 SKILLS

DETERMINING BLOOD GLUCOSE Charting Student Progress: 1. Learning skill 2. Performs skill with direction 3. Performs skill independently Procedure 1. 2. 3.

Prepare the equipment required for blood glucose measurement. Insert the lancet into the adjustable lancing device.

Remove the test strip and insert it into the glucometer test slot. Cleanse the puncture site.

Obtain a drop of blood.

Apply the blood to the reagent strip in the glucose meter. Read the blood glucose level.

7. 8. 9.

Provide appropriate treatment based on result and patient presentation. Record the results on the patient care report.

Comments:

Student’s Name ________________

HANDOUT 4-2 EVALUATION

CHAPTER 4 QUIZ Write the letter of the best answer in the space provided. ______ 1. In contrast to the ______ glands, whose effects tend to be widespread, the ______ glands tend to have more localized effects. a. hypostasis, metabolism c. glucagon, insulin b. endocrine, exocrine d. Kussmaul’s, Cushing’s ______ 2. The natural tendency of the body to keep the internal environment and metabolism steady and normal is called: a. myxedema. c. ketoacidosis. b. homeopathy. d. homeostasis. ______ 3. There are eight major glands in the endocrine system. These include the: a. pseudothyroid. c. pons. b. pancreas. d. parietal. ______ 4. The junction between the central nervous system and the endocrine system is the: a. hypothalamus. c. thyroid. b. pituitary. d. thymus. ______ 5. Antidiuretic hormone, produced by the posterior pituitary gland is also known as: a. epinephrine. c. norepinephrine. b. vasopressin. d. insulin. ______ 6. The anterior pituitary hormone that has a broader effect than the other pituitary hormones is: a. thyroid stimulation hormone. c. luteinizing hormone. b. prolactin. d. growth hormone. ______ 7. Parathyroid hormone increases blood calcium levels in all of the following target tissue EXCEPT: a. the heart. c. the bones. b the intestines. d. the kidneys. ______ 8. The pancreas secretes two major hormones, including: a. prolactin. c. aldosterone. b. calcitonin. d. glucagon. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed

______ 9. Epinephrine and norepinephrine are hormones released by the: a. gonads. c. pituitary. b. thymus. d. adrenal medulla. ______ 10. Aldosterone, a mineralocorticoid, contributes to salt and fluid balance in the body by regulating _____________ and __________ excretion through the kidneys. a. sodium, potassium c. glucose, sodium b. calcium, potassium d. glucose, potassium ______ 11. The hormone familiarly known as the “hormone of pregnancy” is: a. estrogen. c. testosterone. b. progesterone. d. luteinizing hormone. ______ 12. The pineal gland, located in the roof of the thalamus in the brain, releases the hormone: a. melatonin. c. parathyroid hormone. b. cortisol. d. human chorionic gonadotropin. ______ 13. The disorder marked by inadequate insulin activity in the body is called diabetes: a. insipidus. c. pectoris. b. mellitus. d. glycogen. ______ 14. The building phase of metabolism is called: a. catabolism. c. anabolism. b. aerobolism. d. ionolism. ______ 15. The basis of the excessive urination characteristic of untreated diabetes is called: a. facilitated elimination. b. facilitated diffusion. c. osmotic diuresis d. gluconeogensis. ______ 16. As the body switches to fat-based metabolism during diabetic ketoacidosis, the blood level of ________ rises. a. glucose c. ketones b. insulin d. glycogen ______ 17. Which of the following is NOT a sign or symptom of diabetic ketoacidosis? a. Fruity odor to breath c. Malaise b. Ataxic respirations d. Warm, dry skin ______ 18. Which of the following is a sign or symptom of hypoglycemia? a. Abdominal pain ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed

b. Cold, clammy skin c. Polyuria and polydipsia d. Increased mental function ______ 19. All of the following signs and symptoms are characteristic of a thyrotoxic crisis EXCEPT: a. tachycardia and hypotension. c. delirium or coma. b. vomiting and diarrhea. d. profound hypothermia. ______20. The presence of a “moon face” and “buffalo hump” would lead you to believe that your patient has: a. hypothyroidism c. hyperthyroidism b. hypoadrenalism d. hyperadrenalsim ______21. Adrenal insufficiency is also known as: a. Cushing’s syndrome c. Addison’s disease b. myxedema d. thyrotoxic crisis

Student’s Name ________________

HANDOUT 4-3 EVALUATION

CHAPTER 4 SCENARIO Review the following real-life situation. Then answer the questions that follow. You have just gone to the bunk room to get some much-needed sleep. As you finish making up your bunk, you get a dispatch for an unconscious patient. When you arrive on scene, a middle-aged man meets you at the curb. He tells you that he tried to call his mother on the phone and was unable to reach her. He drove 45 miles to her house and found her unconscious on the floor of the upstairs bathroom. You and your partner enter through the front door and are overwhelmed by the sight and stench of a house strewn with garbage. The house’s electricity does not appear to be working. The patient, a 63-year-old woman, is lying unconscious on the floor of the bathroom. She was incontinent of both feces and urine and appears to have been lying there for some time. 1. What are your initial priorities in this situation?

Your partner takes cervical-spine control and places the patient on a nonrebreather face mask at 15 liters per minute. You notice that she has a rapid, weak pulse and that her breathing is rapid and deep. Her skin is warm and dry. On auscultation, some rales are detected in all lung fields. The abdomen, pelvis, and extremities are normal. She is unresponsive to pain, and her pupils are dilated and slow to react. You ask the EMTs to get a set of vitals and to place the patient on a long backboard and the backboard on a stretcher to move her to the paramedic unit for treatment. While they are performing these tasks under the direction of your partner, you ask the son to accompany you to the unit and provide you with the patient’s history while you set up an IV and the ECG monitor. 2. With the information available to this point, what are the possible diagnoses?

While you set up the IV, you ask the son what happened. He says that he hadn’t seen or heard from his mother for about three weeks, so he decided to give her a call this evening. When she did not answer the phone, he became concerned and drove over to see if she was okay. He adds that his mother has a severe alcohol problem. She sometimes forgets to pay her bills, and the electrical utility company has probably shut off the power. You inquire about any other health problems. He says that she has been diagnosed with emphysema, high blood pressure, and “some type of blood sugar problem. “ When you ask about medications, he replies that she has not seen a doctor in years, so there is little ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed

likelihood that she is taking medicine. He is unable to provide any further useful information. Your partner and the EMTs come out of the house with the patient and load her into the ambulance. 3. What do you want to do at this time? You complete your assessment and find that the patient’s blood pressure is 90/50, pulse is 126, respirations are 42 and labored (with a strong, sweet odor on her breath), breath sounds reveal slight diffuse rales, and pulse oximetry is 98%, and the ECG shows a sinus tachycardia without ectopy. Her blood glucose is at the maximum of your ability to determine it (999 on the glucometer). 4. What does this information tell you about the patient?

You start two large-bore (16-gauge) IVs of 0. 9% normal saline, running them wide open. (Before hooking up the IV tubing on the first IV, you draw 20 mL of blood to fill two red-top tubes.) Per your service’s protocols, you administer 100 mg thiamine IV, 50 mL of 50% dextrose in water, and 1 mg of naloxone. There is no change in the patient’s condition following these treatments. Medical direction is contacted, and you give your report. You are told that there are no further orders and that the patient will be placed in bed 5 on your arrival. 5. What information should be included in the report to medical direction?

6. Why would your protocols require administration of dextrose when her blood glucose is so high?

On your arrival at the hospital, you transfer your patient to the hospital stretcher and give a report to the nurse. While you fill out the run sheet, your partner cleans and restocks the ambulance. A couple of days later, you call the emergency department to follow up on the patient’s status. You are informed that she was diagnosed with diabetic ketoacidosis, pneumonia, and malnutrition. She has been admitted to the ICU, is currently on a respirator, and has a poor prognosis.

Student’s Name ________________

HANDOUT 4-4 REINFORCEMENT

CHAPTER 4 REVIEW Write the word or words that best complete each sentence in the space(s) provided. 1. Oxytocin, which stimulates uterine contractions and milk release, is produced by the ________________ gland. 2. The _________ gland stimulates increased reabsorption of water into blood volume, and stimulates __________ ___________ in children. 3. The two lobes of the __________ gland are located in the neck anterior to and just below the cartilage of the laynx. 4. The ____________ gland increased blood calcium levels. 5. The ____________ gland is fairly large in children but shrinks into a small remnant of fat and fibrous tissue in adults. 6. Located in the upper retroperitoneum, the ___________ is composed of both endocrine and exocrine tissues. 7. The process that produces glucose from nonsugar sources is called ________________. 8. ______ is a hormone produced by the pancreas. 9. The ________________ in the male and the ________________ in the female stimulate development of secondary sexual characteristics. 10. The pineal gland releases the hormone _____________ in response to changes in light. 11. An endocrine disorder characterized by inadequate insulin production by the beta cells of the islets of Langerhans is ________________ ________________. 12. The breakdown processes within a cell are collective called _____________. 13. Type II diabetes is associated with a _____________ ___________ in insulin production accompanied by a _____________ ___________ response to insulin. 14. _____________ ________________, or diabetic coma, is a complication of diabetes characterized by high levels of glucose in the blood, metabolic acidosis, and, in advanced stages, coma. 15. As DKA develops, a rapid, deep breathing pattern termed ____________ ______________ helps to expel carbon dioxide from the body. 16. Prolonged exposure of body organs to excess thyroid hormones, produces a condition known as __________________. 17. ________ ________ is likely caused by a shift of thyroid hormone in the blood from the protein-bound (biologically inactive) to the free (biologically active) state. 18. Long-term exposure to excess glucocorticoids is the most common cause of ____________ ___________. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed

19. Adrenal insufficiency, or ______________ ______________, occurs when the adrenal glands fail to produce adequate amounts of the steroid hormones. 20. Destruction of the adrenal cortex results in minimal production of ________________, __________________, and ______________.

Student’s Name ________________

HANDOUT 4-5 REINFORCEMENT

DIABETIC EMERGENCIES Write the letter of the diabetic emergency next to the sign or symptom associated with it. a. Diabetic ketoacidosis b. Hypoglycemia c. Either diabetic ketoacidosis or hypoglycemia ______

1. The patient has not taken insulin.

______

2. The patient has overexerted himself.

______

3. Cold and clammy skin

______

4. Altered mental status

______

5. Seizures

______

6. Polyuria

______

7. Rapid, deep respirations

______

8. Headache

______

9. Tachycardia

______ 10. The patient has not eaten. ______ 11. History of recent illness ______ 12. Skin that is warm and dry ______ 13. Hypotension ______ 14. Hand tremor ______ 15. Sweet, fruity breath odor ______ 16. Intense thirst ______ 17. Unconsciousness ______ 18. Severe electrolyte imbalance ______ 19. True medical emergency ______ 20. Dysrhythmias ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed

Student’s Name ________________

HANDOUT 4-6 REINFORCEMENT

DIAGNOSTIC SIGNS OF DIABETIC EMERGENCIES Complete the chart by filling in the diagnostic signs and symptoms in the correct column. The first line has been filled in for you.

Pulse Blood pressure Respirations Breath odor Headache Mental state Tremors Convulsions Mouth Thirst Vomiting Abdominal pain Vision

Diabetic Ketoacidosis Rapid

Hypoglycemia Normal (may be rapid)

HANDOUT 4-7

Student’s Name ________________

OBJECTIVES ANATOMY AND PHYSIOLOGY OF THE ENDOCRINE SYSTEM Write the word or words that best complete each sentence in the space(s) provided. 1. The pituitary gland is referred to as the ________________ gland of the body. It is divided into ________________ areas, which differ from one another structurally and functionally. 2. The ________________ pituitary produces two hormones: ________________, which stimulates contraction of the gravid uterus, and ________________ hormone (sometimes called vasopressin), which causes the kidney to retain water. 3. The ________________ pituitary produces hormones that regulate other endocrine glands, such as ________________ ________________ ________________ (TSH), which stimulates the thyroid to release its hormones; ACTH, which stimulates the ________________ cortex to release its hormones; and FSH and LH, which stimulate the maturation and release of eggs from the ________________. 4. The ________________ gland lies in the anterior portion of the neck. When stimulated by the pituitary, it releases ________________ and ________________, which function to increase the body’s ________________ rate. 5. Inadequate levels of the hormones produced by the thyroid cause a condition known as ________________. Signs and symptoms of this condition include weakness, facial bloating, ________________ intolerance, lethargy, and altered mental status. 6. An endocrine disorder characterized by excess thyroid hormones is called ________________ disease. Signs and symptoms include insomnia, fatigue, ________________, hypertension, heat intolerance, and weight loss. 7. Located on the posterior lateral surfaces of the thyroid, the ________________ glands are small and pea-shaped. If they release ________________ hormone, the ________________ levels in the body will increase. 8. The pancreas has both endocrine and ________________ functions. The endocrine functions are located in the ________________ ________________ ________________. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed

9. In the pancreas, alpha cells produce ________________, which serves to ________________ the amount of glucose in the blood by stimulating the liver. The beta cells produce ________________, which serves to ________________ the blood glucose level. 10. The ________________ cortex secretes glucocorticoids, which act as anti- ________________ and ________________ agents. They are released in response to ________________, trauma, and serious infection. 11. The female gonads, or ________________, are located in the ________________ on either side of the uterus. They manufacture the hormones ________________ and ________________, which serve in sexual development and preparation of the uterus for implantation of the egg. 12. The male gonads, or ________________, are located outside of the abdominal cavity in the ________________. They manufacture the hormone ________________, which promotes the development and maintenance of male sexual characteristics.

Chapter 4 Answer Key Handout 4-2: Chapter 4 Quiz 1. b 6. d 2. d 7. a 3. b 8. d 4. a 9. d 5. b 10. a 21. c

11. b 12. a 13. b 14. c 15. c

16. c 17. b 18. b 19. d 20. d

Handout 4-3: Chapter 4 Scenario 1. Priority assessment is cervical-spine control and supplemental oxygen by nonrebreather face mask. 2. Possibilities include trauma, cerebrovascular accident, diabetic emergency, dehydration, and poisoning. 3. Patient care should include ECG, blood glucose check, blood sample for lab analysis, two IVs with 0. 9% NS or LR, 100 mg thiamine, 25 g dextrose (D50), 1–2 mg naloxone. 4. The assessment indicates that the patient may be suffering from diabetic ketoacidosis/diabetic coma. 5. Your unit call name and names and numbers of crew; description of scene; patient’s age, sex, and weight; chief complaint; primary problem; associated symptoms; brief history of present illness; pertinent past medical history; physical exam findings; treatment given; and estimated time of arrival. 6. The additional glucose load is negligible in comparison to the quantity already present in the body. Handout 4-4: Chapter 4 Review 1. pituitary 2. pituitary 3. thyroid 4. parathyroid 5. thymus 6. pancreas 7. gluconeogenesis 8. Glucagon 9. testes, ovaries ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed

10. melatonin 11. diabetes mellitus 12. catabolism 13. moderate decline, markedly deficient 14. Diabetic ketoacidosis 15. Kussmaul’s respirations 16. thyrotoxicosis 17. Thyroid storm 18. Cushing’s syndrome 19. Addison’s disease 20. glucocortoids, mineralocorticoids, androgens Handout 4-5: Diabetic Emergencies 1. a 2. b 3. b 4. c 5. b

6. a 7. a 8. b 9. c 10. b

11. a (or c) 12. a 13. a 14. b 15. a

16. a 17. c 18. a 19. b 20. a

Handout 4-6: Diagnostic Signs of Diabetic Emergencies Diabetic Ketoacidosis

Hypoglycemia

Pulse

Rapid pulse

Normal (may be rapid)

Blood pressure

Low blood pressure

Normal blood pressure

Respirations

Exaggerated air hunger

Breath odor

Acetone (sweet, fruity)

Normal or shallow (Kussmaul’s respirations) None

Headache

Absent

Present

Mental state Tremors

Restlessness, unconsciousness Absent

Apathy, irritability, unconsciousness Present

Convulsions

None

In late stages

Mouth

Dry

Drooling

Thirst

Intense

Absent

Vomiting

Common

Uncommon

Abdominal pain

Frequent

Absent

Vision

Dim

Double vision (diplopia)

Handout 4-7: Anatomy and Physiology of the Endocrine System 1. master, two 2. posterior, oxytocin, antidiuretic 3. anterior, thyroid stimulating hormone, adrenal, ovaries 4. thyroid, triiodothyronine, thyroxine, metabolic 5. hypothyroidism, cold 6. Graves’, tachycardia 7. parathyroid, parathyroid, calcium 8. exocrine, islets of Langerhans 9. glucagon, increase, insulin, decrease 10. adrenal, inflammatories, immunosuppressive, stress 11. ovaries, pelvis, estrogen, progesterone 12. testes, scrotum, testosterone

Chapter 5 Allergies and Anaphylaxis Student’s Name ________________

HANDOUT 5-1 EVALUATION

CHAPTER 5 QUIZ Write the letter of the best answer in the space provided. ______

1. Which of the following is TRUE regarding anaphylaxis? a. The signs and symptoms of anaphylaxis begin within 30–60 seconds. b. Reactions that develop more slowly tend to be much more severe. c. Angioneurotic edema is a rare manifestation of anaphylaxis. d. The release of histamine causes gastrointestinal motility to decrease.

______

2. The two MOST common causes of fatal anaphylaxis are: a. injected penicillin and Hymenoptera stings. b. peanuts and sulfites. c. MSG and bee stings. d. lidocaine and tetanus vaccine.

______

3. The type of immunity that involves a direct attack of the foreign substance by specialized cells of the immunse system is: a. humoral immunity. c. natural immunity. b. cellular immunity d. acquired immunity.

______

4. Immunity that develops over time and results from exposure to an antigen is called: a. natural immunity. c. cellular immunity. b. humoral immunity. d. acquired immunity.

