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RESPIRATORY EMERGENCIES CASE ASSESSMENT PATHOPHYSIOLOGY SIGNS AND SYMPTOMS MANAGEMENT TRANSPORT CONSIDERATION STATUS ASTHMATICUS Onset Provocation Quality Radiation Severity SAMPLE Hx Acute asthmatic attack involves airway obstruction due to : 1. Bronchospasm 2. Swelling of mucous membranes 3. Mucus secretions Provocation: 1. Resp Infection 2. Emotional Stress 3. Allergic Reaction 1. Anxiety 2. Patient breathes through pursed lips 3. Wheezing 4. Chest overinflated 5. Tachycardia 6. Tripod post VENTILATION OXYGEN POSITION 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 RATE 2. Cyanosis 3. Distended Neck Veins 4. Wheezing 5. Frothy or flecked sputum 6. Water filled spongy lung 7. Dyspnea 8. Frothy fluid in bronchi 9. Cool, Clammy skin 10. Edema 1. High Flow O2 2. 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. 1. Ventilate with 100% O2.

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Reviewer Table for PSEMT




STATUS ASTHMATICUSOnsetProvocationQualityRadiationSeverity

SAMPLE HxAcute asthmatic attack involves airway obstruction due to :1. Bronchospasm2. Swelling of mucous membranes3. Mucus secretions

Provocation:1. Resp Infection2. Emotional Stress3. Allergic Reaction1. Anxiety2. Patient breathes through pursed lips3. Wheezing4. Chest overinflated5. Tachycardia6. Tripod postVENTILATIONOXYGENPOSITIONIMMEDIATE while monitoring vital signs.

PULMONARY EDEMAExcess 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. Edema1. High Flow O22. Consider PEEP/CPAP



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 lungs surface area) Less oxygen through walls of the alveoli and into the bloodstream.

1. Ventilate with 100% O2.


SAMPLE HxSame as Status AsthmaticusDANGER SIGNS!!!1. Loss of Wheezing2. Change in Sensorium (Confusion, Irritability, Lethargy)3. HypoxiaPrevent Lethal HypoxiaDepending 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 EMBOLISMFormation of blood clot in a deep vein due to VIRCHOWS 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, anxietyC1. 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


Respiratory Infections


SAMPLE HxViralUpper Airway

Agitated and BarkingVENTILATE with 100% O2

EpiglotitisBacterial 1. Swelling cause airway obstruction2. DROOLING SALIVA

PneumoniaVirus, Bacteria, FungiDevelops in daysYoung children and elderly are at high riskAlveoli infected decrease in O2 that leads to dyspnea.Dyspnea



Angina PectorisOPQRSTASudden pain when portion of the myocardium is not receiving enough oxygenated blood1. Indigestion2. Chest pain that comes after exertion3. Chest pain that lasts only for a few minutes4. Relieved after admin of nitroglycerins5. SOB, Nausea, increased pulse rate1. 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.



(Silent MI patient doesnt 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 pain2. Pain lasts 30 minutes to several hours.3. Accompanied dyspnea, nausea, diaphoresis, dizziness, and FEELING OF IMPENDING DOOM.4. Signs of shockConscious:1. High conc. O22. Keep patient calm and still.3. Take the Hx and VS.4. Help patient with prescribed medications5. Transport immediately in semi sitting position. Quiet transport (little or no use of siren)6. Monitor VS throughout care and transport

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.

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

Aortic AneurysmOPQRSTADilatation 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 NRM3. Place in a comfortable position.4. Transport without delay.Transport without delay


Hypertension 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. Hemiparesis1. Secure airway , administer O2.2. Transport without delay3. Seizure precautionTransport 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. Tachycardia5. Pale, cool, sweaty skin. 1. Semi-fowlers 2. O23. Immediate transport4. Monitor5. Surgeons will immediately do a pericardiocentesis


PericarditisInflammation of the pericardium (inner wall of the heart ) Idiopathic infection Metabolic factors Trauma1. Dyspnea2. Chest Pain that aggravates while2.1. Breathing2.2. Lying on left side2.3. Turning on Bed3. Fever, Chills, Fatigue (sign of infection)1. Priority of care CAB, Administer O2.2. Immediate transport in sitting position3. MonitorImmediate 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 pumping1. 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 sputum9. Enlarged liver, spleen with abdominal distention (LATE)

1. Place patient in a comfortable position (Semi fowler or sitting)2. Give high concentration O2 through NRM3. MonitorLights only?

