RESPIRATORY EMERGENCIESCASE ASSESSMENT PATHOPHYSIOLOGY SIGNS AND SYMPTOMS MANAGEMENT TRANSPORT

CONSIDERATIONSTATUS ASTHMATICUS Onset

ProvocationQualityRadiationSeverity

SAMPLE Hx

Acute asthmatic attack involves airway obstruction due to :

1. Bronchospasm2. Swelling of mucous

membranes3. Mucus secretions

Provocation:1. Resp Infection2. Emotional Stress3. Allergic Reaction

1. Anxiety2. Patient breathes through pursed

lips3. Wheezing4. Chest overinflated5. Tachycardia6. Tripod post

VENTILATIONOXYGENPOSITION

IMMEDIATE while monitoring vital signs.

PULMONARY EDEMA Excess FLUID BUILD UP in the lungs often caused by MI or related heart disease and occasionally by inhalation of smoke and or toxic fumes. Alveoli collapse due to adhesive property of H2O.

1. RAPID HEART RATE2. Cyanosis3. Distended Neck Veins4. Wheezing5. Frothy or flecked sputum6. Water filled spongy lung7. Dyspnea8. Frothy fluid in bronchi9. Cool, Clammy skin10. Edema

1. High Flow O22. Consider

PEEP/CPAP

IMMEDIATE

CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)

Chronic Bronchitis

Pulmonary Emphysema

Repeated infections thicken and destroy the lining of the bronchi and bronchioles causing narrowing and becoming obstructive by too much MUCUS and EXCESSIVE CONTRACTIONS of the muscle in their walls.

Alveoli of the lungs become inflated or over distended with trapped air (may burst and merge to make fewer but larger alveoli causing reduction in the lung’s surface area) Less oxygen through walls of the alveoli and

1. Ventilate with 100% O2.

into the bloodstream.

Asthma

OnsetProvocationQualityRadiationSeverity

SAMPLE Hx

Same as Status Asthmaticus

DANGER SIGNS!!!1. Loss of Wheezing

2. Change in Sensorium (Confusion, Irritability, Lethargy)

3. Hypoxia

Prevent Lethal Hypoxia

Depending on the level of hypoxia.

Hyperventilation Syndrome

Abnormal increase in respiration rate and tidal volume.

Anxiety of an emergency often leads to hyperventilation.

Could cause acidosis.

Reassurance and instruct the patient to slow down breathing.

Depending on the severity.

Deep Venous Thrombosis and PULMONARY EMBOLISM

Formation of blood clot in a deep vein due to VIRCHOW’S TRIAD:

Stasis Hypercoagulation Blood vessel

endothelial damage3% chance Pulmonary Embolism will kill your patient.

Blood clot in deep veins goes to the lungs and interrupt blood flow to the lungs.

Affected extremity: Painful Swollen Red Warm Superficial Veins Engorged

Pulmonary Embolism1. LOC restless, anxiety

C1. Rapid heart rate2. Cold clammy skin3. Falling blood pressure4. Distended Neck Veins5. Cyanosis

A & B

1. Sharp and stabbing chest pain2. Sudden unexplained dyspnea3. Cough +/- blood

IMMEDIATE

Respiratory InfectionsCroup Onset

ProvocationQualityRadiationSeverity

SAMPLE Hx

ViralUpper Airway

Agitated and Barking VENTILATE with 100% O2

Epiglotitis Bacterial 1. Swelling cause airway obstruction

2. DROOLING SALIVAPneumonia Virus, Bacteria, Fungi

Develops in daysYoung children and elderly are at high risk

Dyspnea

Alveoli infected decrease in O2 that leads to dyspnea.

CARDIOVASCULAR EMERGENCIESCASE ASSESSMENT PATHOPHYSIOLOGY SIGNS AND SYMPTOMS MANAGEMENT TRANSPORT

CONSIDERATIONAngina Pectoris OPQRSTA Sudden pain when portion of

the myocardium is not receiving enough oxygenated blood

1. “Indigestion”2. Chest pain that comes after

exertion3. Chest pain that lasts only for a

few minutes4. Relieved after admin of

nitroglycerins5. SOB, Nausea, increased pulse

rate

1. High flow O2 asap.

2. Assist in nitroglycerin admin if systo BP is greater than 90 (know if administered already and know how many times)

3. Place in restful and comfortable position.

4. Reassure.

LIGHTS ONLY

ACUTE MYOCARDIAL INFARCTION

(Silent MI – patient doesn’t feel any pain)

Heart AttackPortion of the myocardium dies due to deprived coronary blood flow.

1. Chest Pain rel to stress and exertion or even at rest. Originates from sternum but radiate to arm, neck, and jaw and described as sharp, squeezing or throbbing pain

2. Pain lasts 30 minutes to several hours.

3. Accompanied dyspnea, nausea, diaphoresis, dizziness, and FEELING OF IMPENDING DOOM.

4. Signs of shock

Conscious:1. High conc. O22. Keep patient

calm and still.3. Take the Hx and

VS.4. Help patient

with prescribed medications

5. Transport immediately in semi sitting position. Quiet transport (little or no use of siren)

6. Monitor VS throughout care and transport

Transport immediately in semi sitting position. Quiet transport (little or no use of siren)

Unconscious:1. Establish and

maintain Airway.2. Provide

CPR/Defib if needed. PPV if needed through BVM.

3. High conc. O2.4. Transport

immediately in semi sitting position. Quiet transport (little or no use of siren)

5. Monitor VS throughout care and transpo.

Aortic Aneurysm

OPQRSTA

Dilatation or outpouching of a blood vessel particularly the aorta.

1. Sudden chest pain (ripping, tearing, and sharp that starts between the shoulder blades)

2. BP discrepancy between arm or decrease in femoral or carotid pulse.

3. Signs of Shock.

1. Calm and reassure the patient.

2. Administer 100% O2 by NRM

3. Place in a comfortable position.

4. Transport without delay.

Transport without delay

HYPERTENSIVE EMERGENCIESHypertension Major contributing

cause in many cases of MI, CHF, and CVA.

Present when BP at rest is consistently greater than 140/90 mmHg

Common complication is renal damage, heart failure and brain attack.

1. Severe headache2. Nausea and vomiting3. Altered Mental Status4. Aphasia, sudden blindness5. Muscle twitching6. Seizures7. Hemiparesis

1. Secure airway , administer O2.

2. Transport without delay

3. Seizure precaution

Transport without delay

Cardiac Tamponade Accumulation of blood in the pericardial sac

Most common result in penetrating injury.

1. Muffled heart sounds2. Falling blood pressure3. Distended neck veins4. Tachycardia

1. Semi-fowler’s2. O23. Immediate

transport

IMMEDIATE

5. Pale, cool, sweaty skin. 4. Monitor5. Surgeons will

immediately do a pericardiocentesis

Pericarditis Inflammation of the pericardium (inner wall of the heart ) Idiopathic infection Metabolic factors Trauma

1. Dyspnea2. Chest Pain that aggravates while

2.1. Breathing2.2. Lying on left side2.3. Turning on Bed

3. Fever, Chills, Fatigue (sign of infection)

1. Priority of care CAB, Administer O2.

2. Immediate transport in sitting position

3. Monitor

Immediate transport in sitting position

CHF (Congestive Heart Failure)

Excessive fluid build up in the lungs and or other organs and in the body because of inadequate pumping

1. Anxiety or Confusion2. Engorged, pulsating neck vein

(LATE SIGN)3. Cyanosis4. Normal/ Elevated BP5. Tachycardia6. Pedal Edema7. Dyspnea8. Pulmonary Edema with rales,

sometimes coughing of Frothy white or pink sputum

9. Enlarged liver, spleen with abdominal distention (LATE)

1. Place patient in a comfortable position (Semi fowler or sitting)

2. Give high concentration O2 through NRM

3. Monitor

Lights only?