______

5. Induced active immunity is immunity that: a. is genetically predetermined and is present at birth. b. begins to develop after birth and is continually enhanced by exposure to new pathogens and antigens throughout life. c. is achieved through a vaccination given to generate an immune response that results in the development of antibodies specific for the injected antigen.

d. results from a direct attack of a foreign substance by specialized cells of the immune system. ______

6. The initial exposure of an individual to an antigen is referred to as: a. primary exposure. b. initial exposure. c. sensitization. d. desensitization.

______

7. The principle chemical mediator of allergic reaction is: a. histamine. b. antihistamine. c. epinephrine. d. Benadryl.

______

8. Angioedema, which is a common manifestation of severe allergic reaction and anaphylaxis usually involves the: a. trachea and lungs. c. bronchials. b. head, neck, face, and upper airway. d. tongue.

______

9. The severity of an allergic reaction is often related to the: a. age of the patient. c. antigen. b. previous history of reactions. d. speed of onset.

______

10. A common sign in mild allergic reactions is urticaria, or: a. raised areas, or wheals, that occur on the skin. b. an itching or tickling sensation in the upper airway. c. itchy, watery eyes. d. sneezing or a “runny” nose. 11. Diphenhydramine acts on: a. the H1 receptors. b. the H2 receptors.

______

c. the H1 and H2 receptors. d. neither type of receptor.

12. Administration of corticosteroids in the patient with anaphylaxis helps to: a. block histamine receptors. c. cause direct bronchodilation. b. suppress the inflammatory d. increase the blood response. pressure. 13. The appropriate dose of epinephrine for a patient experiencing an allergic reaction with dyspnea or wheezing is: a. 0.3–0.5 mg epinephrine 1:10,000 IM. b. 0.3–0.5 mg epinephrine 1:1,000 IV.

c. 0.3–0.5 mg epinephrine 1:1,000 IM. d. 3–5 mg epinephrine 1:1,000IM.

Student’s Name ________________

HANDOUT 5-2 EVALUATION

CHAPTER 5 SCENARIO Review the following real-life situation. Then answer the questions that follow. Medic 12 and Engine 2 arrive on the scene of an injury on a very hot summer day. The scene, a single-family suburban house on a half-acre plot, appears safe to enter. The crews find an unconscious 42-year-old man wearing nothing but running shorts and sandals, lying in a flower bed next to a ladder. His wife, who identifies herself as Mrs. Wilson, reports that she heard a noise and found her husband on the ground in that position. As one member of the engine’s crew takes spinal immobilization, the lead paramedic begins an initial assessment. The other firefighters set up the oxygen with a nonrebreather face mask, begin to get the long backboard ready, and take a complete set of vital signs. The second paramedic talks to the wife to obtain a history. 1. What are some of the possibilities that would account for this situation?

2. What should the paramedic look for during the initial assessment and focused physical exam?

3. What information should the second paramedic attempt to obtain from the patient’s wife?

Mrs. Wilson reports that her husband has no health problems and takes no medications. Other than indicating that he had lunch about an hour ago and that he is allergic to wasps, she cannot provide any more useful information. The paramedic performing the assessment finds that the patient has a contusion on the back of the head but no other apparent injuries. (Since the patient is wearing only the running shorts, only the sandals are removed.) There are some expiratory wheezes, and Mr. Wilson appears to be working to breathe. His vital signs are as follows: blood pressure, 114/78; pulse, 120 and weak at the wrist; capillary refill greater than 2 seconds, and respirations, 30. The ECG shows sinus tachycardia, without ectopy. The pulse oximeter reading shows SaO2 to be 95%. Mr. Wilson’s blood glucose is 120. Assessment of level of consciousness reveals that Mr. Wilson responds to pain by moaning but is unresponsive otherwise. No other marks or deformity are found.

4. What treatment is indicated at this time?

Mr. Wilson is immobilized and secured to a long backboard and moved to the unit. Total time on the scene was less than 7 minutes. An IV is initiated en route to the hospital and run at a rate of 100 mL/hour. By the time the patient arrives at the ED, he is wheezing loudly and has developed stridor. The ED physician administers 0. 5 mg of epinephrine 1:1,000 followed by 25 mg of diphenhydramine. Mr. Wilson’s breathing rapidly improves, and he wakes up. When he is fully conscious, he reports that he was on the ladder cleaning out the gutters when he came on a wasp’s nest. One wasp flew up his shorts and stung him on his left hip. (There is a large circular welt on his hip that is visible when his shorts are removed.) As he tried to swat the wasp, he lost his balance and fell. He does not remember anything further. Mr. Wilson receives a second injection of epinephrine and some oral Benadryl. After a full work-up, the head injury is determined to be a concussion, and Mr. Wilson is discharged to home. 5. What are the lessons to be learned from this case?

Student’s Name ________________

HANDOUT 5-3 REINFORCEMENT

CHAPTER 5 REVIEW Write the word or words that best complete the following sentences in the space(s) provided. 1. _________________ is the MOST severe form of allergic reaction and is often life threatening. 2. The two MOST common causes of fatal anaphylaxis are _________________ _________________ and _________________ _________________. 3. The _________________ ___________ is a complex cascade of events that occurs following activation by an invading substance. 4. The initial response to an antigen is called the ___________ _________. 5. Immunity that is designed to provide protection from exposure to an antigen at some time in the future is called __________________ ___________ ___________. 6. ________ ___________ _________ occurs when antibodies cross the placental barrier from the mother to the infant to provide protection against embryonic or fetal infections. 7. An unexpected and exaggerated reaction to a particular antigen is called ______________. 8. Allergens can enter the body by_________________ ingestion, _________________, or _________________ and through _________________ or _________________. 9. A(n) _________________ is a type of white blood cell that participates in allergic responses. A(n) _________________ cell is a specialized cell of the immune system that contains chemicals that assist in the immune response. 10. _________________ is a product of mast cells and basophils that causes vasodilation, capillary permeability, bronchoconstriction, and contraction of the gut. 11. A common manifestation of severe allergic reactions is _________________ edema of the head, neck, face, and upper airway. 12. _________________ are the raised areas, or wheals, that occur on the skin and that are associated with vasodilation due to histamine release; commonly called _________________. 13. The primary drug for the management of anaphylaxis is _________________. 14. _________________ is probably the MOST frequently used antihistamine in the treatment of allergic reactions and anaphylaxis. The standard dose is ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed

_________________ to _________________ mg intravenously or intramuscularly. 15. Albuterol is the MOST commonly used __________________________________ in prehospital care. 16. Epinephrine 1:1,000 is administered _________________ or _________________, whereas epinephrine 1:10,000 is given _________________. 17. The severity of an allergic reaction can be diminished in certain cases through a process called _________________ or the administering of an extremely small amount of the allergen that causes the patient’s anaphylactic reaction.

HANDOUT 5-4

Student’s Name ________________

REINFORCEMENT CLINICAL PRESENTATIONS OF ALLERGIES AND ANAPHYLAXIS In the space provided, list the signs and symptoms that you would expect to see in each specified body system of a patient with anaphylaxis. Skin ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Respiratory system ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Cardiovascular system ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Gastrointestinal system ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Nervous system ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________

Student’s Name ________________

HANDOUT 5-5 REINFORCEMENT

ANAPHYLAXIS MEDICATIONS In the space provided, briefly describe what the following medications are used for and what their actions are when used to treat patients with anaphylaxis. Oxygen ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Epinephrine ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Antihistamines (give examples) ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Corticosteroids (give examples) ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Vasopressors (give examples) ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Beta-agonists (give examples) ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________

Chapter 5 Answer Key Handout 5-1: Chapter 5 Quiz 1. a 4. d 7. a 10. a 2. a 5. c 8. b 11. c 3. b 6. c 9. d 12. b 13. c Handout 5-2: Chapter 5 Scenario 1. Possibilities include heat exhaustion, heatstroke, fall from the ladder, hypoglycemia, allergic reaction, electrocution, or cardiac problem. 2. The paramedic should perform a standard trauma survey with emphasis on ABCs. He should look for injuries resulting from the fall as well as for possible causes of the fall (for example, low blood glucose, signs of dehydration, dysrhythmias, burns, or stings). 3. The paramedic should ask questions about the patient’s medical history using the SAMPLE mnemonic. 4. The crew should provide oxygen at 10 to 15 L/min via nonrebreather mask, apply a cervical spine immobilization device, and immobilize the patient to a long spine board. They should establish one or two IVs of NS or LR. They should follow standing orders or contact medical direction and consider treatment for allergic reaction. 5. Trauma can frequently accompany an allergic reaction. You should try to determine what caused trauma to occur. There may be an underlying medical cause. Remove all of a patient’s clothing when performing an assessment. This scenario also underscores that a well-coordinated effort by all emergency responders can minimize scene time. Handout 5-3: Chapter 5 Review 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13.

Anaphylaxis injected penicillin, Hymenoptera stings immune response primary response induced active immunity Natural passive immunity hypersensitivity oral, inhalation, topically, injection, envenomation basophil, mast Histamine angioneurotic Urticaria, hives epinephrine

14. Diphenhyramine, 25, 50 15. beta-agonist 16. intramuscularly, subcutaneously, intravenously 17. desensitization Handout 5-4: Clinical Presentationsof Allergies and Anaphylaxis Skin: Rash, urticaria (hives), itching, swelling, pallor, diaphoresis Respiratory system: Dyspnea, coughing, sneezing, wheezing, stridor, tightness of the neck/throat, pulmonary edema, tracheal/laryngeal edema, tachypnea Cardiovascular system: Tachycardia, dysrhythmias, hypotension, pallor, diaphoresis, dryness of the mouth Gastrointestinal system: Nausea, vomiting, diarrhea, abdominal cramping, dryness of the mouth Nervous system: Anxiety, restlessness, headache, unconsciousness, convulsions Handout 5-5: Anaphylaxis Medications Oxygen: Oxygen is always the first drug to administer to treat hypoxia in a patient with an anaphylactic reaction. Administer high-concentration oxygen with a nonrebreather mask. If the patient is not breathing adequately, administer oxygen via mechanical ventilation device, such as a bag-valve mask. Epinephrine: Epinephrine is the primary drug for use in treatment of severe allergic reactions and anaphylaxis. It is a sympathetic agonist. It causes an increase in heart rate, increase in the strength of the cardiac contractile force, and peripheral vasoconstriction. It can also reverse some of the bronchospasm associated with anaphylaxis. Epinephrine also reverses much of the capillary permeability caused by histamine. It acts within minutes of administration. In severe anaphylaxis with hypotension and/or severe airway obstruction, administer epinephrine 1:10,000 IV. Standard adult dose of epinephrine 1:10,000 is is 0.1–0.35 mg In severe cases of sustained anaphylaxis, medical direction may order an epinephrine drip. Antihistamines: Antihistamines are second-line agents. They should be given only after the administration of epinephrine. Antihistamines block the effects of histamine by blocking histamine receptors. They do not displace histamine from the receptors. They only block additional histamine from binding. They also help to reduce histamine release from mast cells and basophils. Most antihistamines are nonselective and block both H 1 and H2 receptors. Diphenhydramine (Benadryl) is the most frequently used antihistamine. Other antihistamines used are hydroxyzine (Atarax, Vistaril) and promethazine (Phenergan). The standard dose of diphenhydramine is 25–50 mg slow IV or IM.

Corticosteroids: Corticosteroids are of little benefit in the initial stages of treatment of anaphylaxis, but they help to suppress the inflammatory response associated with these emergencies. Commonly used corticosteroids include methylprednisolone (Solu-Medrol), hydrocortisone (Solu-Cortef), and dexamethasone (Decadron). Vasopressors: Vasopressors are used to treat severe and prolonged anaphylactic reactions to support blood pressure. Use these medications in conjunction with first-line therapy and adequate fluid resuscitation. Commonly used agents include dopamine, norepinephrine, and epinephrine. These medications are prepared as infusions and are continuously administered to support blood pressure and cardiac output. Beta-agonists: Inhaled beta-agonists are used to treat anaphylaxis with bronchospasm (wheezing), laryngeal edema, or both. The most frequently used is albuterol (Ventolin, Proventil). Usually used in the treatment of asthma. Adult dose is 0.5 mL of albuterol in 3 mL of NS via a handheld nebulizer. Other beta-agonists are metaproterenol (Alupent) and levalbuterol (Xopenex).

Chapter 6 Gastroenterology Student’s Name ________________

HANDOUT 6-1 EVALUATION 

CHAPTER 6 QUIZ Write the letter of the best answer in the space provided. ______

1. All of the following are gastrointestinal emergency risk factors EXCEPT: a. excessive smoking. c. excessive exercise. b. poor bowel habits. d. increased stress.

______

2. Pain that originates in the walls of hollow organs is called: a. visceral pain. c. somatic pain. b. peritoneal pain. d. referred pain.

______

3. Somatic pain is described as: a. a dull, achy pain that is vague and difficult to localize. b. a sharp pain that travels along definite neural routes to the spinal column. c. pain that originates in a region other than where it is felt. d. pain originating in the walls of hollow organs, in the capsules of solid organs, or in the visceral peritoneum.

______

4. A dissecting abdominal aortic artery will produce a referred pain felt: a. in the chest. c. between the shoulder blades. b. in the lower extremities. d. in the neck.

______

5. Usually, patients with severe abdominal pathology will: a. be moving around because they cannot get comfortable. b. want to lie supine with legs straight out. c. be seated, leaning forward in an attempt to relieve the pain. d. lie as still as possible in the fetal position.

______

6. Observing distention in a patient’s abdomen is an ominous sign, because the abdomen can hold _________ of fluid before any noticeable change in abdominal girth occurs. a. 4–6 L

b. 2–4 L c. 1–2 L d. 250–500 mL ______

7. Abdominal pain lasting more than 6 hours is considered: a. a chronic condition. b. a surgical emergency. c. significant if vital signs are unstable. d. a typical amount of time for most abdominal complaints.

______

8. Bloody vomitus is called: a. melena. b. hemoptysis. c. hematemesis. d. hematuria.

______

9. A swollen vein in the esophagus is called a(n): a. portal. c. diverticulitis. b. esophageal aneurysm. d. esophageal varix.

______ 10. A sudden onset of diarrhea associated with mucosal inflammation is called: a. gastroenteritis. c. peptic ulcer. b. acute gastroenteritis. d. Zollinger-Ellison syndrome. ______ 11. The MOST common pathogen causing chronic gastroenteritis in the United States is: a. Klebsiella pneumoniae. b. Enterobacter. c. Helicobacter pylori. d. Salmonella. ______ 12. One of the MOST common causes of peptic ulcers is: a. stress. b. spicy food. c. smoking. d. nonsteroidal anti-inflammatory medication. ______ 13. Zollinger-Ellison syndrome is associated with: a. esophageal varices. c. duodenal ulcers. b. hemorrhoids. d. bowel obstruction.

______ 14. Your patient presents with colicky pain, low-grade fever, nausea and vomiting, and tenderness to the lower left side of the abdomen. He is MOST likely suffering from: a. hemorrhoids. c. hernia. b. peptic ulcer. d. diverticulitis. 15. Hemorrhoids are: a. small masses of swollen veins in the anus. b. ulcerations of the anus. c. infected mucosal tissue in the anus. d. outpouching of the lining of the anus. ______ 1 6. Hernias, intussusception, volvulus, and adhesions are the four MOST frequent causes of: a. abdominal pain. b. gastroenteritis. c. inflammatory bowel disorder. d. bowel obstruction. 17. A common site of pain in cases of appendicitis is: a. Hey’s ligament. c. Charcot’s joint. b. Schultze’s tract. d. McBurney’s point. ______

18. Ninety percent of cholecystitis cases are caused by: a. bowel obstruction. c. gallstones. b. hepatitis. d. colon lesions.

______ 19. The cause of over 80 percent of pancreatitis cases in the United States is: a. infectious diseases. c. gallstones. b. thromboembolisms. d. alcoholism. ______ 20. This form of hepatitis, known as “serum hepatitis,” is transmitted as a bloodborne pathogen that can stay active in bodily fluids outside the body for days. a. Hepatitis B c. Hepatitis D b. Hepatitis C d. Hepatitis E

Student’s Name ________________

HANDOUT 6-2 EVALUATION 

CHAPTER 6 SCENARIO Review the following real-life situation. Then answer the questions that follow. Community One Ambulance is dispatched for a sickness call. On arrival, the crew finds a 42-year-old female complaining of nausea, vomiting, and abdominal pain. The lead paramedic starts performing his physical assessment and begins to obtain a history. The patient had dinner about 7:00 P.M. (it is now 1:00 A.M.) and began feeling nauseous at 9:30 P.M. She thought that perhaps her problem was related to some “bad salad dressing.” At 10:15 P.M., she began vomiting. The vomiting continued until 911 was called at 12:45 A.M. Abdominal pain, described as “achy,” began about the time the vomiting started. The patient says that the pain started around her navel and has moved down into her right lower quadrant. 1. What are important aspects of the assessment?

2. What are important aspects of the history?

The patient has no significant medical history. Her last menstrual period was 10 days ago, and she had a tubal ligation 7 years ago. She takes no medications, and the only surgeries are two C-sections over a decade ago. On physical examination, her abdomen is tender, with some guarding. There is some rebound tenderness in the right lower quadrant. Vital signs are as follows: blood pressure, 105/66; pulse, 78 (negative tilt test); respirations, 20 and regular, unlabored, breath sounds equal, clear bilaterally; ECG is NSR, without ectopy; and pulse oximeter is 99 percent on room air. Her skin is warm, dry, and flushed. All other physical examination findings are normal. 3. What is this patient’s problem and what leads to that conclusion?