BLEEDING (Heart, Blood Vessels, Blood)

External BleedingSeverity: 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 spontaneously1. Safety BSI2. Control bleeding2.1. Direct pressure2.2. Elevation above level of heart (if swollen or deformed DO NOT)2.3. Pressure points2.4. Splints2.5. Pressure splints2.6. Torniquet (last resort)2.6.1. Torniquet must be at least 4 inches2.6.2. Put the tourniquet around twice2.6.3. Knot and put a stick2.6.4. Twist and secure the stick or rod until bleeding stops2.6.5. Document2.6.6. NEVER use a wire2.6.7. NEVER remove once secured2.6.8. Leave in OPEN VIEW2.6.9. NEVER APPLY TO JOINTDepends on the amount of bleeding.

Internal BleedingMost common cause : Injured or damaged internal organs Fractured extremities esp. Femur and Pelvis1. Pain, tenderness, swelling, discoloration of site2. Bleeding from mouth, rectum, vagina, other orifice3. 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 shockGoals: Recognize presence of internal bleeding Maintain body perfusion Provide rapid transport1. Safety BSI2. Open airway and provide O2 and ventilation per SpO2 and ETCO23. Transport Immediately4. Shock treatmentIMMEDIATE

SHOCK Scene Size up Monitor for s/sx of shock through focused Hx and PE Establish VS Mental Status Peripheral perfusion

Mental Status:1. Restlessness2. Anxiety3. 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 edema1. Safety BSI2. Maintain open airway3. Control any external bleeding4. Elevate lower extremities approx. 8 to 12 inches5. Splint suspected injuries6. Use blanket to warm patient7. IMMEDIATE TRANSPORT

ADVANCED CARE1. Fluid replacement LR/NSS warm1.1. Large bore IV min. G16, G14 ideal1.2. Use blood tubings1.3. Apply pressure to bag to speed up infusion2. Unless BT is available, titrate fluid infusion to the BP using radial pulse as guide. 250 initial until radial pulse is present then TKO3. Head injury min systolic 90 mmHg


The Four Stages of Shock

Class I (Compensated)Class II (Decompensated)Class III (Decompensated)Class IV (Irreversible)

15% 750 ml30% 1,500 ml40% 2000 ml>40% >2000 ml

Body 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.


Pain after exertion or stressPain often related to stress or exertion

Relieved by RestNot relieved

Usually relieved by nitro (post 3 doses in 15 min assume MI)Nitro may relieve pain

BP not affectedReduced BP. Diaphoresis

Short termPain may last 30 min to hour

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 Death1. Normal Cell2. Hypoxia > Ischemia > Anaerobic metabolism >lactic acid build up > met. Acidosis >sodium pump fails3. Ion Shift sodium rushes into the cell bringing water with it.4. Cellular edema5. Mitochondrial edema cessation of ATP production. 6. Intracellular disruption releases lysosomes (cell digesting enzymes) > cell membrane breakdowns.7. Cell destruction lead to cell death.


Cardiogenic ShockHeart in origin

Hypovolemic ShockSevere Blood loss Hemorrhagic Shock

Obstructive ShockProblem in the vascular system Cardiac tamponade Tension Pneumo Pulmonary embolism

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



Transient 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


Tonic 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 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.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 moving about or fidgeting with clothing.1. Protect the patient from injury2. Guard airway but NPO3. DO NOT restrain patient. Remove objects and gently guide away from danger.4. Loosen obstructive 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 Stroke3 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 support4. Control of agitation and pain.

Ischemic StrokeBlockage in arteries supplying oxygenated blood will result in damage to affected parts of the brain.Pathological Process (applicable on ischemic and hemorrhagic):1. Intrinsic blood vessel pathology (atherosclerosis, lipohyalinosis, 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 circulation3. 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. Cushings Triad9.1. Hypertension9.2. Irregular RR9.3. Slow pulse10. Convulsions11. Coma12. Incontinence13. Inappropriate behavior14. Stiffed neck15. Staggering gateConscious:1. Ensure an open airway2. Keep patient calm3. Maintain eye contact and speak SLOW and CLEARLY. 4. High O2 5. 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 paddingLOAD AND GOWindow period 3 hours but the faster the better.

Hemorrhagic StrokeAn 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 blood2. Pooling blood push increased ICP on the brain, displacing tissue and interfering with function.