BLEEDING (Heart, Blood Vessels, Blood)External Bleeding Severity:

1000 cc for adults 500 cc for child 100 – 200 cc for infant

Arterial – bright red, spurting Venous – dark red, steady flow Capillary – dark red, slowly

oozing, often clots spontaneously

1. Safety BSI2. Control bleeding

2.1. Direct pressure

2.2. Elevation above level of heart (if swollen or deformed DO NOT)

2.3. Pressure points

2.4. Splints2.5. Pressure

splints2.6. Torniquet

(last resort)2.6.1. Torniquet

Depends on the amount of bleeding.

must be at least 4 inches

2.6.2. Put the tourniquet around twice

2.6.3. Knot and put a stick

2.6.4. Twist and secure the stick or rod until bleeding stops

2.6.5. Document2.6.6. NEVER use

a wire2.6.7. NEVER

remove once secured

2.6.8. Leave in OPEN VIEW

2.6.9. NEVER APPLY TO JOINT

Internal Bleeding Most common cause : Injured or damaged

internal organs Fractured extremities

esp. Femur and Pelvis

1. Pain, tenderness, swelling, discoloration of site

2. Bleeding from mouth, rectum, vagina, other orifice

3. Vomiting bright red blood or blood (coffee ground)

4. Dark, tarry stools with bright red color.

5. Tender, rigid, distended abdomen.

LATE SIGNS:1. Altered LOC, Anxiety,

restlessness, combativeness.2. Weakness, faintness, dizziness3. THIRST4. Signs of shock

Goals: Recognize

presence of internal bleeding

Maintain body perfusion

Provide rapid transport

1. Safety BSI2. Open airway

and provide O2 and ventilation per SpO2 and ETCO2

3. Transport Immediately

4. Shock treatment

IMMEDIATE

SHOCK Scene Size – up

Monitor for

Mental Status:1. Restlessness2. Anxiety

1. Safety BSI2. Maintain open

airway

IMMEDIATE

s/sx of shock through focused Hx and PE

Establish VS

Mental Status

Peripheral perfusion

3. Altered LOC

Peripheral Perfusion and skin perfusion1. Pale, cool, clammy skin2. Weak, thread, or absent

peripheral pulses3. Delayed capillary refill in ambient

air temp.

VS1. Increased Pulse rate2. Increased RR deep, shallow,

labored, irregular3. Decreased BP(LATE)

Other:1. Dilated pupils (sluggish)2. Marked thirst3. Nausea and vomiting4. Pallor and cyanosis to the lips

R heart failure – Pulmonary edemaL heart failure – Pedal edema

3. Control any external bleeding

4. Elevate lower extremities approx. 8 to 12 inches

5. Splint suspected injuries

6. Use blanket to warm patient

7. IMMEDIATE TRANSPORT

ADVANCED CARE1. Fluid

replacement LR/NSS warm

1.1. Large bore IV min. G16, G14 ideal

1.2. Use blood tubings

1.3. Apply pressure to bag to speed up infusion

2. Unless BT is available, titrate fluid infusion to the BP using radial pulse as guide. 250 initial until radial pulse is present then TKO

3. Head injury – min systolic 90 mmHg

Stages of Shock

Compensatory Shock – maintain perfusion Progressive Stage – normal compensatory will work

only for so long Irreversible Stage – cannot be reversed.

7 Stages of Cell Death

1. Normal Cell

2. Hypoxia > Ischemia > Anaerobic metabolism >lactic acid build up > met. Acidosis >sodium pump fails

3. Ion Shift – sodium rushes into the cell bringing water with it.

4. Cellular edema

5. Mitochondrial edema – cessation of ATP production.

6. Intracellular disruption – releases lysosomes (cell digesting enzymes) > cell membrane breakdowns.

7. Cell destruction lead to cell death.

The Four Stages of ShockClass I (Compensated)

Class II (Decompensated)

Class III (Decompensated)

Class IV (Irreversible)

15% 750 ml 30% 1,500 ml 40% 2000 ml >40% >2000 mlBody Response

Compensates for Blood loss

Constricts blood vessels in effort to maintain BP and deliver oxygen to ALL organs

Continued vasoconstriction to maintain perfusion but with some difficulty

Blood is shunted to vital organs

Decreased flow to intestines, kidneys, and skin.

Compensatory mechanism become overtaxed.

Vasoconstriction cannot maintain BP begins to fall.

Decreased CO and perfusion

Patient can still recover with prompt treatment.

Compensatory vasoconstriction become a complicating factor further impairing tissue perfusion and cell oxygenation.

Effect on Patient N LOC N VS 750 ml

enough to occupy a limb or a body cavity which could cause little discomfort, pain, swelling.

Decreased pulse pressure

Restlessness and confusion

Pale, cool, dry skin due to shunting

Diastolic pressure rise and fall. May stay the same on healthy patients

Pulse Pressure continues to narrow

Symphatetic response also causes rapid HR

Increased RR Delayed

capillary refill.

Confused, restless, anxious

Classic signs of shock appears

Cool clammy extremities

Lethargy, drowsy, stuporous

Sign of shock become more pronounced

Continued BP fall

Organ failure and death due to insufficient blood flow.

ANGINA ACUTE MIPain after exertion or stress Pain often related to stress or

exertionRelieved by Rest Not relievedUsually relieved by nitro (post 3 doses in 15 min assume MI)

Nitro may relieve pain

BP not affected Reduced BP. DiaphoresisShort term Pain may last 30 min to hour

CLASSIFICATION OF SHOCKCardiogenic Shock Heart in originHypovolemic Shock Severe Blood loss

Hemorrhagic ShockObstructive Shock Problem in the vascular system

Cardiac tamponade Tension Pneumo Pulmonary embolism

Distributive Shock Fluid or blood in the wrong place Spinal/ Vasogenic shock Septic Shock Anaphylactic Shock

NEUROLOGICAL EMERGENCIESCASE ASSESSMENT PATHOPHYSIOLOGY SIGNS AND SYMPTOMS MANAGEMENT TRANSPORT

CONSIDERATIONTransient Ischemic Attack (TIA)

RECURRENT neurological deficits of any type that correspond to the disorientation of a particular cerebral artery and vertebra-basilar artery and last anywhere from a FEW SECOND to 12 HOURS.

Neurologic examination between attacks maybe ENTIRELY NORMAL

Some patients – onset of attack is clearly related to standing up after lying or sitting or it occurs on relation to exertion, emotional stress or bout of coughing.

1. Carotid System Blockage1.1. Hemiparesis / Hemiplegia1.2. Unilateral Numbness1.3. Aphasia1.4. Confusion, coma1.5. Convulsion1.6. Incontinence, sometimes1.7. Numbness of face1.8. Slurred speech1.9. Dysphagia1.10.Posterior headache1.11.Dizziness or Vertigo

SEIZURE DISORDERSTonic Clonic (Grand Mal)

Tonic phase– the body becomes rigid stiffening for no more than 30 sec. Breathing may stop. Patient may bite his tongue. Incontinence may result.

Clonic phase – body jerks about violently, usually for more than 1 – 2 minutes. Patient may foam at the mouth

Types of Seizures:1. Simple partial seizure – (focal

motor, focal sensory or Jacksonian) – tingling, stiffening or jerking in just one part of the body. Aura may present (bright lights, crust of colors, or a rising sensation in the stomach)

2. Complex partial seizure (psychomotor) –abnormal behavior that varies. May involve confusion, glassy stare, lip smacking or chewing, aimless

1. Protect the patient from injury

2. Guard airway but NPO

3. DO NOT restrain patient. Remove objects and gently guide away from danger.

4. Loosen obstructive clothing.

and drools. Face and lips may become cyanotic

Postictal phase – regains consciousness immediately and enter a stage of drowsiness and confusion or he may remain unconscious.

moving about or fidgeting with clothing.