4. What treatment is indicated for this patient?

5. What would be the best way to transport the patient?

Student’s Name ________________

HANDOUT 6-3 REINFORCEMENT 

CHAPTER 6 REVIEW Write the word or words that best complete the following sentences in the space(s) provided. 1. The three types of gastrointestinal pain are _______________________, _______________________, and _______________________. 2. The three mechanisms that produce visceral pain are ___________, ____________________, and ______________. 3. Appendicitis initially presents with vague ______________ ______________ _____ that is classified as ____________. 4. Pain that originates in walls of the body such as skeletal muscles is called _______________________ pain. 5. Pain that originates in a region other than where it is felt is known as _______________________ pain. 6. When using the mnemonic OPQRST-ASPN to gain the history of the present illness of your gastrointestinal patient, the AS stands for _______________________ _______________________, and the PN stands for _______________________ _______________________. 7. Usually, patients with severe abdominal pathology lie as still as possible, often in the ____________ _________. 8. If you _______________________ the abdomen, you must do so before _______________________ it. 9. Persistent abdominal pain lasting longer than _______________________ hours always requires transport. 10. Upper gastrointestinal bleeding is within the GI tract proximal to the _______________________ _______________________ _______________________. 11. A Mallory-Weiss tear is a(n) _______________________ laceration, usually secondary to _______________________. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed

12. Bloody vomitus is known as _______________________, and dark, tarry, foul-smelling stool is known as _______________________. 13. A swollen vein in the esophagus is called an esophageal _______________________. 14. Over time, alcohol consumption can cause a degenerative process known as __________ of the liver. 15. Patients with acute gastroenteritis can have stool that appears watery and might show either melena or _____________, which is bright red blood from erosion of the lining of the lower GI tract. 16. Common medications to reduce mucosal irritation include histamine blockers such as ______ and _________, proton-pump inhibitors such as ______ and _______, and antacids such as __________. 17. Lower GI bleeding occurs in the GI tract distal to the ____ ___ __________. 18. Acute pain associated with cramping or spasms in the abdominal organs is called _______________________. 19. Prehospital diagnosis of _______________________ disease is next to impossible because the patient’s clinical presentations can vary drastically as the disease progresses. 20. _______________________ are small outpouchings in the mucosal lining of the intestinal tract. 21. The four MOST frequent causes of bowel obstruction are _______________________, _______________________, _______________________, and _______________________. 22. A common site of pain associated with appendicitis is 1–2 inches above the anterior iliac crest in a direct line with the umbilicus. This site is known as _______________________ _______________________. 23. Hepatitis _______________________ is transmitted as a bloodborne pathogen and can stay active in bodily fluids outside the body for days. 24. In patients with hepatitis, the stool is often a(n) _______________________ color, while the skin is _______________________.

25. The key to successful treatment of GI ailments is prompt _______________________, _______________________, and _______________________ transport to the hospital.

Student’s Name ________________

HANDOUT 6-4 REINFORCEMENT 

GASTROINTESTINAL TERMINOLOGY Write the letter of the term in the space provided next to the appropriate description. a. Acute abdomen b. Diverticula c. Diverticulitis d. Guarding e. Hematemesis f. Melena g. Peritoneum h. Rebound tenderness i. Portal system j. Hematuria ______

1. A rapid onset of abdominal pain.

______

2. Voluntary or involuntary contraction of the abdominal muscles in response to severe abdominal pain.

______

3. Serous membrane covering the viscera of the abdomen and lining the interior of the abdominal cavity.

______

4. Tenderness on release of pressure from the examiner’s hands, allowing the patient’s abdominal wall to return to its normal position.

______

5. Circulatory system that collects blood from parts of the abdominal viscera and transports it to the liver.

______

6. Small, fingerlike pouches on the colon associated with degeneration of the muscular layer of the organ.

______

7. An inflammation or infection of a diverticulum.

______

8. The vomiting of blood.

______

9. Black, tarry stool due to gastrointestinal bleeding.

Chapter 6 Answer Key Handout 6-1: Chapter 6 Quiz 1. c 2. a 3. b 4. c 5. d

6. a 7. b 8. c 9. d 10. b

11. c 12. d 13. c 14. d 15. a

16. d 17. d 18. c 19. d 20. a

Handout 6-2: Chapter 6 Scenario 1. Initial assessment; ABCs with particular emphasis on assessment of shock. Focused physical examination of the abdomen. Note the patient’s position. Ask the patient to localize the pain, and palpate each quadrant, checking for rebound tenderness. Check vital signs and postural vitals. 2. Information about the pain, using OPQRST mnemonic. Menstrual history of female patients; medications; medical problems, especially abdominal problems; prior surgical history, especially abdominal surgeries; and last oral intake. 3. The problem is acute appendicitis indicated by pain originating in the periumbilical region and moving into the LRQ, rebound tenderness, nausea, and vomiting. 4. Treatment includes prevention/treatment of shock with oxygen, IVs, monitoring of vital signs, and transport. 5. Transport would be best in position of comfort, usually supine, with the knees drawn up. Handout 6-3: Chapter 6 Review 1. visceral, somatic, referred 2. inflammation, distention, ischemia 3. periumbilical abdominal pain, visceral 4. somatic 5. referred 6. associated symptoms, pertinent negatives 7. fetal position 8. auscultate, palpating 9. 6 10. ligament of Treitz 11. esophageal, vomiting 12. hematemesis, melena ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed

13. varix 14. cirrhosis 15. hematochezia 16. ranitidine, famotidine, omeprazole, esomeprazole, sucralfate 17. ligament of Treitz 18. colic 19. Crohn’s 20. Diverticula 21. hernias, intussusception, volvulus, adhesions 22. McBurney’s point 23. B 24. clay, yellow 25. recognition, treatment, rapid

Handout 6-4: Gastrointestinal Terminology 1. a 2. d 3. g 4. h 5. i 6. b 7. c 8. e 9. f 10. j

Chapter 7 Urology and Nephrology

Student’s Name ___________________

HANDOUT 7-1

CHAPTER 7 QUIZ Write the letter of the best answer in the space provided. ______1.

______2.

______3.

______4.

______5.

______6.

______7.

The kidney’s regulation of water and other important substances in blood is an example of: a. dialysis. c. homeostasis. b. metabolism. d. hypertrophy. The most severe form of long-term failure of kidney function due to nephron loss is called: a. acute polynephritis. c. chronic nephritis. b. chronic renal failure. d. end-stage renal failure. Benign prostatic hypertrophy is: a. a noncancerous enlargement of the prostate associated with aging. b. a noncancerous enlargement of the prostate due to fluid/blood engorgement. c. tissue necrosis of the prostate due to decreased perfusion. d. infection caused by swelling of the prostate gland that eventually compresses the urethra. The microscopic structure in the kidney that produces urine is called a: a. Bowman’s capsule. c. glomerulus. b. distal tubule. d. nephron. Which of the following is NOT true regarding the kidneys? a. Each young adult kidney contains about one million nephrons. b. The left kidney lies behind the liver, and the right kidney lies behind the spleen. c. The kidneys are located in the left and right areas of the small of the back, or flanks. d. A healthy kidney in a young adult is about the size of a fist. Which of the following is one of the three general processes involved in formation of urine? a. Glomerular osmosis c. Diffusion b. Secretion d. Refiltration Under normal conditions, about ______ percent of filtered Na + and Cl- is reabsorbed in the proximal tubule. a. 25 c. 55 b. 45 d. 65

______8.

Which of the following is TRUE regarding glucose and the kidneys? a. Glucose is prevented from entering Bowman’s capsule and is not filtered. b. Glucose begins to be lost in urine when the blood glucose level exceeds about 180 mg/dL. c. Normally, glucose is not completely reabsorbed by the time filtrate leaves the proximal tubule. d. In uncontrolled diabetes mellitus type I, the body retains glucose and large amounts of water in the osmotic diuresis process. ______9. A direct indicator of GFR is: a. blood urea nitrogen concentration. b. blood concentration of renin. c. blood concentration of creatinine. d. erythropoietin. ______10. The kidneys regulate systemic arterial blood pressure by the release of: A. renin. c. urea. B. creatinine. d. erythropoietin. ______11. Pain arising in hollow organs such as the ureter and bladder is called: a. referred pain. c. rebound pain. b. visceral pain. d. inflammatory pain. ______12. Besides the OPQRST mnemonic used to obtain information about a patient’s pain, also ask about: a. changes in bowel habits or stool. c. chest pain. b. weight loss. d. all of the above. ______13. If your patient is suffering from peritonitis, his position of comfort will most likely be: a. standing erect. c. seated, leaning forward. b. lying prone. d. lying with knees drawn to the chest. ______14. Pain induced by percussion of the flanks indicates: a. ureter blockage. c. bladder infection. b. kidney infection. d. prostatic enlargement. ______15. A patients is considered to be having a surgical emergency if his abdominal pain has lasted longer than: a. 24 hours. c. 6 hours. b. 12 hours. d. 4 hours. ______16. A sudden drop in urine output to less than 400–500 mL per day or no urine output is an indication of: a. renal calculi. c. chronic renal failure. b. acute renal failure. d. acute urinary tract infection.

______17. Acute renal failure due to decreased blood perfusion to the kidneys is called: a. postrenal ARF. c. prerenal ARF. b. renal ARF. d. anurimic ARF. ______18. Common causes of acute renal failure due to decreased blood perfusion to the kidneys include: a. hemorrhage. c. shock. b. heart failure. d. all of the above. ______19. More than half of all cases of end-stage renal failure are caused by hypertension and: a. heart failure. c. diabetes mellitus. b. infections. d. alcoholism. ______20. The dialysis procedure relying on vascular access to the blood and on an artificial membrane is known as: a. dialysate. c. peritoneal dialysis. b. hemodialysis. d. semipermeable dialysis. ______21. The MOST common type of kidney stone is composed of: a. calcium salts. c. struvite. b. uric acid. d. cystine. ______22. The MOST common cause of nontraumatic priapism is: a. carbon monoxide poisoning. b. leukemia. c. sickle cell disease. D. calcium channel blocker overdose. ______23. Treatment for testicular torsion is necessary within _____ hours to salvage the affected testicle. a. 2 c. 6 b. 4 d. 8 ______24. Nosocomial urinary tract infections are MOST commonly caused by the all of the following bacteria EXCEPT: a. Candida. c. Pseudomonas. b. Klebsiella. d. Proteus. ______25. The triad of _____________ is typical in the history of a patient with a urinary tract infection. a. pain, bleeding, and difficulty urinating b. urgency, pain, and difficulty urinating c. increased urination, bleeding, and diluted urine d. increased urination, pain, and urgency

Student’s Name ___________________

HANDOUT 7-2 EVALUATION

CHAPTER 7 SCENARIO Review the following real-life situation. Then answer the questions that follow. Highland Medic 6 is dispatched for a sickness at the rest area on U.S. Highway 41. On arrival, they find a 48-year-old male complaining of excruciating pain in his back. He was driving to a vacation site in the woods when the pain suddenly came on him. No longer able to drive, he pulled into the rest area, and his wife called 911. Mr. Clark is a slightly overweight man with a history of gout (for which he takes Zyloprim) and high blood pressure. Other than the chronic problems, he has been in excellent health until today. As the crew attempts to obtain a history on Mr. Clark, he is very restless and does not sit still. He keeps asking for something for the pain, but the crew tells him that they have nothing to give him. After some effort, they find that the patient is having difficulty urinating and that there has been some blood in his urine. The patient also reports that he has felt very nauseous since the pain started. Except for the patient’s obvious distress and slightly elevated vital signs, (blood pressure is 150/100, and pulse is 105), the crew can find nothing abnormal on their physical exam. The patient is placed in the ambulance, and an IV of normal saline is started and run at 100 mL/hour. The patient is transported to the hospital without incident. 1. What is Mr. Clark’s problem, and what leads you to that conclusion?

2. What prehospital treatment is indicated for this condition?

3. How will this treatment help to alleviate the problem? 4. What will be Mr. Clark’s hospital course, and what is his prognosis?

Student’s Name ___________________

HANDOUT 7-3 REINFORCEMENT

CHAPTER 7 REVIEW Write the word or words that best complete the following sentences in the space(s) provided. 1. The ability to maintain a stable internal environment despite changing external conditions is called _______________. 2. _______________ is the cellular process that produces energy and molecular materials; the waste derived from ammonia produced through this process is called _______________. 3. _______________ is the medical specialty dealing with the kidneys. 4. An extreme failure of the kidneys due to the loss of nephrons is _______________-______________ _______________ _______________. 5. The common term for renal calculi is _______________ _______________. 6. The noncancerous enlargement of the prostate associated with aging is called _______________ _______________ _______________. 7. The microscopic structure within the kidney that produces urine is the _______________. 8. The removal from blood of water and other elements, which enter the nephron tubule, is called _______________ _______________, and the movement of a substance from a tubule back into the blood is called _______________. 9. _______________ _______________ is the random motion of molecules from an area of high concentration to an area of lower concentration, while _______________ _______________ is a molecule-specific carrier in a cell membrane speeding the molecule’s movement from a region of higher concentration to one of lower concentration. 10. _______________ is the formation and passage of dilute urine, decreasing blood volume, while _______________ is the formation and passage of a concentrated urine, preserving blood volume. 11. Blood concentration of _______________, measured by the BUN test, is an indirect indicator of GFR. Blood concentration of _______________ is a direct indicator of GFR. 12. The enzyme _______________, produced by the kidneys, plays a key role in controlling arterial blood pressure. 13. _______________ pain is pain arising in hollow organs such as the ureter and bladder. 14. Pain felt in a location other than that of its origin is called _______________ pain. 15. Management of the patient with abdominal pain includes the administration of fluids or medication only by _______________ or _______________ routes. Give nothing by _______________. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed

16. _______________ _______________ _______________ is indicated by the sudden onset of severely decreased urine production, or _______________; or urine output falling to zero, a condition called _______________. 17. Permanently inadequate renal function due to nephron loss is called _______________ _______________ _______________. 18. _______________ dialysis is a dialysis procedure that relies on the peritoneal membrane as the semipermeable membrane. 19. _______________ is an infection and inflammation of the urinary bladder. 20. ________________ is an infectious inflammation of the renal parenchyma.

Student’s Name __________________

HANDOUT 7-4 REINFORCEMENT

ANATOMY OF THE KIDNEY Write the letter of the term in the space provided next to the appropriate description. a. Hilum b. Cortex c. Medulla d. Pyramid e. Renal pelvis f. Glomerulus g. Papilla h. Bowman’s capsule i. Proximal tubule j. Descending loop of Henle k. Ascending loop of Henle l. Distal tubule m. Collecting tubule n. Collecting duct The part of the tubule beyond Bowman’s capsule The visible tissue structures within the medulla of the kidney The part of the tubule beyond the ascending loop of Henle The notched part of the kidney where the ureter and other structures join the kidney tissue _______ 5. A part of the tubule beyond the distal tubule _______ 6. The part of the tubule beyond the proximal tubule _______ 7. The hollow, cup-shaped first part of the nephron tubule _______ 8. The outer tissue of the kidney _______ 9. The tip of the pyramid; it juts into the hollow space of the kidney. _______10. The part of the tubule beyond the descending loop of Henle _______11. A tuft of capillaries from which blood is filtered into a nephron _______12. The inner tissue of the kidney _______13. The hollow space of the kidney that junctions with a ureter _______14. The larger structure beyond a collecting tubule into which urine drips _______ 1. _______ 2. _______ 3. _______ 4.

Chapter 7 Answer Key Handout 7-1: Chapter 7 Quiz 1. c 6. b 11. b 2. d 7. d 12. d 3. a 8. b 13. d 4. d 9. c 14. b 5. b 10. a 15. c

16. b 17. c 18. d 19. c 20. b

21. a 22. c 23. c 24. a 25. b

Handout 7-2: Chapter 7 Scenario 1. The problem is a kidney stone, indicated by excruciating back pain of sudden onset, history of gout, difficulty urinating, hematuria, nausea, and anxiousness/restlessness. 2. Treatment is to make the patient as comfortable as possible, provide pain relief as directed by medical direction, and provide IV fluids. 3. The IV fluids will cause dilation of the ureter and help to facilitate passage of the stone. 4. The hospital will provide pain relief and fluids to help pass the stone. If it does not pass, they will use lithotripsy to break up the stone or surgery to remove the stone. Prognosis is good, but possible complications include inflammation, infection, and partial or total urinary obstruction. Handout 7-3: Chapter 7 Review 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19.

homeostasis Metabolism, urea Nephrology end-stage renal failure kidney stones benign prostatic hypertrophy nephron glomerular filtration, reabsorption Simple diffusion, facilitated diffusion Diuresis, antidiuresis urea, creatinine renin Visceral referred IV, IM, mouth Acute renal failure, oliguria, anuria chronic renal failure Peritoneal Cystitis

20.

Pyelonephritis

Handout 7-4: Anatomy of the Kidney 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14.

i d l a m j h b g k f c e n

Chapter 8 Toxicology and Substance Abuse Student’s Name ________________

HANDOUT 8-1 EVALUATION

CHAPTER 8 QUIZ Write the letter of the best answer in the space provided. ______

1. Which of the following statistics is TRUE regarding toxicologic emergencies in the United States? a. Fewer than 1% of all emergency department visits and EMS responses involve toxic exposures. b. A child who has experienced an accidental ingestion has a 75% chance of another, similar ingestion within 1 year. c. Some 80% of all attempted suicides involve a drug overdose. d. Some 25% of accidental poisonings occur in children under the age of 6 years.

______

2. Ingestion is the MOST common route of entry for toxic exposure. Other routes of entry include all of the following EXCEPT: a. inhalation. c. tertiary. b. surface absorption. d. injection.

______

3. Many toxic substances can pass through the skin without puncturing it. An example of this type of substance is: a. snakebite venom. c. gasoline. b. carbon tetrachloride. d. organophosphates.

______

4. Decontamination involves all of the following steps EXCEPT: a. reducing intake of the toxin. b. reducing absorption of the toxin. c. enhancing adsorption of the toxin. d. enhancing elimination of the toxin.