Altered Mental StatusCauses: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 psychiatricS shock, stroke or space occupying lesion.1. Secure airway and control respiration1.1. O2 guided by SpO21.2. Ventilation guided by ETCO22. Protective reflexes (+/-)3. Immobilize spine unless absolutely certain injury not suspected4. Monitor Neuro VS q 5min5. Protect patient eyes on long transpo6. Treat and reassure accordingly

Right Hemisphere LesionLeft Hemisphere Lesion

Impaired Visuomotor perceptionUnable to communicate properly

Visual MemoryX: Loss of visual memoryOK: Positive visuomotor retention and memory

Lack of insight and judgment BUT NOT OBVIOUS because of intact verbal fluencyPositive visuomotor retention and memory

ComprehensionOK: No deficit understand and expressX: Aphasia

ProprioceptionX: Inability to assess position in space and safely interact with the environmentOK: Unimpaired

Verbal MemoryOK: Intact. Perceptual memory impairedX: Impaired ability to retain verbal information; remote memory impaired

Carelessness and ImpulsivenessYES: Careless. Obvious mistakes. Impulsive with decreased ability to anticipate consequence of behavior.NO?: Usually impaired.

Emotion and AffectX: Inappropriate emotion and affectOK: Appropriate

7 Ds 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.

DIABETIC EMERGENCIES normal glucose 60 to 120 mg/dL


Hyperglycemia 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 balance1. Gradual onset in days2. Dry mouth, intense thirst3. Abd. Pain and vomiting common 4. Gradually increasing restlessness, confusion followed by stupor and coma5. Weak, rapid pulse6. Air hunger deep sighing respirations (Kaussmals breathing)7. Acetone breath (child)8. Warm, red, dry skin9. Normal or slightly elevated BP10. Sunken eyes11. No hostile or aggressive behavior1. O2 via NRM2. Transport to medical facility 3. Arrange for ALS intercept.However, all management to DM emeregencies towards hypoglycemia.1. Dehydration and poor nutrition2. Hypokalemia3. Hypoinsulinemia4. DKA (Diabetic Ketoacidosis) ketones in urine > acidosis >compensates by Kaussmals breathing to decrease acidosis > Diabetic COMA

Hypoglycemia Taken too much insulin Not eaten enough to provide N sugar intake Over exercised/ exerted Vomited1. Rapid onset in minutes.2. Copious saliva, drooling3. Patient intensely hungry.4. Dizziness and headache, sudden fainting, seizures and occasionally coma5. 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 liquid1.2. Unconscious:1.2.1. Avoid giving liquid1.2.2. Turn head to side or place in lateral recumbent.2. Provide High O23. Transport to medical facility4. Arrange ALS intercept.Hyperinsulinemia - Insulin Shock.



All adults with abdominal pain always consider MI. Heart problem irritates the vagus nerve> affects gastric mucosa > producing excess HCl and abdominal pain. Causes: Ulcer Intestinal Obstruction Cholecystitis Hernia (emergency due to possibility of circulation obstruction) Abdominal Aortic Aneurysm Pancreatitis Appendicitis Supine Knee chest flexed Examine last most painful part N abd. Assess: No pain, soft, non rigid, warm to touch, not distended1. Pain/ tenderness2. Anxiety / fear3. Guarded position4. Rapid shallow breathing5. Rapid pulse6. Nausea vomiting or diarrhea7. Rigid or tense abdomen8. Internal bleeding1. Safety and BSI2. CAB3. Keep airway patient be alert for vomiting4. Place pt. to position of comfort5. NPO6. Calm and reassure pt.7. Be alert for shock8. Transport efficientlyEfficient Transport

Urinary ColicNephrolitiasis 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. 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 calculus1. If alert, advise to increase fluid intake to over 4000 ml/24 hour.2. Administer analgesic/antispasmodic according to local protocol3. Keep on bed rest (with Entonox)4. Transport to hosp for further management.Transport efficiently



Common Gynecological Emergencies

Ectopic PregnancyDevelopment of a fetus outside the wombCauses: Past ectopic pregnancy Past salpingitis Surgery of the fallopian tube1. Ammenorhea2. Pain in the L/R iliac region3. Abnormal vaginal bleeding4. Low back pain5. Breast tenderness6. Nausea1. Ensure open airway2. O2 as required3. NPO4. Vomiting precaution (positioning)5. Monitor VS6. Shock precautionALL LOAD AND GO

Rupture of Ovarian CystFormation 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 disease1. 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 periodCause: Estrogen imbalance Menopause syndrome Female of advanced age1. Increase PR >20 bpm when pt. sits from supine position. > blood loss of 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 patients privacy Document1. Ensure open airway2. O2 as required3. NPO4. Vomiting precaution (positioning)5. Monitor VS6. Shock precaution