5. Take vital signs and monitor respirations closely.

Causes of seizure:1. Febrile2. Idiopathic3. Brain tumor4. Congenital brain

deficits5. Metabolic6. Infection7. Toxic8. Trauma

Absence (Petit mal) Seizure is brief usualy only 1 – 10 sec. There is no dramatic motor activity. Person does not slump on face. Goes unnoticed by everyone except by the person and knowledgeable members of the family.

Same as grand mal

Stroke (Cerebrovascular Accident/ CVA)

Sudden onset of focal neurological deficit caused by a non-traumatic brain injury resulting in occlusion or rupture of the cerebral blood vessel.

Classification:1. Transient Ischemic Attack2. Reversible Ischemic Neurologic

Deficit3. Stroke in Evolution/Completed

Stroke

3 Types of Cerebral Edema1. Cytotoxic2. Vasogenic3. Interstitial

If Brain Edema suspected:1. Modest Fluid

restriction2. Elevation of head

of bed (20 – 30 degree)

3. O2 and Ventilation support

4. Control of agitation and pain.

Ischemic Stroke Blockage in arteries supplying oxygenated blood will result in damage to affected parts

Pathological Process (applicable on ischemic and hemorrhagic):1. Intrinsic blood vessel pathology

(atherosclerosis, lipohyalinosis,

Conscious:1. Ensure an open

airway2. Keep patient calm

LOAD AND GOWindow period 3 hours but the

faster the

of the brain. inflammation, amyloid deposition, arterial dissection, developmental malformation, aneurismal dilation and /or venous thrombosis.)

2. Lodging of embolus in intracranial vessel from a remote part such as heart or extracranial circulation

3. Decreased perfusion pressure or increased blood viscosity with inadequate cerebral blood flow.

4. Vessel rupture in subarachnoid space or intracerebral tissue.

S/Sx:1. Confusion2. Hemiparesis3. Hemiplegia4. Impaired speech5. Facial flaccidness and loss

expression6. Headache7. Unequal pupil size8. Impaired vision9. Cushing’s Triad

9.1. Hypertension9.2. Irregular RR9.3. Slow pulse

10. Convulsions11. Coma12. Incontinence13. Inappropriate behavior14. Stiffed neck15. Staggering gate

3. Maintain eye contact and speak SLOW and CLEARLY.

4. High O25. Monitor VS6. Semi reclined post7. NPO8. Keep warm9. Sit in front of

patient.

Unconscious:1. Maintain open

airway2. High O23. Ventilation if

needed4. Monitor VS5. Lateral recumbent

post.6. Protective

padding

better.

Hemorrhagic Stroke An aneurysm or other weakened are of an artery ruptures.Often associated with arteriosclerosis and hypertensionTwo effects:1. An area of the brain

is deprived of oxygenated blood

2. Pooling blood push increased ICP on the brain, displacing tissue and interfering with function.

Altered Mental Status Causes:A – Alcohol and other drugsE – pilepsy, Endocrine/ExocrineI – insulin, hypo/hyperO – oxygen, overdose and opiatesU – Uremia

T – trauma and tempI – infection (Sepsis or Meningitis)P – poisons and psychiatric

1. Secure airway and control respiration1.1. O2 – guided

by SpO21.2. Ventilation –

guided by ETCO2

2. Protective reflexes (+/-)

3. Immobilize spine unless absolutely certain injury not suspected

4. Monitor Neuro VS q 5min

S – shock, stroke or space occupying lesion.

5. Protect patient eyes on long transpo

6. Treat and reassure accordingly

7 D’s of Stroke Management:

1. Detection – recognition of the s/sx of stroke or TIA and activate EMS.

2. Dispatch – EMS dispatcher must prioritize the call same as an AMI.3. Delivery – transport to stroke center.4. Door – hospital that can provide fibrinolytic therapy within 1 hour

after arrival.5. Data – hospital obtaining CT scan.6. Decision – identifying eligible patient for fybrinolytic therapy.7. Drug – treating with fibrinolytic therapy.

Right Hemisphere Lesion Left Hemisphere LesionImpaired Visuomotor perception

Unable to communicate properly

Visual Memory

X: Loss of visual memory OK: Positive visuomotor retention and memory

Lack of insight and judgment BUT NOT OBVIOUS because of intact verbal fluency

Positive visuomotor retention and memory

Comprehension

OK: No deficit understand and express

X: Aphasia

Proprioception

X: Inability to assess position in space and safely interact with the environment

OK: Unimpaired

Verbal Memory

OK: Intact. Perceptual memory impaired

X: Impaired ability to retain verbal information; remote memory impaired

Carelessness and Impulsiveness

YES: Careless. Obvious mistakes. Impulsive with decreased ability to anticipate consequence of behavior.

NO?: Usually impaired.

Emotion and Affect

X: Inappropriate emotion and affect

OK: Appropriate

DIABETIC EMERGENCIES normal glucose 60 to 120 mg/dLCASE ASSESSMENT CAUSES SIGNS AND SYMPTOMS MANAGEMENT CAUSE OF

DEATHHyperglycemia Have you

taken your meals?

Have you taken your insulin?

Have you vomited your meals?

Have you done strenuous activities?

Condition has not been diagnosed or treated

Has not taken insulin Over eaten – flooding

the body with excess carbs

Diabetic suffers an infection that disrupts his glucose/insulin balance

1. Gradual onset in days2. Dry mouth, intense thirst3. Abd. Pain and vomiting common4. Gradually increasing restlessness,

confusion followed by stupor and coma

5. Weak, rapid pulse6. Air hunger – deep sighing

respirations (Kaussmal’s breathing)

7. Acetone breath (child)8. Warm, red, dry skin9. Normal or slightly elevated BP10. Sunken eyes11. No hostile or aggressive behavior

1. O2 via NRM2. Transport to

medical facility

3. Arrange for ALS intercept.

However, all management to DM emeregencies towards hypoglycemia.

1. Dehydration and poor nutrition

2. Hypokalemia3. Hypoinsuline

mia4. DKA (Diabetic

Ketoacidosis) – ketones in urine > acidosis >compensates by Kaussmal’s breathing to decrease acidosis > Diabetic COMA

Hypoglycemia Taken too much insulin Not eaten enough to

provide N sugar intake Over exercised/ exerted Vomited

1. Rapid onset in minutes.2. Copious saliva, drooling3. Patient intensely hungry.4. Dizziness and headache, sudden

fainting, seizures and occasionally coma

5. Full rapid pulse6. Normal respiration , no odor7. Cold, clammy, pale skin.8. N BP9. N eyes10. Hostile/aggressive behavior.

1. Granular Sugar under tongue.

1.1. Conscious: any sweet solid or liquid

1.2. Unconscious:

1.2.1. Avoid giving liquid

Hyperinsulinemia - Insulin Shock.

1.2.2. Turn head to side or place in lateral recumbent.

2. Provide High O2

3. Transport to medical facility

4. Arrange ALS intercept.

ACUTE ABDOMINAL EMERGENCIESCASE ASSESSMENT PATHOPHYSIOLOGY SIGNS AND SYMPTOMS MANAGEMENT TRANSPORT

CONSIDERATION All adults with

abdominal pain always consider MI.o Heart problem

irritates the vagus nerve> affects gastric mucosa > producing excess HCl and abdominal pain.

Causes:o Ulcero Intestinal

Obstructiono Cholecystitiso Hernia

(emergency due to possibility of circulation obstruction)

o Abdominal Aortic Aneurysm

o Pancreatitis

Supine Knee chest

flexed Examine

last most painful part

N abd. Assess:

No pain, soft, non rigid, warm to touch, not distended

1. Pain/ tenderness2. Anxiety / fear3. Guarded position4. Rapid shallow breathing5. Rapid pulse6. Nausea vomiting or diarrhea7. Rigid or tense abdomen8. Internal bleeding

1. Safety and BSI

2. CAB3. Keep airway

patient – be alert for vomiting

4. Place pt. to position of comfort

5. NPO6. Calm and

reassure pt.7. Be alert for

shock8. Transport

efficiently

Efficient Transport

o AppendicitisUrinary Colic Nephrolitiasis – formation

of stone in the kidney (or anywhere in the urinary tract but calculi begin to form in kidney). Stone size may vary in size.