______

5. Benzodiazepine overdoses are treated with the antidote: a. diazepam. c. flumazenil. b. amyl nitrite. d. naloxone.

______

6. One of your major objectives in treating a poisoning patient is: a. the administration of an antidote. b. prevention of aspiration. c. administration of IV fluids.

d. induction of vomiting. ______

7. You are caring for a patient with carbon monoxide poisoning. An important point to remember is which of the following? a. Carbon monoxide has a distinctive, “rotten egg” odor. b. Oxygen has more than 200 times the affinity of carbon monoxide to bind with hemoglobin. c. Once the carbon monoxide molecule binds with hemoglobin, it is very resistant to removal. d. Because carbon monoxide binds with red blood cells, internal hemorrhage is a serious complication of exposure.

______

8. Cyanide enters the body by: a. ingestion. b. absorption.

______

c. inhalation. d. all of the above.

9. Strong alkaline agents cause injury by inducing: a. hemorrhage. c. acidemia. b. tissue coagulation. d. liquefication necrosis.

______ 10. The range between curative and toxic doses of medications is called the: a. therapeutic index. c. cumulative dosage. b. toxic window. d. curative level. ______ 11. Elavil, imipramine, nortriptyline, and clomipramine are all examples of: a. MAO Inhibitors. c. SSRIs. b. tricylic antidepressants. d. salicylates. ______ 12. The drug that is MOST effective for treating bipolar disorder is: a. trazodone. c. Valium. b. Haldol. d. lithium. ______ 13. One of the MOST common salicylates is: a. Tylenol. c. acetaminophen. b. aspirin. d. ibuprofen.

______ 14. Your patient has deliberately ingested a large dose of aspirin. Which of the following is TRUE regarding these types of overdoses? a. Signs and symptoms associated with the overdose are likely to include hyperthermia, confusion, and rapid respirations. b. About 150 mg/kg is the dose required to cause toxicity. c. Aspirin overdose can result in metabolic alkalosis, further injuring organ systems.

d. The antidote for aspirin overdose, N-acetylcysteine, is most effective when given rapidly in the prehospital setting. ______ 15. Signs and symptoms of poisonous mushroom ingestion include: a. hallucinations. c. diaphoresis. b. dry mouth. d. constipation. ______ 16. You are caring for a patient who is complaining of chills, fever, and nausea that developed since he awoke this morning. He discovered a small, painful, erythematous macule surrounded by a white ring on his arm. You suspect a: a. brown recluse spider bite. c. scorpion sting. b. black widow spider bite. d. Hymenoptera sting. ______ 17. Management of the patient who has been bitten by a pit viper includes: a. application of constricting bands above and below the bite. b. application of a cold pack to reduce swelling and pain. c. maintaining the extremity in a neutral position. d. application of electrical stimulation to retard venom spread. ______ 18. To relieve the pain and inactivate the venom of a marine animal injection, you should: a. administer acetaminophen orally. b. apply constricting bands above and below the site. c. apply ice or cold pack to relieve pain and reduce swelling. d. apply heat or hot water (110°F to 113°F). ______ 19. The condition is which the body reacts severely when deprived of an abused substance is called: a. withdrawal. c. tolerance. b. addiction. d. dependence. ______ 20. An absolute contraindication in the treatment of cocaine overdose is: a. benzodiazepines. c. flumazenil. b. naloxone. d. beta-blockers. ______ 21. The drug commonly referred to as the “date rape drug” is: a. Restoril. c. Rohypnol. b. Halcion. d. PCP. ______ 22. Alcohol abuse may be indicated by a number of warning signs, including “green tongue syndrome” resulting from: a. an adverse reaction of the taste buds in the tongue to excessive exposure to alcohol. b. decreased oxygen perfusion to tissues caused by chronic lung diseases often experienced by alcoholics.

c. the use of chlorophyll-containing substances to disguise alcohol odor on the breath. d. toxins in the blood caused by liver disease. ______ 23. Chronic alcoholics may exhibit or experience which of the following? a. Death resulting from delirium tremens b. Decreased xyphoid–umbilical distance c. Distended external jugular veins d. Testicular enlargement ______ 24. Delirium tremens usually develop in habitual alcoholics within ______ after cessation of drinking. a. 10–12 hours c. 48–72 hours b. 24–36 hours d. 72–96 hours _____ 25. Common signs and symptoms of withdrawal syndrome from alcohol include all of the following EXCEPT: a. tachycardia. c. hypotension. b. sweating. d. tremors.

Student’s Name ________________

HANDOUT 8-2 EVALUATION

CHAPTER 8 SCENARIO Review the following real-life situation. Then answer the questions that follow. A woman returns home after work and finds her 14-year-old son unconscious in the empty bathtub. When she is unable to wake him, she calls 911 and returns to the bathroom, where the boy is having a grand mal seizure. Shortly thereafter, both police and paramedic units arrive on the scene. The police indicate that the scene is secure, and the paramedics enter the house. They find the boy still in the bathtub. A quick assessment of the scene reveals a syringe lying beside the patient in the bathtub. A tie is secured around the boy’s upper arm, and a fresh puncture wound is noted just below the tie. The primary survey reveals that the patient is unresponsive, breathing at a rate of 4 breaths per minute, with a weak radial pulse of 132. Blood pressure is palpated at 94. Pupils are dilated and slow to react. Several needle tracks are noticed on both arms. As the survey is completed, the patient begins another grand mal seizure. After paramedics manage the patient’s airway, they place him on the ECG monitor, initiate an IV, and obtain a blood glucose reading of 88. The monitor shows a sinus tachycardia with frequent unifocal PVCs. Per protocol, the paramedics administer 1 mg/kg of lidocaine IV push and a lidocaine drip at 2 mg/min. They contact the hospital, report their findings and treatment to the emergency department physician, and request an order to administer 5 mg of Valium. The physician gives the order for the Valium, and it is administered. The patient is packaged and transported rapidly to the hospital. En route, the patient goes into respiratory arrest and is intubated. The patient remains unresponsive with a slight twitching of the right arm. Another set of vital signs taken after medication administration show a radial pulse of 100, blood pressure of 98/60, and respirations of 0. The monitor shows a sinus tachycardia with an occasional PVC. The paramedics turn the patient over to the emergency department staff with an update on his condition. 1. What type of drug would you suspect that the patient overdosed on?

2. Why do you suspect this drug?

3. Was administration of lidocaine indicated? Why or why not?

4. What information was necessary to convey to the emergency department physician? HANDOUT 8-3

Student’s Name ________________

REINFORCEMENT CHAPTER 8 REVIEW Write the word or words that best complete the following sentences in the space(s) provided. 1. Toxicology is the study of toxins, which include drugs and _________. 2. The term _________ is used to describe exposure to nonpharmacological substances, while _________ is used to describe exposure to pharmacological substances. 3. Some _________ percent of accidental poisonings occur in children under the age of 6 years. 4. Some 80 percent of all attempted suicides involve _________ _________. 5. _________ is the MOST common route of entry to toxic exposure. 6. The entry of a substance into the body through the respiratory tract is called _________. 7. MOST insects that can sting and bite belong to the class _________. 8. Principles of decontamination include reducing _________, reducing _________, and enhancing _________. 9. _______ __ _______ is no longer recommended to induce vomiting. 10. The MOST effective and widely used method of reducing absorption of toxins is _________ _________. 11. Preventing _________ must be one of the major objectives in treating a poisoning patient. 12. If chronic alcoholsim is suspected, consider administration of ____mg of ______. 13. Your FIRST priority in any inhalation emergency is _________ _________. 14. A group of typical signs and symptoms consistently associated with exposure to a particular type of toxin is called a(n) _________. 15. _________ _________ is an odorless, tasteless gas that is often the byproduct of incomplete combustion. 16. Once cyanide enters the body, it causes the cells to shift from ____________ metabolism to _____________ metabolism. 17. A cyanide antidote kit contains _________ _________ ampules. 18. A strong acid burn can produce an ______ at the burn site, which acts like a shield to prevent further tissue damage. 19. Absorption of acids into the vascular system will cause a significant ___________. 20. Death has been reported from exposure of less than 2.5% body surface area to a highly concentrated solution of ___________ ______. 21. Toxicity from hydrocarbons can occur through any route, including _________, ____________, or __________ __________. 22. Trazodone and Wellbutrin belong to a class of drugs known as ______ _______ _________ __________. 23. The onset of serotonin syndrome is usually within ______ ______ of ingestion.

24. Lithium has a narrow ___________ ________ that results in toxicity during normal use and in overdose situations. 25. Activated charcoal does NOT bind with __________ and need NOT be given. 26. In toxic amounts, _________ inhibit normal energy production and acid buffering in the body, resulting in metabolic _________. 27. Aspirin overdose patients should receive _________ _________, which reduces drug absorption. 28. N-acetylcysteine is an antidote for ____________. 29. Gastrointestinal symptoms and diseases such as food poisoning are produced by _________. 30. EXCEPT for _________, food poisoning is rarely life threatening. 31. _________ account for over 90% of all mushroom poisoning deaths. 32. Signs and symptoms of _________ _________ _________ bites start as immediate localized pain, redness, and swelling, progressing to spasms of large muscle groups with severe pain. 33. Severe muscle spasms due to certain insect bites may be treated with either IV _________ or IV _________ _________. 34. When caring for a patient who has been bitten by a pit viper, three “don’ts” include DO NOT apply _________ or a _________ pack or _________ spray to the wound, DO NOT apply an arterial _________, and DO NOT apply _________ stimulation from any device. 35. Treat marine animal injection by applying _________ or _________ water. 36. Use of a pharmacological substance for purposes other than medically defined reasons is known as _________ _________. 37. A compulsive and overwhelming dependence on a drug is called a(n) _________. 38. The need to progressively increase the dose of a drug to reproduce the effect originally achieved by smaller doses is called _________. 39. The term _________ refers to a patient suffering physical manifestations when the drug levels fall. 40. A disorder found in habitual and excessive users of alcoholic beverages after cessation of drinking for 48 to 72 hours is known as _________ _________.

Student’s Name ________________

HANDOUT 8-4 REINFORCEMENT

POISON TREATMENT TRUE OR FALSE Indicate whether the following statements are true or false by writing T or F in the space provided. ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______

______ ______

______ ______ ______

1. Syrup of ipecac is widely used in both the prehospital and hospital phases of decontamination in poisoning cases. 2. Cyanide poisoning should initially be treated by inhaling a crushed pearl of amyl nitrite for 30 seconds, then oxygen for 30 seconds. 3. Naloxone has been found to be beneficial in the treatment of benzodiazepine overdose. 4. Treatment of comatose patients should always include a “coma cocktail” consisting of D50W, Narcan, and thiamine. 5. Induction of vomiting is a routine intervention for patients who have ingested a toxin or overdose of medication. 6. Severe cases of carbon monoxide poisoning may require treatment in a hyperbaric chamber to remove CO from hemoglobin. 7. Ingestion of caustic substances (acids, alkalis) may be treated by the administration of activated charcoal to absorb the substances. 8. Since activated charcoal does NOT bind with lithium, administration of it is unnecessary. 9. A dose of 100 mg/kg of aspirin is usually sufficient to cause toxicity in an adult patient. 10. Acetaminophen overdose is effectively treated with Nacetylcysteine. 11. Activated charcoal binds well with heavy metals such as lead and mercury. 12. Except for botulism, food poisoning is rarely life threatening. 13. Management of patients with Hymenoptera stings should include applying hot water or a hot pack to the injection site. 14. Patients who are experiencing severe muscle spasms resulting from a black widow spider bite may be treated with calcium gluconate. 15. Constricting bands should be placed above and below the injection site of either a scorpion sting or a pit viper bite. 16. Treatment for a marine animal injection includes applying a constricting band between the wound and the heart and application of heat or hot water to the site. 17. Naloxone is effective in reversing the effects of benzodiazepine overdose. 18. Forced diuresis and alkalinization of the urine improve elimination of barbiturates from the body. 19. Mixed overdoses that include benzodiazepines should be treated with flumazenil to prevent seizures.

______ 20. Beta-blockers may be beneficial in the treatment of cocaine abuse.

Student’s Name ________________

HANDOUT 8-5 REINFORCEMENT

TOXICOLOGY MATCHING Write the letter of each term below in the space provided next to the appropriate description. a. Absorption b. Acid c. Alkali d. Antidote e. Activated charcoal f. Benzodiazepine g. DTs h. Ingestion ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______

i. Inhalation j. Injection k. Overdose l. Poison control m. Toxin n. Toxicology o. Toxidrome

1. The entrance of a substance into the body through the gastrointestinal tract. 2. The entrance of a substance into the body through a break in the skin. 3. A substance used to absorb toxins by chemically binding to its surface area. 4. The entrance of a substance into the body directly through the skin or mucous membrane. 5. Medical or biological science that studies poisons. 6. General term to describe one of a group of tranquilizing drugs with similar chemical structures. 7. A substance that neutralizes a poison or the effects of a poison. 8. Any chemical that causes adverse effects on an organism that is exposed to it. 9. Disorder found in habitual and excessive users of alcoholic beverages after cessation of drinking. 10. Information center staffed by trained personnel that provides up-todate toxicological information. 11. Dose of a drug in excess of that usually prescribed. 12. The entrance of a substance into the body through the respiratory tract. 13. A group of typical signs and symptoms consistently associated with exposure to a particular type of toxin. 14. A substance that liberates hydroxyl ions when in solution. 15. A substance that liberates hydrogen ions when in solution.

Chapter 8 Answer Key Handout 8-1: Chapter 8 Quiz 1. c 2. c 3. d 4. c 5. c 6. b 7. c

8. d 9. d 10. a 11. b 12. d 13. b 14. a

15. c 16. a 17. c 18. d 19. a 20. d 21. c

22. c 23. a 24. b 25. c

Handout 8-2: Chapter 8 Scenario 1. Cocaine. 2. It is the prime suspect because of method of administration, seizure activity, dysrhythmias, dilated pupils, and tachycardia. 3. Administration of lidocaine was indicated for the frequent PVCs. A cocaine overdose may cause life-threatening dysrhythmias, which should be treated according to protocol. 4. The report to the ED physician should include how the patient was found, initial vital signs, heart rhythm, treatment administered, results of the treatment, and current patient condition. Handout 8-3: Chapter 8 Review 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22.

poisons poisoning, overdose 50 drug overdose Ingestion inhalation Hymenoptera intake, absorption, elimination Syrup of ipecac activated charcoal aspiration 100, thiamine personal safety toxidrome Carbon monoxide aerobic, anaerobic amyl nitrite eschar acidemia hydrofluoric acid ingestion, inhalation, surface absorption selective serotonin reuptake inhibitors

23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40.

6 hours therapeutic index lithium salicylates, acidosis activated charcoal acetaminophen enterotoxins botulism Amanita black widow spider diazepam, calcium gluconate ice, cold, Freon, tourniquet, electrical heat, hot substance abuse addiction tolerance withdrawal delirium tremens

Handout 8-4: Poison Treatment True or False 1. F 2. T 3. F 4. F 5. F

6. T 7. F 8. T 9. F 10. T

11. F 12. T 13. F 14. T 15. F

16. T 17. F 18. T 19. F 20. F

Handout 8-5: Toxicology Matching 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.

h j e a n f d m g l k i o c b

Chapter 9 Hematology

HANDOUT 9-1

Student’s Name __________________

EVALUATION CHAPTER 9 QUIZ Write the letter of the best answer in the space provided. ______ 1. The cell from which the various types of blood cells can form is called a(n): a. erythropoietin. c. multipotent stem cell. b. pluripotent stem cell. d. unipotent progenitor. ______ 2. The hormone that is responsible for red blood cell production is: a. thrombocyte. c. oxytocin. b. insulin. d. erythropoietin. ______ 3. Plasma is made up of 90–92%: a. proteins. c. water. b. carbohydrates. d. gases. ______ 4. Each complete hemoglobin molecule can carry: a. one platelet. c. four oxygen molecules. b. one red blood cell. d. two white blood cells. ______ 5. The effectiveness of oxygen transport depends on: a. red blood cell mass. c. exercise. b. pH. d. all of the above. ______ 6. The packed cell volume of red blood cells per unit of blood is known as: a. hematocrit. c. sequestration. b. hemolysis. d. erythropoiesis. ______ 7. Providing protection from foreign invasion is the job of the: a. leukocytes. c. platelets. b. erythrocytes. d. red blood cells. ______ 8. The highly specialized member of the granulocytic series that can inactivate the chemical mediators of acute allergic reactions is the: a. neutrophil. c. basophil. b. monophil. d. eosinophil. ______ 9. The “garbage collectors” of the immune system are the: a. macrophages. c. monocytes. b. lymphocytes. d. granulocytes. ______10. The two basic subpopulations of lymphocytes are T cells and B cells. Which of the following statements is TRUE regarding T cells? a. T cells engulf foreign invaders and dead neutrophils. b. T cells produce antibodies to combat infections. c. T cells migrate to peripheral lymphatic tissues from the bone marrow. d. T cells are responsible for developing cell-mediated immunity. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed

______11. After a local tissue injury occurs, the damaged tissues release chemical messengers that: a. decrease capillary permeability. c. cause vasoconstriction. b. attract white blood cells. d. reduce swelling. ______12. The term for the process of three mechanisms that work to control blood loss is: a. homeostasis. c. erythropoiesis. b. sequestration. d. hemostasis. ______13. The combined three mechanisms that work to prevent or control blood loss include all of the following EXCEPT: a. vascular spasms. c. platelet plugs. b. inflammation. d. stable fibrin blood clots. ______14. One element of the coagulation cascade is the common pathway, during which: a. tissue damage causes platelet aggregation and the formation of prothrombin activator. b. the prothrombin activator, in the presence of calcium, converts prothrombin to thrombin. c. platelets release substances that lead to the formation of prothrombin activator. d. thrombin, in the presence of calcium, converts fibrinogen to stable fibrin, which then traps blood cells and more platelets to form a clot. ______15. Which of the following enhances blood clotting? a. Vitamin D c. Smoking b. Aspirin d. Low red blood cell count ______16. A person with which blood type is considered the “universal donor”? a. A c. B b. AB d. O ______17. Checking blood samples from both donor and recipient to ensure the greatest compatibility is called: a. universal selection. b. type and crossmatch. c. typing. d. crossmatching. ______18. Erythroblastosis fetalis is caused by: a. sensitization to antigens on the white blood cells, platelets, or plasma proteins. b. a recipient of a blood transfusion receiving an incompatible blood type. c. erythrocytes being damaged during the transfusion process. d. an Rh− mother previously sensitized by pregnancy with an Rh+ child becoming pregnant with an Rh+ child. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed

______19. During your physical exam of a patient, you note jaundice, or yellow skin. This could be caused by: a. decreased perfusion to vital organs. c. kidney disease. b. hemolysis of red blood cells. d. anemia. ______20. The MOST common cause of priapism in the emergency setting is: a. spinal cord injuries. c. sickle cell disease. b. polycythemia. d. hemophilia. ______21. Employing proper isolation techniques is extremely important in caring for patients with leukemia and lymphoma because: a. these patients are at an increased risk of developing infection. b. both diseases are transmitted by airborne pathogens. c. these patients will typically have open lesions. d. both diseases are highly infectious in the early stages. ______22. An abnormal decrease in the number of platelets is known as: a. thrombocytosis. c. thrombocytopenia. b. disseminated intravascular coagulation. d. factor IX disease. ______23. Hemophilia A is a blood disorder caused by a deficiency of: a. erythrocytes. c. leukocytes. b. factor VIII. d. factor IX. ______24. A disorder of coagulation caused by systemic activation of the coagulation cascade is: a. thrombocytosis. c. thrombocytopenia. b. disseminated intravascular coagulation. d. factor IX disease. ______25. A cancerous disorder of plasma cells is: a. von Willebrand’s disease. c. thrombocytopenia. b. disseminated intravascular coagulation. d. multiple myeloma.