3 weeks zygote/ fertilized ovum 3-8 weeks embryo 9-38 weeks fetus Birth to 28 days neonate 29 days to 1 yo infant 1 yo to 12 yo child UTZ most reliable dx toolImportant 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?6. Broken bag of water?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 ( support the baby 7. Grasp the feet firmly with one hand8. Clean out the babys mouth with gauze. Suction. The baby should start to cry. If not, ABC of resuscitation. Intervention for non breathing baby1. 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 blowbyImminent 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 delivery2. Assist3. Initial care of the newborn


AbortionTermination of pregnancy before 28 weeks

1. Threatened2. Closed cervixa. 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. Shock4. Incomplete placental/fetal fragments expelled5. Complete abortus/fetus expelled out with bleeding6. Criminal7. Therapeutic

Pre EclampsiaHypertension. BP of more than 130/80.Comlications: Eclampsia Abrutio Placenta Cerebral retinal damage Pulmonary edema1. Transport2. FHT monitoring3. CAB4. Prevent stimulus5. O2 per SpO26. Therapeutic EnvironmentLIGHTS ONLY


Supine HypotensionCompression of the Vena Cava due to pregnancy.Left Lateral Position

H-moleNo fetus but with signs of pregnancy

Incompetent Cervix1. Complete bed rest2. Constant OB supervision 3. Cervical Cerclage

Hyperemesis GravidumExcessive vomiting during pregnancy1. Crackers on bed side2. Small frequent feeding3. Ensure nutrition4. Maintain hydration


Abruptio PlacentaPremature separation of the placenta before labor and delivery1. Mild to moderate vaginal bleeding2. Sx of shock3. Continous knife like pain in the abdomen4. Rigid tender uterusTransport for Emergency CSIMMEDIATE

Placenta PreviaImplantation of the placenta over the cervical openingPainless bright red vaginal bleeding.

1. Transport immediately2. Shock precaution3. Do not IE

Uterine Rupture Common to G3 above Due to Blunt Trauma. Repeated stretching of the uterine wall Old CS Prolonged labor against Obstruction Weakened uterine wall

1. Tearing abdominal pain2. Severe hypovolemic shock3. Firm rigid abd.4. Vaginal bleeding1. CAB2. Transport


Prolapsed Cord For emergency CS Cord compressed between the neonates head and birth canalNo pulsation of the umbilical cord1. Position mother to knee chest position2. Push the neonates head to relieve compression to cord3. Wrap cord with moist sterile gauze to prevent damageIMMEDIATE

Cord coil/ Cord loop1. Upon delivery of head look for the cord if looped around the neck2. Gently slip if possible3. 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: Neonatal Sepsis meconium aspiration Neonatal respiratory distress neonate may not be able to clear lungs.Sign of fetal distress1. No FHR 2. FHR < 120 3. Mother do not feel baby moving

Amniotic Fluid Leak Difficulty of fetus to come out Infection Trauma Complication to mother Leak to pelvis >Amniotic fluid enter circulation > Pulmonary Embolism


Cardio respiratory changes that occur in birth: To get rid of the fluid filling the lungs so that it can expand Closing of the foramen ovale and ductus arteriosusRoutine care:1. Warming2. Airway3. Position4. Cord cutting5. Prevention of meconium aspirationRisk factor for shock and hypotension1. Low birth weight2. Maternal sepsis3. Prolapsed cord4. Acute onset of maternal vaginal bleedingN 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 15%All complicated by injury of soft tissue and bones

Partial Thickness30%

Full Thickness10% Partial full thickness on hands, genitalia, circumferential burn.

Insert Rule of Nines for Adult, Child and Pedia



Poisons 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? Antidote?Vomited, if so how long after the ingestion?Why? 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 mouth2. Unusual breath/body/ clothing/scene odor3. 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 shockGeneral approach: Circulation Airway Breathing Drug induced CNS depression Electrolytes and metabolic abnormalities Oxygen precautions Watusi Paraquat Zinc phosphate

Activated Charcoal Absorbs many poisonous compounds to its surface, thereby reducing their absorption by the body Effective among: Aspirin Amphetamines Strychnine Dilantin Theophylline Phenobarbitals Ineffective: Methanol Caustic acids Alkalis Iron tables and lithium 1g/kg

Syrup of IPECAC Induces vomiting Contraindications Stupor/Coma Absent gag reflex Seizures Pregnancy Acute MI Children < 6 mo Ingestion of corrosives Volatile hydrocarbons Strycnines or iodides Dosage Children 3-5 tsp followed by a glass of water Adults 1-2 tsp followed by water