Renal calculi classification Calcium Phosphate –

65% Calcium Oxalate Magnesium

Ammonium Phosphate (stravite) –

15% Uric Acid – 10% Cystine Stone – 10%

Factors promoting to Stone Formation:

Supersaturation of Urine – stone formation due to crystalloid

Presence of Nidus – a must. Nidus or nuclei which layer can be deposited

Stasis – further promotion of stone formation

pH or solution

Pain – intensity depends upon the size of the calculi.

Renal colic – a group of symptoms associated with movement of a calculus through the narrow anatomical points in the ureter causing obstruction of urine.o Severe costovertebral angle

pain radiates throughout the flank area and groin due to the muscle spasm injured by the stretching and obstruction of the ureter by the calculus

1. If alert, advise to increase fluid intake to over 4000 ml/24 hour.

2. Administer analgesic/antispasmodic according to local protocol

3. Keep on bed rest (with Entonox)

4. Transport to hosp for further management.

Transport efficiently

OBSTETRICS - GYNECOLOGICAL EMERGENCIESCASE ASSESSMENT PATHOPHYSIOLOGY SIGNS AND SYMPTOMS MANAGEMENT TRANSPORT

CONSIDERATIONCommon Gynecological EmergenciesEctopic Pregnancy Development of a fetus

outside the wombCauses:

Past ectopic pregnancy

Past salpingitis Surgery of the

fallopian tube

1. Ammenorhea2. Pain in the L/R iliac region3. Abnormal vaginal bleeding4. Low back pain5. Breast tenderness6. Nausea

1. Ensure open airway

2. O2 as required

3. NPO4. Vomiting

precaution (positioning)

5. Monitor VS6. Shock

precaution

ALL LOAD AND GO

Rupture of Ovarian Cyst

Formation of mass in the ovary with idiopathic cause.

1. Sharp, piercing pain in the lower abdominal quadrant.

2. Fever3. Nausea4. Vomiting5. Weakness, dizziness or fainting6. Signs of internal bleeding

Pelvic Inflammatory Disease (PID)

Infection from the vagina making the pelvis inflamed.Causes:

Sexually – transmitted disease

1. Fever2. Profuse discharge from the

vagina3. Malaise4. Lower abd pain5. Difficulty passing urine6. Irregular vaginal bleeding

Dysfunctional Uterine Bleeding (DUB)

Bleeding from the uterus that is not due to menstrual period

1. Increase PR >20 bpm when pt. sits from supine position. > blood loss of

Cause: Estrogen imbalance Menopause syndrome Female of advanced

age

more than 1 unit.2. Abnormal vaginal bleeding3. Abnormal spotting4. Metrorrhagia – bleeding in b/t

period5. Menorrhagia – excessive

bleeding6. Bleeding after menopause7. Bleeding unrelated to periods8. Bleeding in young girls

Other : Rape Maximum tact and sensitivity

Female EMT should be present

EMT must take care of urgent med. Problems

Preserve evidence

Protect patient’s privacy

Document

1. Ensure open airway

2. O2 as required

3. NPO4. Vomiting

precaution (positioning)

5. Monitor VS6. Shock

precaution

OBSTETRICS

o 3 weeks – zygote/ fertilized ovum

o 3-8 weeks – embryo

o 9-38 weeks – fetus

o Birth to 28 days – neonate

o 29 days to 1 yo – infant

o 1 yo to 12 yo – child

o UTZ – most reliable dx tool

Important elements of Assessment:1. Age of

patient2. LMP3. AOG4. Gravida5. Parity

Criterias:1. Due date2. Contraction

? Frequency and Duration?

3. Increase Spressure in vagina?

4. Urge to push?

5. Crowning?

Mech. Of Delivery:Engagement > Descent > Flexion > Internal Rotation > Extension > Expulsion

Equipments:1. Gloves2. Drawsheet3. Suction Bulb4. Towels5. Gauze6. Scalpel7. Umbilical clamp8. Cotton with alcohol

Premature (<38 weeks/ <2500 kg) – TRANSPORT to ER for incubator

500 ml – normal bleeding during deliveryCord Cutting – 10 incles away

Sx of imminent delivery:1. Urgeto push2. Presence of crowning3. Increase pressure in the vagina

Labor and Delivery1. Safety BSI2. Lie knee flexed drawn up wide

separated, semi-fowlers3. Create sterile field around vag.

Opening with sterile towels4. Crowning – place gentle pressure

on perineum5. Once delivered, support the head

as it rotates and wipe neonate’s mouth and nose > suction mouth and nose

6. Guide head down to deliver 1st shoulder, then up to deliver the 2nd shoulder > support the baby

7. Grasp the feet firmly with one hand

Imminent delivery:1. Do not allow

to use toilet2. Consult MD

concerning decision to deliver baby at the scene.

3. Do not clamp/cut cord if the baby is not breathing on its own.

If within 5 minutes woman will deliver the baby, do not load and go. If inside the ambu,stop and deliver the baby.

General Steps in NSD1. Prepare

mother for delivery

2. Assist3. Initial care of

the newborn

6. Broken bag of water?

from umbilicus 8. Clean out the baby’s mouth with gauze. Suction. The baby should start to cry. If not, ABC of resuscitation.

Intervention for non breathing baby

1. Rub the back2. Snap fingers at soles of the

feet3. ABC4. If with spontaneous breathing,

let neonate breath room air5. If APGAR is low (4-7) give O2

via blowbyCOMPLICATION ONFIRST TRIMESTERAbortion Termination of pregnancy

before 28 weeks

1. Threatened2. Closed cervix

a. Mild pain (back pain, lower abd.)

b. Mild vaginal spotting3. Inevitable – cannot

preserve pregnancya. With placental/fetal

fragments came outb. Severe back painc. Moderate, obvious

bleedingd. Shock

4. Incomplete – placental/fetal fragments expelled

5. Complete – abortus/fetus expelled out with bleeding

6. Criminal7. Therapeutic

Pre – Eclampsia Hypertension. BP of more than 130/80.Comlications:

Eclampsia Abrutio Placenta Cerebral retinal

damage Pulmonary edema

1. Transport2. FHT

monitoring3. CAB4. Prevent

stimulus5. O2 per SpO26. Therapeutic

Environment

LIGHTS ONLY

Eclampsia Neurological

Supine Hypotension Compression of the Vena Cava due to pregnancy.

Left Lateral Position

H-mole No fetus but with signs of pregnancy

Incompetent Cervix 1. Complete bed rest

2. Constant OB supervision

3. Cervical Cerclage

Hyperemesis Gravidum Excessive vomiting during pregnancy

1. Crackers on bed side

2. Small frequent feeding

3. Ensure nutrition

4. Maintain hydration

3RD TRI/ANTENATAL COMPLICATIONSAbruptio Placenta Premature separation of the

placenta before labor and delivery

1. Mild to moderate vaginal bleeding

2. Sx of shock3. Continous knife like pain in the

abdomen4. Rigid tender uterus

Transport for Emergency CS

IMMEDIATE

Placenta Previa Implantation of the placenta over the cervical opening

Painless bright red vaginal bleeding. 1. Transport immediately

2. Shock precaution

3. Do not IEUterine Rupture Common to G3 above

Due to Blunt Trauma. Repeated stretching of

the uterine wall Old CS Prolonged labor against

o Obstructiono Weakened uterine

wall

1. Tearing abdominal pain2. Severe hypovolemic shock3. Firm rigid abd.4. Vaginal bleeding

1. CAB2. Transport

COMPLICATIONS OF LABOR and DELIVERYProlapsed Cord For emergency CS

Cord compressed No pulsation of the umbilical cord 1. Position

mother to IMMEDIATE

between the neonate’s head and birth canal

knee chest position

2. Push the neonate’s head to relieve compression to cord

3. Wrap cord with moist sterile gauze to prevent damage

Cord coil/ Cord loop 1. Upon delivery of head look for the cord if looped around the neck

2. Gently slip if possible

3. If not, clamp the cord and cut (protocol)

Meconium Staining Common in pre term and post term

Lack of O2 > Spasm of the large intestines > meconium staining > greenish discoloration of the amniotic fluid

Complication:o Neonatal Sepsis –

meconium aspiration

o Neonatal respiratory distress – neonate may not be able to clear lungs.