Student’s Name __________________

HANDOUT 9-2 EVALUATION

CHAPTER 9 SCENARIO Review the following real-life situation. Then answer the questions that follow. Placerville Rescue 2 has been called to a nearby mobile home park for a patient with weakness and shortness of breath. The paramedics arrive to find a 72-year-old male seated in a chair. They immediately note that the patient is conscious and breathing but appears pale and fatigued. His wife relates that her husband (your patient), had made reservations for a whitewater rafting trip next month and, to prepare himself physically, had purchased a treadmill to use in the house for exercise. However, every time he used it, he quickly became tired. In fact, lately, he has become very tired and short of breath with even small amounts of activity, such as getting out of his chair and walking from the living room to other rooms in the house. He had a recent appointment with his doctor and had an ECG, which was normal. He is scheduled for other tests but has not had them yet. His weakness and shortness of breath with exertion have gotten worse over the past several weeks. The patient’s wife tells the paramedics that he has also been very irritable lately. When asked about bleeding disorders, the patient admits that he has had some rectal bleeding for a few weeks, but he hasn’t told his doctor about it. On performing a physical exam, the paramedics find clear lungs, pale but warm skin, and a slightly tachycardic heart rate. George’s heart rhythm is regular, and the ECG shows a sinus tachycardia. Postural vitals are basically unchanged. The paramedics apply high-concentration oxygen via nonrebreather mask and start an IV of normal saline at a keep-open rate. The patient is placed in the semi-Fowler’s position on the stretcher and moved to the ambulance. Another set of vital signs is taken, and the patient is transported to the hospital a few miles away without incident. 1.What do you believe the patient’s problem is, and what might be causing it?

2.What signs and symptoms lead you to this conclusion?

3.What might the hospital treatment for this condition be?

Student’s Name __________________

HANDOUT 9-3 REINFORCEMENT

CHAPTER 9 REVIEW Write the word or words that best completes the following sentences in the space(s) provided. 1. ___________ is the study of blood and the blood-forming organs. 2. The organs included in the hematopoietic system are the ___________, ___________, and the ___________. 3. The cell from which the various types of blood cells can form is called a(n) ___________ ___________ ___________. 4. ___________ is the process through which pluripotent stem cells differentiate into various types of blood cells. 5. The hormone responsible for red blood cell production is ___________. 6. Components of blood include ___________, which is the liquid part, and the formed elements, ___________ ___________ ___________, ___________ ___________ ___________, and ___________. 7. ___________ are red blood cells, and ___________ are white blood cells. 8. ___________ is the oxygen-bearing molecule in the red blood cells. 9. Each complete hemoglobin molecule can carry up to ___________ oxygen molecules. 10. 2,3-Bisphosphoglycerate is the chemical in red blood cells that affects ___________ affinity for ___________. 11. ___________ is the process of producing red blood cells. 12. ___________ is the destruction of red blood cells. 13. The spleen and ___________.

liver

contain

specialized

scavenger

cells

called

14. Placing a blood sample in a centrifuge and spinning it at high speed so that the cellular elements separate from the plasma will give you the blood’s ___________.

15. The process by which white blood cells squeeze between the cells lining the blood vessels and follow chemical signals to the infection site is called ___________. 16. The process in which white blood cells engulf and destroy an invader is called ___________. 17. White blood cells are differentiated into three main immature forms known as ___________, ___________, and ___________. 18. White blood cells are categorized as ___________, ___________, and ___________. 19. The three mature forms of granulocytes are ___________, ___________, and ___________. 20. The primary cells involved in the body’s immune response are the ___________. 21. ___________ ___________ is the condition in which the body makes antibodies against its own tissue. 22. A nonspecific defense mechanism that wards off microorganisms or trauma is the ___________ process.

damage

from

23. The combined three mechanisms that work to prevent or control blood loss are ___________ spasms, ___________ plugs, and ___________ ___________ blood clots. 24. The two best-known clotting proteins that circulate in an inactive state are ____________ and ___________. 25. Plasmin dismantles, or lysing, a blood clot by a process known as ___________. 26. Clot formation, which is extremely dangerous when it occurs in coronary arteries or cerebral vasculature, is called ___________. 27. Blood type ___________ is considered the universal donor, and blood type ___________ is considered the universal recipient. 28. The most common transfusion _____________ _____________.

reaction

the

______________

29. Bleeding gums are often associated with a decreased ___________ count.

30. An oral yeast infection in an adult is commonly associated with ___________. 31. ___________ ___________ disease is a common cause of priapism in the emergency setting. 32. ___________ is an excess of red blood cells. 33. ___________ is an inadequate number of red blood cells. 34. A cancer of the hematopoietic cells is ___________. 35. Too few white cells is known as ___________, and too many white blood cells is known as ___________.

Student’s Name __________________

HANDOUT 9-4 REINFORCEMENT

TRANSFUSION TABLE Complete the table below by filling in the missing information about transfusions. Type of Transfusion Use Whole blood Packed red blood cells (PRBCs) Platelets Fresh frozen plasma (FFP) Clotting factors

Contents of Transfusion All blood cells, platelets, clotting factors, and plasma

Thrombocytes and some plasma Specific clotting factors needed for coagulation

Use

Chapter 9 Answer Key Handout 9-1: Chapter 9 Quiz 1. b 10. d 18. d 2. d 11. b 19. b 3. c 12. d 20. c 4. c 13. b 21. a 5. d 14. b 22. c 6. a 15. c 23. b 7. a 16. d 24. b 8. d 17. d 25. d 9. a Handout 9-2: Chapter 9 Scenario 1. The patient’s problem is anemia, possibly caused by internal bleeding as evidenced by his reporting rectal bleeding for a few weeks. Remember that anemia is a sign, not a disease in itself. 2. The patient is showing several signs and symptoms of anemia. These include dyspnea and fatigue during exercise or physical activity, irritability, and tachycardia. 3. For mild anemia, treatment may begin with oral iron supplements. More severe cases may be treated by administration of packed red cells, as the problem is a decrease in the number of red cells in the blood. The most definitive treatment is to find the cause of the anemia and correct it. In this patient’s case, it may be a lower GI bleed, on the basis of his admission of having rectal bleeding. Control of the bleeding would be the final, definitive treatment. Handout 9-3: Chapter 9 Review 1. Hematology 2. liver, spleen, kidneys 3. pluripotent stem cell 4. Hematopoiesis 5. erythropoietin 6. plasma, red blood cells, white blood cells, platelets 7. Erythrocytes, leukocytes 8. Hemoglobin 9. four 10. hemoglobin’s, oxygen 11. Erythropoiesis 12. Hemolysis 13. macrophages 14. hematocrit 15. chemotaxis ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed

16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35.

phagocytosis myeloblasts, monoblasts, lymphoblasts granulocytes, monocytes, lymphocytes basophils, eosinophils, neutrophils lymphocytes Autoimmune disease inflammatory vascular, platelet, stable fibrin prothrombin, fibronogen fibrinolysis thrombosis O, AB febrile nonhemolytic reaction platelet AIDS Sickle cell Polycythemia Anemia Leukemia leukopenia, leukocytosis

Handout 9-4: Transfusion Table Whole blood. Use: Replace blood loss from hemorrhage. Packed red blood cells. Contents: Red blood cells and some plasma. Use: Replace blood cells in anemic patients. Platelets. Use: Replace platelets in a patient with thrombocytopenia. Fresh frozen plasma. Contents: Plasma, a combination of fluids, clotting factors, and proteins. Use: Replace volume in a burn patient or in hypovolemia secondary to low oncotic pressure. Clotting factors. Use: Replace factors missing due to inadequate production as in hemophilia.

Chapter 10 Infectious Disease

Student’s Name_________

HANDOUT 10-1 EVALUATION

CHAPTER 10 QUIZ Write the letter of the best answer in the space provided. ______1.

The individual who FIRST introduces an infectious agent to a population is called the: a. initial infection. c. index carrier. b. index case. d. pathogen introduction.

______2.

Organisms that live inside our bodies without ordinarily causing disease are known as: a. benign pathogens. c. normal flora. b. host flora. d. harmless flora.

______3.

An ordinarily harmless bacterium that may cause disease if a patient has a weakened immune system or is under unusual stress is called a(n): a. advantageous bacteria. c. susceptible bacteria. b. immune deficient pathogen. d. opportunistic pathogen.

______4.

Microscopic single-celled organisms that range in length from 1 to 20 micrometers are called: a. bacteria. c. viruses. b. exotoxins. d. fungi.

______5.

Living pathogenic bacteria may harm their human hosts by releasing toxic waste products called: a. endotoxins. c. spheres. b. bactericides. d. exotoxins.

______6.

It is necessary to use an electron microscope to see: a. bacteria. c. fungi. b. viruses. d. protozoa.

______7.

Viruses are known as obligate intracellular parasites because they: a. can grow and reproduce only within a host cell. b. are folded in such a way that protease enzymes cannot act upon them. c. can remain active for several days in fluid outside of the body. d. can reproduce quickly in any body fluid.

______8.

Yeasts, molds, and mushrooms are all types of: a. bacteria. c. fungi. b. viruses. d. spores.

______9.

Protozoa cause diseases such as: a. pneumonia. c. Lyme disease. b. malaria. d. meningitis.

______10. Epigastric pain and anemia are possible when a person is infected with: a. pinworms. c. hookworms. b. tapeworms. d. trichinosis. ______11. An example of a disease transmitted by contact with blood or body fluid is: a. hepatitis B. c. measles. b. tuberculosis. d. meningitis. ______12. Which of the following is NOT an example of a disease that may be transmitted through the air on droplets expelled during a productive cough or sneeze is: a. measles. c. rubella. b. RSV. d. hepatitis. ______13. Agents and diseases that are capable of being transmitted to another host are called: a. contaminant. c. communicable. b. virile. d. virulent. ______14. The period of time when a host cannot transmit an infectious agent to someone else is called the: a. incubation period. c. noncommunicable period. b. latent period. d. window period. ______15. Seroconversion is said to have occurred when: a. a person begins to show signs and symptoms of the disease. b. signs and symptoms of a disease disappear. c. the host is now able to transmit the disease to someone else. d. the person develops antibodies after exposure to a disease. ______16. The duration from the onset of signs and symptoms of disease until the resolution of symptoms or death is called the: a. disease period. c. window phase. b. communicable period. d. latent period. ______17. Neutrophils and macrophages are both types of: a. antigens. c. leukocytes. b. immunoglobulins. d. antibodies.

______18. There are five classes of human antibodies. The class that attaches to mast cells and plays a major role in allergic reactions is: a. IgG. c. IgD. b. Iga. d. IgE. ______19. The overflow circulatory fluid in spaces between tissues is called: a. plasma. c. serum. b. lymph. d. synovial. ______20. Passive immunity generally lasts: a. less than 24 hours. c. 5 to 7 years. b. from days to months. d. for a lifetime. ______21. An immunity provided by antibodies that the patient did NOT manufacture is called: a. active immunity. c. acquired immunity. b. passive immunity. d. artificial immunity. ______22. There are four phases of prehospital infection control. Putting on gloves and donning eye and face protection are part of which phase? a. Preparation for response c. Patient contact b. Response d. Recovery ______23. Guidelines for prehospital infection control during patient contact include: a. wearing gloves, goggles, and gowns on all calls. b. allowing only necessary personnel to make patient contact. c. carefully recapping IV needles after use. d. eating or drinking in the patient compartment only after it has been cleaned. ______24. Any reusable item that comes in contact with the patient’s mucous membranes should receive: a. low-level disinfection. c. high-level disinfection. b. intermediate-level disinfection. d. sterilization. ______ 25. The Ryan White Act outlines rights and responsibilities when an infectious disease exposure occurs to: a. minor children. b. agencies and health care workers. c. institutionalized individuals. d. the general public. ______ 26. A common consequence of infectious diseases is: a. fever. c. endocarditis. b. dehydration. d. hypertension. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed

______ 26. Which of the following is TRUE regarding the human immunodeficiency virus? a. HIV causes a cellular immune system response and then remains in a dormant phase. b. HIV specifically targets T lymphocytes with the CD4 marker. c. Reports of the transmission rate from mother to infant range from 60% to 70%. d. HIV is much more contagious than hepatitis B. ______ 27. What percentage of hepatitis B infections are asymptomatic? a. 5–10 c. 40–60 b. 20–30 d. 60–80 ______ 28. The MOST common preventable adult infectious disease in the world is: a. pneumonia. c. measles. b. hepatitis A. d. tuberculosis. ______ 29. The infectious agent that is MOST often associated with pneumonia is: a. Klebsiella pneumoniae. b. Mycoplasma pneumoniae. c. Streptococcus pneumoniae. d. Haemophilus influenzae. ______ 30. When purulent fluids accumulate in the lungs and alveoli collapse, the patient is said to have signs of: a. consolidation. c. congestion. b. compartment syndrome. d. pleurisy. ______ 30. A patient with SARS is considered contagious: a. until the patient is asymptomatic. b. for 2–7 days after the onset of symptoms. c. for 10–14 days after the onset of symptoms. d. for 10 days after the patient is asymptomatic. ______ 31. Signs and symptoms associated with SARS include: a. rhinorrhea. c. diarrhea. b. rigors. d. all of the above. ______ 32. All of the following are treatment steps for a patient with suspected SARS EXCEPT: ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed

a. ventilatory assistance, as needed. b. placing a HEPA mask on the patient. c. place the patient in a position of comfort. d. IV fluids if patient is dehydrated.

______ 33. Varicella is more commonly known as: a. measles. b. chickenpox. c. mumps. d. herpes. 34. Postive Brudzinski’s sign is suggestive of meningitis. A positive Brudzinski’s sign is: a. the inability to fully extend the knee when the hips are flexed. b. the inability to form a fist with one or both hands. c. a physical exam finding in which flexion of the neck causes flexion of the hips and knees. d. the inability to flex one’s head forward and touch the chin to the chest. 35. Koplik’s spots are seen in: a. measles. c.mumps. b. chickenpox. d.menigitis. 36. An infant acquiring rubella infection in utero is likely to be: a. born prematurely. c.unaffected. b. developmentally delayed. d.stillborn. 37. Pertussis has three clinical phases. Which of the following is NOT one of those phases? a. Paroxysmal c.Catarrhal b. Convalescent d.Prodromal 38. EMS personnel working in dusty, unoccupied buildings for extended times should wear face masks to prevent exposure to: a. RSV. c.hantavirus. b. Tuberculosis. d.sinusitis. _____39. The predominant infectious agents for encephalitis are: a. viruses. c.bacteria. b. fungi. d.parasites. 40. Left untreated, rabies can cause death within: a. 2–6 days. c.1–2 weeks. b. 3–6 months. d.hours of a bite by an infected animal. 41. Lyme disease is a recurrent inflammatory disorder caused by bacteria transmitted through the bite of a: ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed

a. bat. c. flea. b. tick. d. fly. 42. _________ is one of the MOST commonly diagnosed communicable diseases in the United States. a. Syphyllis c.Herpes b. Genital warts d.Gonorrhea 43. Syphilis may occur in four stages. The period of time when symptoms improve or diappear completely, which may last from months to many years, is known as: a. primary syphilis. c.latent syphilis. b. secondary syphilis. d.tertiary syphilis. 44. Lice are a parasitic _______ of the skin of the scalp, trunk, or pubic area. a. infection c.infestation b. rash d.burrowing 45. Bedbugs have been shown to travel over ____ feet in a night. a. 10 c. b. 50 d. 46. Hospital-acquired diseases are called:

75 100

a. nosocomial. c.opportunistic. b. zoonotic. d.infectious. 47. You should NOT go to work if you have strep throat unless: a. you no longer have a sore throat. b. you no longer have a fever. c. you have been taking antibiotics for at least 24 hours. d. you have been taking antibiotics for at least 48 hours. 48. The tenth MOST common cause of death in the world and the MOST common cause of death in a debilitated patient in hospital intensive care units is: a. pneumonia. b. sepsis.

c.influenza. d.meningitis.