Sign of fetal distress1. No FHR2. FHR < 1203. Mother do not feel baby

moving

Amniotic Fluid Leak Difficulty of fetus to come out

Infection Trauma Complication to mother

o Leak to pelvis >Amniotic fluid enter circulation > Pulmonary Embolism

NEONATAL CARE

Cardio respiratory changes that occur in birth:o To get rid of the

fluid filling the lungs so that it can expand

o Closing of the foramen ovale and ductus arteriosus

Routine care:1. Warming2. Airway3. Position4. Cord

cutting5. Prevention

of meconium aspiration

Risk factor for shock and hypotension

1. Low birth weight2. Maternal sepsis3. Prolapsed cord4. Acute onset of

maternal vaginal bleeding

N neonatal vital signsRR 30 – 50 cpmPR 120 – 160 bpmBP >60 mmHg

HR < 60 – CPR >100 – breath on room air 60 – 100 ventilate (full 5 Lpm;

premature 3 Lpm)

APGAR8 – 10 mild distress4 – 7 moderate1 – 3 severe

Medical Unconscious or decreasing level of

consciousness Dilated pupil GCS <10 Pediatric trauma score <8 Persistent Fever Increase effort in breathing

Trauma Fall from a height of 20 ft Involved in an accident with

fatalities Ejected in a car accident Struck by a car.

NEONATAL SEIZURES

Causes:1. Hypoxic – Ischemic

Encephalopathy2. Metabolic Disturbance3. Meningitis or

Encephalitis4. Developmental

abnormalities5. Drug withdrawal6. Maternal anesthesia7. Stroke

Types:1. Subtle – Head part – ocular, facial,

oral or ligual movements and respiratory manifestation such as apnea or stutortorous breathing

2. Tonic – pre-term infant: seizure appear decerebrate or decorticate posturing

3. Multifocal clonic – term infants: noted in one limb and migrate to another part of the body.

4. Focal clonic – term infants: localize and are accompanied by short activity of EEG.

5. Myoclonic –premature and term

infants: single multiple jerk and flexion of the upper and lower extremities

Stage Hallmark Signs Duration for Primi Duration for Multi1st True labor to full cervical dilation 12 to 16 hours 30 min2nd Full cervical dilatation to birth of neonate 30 min Matter of minutes3rd Birth of neonate to placental delivery Within 20 min Within 20 min

APGAR SCORING

SIGN 0 1 2Appearance Bluish or pale Pink trunk, blue

extremityPink

Pulse Absent <100 bpm >100 bpmGrimace No Response Some motion,

grimaceCry, cough, sneeze

Activity Limp Some flexion, extremeties

Active, good motion

Respiration Absent Slow and irregular

Normal, crying

Insert Neonatal Circulation and Neonatal Resuscitation

BURN EMERGENCIESCASE ASSESSMENT PATHOPHYSIOLOGY SIGNS AND SYMPTOMS MANAGEMENT TRANSPORT

CONSIDERATIONType of burns

1. Chemical2. Radiation3. Electrical4. Thermal5. Scald6. Contact7. Flash

Factors to consider in evaluating burns1. Agent of burn2. Depth3. Severity (BSA)a. Rule of ninesb. Palm rule

4. Age – under 5 and over 55 (adult’s

Thermal Burn:1. Emergent Phase –

response to pain > catecholamine release.

2. Fluid shift – massive shift from intracellular to extracellular fluid

3. Hypermetabolic phase – increase demands for

Special Considerations:Pedia:1. Thin skin2. Large surface volume

2.1. Rapid fluid loss2.2. Increased heat loss

3. Dehydration vs. Overhydration4. Immature Immunological response

Treatment of burn wound1. Low priority

after CAB and IV

2. Do not rupture blisters.

3. Dry Sterile

False Labor True LaborContractions Irregular RegularPain radiation Abdomen Lower back then

abdomenPain alleviation Alleviated by

ambulationNot alleviated

Frequency, Duration, Intensity

No increase Increasing

Cervical Dilatation No dilatation With dilatation

reaction to burn injury increases after age 35)

a. Infants and children are at higher risk due to more body surface area

i. Hypovolemic shock

ii. Airway problemiii. Hypothermia

5. Other illnesses and injuries

nutrients4. Resolution phase –

scar tissue and remodeling of tissue

Complications:1. Hypovolemia leading to

shock - Leading2. Infection3. Renal/hepatic failure4. Formation of eschar5. Complication of

circumferential burn (tourniquet effect)

6. Increase catecholamine release, vasoconstriction

7. Inability to maintain body temperature

Eschar formation:1. Skin denaturing2. Skin constricts over

wound3. Respiratory compromise4. Circulatory compromise

Jackson’s Burn Theory1. Zone of Coagulation2. Zone of Stasis3. Zone of Hyperemia

Geria:1. Decreased Myocardial reserve2. Fluid resuscitation difficult3. Peripheral vascular disease4. COPD5. Decreased immune response6. % mortality = age + % of BSA

affected

Dressings4. Cover with burn

sheet

4 Phases of burn management1. Emergent

Phase – time of injury to structural

2. Resuscitation Phase – admin of IV fluids, return of capillary membrane to N level

2.1. Parkland formula: 4 mL/kg * total BSA

2.2. 1st half in first 8 hrs

2.3. 2nd half in next 16 hrs.

3. Acute Phase – hemodynamically stable

4. Rehabilitation Phase

Thermal Rapid PE1. Check for other

injuries2. Rapid estimate

burned wound3. Remove restricting

band

Hx:1. How long ago?2. What has been done?3. What cause?4. Close space?5. LOC?6. Allergies/meds?7. Past med Hx?

1. Remove patient from the scene

2. Stop burning process

3. Ensure open airway, assess breathing

4. Look for signs of airway injury, soot deposits, burnt nasal hair, facial burns

5. Complete the intial assessment.

6. Treat for shock. High O2 (per SpO2). Treat

IMMEDIATELY

serious injuries.7. Evaluate burns

by depth, extent and severity.

8. Do not clear debris

9. Wrap with dry sterile dressing.

10. Burns of hands or feet – remove rings and jewelry that may constrict with swelling. Separate fingers or toes with gauze pads.

11. Burns to eyes – do not open eyelids if burned.

11.1.Be certain burn is thermal, not chemical.

11.2.Apply sterile gauze pads to both eyes to immobilize.

11.3. If burn is chemical, flush eyes for a minimum of 20 minutes.

12. Shock precaution (if there’s other injuries)

Others:1. Analgesic –

Morphine Sulfate

1.1. 2-3 mg q 10 min titrated to

adequate ventilation and BP

1.2. 0.1 mg/kg for pedia

1.3. May require large but tolerable doses.

2. Avoid topical agent except per protocol (Silvadine)

3. Fluid Therapy3.1. Objective:3.2. HR < 110

bpm3.3. Urine output:

30 – 50 cc per hour or 0.5-1  cc/kg/hr for pedia

Chemical Insert chemical burn handout

Generally get chemical contaminated object off the body and flush with LR/NS except if chemical reacts with water.

Inhalation Problems:1. Hypoxia2. CO toxicity

2.1. SpO2 could be meaningless

3. Upper airway injury3.1. May result to edema

of pharynx and larynx4. Lower airway injury

4.1. Rare, involves lung parenchyma, Transport

Anticipate respiratory problems1. Head, Face, Neck or Chest burns2. Nasal/ eyebrow hairs signed3. Hoarsness, tachypnea4. Coughing - Black sputum

Airway, O2, Ventilation:1. Bronchodilators

needed?2. Diuretics are

not appropriate

Circulation:1. Treat for Shock

(rare)2. IV access2.1. LR/NS large

bore multiple IV’s

2.2. Titrate fluids to maintain systolic BP

Others:Treat burns and injuries

Electrical Ohm’s law – 1 = V/RLow voltage – 500 – 1000VHigh voltage 1000V up (Lightning)

Severity depends on1. Tissue2. With or extent of current3. AC/DC4. Duration of current

contact

AC current:1. Tetanic Muscle Contraction

1.1. Muscle injury1.2. Tendon rupture1.3. Joint distraction1.4. Fractures

2. Cardiac arrhythmias3. Apnea4. Seizure5. Contact burn/Flash burn6. Flame burn

1. TRANSPORT2. Make sure

current is off3. CAB4. Rhabdomyolysis

– breakdown of muscle fiber that leads to release of myoglobin to bloodstream which is harmful to the kidneys.

Radiation Alpha – large Beta – small Gamma – most

dangerous

Burn severityDepth Minor Moderate CriticalSuperficial < 50% >15% All complicated by

injury of soft tissue

Burn Depth Characteristics1st Degree 2nd Degree 3rd Degree

Cause Sun or minor flash

Hot liquids, flashes or flame

Chemicals, electricity, flame, hot metals

Skin Color

Red Mottled red, moist and shiny

Pearly white and or charred translucent and parchmentlike

Skin Surfaces

Dry (-) blisters

(+) blisters with weeping

Dry with thrombosed blood vessels

Sensation

Painful Painful Anesthetic

Healing 3-6 days 2 – 4 weeks depending on depth

Requires skin grafting

and bonesPartial Thickness <15% 15 – 30% >30%Full Thickness <2% except for

face, genitalia, hands and feet

2 – 10% >10% Partial full thickness on hands, genitalia, circumferential burn.

Insert Rule of Nines for Adult, Child and Pedia

POISONING EMERGENCIESCASE ASSESSMENT PATHOPHYSIOLOGY SIGNS AND SYMPTOMS MANAGEMENT TRANSPORT

CONSIDERATIONPoisons could be:IngestedInhaledAbsorbedInjected

OdorLevel of ConsciousnessVital Signs

HxWhat?When?How much?What else was taken, if anything? Antidote?Vomited, if so how long after the ingestion?Why?OdorLevel of ConsciousnessVital Signs

HxWhat?When?How much?What else was taken, if anything?

Poison (toxin ) substance which, if taken into the body in sufficient quantity can cause temporary or permanent damage

Self poisoning and parasuicide – deliberate ingestion of more than the therapeutic dose of a drug or substance not intended for consumption usually by an adult in a moment of distress

Accidental poisoning – non intentional

3 Leading causes of Poisoning:

1. Alcoholic intoxication2. Methamphetamine3. Isoniazid toxicity

Organophosphate – agent most commonly associated with mortality.

1. Burns and strains around mouth

2. Unusual breath/body/ clothing/scene odor

3. AbN breathing4. AbN pulse rate5. Profuse sweating,

headache, dizziness6. Excessive salivation or

foaming at the mouth7. Pain in the mouth or throat8. Abdominal pain9. Abdominal tenderness

sometimes with distention10. Nausea, vomiting11. Seizures12. Altered mental status13. Signs of shock

General approach: Circulation Airway Breathing Drug induced CNS

depression Electrolytes and

metabolic abnormalities

Oxygen precautionso Watusio Paraquato Zinc phosphate

Activated Charcoal Absorbs many

poisonous compounds to its surface, thereby reducing their absorption by the body

Effective among:o Aspirino Amphetamineso Strychnineo Dilantin

Antidote?Vomited, if so how long after the ingestion?Why?

o Theophyllineo Phenobarbitals

Ineffective:o Methanolo Caustic acidso Alkaliso Iron tables and

lithium 1g/kg

Syrup of IPECAC Induces vomiting Contraindicationso Stupor/Comao Absent gag reflexo Seizureso Pregnancyo Acute MIo Children < 6 moo Ingestion of

corrosiveso Volatile

hydrocarbonso Strycnines or

iodides Dosageo Children 3-5 tsp

followed by a glass of water

o Adults 1-2 tsp followed by water

Ingested 1. Maintain open airway

2. Transport Immediately

3. Follow protocol of your EMS system

4. Keep patient on NPO

5. Position the conscious patient in semi recumbent position

6. Monitor vomiting

7. Save all vomits

and endorse to the hospital

Inhaled 1. Remove patient from inhaled poison. Avoid touching contaminated clothing.

2. Maintain open airway

3. Provide needed BLS measures and administer O2 (if not contrainidicated) NRM

Injected 1. Follow local protocol

2. Monitor patient and maintain open airway

3. Remove jewelry from affected limbs

4. Keep the limb immobilized

5. Transport immediately

Absorbed 1. Move the patient from the source of the poison while avoiding contact with the substance

2. Use water to immediately flood all the areas of the patient’s body that has been exposed to the poison

3. Monitor patient and transport immediately

Insert Table of S/Sx of common poisons.

COLD EMERGENCIESCASE ASSESSMENT PATHOPHYSIOLOGY SIGNS AND SYMPTOMS MANAGEMENT TRANSPORT

CONSIDERATIONTemp Conversion:C = (F-32)*5/9F = C*5/9 +32

Keeping warm: Thermogenesis

o Conversion of food to energy in body cells

o Muscle activity, voluntary or involuntary

Heat absorption During cold conditions

o Constricting blood vessels at body surface to keep warm blood at the core

o Reducing sweatingo Erecting body hairs

to “trap: the warm air at the skin

Core Temp Internal temp of

normothermic humans Does not vary >1-2 º from

normal temp Esophageal and tymphanic

temp almost the same with pulmonary artery

May cause permanent disability or death

Hypothalamus – temp regulator center

Mechanism of Heat Loss1. Convection – heat loss

to surrounding air2. Conduction – heat loss

to nearby objects through physical contact

3. Radiation – Body heat is lost to nearby objects without direct contact

Losing body heat Heat maybe lost to

o Cool surrounding airo Cool objects in

contact with skin In hot conditions, the

body reacts to lose heato Blood vessels in or

near the skin dilate tin order to lose blood heat

o Sweat glands become active. Sweat evaporates in cooler air. Hairs are flat

o The rate and depth of breathing will increase

4. Evaporation – Body heat loss through perspiration

5. Respiration

Local Cold Injury1st degree frostbite (Frostnip)

General S/Sx1. Shivering2. Numbness3. Stiff, rigid posture4. Drowsiness or inability

to do even simplest activity

5. Rapid breathing and rapid pulse in early stages, Late stage: Slow pulse and breathing.

6. Decrease LOC7. Cool skin temp8. Loss of motor

coordination9. Joint, muscle stiffness

and rigidity.

Victim unaware unless he sees himself in the mirror and notices unusual pallor and the return of the warmth to frotnipped area

Redness and tingling sensation

1. Remove patient from site

2. Remove all of the patient’s clothing that is wet

3. During transport, rewarm the patient

4. Shock treatment5. Give warm fluid for

conscious and alert patient

6. Keep patient at rest.

2nd degree (Superficial Frost)

Skin is stiff but underlying tissue is soft

1. Waxy and white2. Numbness3. As thawing occurs

3.1. Area turned mottled blue

3.2. Stinging sensation

3.3. Edema and blister within a few hours

3rd Degree to 4th Degree (Deep Frostbite)

1. White , mottled blue or white hard cold

2. Tissue feels like block of wood

3. When thawed3.1. Soothing pain3.2. Burning3.3. Throbbing3.4. Aching3.5. Possible joint pains

1. If still frozen, leave it frozen

2. Pad the injured extremity to protect from further trauma

3. Do not massage4. Notify the

receiving facility so that they can

3.6. Gangrene within a few days requiring amputation of injured part

start preparing and re-warming both.