Student’s Name_________

HANDOUT 10-2 EVALUATION

CHAPTER 10 SCENARIO Review the following real-life situation. Then answer the questions that follow. Medic 1 is dispatched to assist another ambulance at the scene of a multiple vehicle crash. On arrival on the scene, Medic 1’s crew is directed to an inverted vehicle some 25 feet off the edge of the road. The vehicle’s driver has been ejected from the vehicle and is supine on the ground. Fire department personnel are performing CPR. The paramedics’ assessment confirms that the patient is pulseless and apneic. CPR is continued as the patient is prepared for intubation. Because of the massive facial injuries, intubation is impossible. It is not possible to maintain an airway for adequate ventilation, so the senior paramedic prepares to perform a cricothyrotomy while her partner secures the heart monitor and intravenous access to the patient. The first round of medications are administered, and the cricothyrotomy is performed, producing good ventilations. The patient is packaged and loaded into the unit for a short trip to an improvised landing zone. There, a helicopter awaits to transport the patient to a trauma center. Patient care is transferred to the helicopter medical personnel. At transfer, the patient has two largebore IVs and is in an idioventricular rhythm. Ventilations through the cricothyrotomy are continuing. Medic 1 confirms this information in a verbal report to the air transport personnel, and the patient is transported to the trauma center. 1.

What precautions against infectious diseases should the paramedics have followed in this scenario?

To what infectious diseases might the crew of Medic 1 have been exposed from this patient?

Student’s Name_________

HANDOUT 10-3

REINFORCEMENT CHAPTER 10 REVIEW Write the word or words that best complete the following sentences in the space(s) provided. 1. An illness caused by an infestation of the body by biological organisms is called a(n)______________ ___________. 2. The individual who FIRST introduced an infectious agent to the population is called the _________ ______. 3. __________ __________ are organisms that live inside our bodies without ordinarily causing disease. 4. An organism that is capable of causing disease is called a(n) __________. 5. An ordinarily harmless bacterium that causes disease only under unusual circumstances is called a(n) __________ __________. 6. __________ are microscopic single-celled organisms that range in length from 1 to 20 micrometers. 7. Bacteria are categorized into groups based on their general appearance: __________ are round, __________are elongated, and __________ are coiled. 8. __________ are toxic waste products released by living bacteria, while __________ are toxic products released when bacteria die and decompose. 9. __________ means that a substance is capable of inhibiting bacterial growth or reproduction, while __________ means capable of killing bacteria. 10. A(n) __________ is a disease-causing organism that can be seen only with an electron microscope. 11. A(n) __________ __________ __________ is an organism that can grow and reproduce only within a host cell. 12. Plantlike microorganisms are called __________. 13. Single-celled parasitic organisms with flexible membranes and the ability to move are called ____________. 14. Any living creature or environment that can harbor an infectious agent is called a(n) __________. 15. The risk of infection is considered __________ if transmission is acknowledged to be possible but has NOT actually been reported. 16. __________ is an organism’s strength or ability to infect or overcome the body’s defenses.

17. The __________ period is when a host cannot transmit an infectious agent to someone else, while the __________ period is when a host can transmit an infectious agent to someone else. 18. The time between exposure and presentation is know as the _____________ _______. 19. The measure of a particular vaccine’s effectiveness is reported as the ________ _______. 20. Phases of prehospital infection control include __________ __________, __________, __________ __________, and __________. 21. To destroy certain forms of microorganisms, but NOT all, is to __________. To destroy all microorganisms is to __________. 22. The federal law, originally passed in 1990, that outlines the rights and responsibilities of agenices and health care workers when an infectious disease exposure occurs is the ______ _______ ______. 23. HIV is transmitted through contact with ______, ______ _______, and ______ _____. The virus has been noted in _____, _____, _____ __________, and _______ _____. 24. Health care workers infected by hepatitis B can develop _____ _______, _______, and _____ _____. 25. __________ is the MOST common preventable adult infectious disease in the world. 26. The infectious agent that is MOST often associated with pneumonia and against which the pneumococcal vaccine is targeted is ____________ __________, which take the form of _______-______ _______ found in pairs or chains. 27. _____ _____ _________ ______ is a viral respiratory illness that first appeared in southern China is 2002 and became a global threat in 2003 by spreading internationally. 28. Although varicella in pediatrics is considered a self-limited disease that rarely causes severe complications, it is much more _____ in ______. 29. Brudzinski’s sign is a physical exam finding that is suggestive of meningitis and causes flexion of the ______ and _____ when the _____ is flexed. 30. Three antiviral drugs are available for the prevention and treatment of influenza. They are ________, __________, and___________. 31. A particularly infectious form of __________ __________ virus (H5N1) was identified in Asia. There were cases where the virus infected humans, often causing death. 32. __________ is a highly contagious, acute viral disease characterized by a reddish rash that appears on the fourth or fifth day of illness. 33. _________ ______ ____ is a common cause of pneumonia and bronchiolitis in infants and young children. 34. The three phases of pertussis are __________, __________, and __________. 35. The viral disease known as the “kissing disease” is __________. 36. Herpes simplex virus type 1 is transmitted in the saliva of carriers and commonly infects the _______, ____, ____, ____, _______, and ____.

37. Patients with epiglottitis present with one or more of the “four Ds”: _________, ________, _________, and ________. 38. __________ is a family of viruses carried by rodents such as the deer mouse. 39. __________ is an inflammation caused by infection of the brain and its structures. 40. The three stages of Lyme disease are __________ __________, __________ __________, and __________. 41. _________ is one of the MOST commonly diagnosed communicable diseases in the United States. 42. The four stages of syphilis that may occur are _______, _________, ______, and ________. 43. _______ are small, flat, parasitic insects that feed solely on the blood of people and animals while they sleep. 44. Infections that are acquired while in the hospital are called __________. 45. You should NOT go to work if you have ________, have a _______ _____ or any type of wet lesion, are ________, have ____________, have been exposed to ____ or ______ and have NOT yet been treated, have _____ ______ and have NOT been taking antibiotics for at least 24 hours, or have a ____. 46. _____ is the tenth MOST common cause of death in the world and the MOST common cause of death in _________ patients in hospital intensive care units. 47. The people who are MOST at risk for developing sepsis are people with _______________, patients who are __________, people with preexisting ________ or medical conditions, people with severe ______, people with a genetic _______ for sepsis, and the very ____ or very ____.

Student’s Name_________

HANDOUT 10-4

REINFORCEMENT INFECTIOUS DISEASE MATCHING Write the letter of the disease in the space next to the appropriate description. a. Human immunodeficiency virus (HIV) b. Hepatitis c. Tuberculosis (TB) d. Pneumonia e. Severe acute respiratory syndrome (SARS) f. Chickenpox g. Meningitis h. Avian influenza i. Measles j. Mumps k. Rubella l. Respiratory syncytial virus (RSV) m. Pertussis n. Mononucleosis o. Herpes simplex virus type 1 p. Epiglottitis q. Croup r. Pharyngitis s. Hantavirus t. Encephalitis u. Tetanus v. Lyme disease w. Gonorrhea x. Impetigo y. Lice z. Scabies ______1. ______2.

______3.

Often associated with outbreaks of lower respiratory infections from November to April. Very contagious infection of the skin caused by staphylococci or streptococci. The disease begins as a single vesicle that ruptures and forms a thick, honey-colored crust with a yellowish-red center. Lesions MOST commonly occur on the extremities and joints. Caused by a Gram-negative bacterium, it is one of the MOST commonly diagnosed communicable diseases in the United States.

______4.

______5. ______6.

______7.

______8. ______9. _____10. _____11.

_____12. _____13. _____14.

_____15.

_____16. _____17. _____18.

_____19.

_____20.

_____21.

Parasitic infestation of the skin of the scalp, trunk, or pubic area. The host is infested rather than infected because the skin is NOT broken. MOST common preventable adult infectious disease in the world. Caused by bacteria in the Mycobacterium family. Caused by the varicella zoster virus. In pediatrics, it is considered a self-limited disease that rarely causes severe complications. It is much more lethal in adults. Transmitted through respiratory droplets and direct contact with the saliva of infected patients. It is characterized by painful enlargement of the salivary glands. Caused by an infestation of a mite that is barely visible without magnification. Inflammation of the liver caused by viruses, bacteria, fungi, parasites, excessive alcohol consumption, or medications. Inflammation of the meninges and cerebrospinal fluid, caused by bacterial and viral infections. Inflammation caused by infection of the brain and its structures, usually by viruses such as equine viruses, arboviruses, the rubella virus, or the mumps virus. Systemic disease caused by a virus of the genus Morbilli. It is highly communicable. Transmitted in the saliva of carriers and commonly infects the oropharynx, face, lips, skin, fingers, and toes. Acute lung inflammation, which is NOT a single disease but a family of diseases that result from respiratory infection by viruses, bacteria, or fungi. A viral illness characterized by inspiratory and expiratory stridor and a seal-bark-like cough, it is MOST common in children under the age of 3 years. Virus that causes acquired immunodeficiency syndrome (AIDS). Caused by the Epstein-Barr virus (EBV). It affects the oropharynx, the tonsils, and the reticuloendothelial system (the phagocytes). Family of viruses carried by rodents such as the deer mouse. Other known carriers are the rice and cotton rats in the southeastern United States, and the white-footed mouse of the northeastern states. Viral respiratory illness that FIRST appeared in southern China in 2002 and became a global threat in 2003 by spreading internationally. Recurrent inflammatory disorder accompanied by skin lesions, polyarthritis, and involvement of the heart and nervous system. It is the MOST commonly reported vector-borne disease in the United States. Systemic viral disease caused by a virus of the genus Rubivirus. Characterized by sore throat and low-grade fever, accompanied

_____22. _____23.

_____24.

_____25. _____26.

by a fine pink rash on the face, trunk, and extremities that lasts about 3 days. Inflammation of the epiglottis that may also involve the areas just above and below it. In children it is a TRUE emergency. MOST do NOT infect humans except in cases of prolonged contact. However, some can mutate or merge with a human influenza virus to form a virus that can infect humans. Acute bacterial infection of the central nervous system. It presents with musculoskeletal signs and symptoms caused by an exotoxin of the Clostridium tetani bacillus. Means “violent cough.” Common infection of the pharynx and tonsils. It may be caused by a virus or bacteria and is characterized by a sudden onset of sore throat and fever.

Student’s Name_________

HANDOUT 10-5

REINFORCEMENT IMMUNE SYSTEM MATCHING Write the letter of the term in the space next to the appropriate description. a. b. c. d. e. f. g.

Reticuloendothelial system Antigen Leukocyte Neutrophil Macrophage Immunoglobulin Humoral

_____ 1. _____ 2. _____ 3. _____ 4. _____ 5. _____ 6. _____ 7. _____ 8. _____ 9. _____ 10. _____ 11. _____ 12. _____ 13.

h. i. j. k. l. m. n.

Phagocytosis Cell-mediated Lymphocyte T lymphocytes B lymphocytes Antibody Immune system

Cell that attacks invader in immune response. The MOST common phagocytic white blood cell. Cells that attack invaders in humoral immune responses. Generalized immunity; temporary defense against any invader. The cells involved in the immune response. Cells that attack invaders in cell-mediated immune responses. The second MOST common phagocytic white blood cell. Marker on the surface of a cell that identifies it as self or nonself. White blood cell. Process in which certain white blood cells ingest invaders. The body’s mechanism for defending against foreign invaders. An antibody. A substance that is produced in response to and that destroys a particular antigen. _____ 14. Specialized immunity; permanent defense against a particular foreign antigen.

Chapter 10 Answer Key Handout 10-1: Chapter 10 Quiz 1. b 10. c 19. b 28. d 2. c 11. a 20. b 29. c 3. d 12. d 21. a 30. a 4. a 13. c 22. b 31. d 5. d 14. b 23. b 32. b 6. b 15. d 24. c 33. b 7. a 16. a 25. b 34. c 8. c 17. c 26. b 35. a 9. b 18. d 27. d 36. b

37. d 38. c 39. a 40. a 41. b 42. d 43. c 44. c 45. d

46. a 47. c 48. b

Handout 10-2: Chapter 10 Scenario 1. Precautions should have included gloves, goggles, mask or shield (because of large amount of blood), bagging and labeling of linens, intermediate- and high-level disinfections of the vehicle and instruments, and medical follow-up. 2. Possibilities include tuberculosis, hepatitis, and HIV. Handout 10-3: Chapter 10 Review 1. infectious disease 2. index case 3. Normal flora 4. pathogen 5. opportunistic pathogen 6. Bacteria 7. spheres, rods, spirals 8. Exotoxins, endotoxins 9. Bacteriostatic, bactericidal 10. virus 11. obligate intracellular parasite 12. fungi 13. protozoa 14. reservoir 15. theoretical 16. Virulence 17. latent, communicable 18. incubation period 19. antibody titer 20. preparation response, response, patient contact, recovery 21. disinfect, sterilize 22. Ryan White Act 23. blood, blood products, body fluids, blood, semen, vaginal secretions, breast milk. 24. acute hepatitis, cirrhosis, liver cancer 25. Tuberculosis ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed

26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. 46. 47.

Streptococcus pneumoniae, Gram-positive spheres Severe acute respiratory syndrome lethal, adults hips, knees, neck amantadine, oseltamivir, rimantadine avian influenza Measles Respiratory syncytial virus catarrhal, paroxysmal, convalescent mononucleosis oropharynx, face, lips, skin, fingers, toes dysphonia, drooling, dysphagia, distress Hantavirus Encephalitis early localized, early disseminated, late Gonorrhea primary, secondary, latent, tertiary Bedbugs nosocomial diarrhea, draining wound, jaundiced, mononucleosis, lice, scabies, strep throat, cold Sepsis, debilitated immunosuppression, hospitalized, infections, trauma, tendency, old, young

Handout 10-4: Infectious Disease Matching 1. l 8. z 15. q 22. p 2. x 9. b 16. a 23. h 3. w 10. g 17. n 24. u 4. y 11. t 18. s 25. m 5. c 12. i 19. e 26. r 6. f 13. o 20. v 7. j 14. d 21. k Handout 10-5: Immune System Matching 1. j 5. a 9. c 13. m 2. D 6. K 10. H 14. g 3. l 7. e 11. n 4. i 8. b 12. f

Chapter 11 Psychiatric and Behavioral Disorders

Student’s Name ________________

HANDOUT 11-1 EVALUATION

CHAPTER 11 QUIZ Write the letter of the best answer in the space provided. ______

1. A person’s observable conduct and activity is known as his: a. makeup. c. behavior. b. affect. d. socialization.

______

2. Which of the following is NOT one of the general causes of behavioral emergencies? a. Sociocultural (situational) c. Genetic (physical) b. Psychosocial (personal) d. Biological (organic)

______

3. Conditions related to a patient’s personality style, dynamics of unresolved conflict, or crisis management methods are called: a. psychosocial. c. biological/organic. b. sociocultural. d. sociobehavioral.

______

4. In behavioral emergencies, as with any other emergency calls, it is of utmost importance to determine: a. the number of patients. c. scene safety. b. the chief complaint. d. the patient’s level of consciousness.

______

5. When faced with a violent patient with a weapon, you should: a. immediately take the weapon from the patient. b. have your partner assist you in “taking down” the patient. c. ask a family member to take the weapon from the patient. d. request law enforcement assistance.

______

6. When assessing a patient with behavioral issues, you should: a. ask “yes or no” questions. b. ask open-ended questions. c. not ask any questions so you don’t agitate the patient. d. always assume that the patient is not telling the complete truth.

______

7. In assessing a patient with a behavioral emergency, guidelines include: a. standing close to the patient so that he must focus on you. b. positioning yourself at a higher level than the patient so that he must look up at you. c. realizing that silence is nothing to fear and can be appropriate.

d. spending as little time on scene as possible, since proper treatment will begin only at the care facility. ______

8. A structured exam designed to evaluate quickly a patient’s level of mental functioning is called the: a. focused mental examination (FME). b. focused mental evaluation (FME). c. mental status examination (MSE). d. field psychiatric evaluation (FPE).

______

9. Psychiatric disorders with organic causes are known as cognitive disorders, one example of which is: a. delirium. c. anxiety disorder. b. delusions. d. posttraumatic stress.

______ 10. One of the cognitive disturbances that is seen in dementia is: a. aphasia. c. hallucinations. b. delusions. d. anxiety. ______ 11. Common symptoms of schizophrenia include: a. gradual impairment of memory. b. extreme periods of anxiety resulting in emotional stress. c. excessive fear that interferes with functioning. d. sensory perceptions with no basis in reality. ______

12. A patient who is preoccupied with a feeling of persecution and who may suffer delusions or auditory hallucinations has _______ schizophrenia. a. disorganized c. catatonic b. paranoid d. undifferentiated

______ 13. One of the major types of schizophrenia is “catatonic.” This means that the patient: a. displays grossly disorganized behavior. b. does not readily fit into one of the defined categories. c. is preoccupied with a feeling of persecution. d. exhibits rigidity, immobility, stupor, or peculiar movements. ______ 14. Major alterations in the pervasive and sustained emotion that colors a person’s perception of the world are known as: a. mood disorders. c. schizophrenia. b. anxiety disorders. d. cognitive disorders. ______ 15. Symptoms of a major depressive disorder include: a. loss of any feelings of guilt. b. hyperactivity or increased agitation. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed

c. recurrent thoughts of death. d. the impaired ability to deal with reality. ______ 16. A screening acronym for major depression is: a. BAD NEWS. c. BEREAVE. b. In SAD CAGES. d. A DOWN DAY. ______ 17. Bipolar disorder is characterized by one or more manic episodes. The term “manic” refers to: a. periods of elation. b. profound sadness or feeling of melancholy. c. excessive fear that interferes with functioning. d. hostility or rage. ______ 18. Somatoform disorders are characterized by: a. a state of constant sleepiness or drowsiness. b. physical symptoms that have no apparent physiological cause. c. the relatively rapid onset of widespread disorganized thought. d. failure to recall, as opposed to inability to recall. ______ 19. Similar personality disorders are grouped into three broad types, or clusters. Which of the following is NOT a disorder in cluster A? a. Obsessive-compulsive c. Schizoid b. Paranoid d. Schizotypal ______ 20. A condition characterized by the patient’s failure to control recurrent impulses is called: a. obsessive-compulsive disorder. c. impulse control disorder. b. personality disorder. d. somatoform disorder. ______ 21. Which of the following statements is TRUE regarding suicide? a. Men attempt suicide more often than women. b. The most common method of suicide is poisoning. c. Suicide is the third leading cause of death in the 15- to 24-year age group. d. Suicide rates for younger age groups and the elderly are decreasing. ______ 22. What percentages of people who successfully commit suicide have made a previous attempt? a. 50% b. 60% c. 70% d. 80% ______ 23. The elderly often experience _______ that is mistaken for dementia. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed

a. depression. b. Alzheimer’s.

c. dissociative disorder. d. delirium.