5. If the extremity is partially thawed, rewarm the injured area at 38 – 42 ºC

6. Once rewarming is comlete

6.1. Dry extremity very gently and apply it gently to thawed part

6.2. Take care not to rupture blisters.

6.3. Use soft sterile gauze or cotton to separate frostbiten fingers and toes

7. Transport the patient in supine position and elevate the injured extremity on soft pillow, well covered and protect from cold.

Hypothermia Prolonged exposure to cold outdoor especially in wet and windy conditions

Death from cold water immersion may be caused by hypothermia rather than drowning

1. Remove patient from cold environment

2. Remove any wet clothing and cover the patient with blanket

3. Handle the patient with extreme care. Avoid rough handling at all cost

4. Admin high flow O2 (warmed and humidified)

5. Do not allow the patient to eat or drink stimulants

6. Do not massage extremities

7. Check for a pulse for an extended period of 30 to 45 sec before initiating BLS

HEAT EMERGENCIESCASE ASSESSMENT PATHOPHYSIOLOGY SIGNS AND SYMPTOMS MANAGEMENT TRANSPORT

CONSIDERATIONHeat Cramps Severe muscle cramps

(usually in the legs and abdomen)

1. Exhaustion2. Dizziness3. Periods of faintess

1. Move patient to a nearby cool place

2. Give the conscious patient fluids and electrolytes

3. Massage the cramped muscle to help ease the patient’s discomfort. Massaging with pressure will be more effective than light rubbing

4. Apply moist towels to the patient’s forehead and over cramped muscles

5. If cramps persists, or if more serious symptoms and signs develop, ready the patient and transport

Too hot Too coldBlood vessels

Vasodilation Vasoconstriction

Perspiration

Increase Decrease

Cardiac output

Increase Decrease

Respiratory Rate

Increase Decrease

Heat production

Decrease Decrease

Progression of HypothermiaBody Temperature Symptoms37 – 35.5 ºC Shivering35.5 – 32.7 ºC 1. Decreased shivering replaced

by strong muscular rigidity2. Less clear thinking3. General comprehension is

dull4. Possible total amnesia

29.4 – 27.7 ºC 1. Irrational2. Loses contact with envi and

drifts into stuporous state3. Slow pulse and respiration4. Possible cardiac

dysrhythmias26.6 – 20.5 ºC Unconscious without reflexes

Stages of Hypothermia (ILCOR 2005)ºC ºF

Mild 36 – 34 ºC 96.8 – 93.2 ºFModerate

34 – 30 ºC 86 ºF

Severe < 30 ºC <86 ºF

Heat Exhaustion Volume and electrolytes lost through perspiration and is not replaced > dehydration > hypovolemia > decrease brain perfusion

1. Rapid, shallow RR2. Weak pulse3. Cold, clammy skin4. Heavy perspiration5. Total body weakness6. Dizziness7. Possible

unconsciousness

1. Move to cool place2. Keep @ rest3. Remove enough

clothing to cool the patient without chilling him (watch for shivering)

4. Fan the patient’s skin5. Give the conscious

patient fluids with electrolytes.

6. Do not try to administer fluids to an unconscious patient

7. Treat for shock but do not cover to the point of overheating patient

8. Provide high conc. O29. If unconscious, fails to

recover rapidly, has other injuries, or has a hx of medical problems, transport as soon as possible

Heat Stroke 1. Deep breaths and shallow breathing

2. Rapid, strong pulse, then rapid weak pulse.

3. Dry hot skin4. Dilated pupils5. Loss of consciousness

(possible coma)6. Seizures or muscular

twitching may be seen

1. Cool the patient – in any manner – rapidly. Remove from heat source.

2. Remove patient’s clothing and wrap him in wet towels and sheets. Pour cool water over these wrappings. Body heat must be lowered rapidly or brain cells will die.

3. Treat for shock and administer high conc. O2.

4. If cold packs or ice bags are available,wrap and place one under each

4.1. Armpit4.2. Knee4.3. Groin4.4. Wrist and ankle4.5. Each side on

patient’s neck5. Immediate transport6. Delayed transport: Find

a tub or container. Immerse patient up to the face in cooled water. Constantly monitor to prevent drowning

7. Monitor vital signs throughout process

Condition Muscle Cramps

Weakness

Breathing Pulse Skin Perspiration

Loss of Consciousness

Heat Cramps Varies Varies Moist-warm

Heavy Seldom

Heat Exhaustion Rapid shallow Weak Cold

clammyHeavy Sometimes

Heat Stroke Deep, then shallow

Full Rapid Dry-hot Little or none

Often

INSECT BITES & STINGS EMERGENCIESCASE ASSESSMENT PATHOPHYSIOLOGY SIGNS AND SYMPTOMS MANAGEMENT TRANSPORT

CONSIDERATIONTypical sources of infected poisons or toxins (insect, spider & scorpion)

Gather information from the patient, bystanders, at the scene.

Find out whatever you can about the insect or

1. Noticeable bites and stings on the skin

2. Blotchy skin3. Localized pain or itching4. Numbness5. Muscle cramps, chest

tightening & joing pains6. Burning sensation7. Difficulty of brerathing and

abnormal pulse rate8. Excessive saliva formation,

profuse sweating9. Weakness/ collapse

1. CAB – treat for shock

2. Follow insect bites and sting protocol in your local EMS

3. Remove jewelry from affected limb

4. Immobilized the affected part, if allowed by your protocol, apply cold compress

5. Transport in semi-

other possible source of the poisoning

10. Headaches/Dizziness11. Chills and fever12. Nausea and vomiting13. Redness14. Swelling or blistering15. Anaphylaxis

sitting position for conscious patient and recovery position for unconscious patient

Snake bites 1. Bite on the skin2. Discoloration, pain, swelling, at

area. Slow to develop from 30 min to hours

3. Rapid pulse and labored breathing

4. Progressive general weakness5. Blurring of vision6. Nausea and vomiting7. Seizures8. Drowsiness of unconsciousness

1. Locate the fang marks and clean the site with soap and water

2. Remove any jewelry from the bitten extremity

3. Keep the bitten extremity immobilized

4. Apply light contracting band above the bitten part if allowed by local protocol

5. Transport and monitor the patient

Pit Viper Has pit in

maxillary bone Eliptical pupil Triangular head

Tissue Necrosis Minimal None Swelling Pain

Moderate Progressive swelling

1. Safety BSI2. Supine3. Open and maintain

airway4. Immobilize injured

limb and maintain it.

IMMEDIATE

Coral Snake “Red on yellow

kill a fellow; Red on black venom lack”

Thin Small rounded

1. Calm Victim2. O23. Proximal

constricting band (+/-)

4. Clean bandage wound

5. Immobilize bitten area

6. Watch constricting bands

7.Dog bites Very common street 1. Immediately and

emergency especially in rural areas

Areas of the body most commonly bitten: Head Neck Upper Extremities

PercentageFace – 11%Trunk – 7%Upper extremity – 28%Lower extremity – 31%

Children <12 yo are usually bitten on the face.

Most dog bites occur in hot weather when a person provokes a dog

thoroughly wash the wound with soap and water

2. Flush the wound with water and apply dressing

3. Transport the patient to the hospital for medical care especially if the wound needs stitching or occurred in the face or neck

4. Do not kill the dog unless it is absolutely necessary to prevent a full scale crippling attack.

5. If you kill the dog, call for an animal officer and request that the corpse be examined for rabies.

6. Immobilize injured part

7. Patient is usually frightened – calm him/her down.

Bee Sting (insert bee scientific name)

Local reactionBronchospasmHypotensionAnaphylaxis

1. Remove stinger by scraping with a plastic card or blunt edge of a knife

2. Manage airway3. O2 / Ventilation4. Shock position5. Epinephrine

5.1. Dilate airway5.2. Constrict Blood

vessels5.3. Ask for

medical direction

5.4. Dosage

5.4.1. Adult 0.3 mg yellow

5.4.2. Child 0.15 mg

SpidersBlack Widow (Larodectus mactans)

Neurotoxic 1. Muscle Spasms within 15 min to 2 hours

2. Bite of 1mm apart fang mark

1. Local cold application

2. Symptomatic care3. Immediate

transport

IMMEDIATE

Brown recluse (Loxosceles reclusa)

Fiddle-back spiders

6 eyes Violin markings

Hemolytic Anemia > Necrosis

1. Necrosis2. Hemoglobinuria3. Hypotension4. Possibility of death

Supportive care

Scorpion ( Centuroides sculpturatus)

1. Airway management

2. Look out for cardiac dysrrhytmias

Sting ray 1. CAB2. Flush with water3. Immerse in warm

waterJellyfish Hypotension Vinegar and hot

water1. Safety BSI2. LOC3. CAB4. O2/ ventilation5. Immerse wound

30-40 min as hot as can be tolerated, repeat as necessary to control pain without scalding

6. Transport

Scorpion/Lion/Stonefish

Stonefish being the most poisonous of them

Sea Urchins

WATER EMERGENCIESCASE ASSESSMENT PATHOPHYSIOLOGY SIGNS AND SYMPTOMS MANAGEMENT TRANSPORT

CONSIDERATIONDrowning Active Step 1 Stages of water rescue: Stages of

Causes:Rip Currents

drowning: Conscious Thrashing Vertical in

H2O Unable to

call for help

Body maybe low in H2O

o Victim goes under, water enters the airway.

o Coughing and gasping – victim swallows water

Step 2o A small amount

enters the larynx and causes laryngospasm

o Breathing ceases and metabolic acidosis occurs. Dry drowning (10 – 15% of gases)

Step 3o Laryngeal muscles

became severely hypoxic and relax allowing air and water to enter the lungs. (Wet drowning)

o Triggers peripheral airway resistance and constriction of the pulmonary vessels > Stiff Lung – lung ceases to be compliant.

Step 4o Victem’s

hypercarbic/hypoxic drive further stimulate inhalation of water which mixes with air and chemical resident in the lungs to form a froth.

o Brain damage and death follows

1. Yell2. Reach and pull3. Throw4. Tow5. Go

Fresh water drowning – not much problemSalt wather drowning – water has high osmolarity which attracts fluids which results to pulmonary edema

management of drowning1. Do not enter

unless trained in water rescue

2. Ensure open airway and attempt rescue breathing

3. Continue rescue breathing and remove from the water

4. Check pulse, if no pulse, start chest compression

5. Transport6. If given the

opportunity – positive pressure ventilation using PEEP to dry the lungs.

Diving Emergencies Boyle’s lawo As pressure

What to find out about a diving emergency

increase, volume decreases

o As pressure decreases, volume increases

Dalton’s lawo P1= P(O2) + P(N2)

+ P(X)o Total pressure of gas

mix is sum of partial pressure of it’s components

Henry’s lawo Pressure of a gas in

liquid is proportional to it’s pressure in the atmosphere

o 1 atm – 34 ft water

1. Type of diving and the Type of Equipment

2. Diving activity (photographing, fishing)

3. Number of dives made the past 72 hours with each has

4. Depth5. Bottom time6. Surface Interval7. Details of in-water decompression8. In-water recompression? (a no-no!)9. Dive complications, if any.10. Pre-dive and post-dive activity11. Onset of symptoms (when and

what came first)

Barotrauma – compression or expansion of gas actually in adjacent to body air spacesDescent

Ear Squeeze External Middle

Sinus Squeeze Lung Squeeze

Body air spaces attempts to equilibrate on the outside atmospheric pressure > blockage> barotrauma

Lung SqueezeBreath hold > 100 fsw > compression of volume > negative pressure of lungs > pulling of interstitial fluid and blood in shrunken air spaces

Lung squeeze is typically rare. For lung squeeze to occur, a breath-hold diver must descend to a depth which total lung volume is significantly compressed (100 feet)

Lung Squeeze Dyspnea Chest pain Cough Hemoptysis Pulmonary edema

Lung Squeeze1. No PPV or

PEEP2. 100% O2 NRM3. IV4. Keep patient

sitting up5. TRANSPORT to

hosp

AscentPOPS (Pulmonary Overpressure Syndrome)“Burst lung”

Could cause: Pneumothorax/Tension

Pneumothorax Pneumomediastinum Subcutaneous

emphysema Arterial Air Embolism

Pneumomediastinum/ Subcutaneous emphysemao Fullness of his throato Dysphagiao Dyspneao Substernal chest paino Subcutaneous air palpable

above clavicleso Crunching noise synch with

heart beat

Dysbaric Air Embolism -

Pneumomediastinum/ Subcutaneous emphysemao Bed rest and

oxygen therapy

POPSo 100% O2

NRMo Don’t give

PEEP to

Symptoms occurs within seconds or minutes after surfacing. Air bubbles coalesce into larger and larger bubbles as they travel through the veins >o Cornoray arteries > MIo oro Cerebral artery > just like

Stroke Pneumothorax/Tension

Pneumothoraxo Tracheal deviationo Unequal breath soundso Hyper – resonance on the

affected side

POPSo keep patient

quieto transport him

to hospital.o If in doubt of

AIR EMBOLISM > go to hyperbaric chamber facility

Decompression SicknessNarcosis (Narcs/Rapture of the deep)Not dangerous but can impair the diver’s judgment.

Accumulation of nitrogen in the tissues > increase pressure > increase amount of dissolved nitrogen in the tissues > anesthetic effect > martini effect

Ascend slowly to alleviate “martini” effect.

Type I DSDS of the skin Most common but least

reported1. Pruritis2. SQ emphysema3. Mottled rashes

1. Ensure Adequate Airway

2. Give 100% oxygen

3. Start an IV with LR and give as directed

4. Give steroids, preferably Methylprednisilone 125 mg IV

5. Do not use nitrous oxide for analgesia

6. Advise hospital that you will require a use of a hyperbaric chamber

DS of the joints (musculoskeletal)

1. Deep, dull aches in muscle/joints2. Movement worsen pain3. Fatige4. Inflating cuff will relieve pain

TYPE II DSDS of the CNS4-10 min rule

Brain involvement 1. Paresthesia2. Seizure3. Spinal cord involvement4. Paralysis

1. Ensure Adequate Airway

2. Give 100% oxygen

3. Start an IV with LR and give as directed

4. Give steroids, preferably Methylprednisilone 125 mg IV

5. Do not use nitrous oxide for analgesia

6. Advise hospital that you will require a use of a hyperbaric chamber

CHOKES 1. Chest pain2. Dry cough3. Dyspnea4. Pulmonary edema

Treatment of Suspected Air Embolism1. Ensure adequate airway, especially in the unconscious

patient – if licensed to do so, INTUBATE2. Admin. 100% O23. Transport in L Lateral recumbent with 10 degree head

down tilt4. If licensed – establish an IV lifeline with LR5. Monitor cardiac rhytm and be prepared to treat

dysrhythmias6. Have the following drugs ready for use Under Medical

Direction:6.1. Diazepam, 5mg for Seizures6.2. Dopamine infusion 10mg/kg/min for treatment of

Hypotension7. Notify medical command/ hospital to make arrange for

reception at a hyperbaric chamber facility

Treatment of Decompression Sickness

1. Ensure Adequate Airway2. Give 100% oxygen3. Start an IV with LR and give as directed4. Give steroids, preferably Methylprednisilone 125 mg

IV5. Do not use nitrous oxide for analgesia6. Advise hospital that you will require a use of a hyperbaric

chamber

WATER EMERGENCIESCASE ASSESSMENT PATHOPHYSIOLOGY SIGNS AND SYMPTOMS MANAGEMENT TRANSPORT

CONSIDERATIONDrowning