______ 24. Excited delirium may be a result of: a. increased level of adrenalin. b. decreased level of adrenalin. c. decreased level of dopamine. d. increased level of dopamine. ______ 25. Which of the following signs, if present, should prevent a patient from being released to law enforcement after being subdued with a TASER? a. Glasgow Coma Scale of 15 b. Systolic Blood Pressure > 100 mmHg c. Heart rate > 110/minute d. Respiratory rate > 12/ minute ______ 26. Methods of restraint include: a. physical restraint. b. chemical restraint.

c. verbal deescalation. d. all of the above.

______ 27. Verbal deescalation involves all the following EXCEPT: a. avoiding entering the patient’s personal space. b. looking the patient directly in the eyes. c. being honest. d. using a friendly tone of voice. ______ 28. All of the following are examples of soft restraints EXCEPT: a. leathers. c. sheets. b. chest Posey. d. wristlets. 29. Which of the following is an acceptable manner of restraining a patient? a. Hobbled b. Sandwiched between backboards c. Prone d. None of these are acceptable. ______

30. Which of the following is NOT a benzodiazepine that is commonly used for chemical restraint? a. Midazolam (Versed) c. Haloperidol (Haldol) b. Diazepam (Valium) d. Lorazepam (Ativan)

Student’s Name ________________

HANDOUT 11-2 EVALUATION

CHAPTER 11 SCENARIO Review the following real-life situation. Then answer the questions that follow. It is early evening in late spring. You have been dispatched to a home in an upper-middle-class neighborhood for an “unknown medical” call. The dispatcher tells you that police will meet you at the scene, since the caller reported that she could hear things being thrown against the walls and lots of shouting. The police car is in the driveway when you arrive. A middle-aged woman comes out of the house next door and joins the officer on the front sidewalk as you and your partner grab your jump kit and approach. As you get closer to the front door, you can hear the sounds from inside the house. Dispatch was right; it does sound as though things are being thrown. However, you hear only a single voice shouting. The neighbor, Mrs. Rozenman, reports that the family who lives at this address is fairly new to the neighborhood. She says that she knows they have a teenage son and thinks that both parents are attorneys. The police officer goes to the front door, knocks, and identifies himself. There is no answer. He knocks again, and there is still no answer. He then tries the doorknob and finds the door unlocked. He motions for you to join him as he enters the house. You and your partner enter the house behind the officer. The noise seems to be coming from the room with the open door just to the right of the front door. You all turn in the direction of the noise, and the police officer again identifies himself. In the room to the right is a slightly built adolescent male who is standing in the center of the room amidst overturned furniture. His clothes are disheveled, and it appears that he is sweating profusely. Although he is looking at you, your impression is that he is not aware that you are there, but he does stop yelling. 1. What are at least three possible causes for the young man’s condition?

The police officer again identifies himself and identifies you and your partner as paramedics. The patient shouts, “Go to hell!” Your partner goes to check the medicine cabinets for a clue about what is going on while you and the police officer prepare to restrain the patient. 2. How should restraint of this patient be handled?

Just as you get the patient into a prone position, a well-dressed middle-aged woman enters the room with your partner. She identifies herself as Mrs. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed

Spencer, the patient’s mother, and tells you that her son, Bob, is diabetic and recently changed his insulin dosage. 3. What should you do now?

After your intervention, Bob is alert and oriented, quiet, and cooperative. He apologizes for giving you such a hard time. Mrs. Spencer thanks you for coming and tells you that she will contact Bob’s doctor immediately. You contact medical direction and are cleared to return to quarters.

Student’s Name ________________

HANDOUT 11-3 EVALUATION

CHAPTER 11 REVIEW Write the word or words that best complete each sentence in the space(s) provided. 1. A person’s observable conduct and activity is called _________ 2. A(n) _________ _________ is a situation in which a patient’s behavior becomes so unusual that it alarms the patient or another person and requires intervention. 3. _________ (_________) causes of behavioral emergencies are related to disease processes or structural changes. 4. _________ conditions are related to a patient’s personality style, dynamics of unresolved conflict, or crisis management methods. 5. _________ causes of behavioral disorders are related to the patient’s actions and interactions within society. 6. During the primary assessment, be cautious of any overt behavior such as _______ or _____ ________. 7. An approximate 3-foot radius around every person is considered the person’s ________ _____. 8. Talking to patients about _______, ____-_____________, or other ___________ conditions is difficult. 9. Avoid appearing __________ when assessing the patient. 10. Never ___ to the patient. 11. The initials MSE stand for _________ _________ _________. 12. Components of an MSE include general _________ and behavioral _________. 13. Cognitive disorders include _________ and _________. 14. Symptoms of schizophrenia include _________, _________, disorganized speech, grossly _________ behavior, and _________ symptoms. 15. Types of schizophrenia are _________, _________, _________, and _________. 16. A(n) _________ disorder is a condition characterized by dominating apprehension and fear. 17. A(n) _________ _________ is an extreme period of anxiety resulting in great emotional stress. 18. An excessive fear that interferes with functioning is called a(n) _________ 19. ______-________ ______ ________ is a reaction to an extreme, usually lifethreatening stressor. 20. The main mood disorders are __________ and _____ ________. 21. When depression becomes prolonged or severe, however, it is diagnosed as a(n) _____ __________ _______. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed

22. The acronym _________ _________ _________ provides a screening mnemonic for major depression. 23. The condition characterized by one or more manic episodes, with or without periods of depression, is called a(n) _________ disorder. 24. Bipolar patients in an extreme manic phase may be _______ _________. 25. If a patient has a somatization disorder, he is preoccupied with _________ symptoms. 26. A(n) _________ disorder is the condition in which the patient feigns illness in order to assume the sick role. 27. _________ nervosa is characterized by voluntary refusal to eat, and _________ nervosa is recurrent episodes of binge eating. 28. Kleptomania and pyromania are examples of _____________ ___________ disorders. 29. The MOST common method of suicide (in 2002) was ______ ______. 30. Giving away personal belongings, increased isolation, and lack of goals and plans for the future are all risk factors for _______. 31. Excited delirium syndrome appears to be a factor in sudden death associated with _______ _________. 32. The TASER fires two small _________-________ that make contact with the skin. 33. The three methods of restraint include _________________, ________ _________, and _______ ________. 34. Restraining a patient in a prone position has been associated with __________ ________. 35. ________ _________ is defined as the administration of specific pharmacological agents to decrease agitation and increase the cooperation of patients who require medical care and transportation. 36. The five medications that can be given IM or IV and are often included in a chemical restraint protocol are ______, ________, _______, _________, and ___________.

HANDOUT 11-4

Student’s Name ________________

REINFORCEMENT BEHAVIORAL EMERGENCY ROLE-PLAY INSTRUCTIONS This activity will be a role-play for dealing with behavioral emergencies. You may not hurt any of your fellow students. Take the role assigned to you, and use your education and experience to fill in the blanks. If there are any medical questions, first verbalize the actions you would take and then ask the instructor for the results. Make no assumptions. Act as you would in a similar situation in the real world. At the conclusion of each scenario, you will be asked to evaluate the performance of the caregivers in the following areas, using the sheets provided. • Scene survey • Assessment • Interview techniques • General management and intervention techniques

SCENARIO 1 Caregivers: You have been dispatched to a rest stop on the interstate for an “unknown emergency.” Patient: Depression You are a young college student who has just failed out of school and are found crying in the rest stop snack bar. You are very depressed and do not know how you can face your parents. You are on your way home and are at a loss as to what to do. Engine Company: Arrive with the paramedics. Crew is to take no action unless ordered to by the paramedics. SCENARIO 2 Caregivers: You have been dispatched to a townhouse for an “illness.” Dispatch reports that this was a third-party call from the adult child (who lives in another state) of this patient. The caller reported that the patient “sounded very sick on the phone.” Patient: Suicide You are a 54-year-old who has been very sick for the past several months. You are divorced, living alone, and very depressed. Because of your recent diagnosis of cancer, you are planning to take an overdose. Although you have not told your 30-year-old daughter anything about your illness, you did tell her that you were sending her a revised copy of your will. Engine Company: Arrive with the paramedics. Crew is to take no action unless ordered to by the paramedics. SCENARIO 3 Caregivers: You have been dispatched to assist another paramedic unit at a multiple-fatality auto collision. They are transporting one of two survivors, a pregnant adult female who is critically injured. You are assigned to the other survivor who was just extricated from the wreckage. Patient: Anxiety Disorder You were just involved in a multiple-vehicle auto collision in which two people were killed and one was seriously injured. You were alone in your car and were unhurt from the accident but were trapped in the wreckage. Your seat belt and the air bag saved you. You are unable to function. You are overwhelmed by having had to look at the two dead people in the other vehicle while extrication was taking place. You are hyperventilating and have chest pain (non-cardiac-related). You are trembling all over. You doubt that you will ever be able to drive again. You were not at fault; the other driver ran the red light. Engine Company: Arrive with the paramedics. Crew is to take no action unless ordered to by the paramedics. SCENARIO 4 ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed

Caregivers: You are dispatched to a local high school for an “illness.” Patient: Manic Disorder You are a high school student using cocaine. You are experiencing mood swings. You alternate between depression and elation. You have greatly increased activity levels and have been sleeping a lot less lately. You are restless and talkative. You cannot concentrate but do not think there is a problem you cannot handle. Teacher: You report that this student has really changed over the past several weeks. Grades have fallen dramatically, and truancy has increased. You called 911 because, from your viewpoint, the student is really acting strange today and was very restless and talkative in class. You are very concerned about the student’s health and think that the student is “whacked out” on drugs. SCENARIO 5 Caregivers: You are dispatched to assist the police for a “mental patient” at a local homeless shelter. Patient: Schizophrenia You are a young adult who has withdrawn from society. You are dirty and dull-witted, and you have difficulty communicating. You can communicate that you are a close personal friend of Bart Simpson and have been asked to attend the next Kanye West concert to interview him for TMZ. You have accepted the assignment and now need to go get your tickets and press pass. You are quite excited about the opportunity and are anxious to leave, but you are worried that everyone is going to try to steal your tickets and backstage pass. You are nonviolent but not cooperative. Shelter Manager: You are concerned that the patient’s agitation will set off a chain reaction among your clients, many of whom are deinstitutionalized psychiatric patients. You want this patient out of your facility but are concerned about the patient’s safety on the street in the patient’s present condition. SCENARIO 6 Caregivers: You are dispatched to a residential neighborhood for an “elderly patient with an illness.” This is the fourth time this month that you have gone to this address for an 82-year-old who seems to be trying to test your assessment skills. On the first call, the patient was in heart block and had experienced a syncopal episode. The second and third calls were to deal with an “injury from a fall.” Your last call was again for a syncopal episode. Patient: Geriatric Crisis You are an 82-year-old who is failing fast, but you have all your mental faculties and want to stay in your own home until the end if at all possible. All you did was refuse breakfast, but your daughter got angry and called 911 because she wants you to go to a “home.” You want to stay in your own house. After all, you have lived here since you got married 62 years ago. Your spouse died 10 years ago, and you have lived alone ever since. You think you can still manage your own affairs. It seems to you that the doctor solved your “palpitation” problem just fine. You were not in any mood to eat after fighting with ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed

your child about her wanting you to go to the “raisin farm,” so you refused breakfast. Daughter: You are the 54-year-old only child of this patient. You want the paramedics to convince your parent it is time to go to an extended care facility. SCENARIO 7 Caregivers: You are dispatched for an “injury” at a home in a middle-class residential neighborhood. Patient: Domestic Violence You are a husband and wife who have been fighting. The husband has been hitting the wife in the face, and she is holding her head but does not appear to be seriously injured. Both are quite agitated. Engine Company: Arrive with the paramedics. Crew is to take no action unless ordered to by the paramedics. If asked, acknowledge that the police are en route and should arrive in the next 10 minutes.

HANDOUT 11-6

Student’s Name ________________

REINFORCEMENT BEHAVIORAL EMERGENCIES ROLE-PLAY EVALUATION SHEET Using the following scale, rank the “performance” of the caregivers in the scenario you have just observed. 1 = Well done 2 = Not bad 3 = Needs improvement 4 = Don’t come to my house Component Scene Survey Comments:

Assessment Comments:

Interview Techniques Comments:

General Management and Intervention Techniques Comments:

Total = _____________

Score

Chapter 11 Answer Key Handout 11-1: Chapter 11 Quiz 1. c 2. c 3. a 4. c 5. d 6. b 7. c 8. c

9. a 10. a 11. d 12. b 13. d 14. a 15. c 16. b

17. a 18. b 19. a 20. c 21. c 22. d 23. a 24. d

25. c 26. d 27. b 28. a 29. d 30. c

Handout 11-2: Chapter 11 Scenario 1. Possible causes include alcohol abuse, drug abuse, trauma, behavioral causes (mental illness), and medical illness (e.g., diabetes). 2. Make sure you have enough assistance. Offer the patient one final opportunity to cooperate. If there is no response to this request, at least two persons should move swiftly toward the patient at the same time while one paramedic continues talking to the patient. The two persons should cautiously move closer toward the patient. If the patient calms down, you may elect to transport without restraints. Continue to reassure the patient. Have the patient lie down, and position yourself between him and the door. If the patient continues to resist, position your inside leg in front of the patient’s leg, and force the patient forward into a prone position. Continue to reassure the patient. Once subdued, position the patient prone or on his side, then secure his arms and legs. Transport patient. 3. Follow local protocols for management of a diabetic emergency. Get baseline vital signs, and draw a blood sample to check the patient’s blood sugar. Establish an IV, and administer 50% dextrose IV. Recheck blood sugar. Handout 11-3: Chapter 11 Review 1. behavior 2. behavioral emergency 3. Biological, organic 4. Psychosocial 5. Sociocultural 6. posture, hand gestures 7. personal space 8. suicide, self-mutilation, psychological 9. judgmental 10. lie 11. mental status examination 12. appearance, observations ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed

13. delirium, dementia 14. delusions, hallucinations, disorganized, negative 15. paranoid, disorganized, catatonic, undifferentiated 16. anxiety 17. panic attack 18. phobia 19. Post-traumatic stress syndrome 20. depression, bipolar disorder 21. major depressive episode 22. In SAD CAGES 23. bipolar 24. overtly psychotic 25. physical 26. factitious 27. Anorexia, bulimia 28. impulse control 29. bullet wounds 30. suicide 31. restraint situations 32. dart-like electrodes 33. verbal deescalation, physical restraint, chemical restraint 34. positional asphyxia 35. Chemical restraint 36. diazepam, lorazepam, midazolam, droperidol, haloperidol

Chapter 12 DISEASES OF THE EYES, EARS, NOSE AND THROAT

Student’s Name ________________

HANDOUT 12-1 EVALUATION 

CHAPTER 12 QUIZ Write the letter of the best answer in the space provided. ______

1. Movement of the eye is controlled by ____________ extraocular muscles. a. three c. five b. four d. six

______

2. Eyelashes function as: a. sensors. b. filters.

______

3. Tears are manufactured in the: a. lacrimal ducts. b. lacrimal glands. c. posterior cavity. d. anterior cavity.

______

4. Vitreous humor is found in the: a. posterior chamber. b. anterior chamber.

c. protectors. d. sun blockers.

c. posterior cavity. d. anterior cavity.

______

5. The middle layer of the eye is the: a. retina. b. choroid. c. sclera. d. scleraderma.

______

6. The light-sensing receptors that are effective in dim light and do not perceive color are called: a. rods. b. cones. c. spheres. d. cylinders.

______

7. Which of the following is NOT a type of conjunctivitis? a. Bacterial b. Viral c. Allergic

d. Infectious ______

8. The MOST frequent cause of corneal blindness in the United States is: a. herpes zoster ophthalmicus. b. herpes simplex virus keratitis. c. glaucoma. d. pterygium.

______

9. If a patient presents with blurred vision and the presence of “floaters” in the eye, you should suspect: a. ocular hemorrhage. c. central retinal vein occlusion. b. central retinal artery occlusion. d. retinal detachment.

______ 10. Which of the following bones is NOT found in the middle ear? a. Bony labyrinth c. Incus b. Malleus d. Stapes ______ 11. The condition consisting of swelling and irritation of the inner ear is called: a. malignant otitis externa. c. labrynthitis. b. mastoiditis. d. otitis media. ______ 12. Ninety percent of all nosebleeds occur in: a. Kiesselbach’s plexus. b. Broca’s area. c. Meniere’s disease. d. a bowel disorder that can affect any portion of the GI tract. ______ 13. The structure that hangs from the posterior aspect of the mouth and helps to block food and other substances from entering the nose during swallowing is called the: a. tonsils. c. pharynx. b. uvula. d. adenoids. ______ 14. The function of the epiglottis is to: a. aid in formation of sound. b. cover the esophagus during inhalation. c. prevent food, water, and saliva from entering the respiratory tract. d. initiate the cough response.

______ 15. A condtion that involves inflammation of the floor of the mouth under the tongue and can be life threatening is: a. peritonsillar abscess. c. dentalagia. b. Ludwig’s angina. d. epiglottitis.

Student’s Name ________________

HANDOUT 12-2 EVALUATION 

CHAPTER 12 SCENARIO Review the following real-life situation. Then answer the questions that follow. You and your partner are just arriving at the station to begin your shift, and you hear the off going crew getting toned out on a “man ill” call. You both offer to take the call, and after receiving a brief run-down from the off going crew, you head out to the dispatch location. You arrive at a home in a nicely kept neighborhood and are met at the door by a woman who appears to be in her early forties. She states that she called 911 for her husband, who has been ill since early this morning. She goes on to tell you that he has had a “toothache” for approximately 5 days but has been unwilling to see a dentist. The woman leads you back to the master bedroom, where you find a man who is sitting on the bed, looking at you but appearing in moderate distress. He appears to have some swelling to his face, around the area of his jaw, and some mild swelling to his neck. When you attempt to ask him what is wrong, he simply shakes his head and points to his wife, as if he wants her to answer the questions. You ask your partner to interview his wife and gather as much information as possible, and you begin your physical assessment of the patient. 1. What might be wrong with the patient?

2. When you question the wife, what symptoms should you ask if the patient has experienced?

After questioning the patient’s wife, you determine that your initial diagnosis is correct, as the patient has experienced the majority of the symptoms associated with that condition. On physical examination, he has mild neck swelling and redness, difficulty swallowing, and drooling, and he is unwilling to speak because of the pain it causes. Vital signs are blood pressure, 146/90; pulse, 110; respirations, 24 and regular, unlabored, breath sounds equal, clear bilaterally; ECG is NSR, without ectopy; and pulse oximeter is 99% on room air. His skin is warm, dry, and flushed. All other physical examination findings are normal. After completing your exam, you advise that patient that he needs to be transported to the emergency department for further evaluation. The patient

shakes his head back and forth several times and writes on a piece of paper that he will go to his dentist later if he doesn’t feel any better. 3. What information should you provide to the patient and his wife regarding his potential diagnosis to convince the patient to allow you to transport him to the emergency department? After explaining your findings and possible complications of remaining at home, the patient reluctantly agrees to transport. You place the patient on a nasal cannula at 4 LPM, and establish an IV of NaCl to run at TKO. The patient is placed on the stretcher in a high-Fowler’s position and wheeled to the ambulance. You load the patient and begin the 20-minute trip to the closest emergency department.

4. What equipment should you have ready during the transport to the hospital?

The patient has an uneventful trip to the emergency department, and vitals have remained unchanged throughout transport. The emergency department staff takes over care of the patient, and when you return to the emergency department several hours later, the doctor who treated the patient commends you on an excellent job of identifying the patient’s problem. The patient was admitted on a course of antibiotics for Ludwig’s angina, was evaluated by a dentist for this absessed tooth, and is expected to be discharged after 24 hours.

Student’s Name ________________

HANDOUT 12-3 REINFORCEMENT 

CHAPTER 12 REVIEW Write the word or words that best complete the following sentences in the space(s) provided. 1. Tears are manufactured in the ________ ______ and then spread across the eye _____ to ________, when they then drain through the ________ _____ into the nose. 2. The eye comprises three layers. The innermost layer is the ______. The middle layer is the _______. The outermost layer is the ______. 3. The three main causes of conjunctivitis are ________, _____, and ________. 4. ______ _______ _____ _________ is an infection and inflammation of the cornea that results from the herpes simplex virus. 5. When herpes zoster affects the eye, it is known as _____ _____ ____________. 6. Protrusion of the eye, as seen in orbital cellulitis, is called _________. 7. Glaucoma results from the blockage of the flow of _______ _____ from the _______ _______. 8. A clouding of the lens of the eye is called a ________. 9. Central retinal vein occlusion is a blockage of the small veins that drain the retina and is MOST commonly caused by _______________ or a ________. 10. Patients with _______ __________ will report blurred vision and the presence of “floaters” in the eye. 11. The three bones of the middle ear are the _______, _____, and ______. 12. The bony labyrinth can generally be divided into three parts, the ________, __________ ______, and the ______. 13. In children, pulling at the ear is often a sign of ______ _____. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed

14. ____________ _____, is a network of four arteries located in the ____________ region of the nasal septum and is the region where approximately 90% of nosebleeds occur. 15. Nosebleeds can arise from such conditions as low ________, _______ ___________, _______ ____________, ___________, _____, _____ ________ ________, and __________. 16. Oral candidiasis, commonly called thrush, is MOST common in _______, in ________ with poor glucose control, in ____ patients, and as a side effect of taking ____________. 17. ________ ______ is a type of oral bacterial cellulitis, or inflammation, that involves the floor of the mouth under the tongue.

Student’s Name ________________

HANDOUT 12-4 REINFORCEMENT 

ANATOMY OF THE EYE Write the letter of the term in the space provided next to the appropriate description. a. Ocular orbit b. Extraocular muscles c. Eyelashes d. Sebum e. Conjunctiva f. Lacrimal apparatus g. Posterior cavity h. Anterior cavity i. Retina j. Choroid k. Sclera l. Iris m. Ciliary muscles n. Lens ______

1. Membrane that covers and protects the exposed surface of the eye.

______

2. Colored portion of the eye.

______

3. Referred to as the “whites of the eyes.”

______

4. Group of bones that protect the eye.

______

5. The structure that focuses the incoming light images onto the retina.

______

6. The portion of the eye in front of the lens, containing the aqueous humor.

______

7. Contains the nerve endings that receive and interpret the incoming image.

______

8. Set of six muscles that control movement of the eyes.

______

9. Muscles that surround and change the shape of the lens.

______ 10. Function as sensors to cause rapid closure of the eyelid when a foreign substance approaches the eye. ______ 11. Portion of the eye behind the lens, containing vitreous humor. ______ 12. Manufactures and stores tears. ______ 13. Oily substance secreted on the eyelids to keep them soft and pliable. ______ 14. Highly vascular tissue that provides essential nutrients to the tissues of the eye.

Student’s Name ________________

HANDOUT 12-5 REINFORCEMENT 

ANATOMY OF THE EAR Write the letter of the term in the space provided next to the appropriate description. a. b. c. d. e. f. g. h. i. j. k.

Pinna Cerumen Auditory ossicle Tympanic cavity Eustachian tube Oval window Bony labyrinth Endolymph Vestibule Semicircular canals Cochlea

______

1. Protects the malleus, incus, and stapes.

______

2. Protects the specialized receptor within the inner ear.

______

3. Contains sensory structures that detect rotation of the head.

______

4. Protective substance, also known as earwax.

______

5. Separates the inner ear from the middle ear.

______

6. Structure that houses the receptors that provide sense of hearing.

______ 7. Collects sound waves and directs them into the external auditory canal. ______

8. Fluid that fills the membranous labyrinth.

______

9. Connects the middle ear to the pharynx.

______ 10. Three small bones that are joined together and function to amplify sound waves received by the tympanic membrane. ______ 11. Contains membranous sacs that sense gravity and linear acceleration. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed

Student’s Name ________________

HANDOUT 12-6 REINFORCEMENT 

ANATOMY OF THE MOUTH AND THROAT Write the letter of the term in the space provided next to the appropriate description. a. Labia b. Palate c. Tongue d. Pharynx e. Uvula f. Tonsils and adenoids g. Teeth h. Salivary glands i. Esophagus j. Larynx

______

1. Lymph glands that aid in fighting infection.

______

2. The organ of speech.

______

3. Muscular structure that is needed to move and manipulate food into the gastrointestinal system.

______

4. Structure that helps to block food and other substances from entering the nose during swallowing.

______

5. Plays a major role in the mechanical breakdown of food for digestion.

______

6. Structures that protect the mouth from the environment.

______

7. Excrete 1–1.5 L of saliva daily.

______

8. The posterior aspect of the oral cavity, bounded by the posterior pharyngeal wall and associated structures.

______

9. The upper portion of the oral cavity.

Chapter 12 Answer Key Handout 12-1: Chapter 12 Quiz 1. d 2. a 3. b 4. c

5. b 6. a 7. d 8. b

9. d 10. a 11. c 12. a

13. b 14. c 15. b

Handout 12-2: Chapter 12 Scenario 1. Several conditions may be causing the patient’s presentation: an allergic reaction, angioedema, or Ludwig’s angina. On the basis of the initial information of a toothache, you determine that the most likely cause is Ludwig’s angina. 2. On the basis of the determination of Ludwig’s angina, the wife should be asked about: difficulty breathing, confusion, fever, neck swelling or redness, difficulty swallowing, drooling, earache, unusual speech, and weakness or fatigue 3. You should explain to the patient that you suspect he has Ludwig’s angina that has developed after an infection at the root of his aching tooth. You should advise the patient that this develops quickly and that swelling to his tongue and roof of his mouth can occlude his airway. You should also explain that this condition can be life threatening. 4. Suction should be available to control secretions. You can instruct the patient on how to use the suction catheter himself if that is more comfortable for him. If the swelling occludes his airway, you should be prepared to perform a surgical airway (if your local protocols permit that procedure).

Handout 12-3: Chapter 12 Review 1. lacrimal glands, laterally, medially, lacrimal ducts 2. retina, choroid, sclera 3. bacterial, viral, allergic 4. Herpes simplex virus keratitis 5. herpes zoster ophthalmicus 6. proptosis 7. aqueous humor, anterior chamber 8. cataract 9. atherosclerosis, thrombus 10. retinal detachment 11. malleus, incus, stapes 12. vestibule, semicircular canals, cochlea ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed

13. otitis media 14. Kiesselbach’s plexus, anteroinferior 15. humidity, topical medications, structural abnormalities, inflammation, tumors, blood coagulation disorders, hypertension 16. infants, diabetics, AIDS, antibiotics 17. Ludwig’s angina Handout 12-4: Anatomy of the Eye 1. e 2. l 3. k 4. a 5. n 6. h 7. i 8. b 9. m 10. c 11. g 12. f 13. d 14. j Handout 12-5: Anatomy of the Ear 1. d 2. g 3. j 4. b 5. f 6. k 7. a 8. h 9. e 10. c 11. i Handout 12-6: Anatomy of the Mouth and Throat 1. f 2. j 3. c 4. e ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed

5. g 6. a 7. h 8. d 9. b 10. i

Chapter 13 NONTRAUMATIC MUSCULOSKELETAL DISORDERS

Student’s Name ________________

HANDOUT 13-1 EVALUATION 

CHAPTER 13 QUIZ Write the letter of the best answer in the space provided. ______

1. Which type of bone is found in the wrist and ankle? a. Long c. Flat b. Short d. Irregular

______

2. The joint at the base of the thumb is an example of what type of joint? a. Saddle c. Pivot b. Gliding d. Hinge

______

3. _________ is an avascular tissue, meaning that it is NOT supplied by blood vessels. a. Tendon b. Bone c. Cartilage d. Ligament

______

4. ______________ is the strongest and MOST rigid type of cartilage. a. Double-stranded cartilage c. Elastic cartilage b. Hyaline cartilage d. Fibrocartilage

______

5. Lateral epicondylitis is more commonly known as: a. tennis elbow. b. golfer’s elbow. c. carpal tunnel syndrome. d. bursitis.

______

6. The bursae are small sacs filled with: a. plasma. b. synovial fluid. c. surfactant. d. spinal fulid.

______

7. Carpal tunnel syndrome is caused by pressure on the: a. lateral nerve of the forearm. b. median nerve of the forearm. c. lateral nerve of the wrist. d. median nerve of the wrist.

______

8. Virtually every person will have some signs or symptoms of osteoarthritis by the age of: a. 50. b. 60. c. 70. d. 80.

______

9. The pain and stiffness associated with osteroarthritis occur primarily: a. in the evenings. c. on arising in the morning. b. when the weather changes . d. after strenuous work.

______ 10. Osteoporosis in women is primarily caused by a loss of: a. estrogen. c. progesterone. b. testosterone. d. calcium. ______ 11. The condition in which joints become swollen to the extent at which they lose range of motion is called: a. debilitating arthritis. c. arthritis. b. chronic arthritis. d. rheumatoid arthritis. ______ 12. Gout occurs when ________ accumulates in the joints. a. calcium chloride b. uric acid c. sodium d. potassium ______ 13. The so-called flesh-eating disease is a life-threatening form of: a. cellulitis. c. gangrene. b. tenosynovitis. d. fasciitis. ______ 14. Which of the following is NOT one of the six D’s associated with chronic pain syndrome? a. Disability c. Dependency b. Diabetes d. Depression

______ 15. The condition that is characterized by widespread pain in the muscles and soft tissues and is more common in young or middleaged women is called: a. fibromyalgia. c. chronic pain syndrome. b. lupus. d. reflex sympathetic dystrophy.

Student’s Name ________________

HANDOUT 13-2 EVALUATION 

CHAPTER 13 SCENARIO Review the following real-life situation. Then answer the questions that follow. You and your partner are working a 12-hour shift in a large city when you are dispatched to the bus stop at 63rd and Fountain Streets. You make your way through rush hour traffic, and when you arrive on scene, you find an elderly female sitting on the bus bench, surrounded by several people. You quickly evaluate the scene, do not see any hazards, and approach the patient. When asked, the patient tells you that her name is Mrs. Robinson and asks you to please help her with her arm. As your partner begins to gather vital signs, you begin your assessment. Mrs. Robinson tells you that she was out shopping today, and when she was finished, she rode the bus back to her neighborhood. She goes on to tell you that when she stepped off the bus, she twisted her ankle, and as she was falling, she instinctively stuck out both arms to brace herself. She states that she never fell completely to the ground, only hit her knees on the pavement and her hands on the curb. You ask her how she got to the bus bench, and she said that she walked there without any assistance. It was only after sitting for several minutes that she realized that her left arm was beginning to swell and becoming very painful. After completing a thorough rapid trauma assessment, you determine that Mrs. Robinson’s injuries are confined to her left arm and abrasions to both knees. Mrs. Robinson states that she is generally in good health, has a mildly elevated cholesterol level, but does have some “bone problems” like most people her age. You quietly ask Mrs. Robinson how old she is, and she tells you that she will be 80 years old next spring. You examine Mrs. Robinson’s left arm and determine that there is swelling and bruising to the distal end of her forearm and tenderness upon palpation. There is positive pulse, motor movement, sensation, and capillary refill in the extremity. You advise Mrs. Robinson that you are going to place her arm in a splint for comfort and go on to tell her that you think it is best if she lets you transport her to the nearest emergency department for X-rays and further treatment. After placing a splint on her left arm, you transport Mrs. Robinson to the local emergency department, where it is determined that she has a fracture to her left arm and abrasions to both knees.

As you stop in to say goodbye to Mrs. Robinson, she thanks you for taking such good care of her and says, “I just don’t understand how I broke my arm. It seemed like such a little fall.” 1. Early in the assessment, Mrs. Robinson stated that she had “bone problems” like most people her age. What types of nontraumatic musculoskeletal disorders are common in this patient’s age group? 2. The patient’s fall appeared to be minor, yet the patient sustained a fracture to her arm. Which nontrauma musculoskeletal disorder would account for the fracture that the patient sustained?

Student’s Name ________________

HANDOUT 13-3 REINFORCEMENT 

CHAPTER 13 REVIEW Write the word or words that best complete the following sentences in the space(s) provided. 1. The 206 bones of the human body are classified based on their shape and include ____ _____, _____ _____, ____ _____, and ________ _____. 2. The six classes of joints are _______, _____, _____, _____, ___________, and ___ ___ ______. 3. The three types of cartilage are _______, _____, and ______________. 4. Joints contain a lubricant referred to as ________ _____. 5. Lateral epicondylitis is commonly known as _____ _____, and medial epicondylitis is commonly known as ________ _____. 6. _____ are small synovial sacs that are located along tendons at points where friction can develop. 7. The signs and symptoms of carpal tunnel syndrome include ________, ________, ________, or ____ that is felt in the fingers and hands. 8. The signs and symptoms or osteoarthritis include pain and stiffness that are present primarily on _______ __ ___ _______. 9. ____________ is the MOST common form of bone disease. 10. ___________ ____ _______ is one of the MOST common causes of low back pain. 11. __________ _________ is a chronic disease that leads to inflammation and injury to the joints and the surrounding tissues. 12. The form of inflammatory arthritis that primary affects the spine is called __________ __________. 13. Systemic lupus erythematosis is a chronic autoimmune disease that can affect the ____, ______, _______, and other organs. ©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed

14. Gout is a form of inflammatory arthritis that occurs when _____ _____ accumulates in the joints. 15. ___________ _________ is a life-threatening form of fasciitis and is commonly known as flesh-eating disease. 16. An infection of the bone is called _____________. 17. _______ ____ ________ is a poorly defined condition but generally includes ongoing pain that lasts anywhere in excess of 3 to 6 months. 18. A somewhat enigmatic condition characterized by widespread pain in the muscles and soft tissues throughout the body is known as ____________.

CHAPTER 13 ANSWER KEY Handout 13-1: Chapter 13 Quiz 1. b 2. a 3. c 4. d

5. a 6. b 7. d 8. c

9. c 10. a 11. d 12. b

13. d 14. b 15. a

Handout 13-2: Chapter 13 Scenario 1. Several conditions are typical in this patient’s age group, including osteoarthritis, osteoporosis, and degenerative disk disease. 2. Fractures with little or no trauma are seen in osteoporosis. The patient’s age of 79 places her at increased risk for developing osteroporosis.

Handout 13-3: Chapter 13 Review 1. long bones, short bones, flat bones, irregular bones 2. gliding, hinge, saddle, pivot, ellipsoidal, ball and socket 3. hyaline, elastic, fibrocartilage 4. synovial fluid 5. tennis elbow, golfer’s elbow 6. Bursae 7. tingling, numbness, weakness, pain 8. arising in the morning 9. Osteoporosis 10. Degenerative disc disease 11. Rheumatoid arthritis 12. ankylosing spondylitis 13. skin, joints, kidneys 14. uric acid 15. Necrotizing fasciitis 16. osteomyelitis 17. Chronic pain syndrome 18. fibromyalgia