Ingested1. Maintain open airway 2. Transport Immediately3. Follow protocol of your EMS system4. Keep patient on NPO5. Position the conscious patient in semi recumbent position6. Monitor vomiting7. Save all vomits and endorse to the hospital

Inhaled1. Remove patient from inhaled poison. Avoid touching contaminated clothing.2. Maintain open airway3. Provide needed BLS measures and administer O2 (if not contrainidicated) NRM

Injected1. Follow local protocol2. Monitor patient and maintain open airway3. Remove jewelry from affected limbs4. Keep the limb immobilized5. Transport immediately

Absorbed1. Move the patient from the source of the poison while avoiding contact with the substance2. Use water to immediately flood all the areas of the patients body that has been exposed to the poison3. Monitor patient and transport immediately

Insert Table of S/Sx of common poisons.



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

Keeping warm: Thermogenesis Conversion of food to energy in body cells Muscle activity, voluntary or involuntary Heat absorption During cold conditions Constricting blood vessels at body surface to keep warm blood at the core Reducing sweating Erecting body hairs to trap: the warm air at the skin

Losing body heat Heat maybe lost to Cool surrounding air Cool objects in contact with skin In hot conditions, the body reacts to lose heat Blood vessels in or near the skin dilate tin order to lose blood heat Sweat glands become active. Sweat evaporates in cooler air. Hairs are flat The rate and depth of breathing will increase

Core Temp Internal temp of normothermic humans Does not vary >1-2 from normal temp Esophageal and tymphanic temp almost the same with pulmonary artery May cause permanent disability or deathHypothalamus temp regulator center

Mechanism of Heat Loss1. Convection heat loss to surrounding air2. Conduction heat loss to nearby objects through physical contact3. Radiation Body heat is lost to nearby objects without direct contact4. Evaporation Body heat loss through perspiration5. Respiration

Local Cold Injury

1st degree frostbite (Frostnip)General S/Sx1. Shivering2. Numbness3. Stiff, rigid posture4. Drowsiness or inability to do even simplest activity5. 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 areaRedness and tingling sensation1. Remove patient from site2. Remove all of the patients clothing that is wet3. During transport, rewarm the patient4. Shock treatment 5. Give warm fluid for conscious and alert patient6. Keep patient at rest.

2nd degree (Superficial Frost)Skin is stiff but underlying tissue is soft1. Waxy and white2. Numbness3. As thawing occurs3.1. Area turned mottled blue3.2. Stinging sensation3.3. Edema and blister within a few hours

3rd Degree to 4th Degree (Deep Frostbite) 1. White , mottled blue or white hard cold2. Tissue feels like block of wood3. When thawed3.1. Soothing pain3.2. Burning3.3. Throbbing3.4. Aching3.5. Possible joint pains3.6. Gangrene within a few days requiring amputation of injured part1. If still frozen, leave it frozen2. Pad the injured extremity to protect from further trauma3. Do not massage 4. Notify the receiving facility so that they can start preparing and re-warming both.5. If the extremity is partially thawed, rewarm the injured area at 38 42 C6. Once rewarming is comlete6.1. Dry extremity very gently and apply it gently to thawed part6.2. Take care not to rupture blisters.6.3. Use soft sterile gauze or cotton to separate frostbiten fingers and toes7. 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 drowning1. Remove patient from cold environment2. Remove any wet clothing and cover the patient with blanket3. Handle the patient with extreme care. Avoid rough handling at all cost4. Admin high flow O2 (warmed and humidified)5. Do not allow the patient to eat or drink stimulants6. Do not massage extremities7. Check for a pulse for an extended period of 30 to 45 sec before initiating BLS

Too hotToo cold

Blood vesselsVasodilationVasoconstriction


Cardiac outputIncreaseDecrease

Respiratory RateIncreaseDecrease

Heat productionDecreaseDecrease

Progression of Hypothermia

Body TemperatureSymptoms

37 35.5 CShivering

35.5 32.7 C1. Decreased shivering replaced by strong muscular rigidity2. Less clear thinking3. General comprehension is dull4. Possible total amnesia

29.4 27.7 C1. Irrational2. Loses contact with envi and drifts into stuporous state3. Slow pulse and respiration 4. Possible cardiac dysrhythmias

26.6 20.5 CUnconscious without reflexes

Stages of Hypothermia (ILCOR 2005)


Mild36 34 C96.8 93.2 F

Moderate34 30 C86 F

Severe< 30 C dehydration > hypovolemia > decrease brain perfusion1. Rapid, shallow RR2. Weak pulse3. Cold, clammy skin4. Heavy perspiration5. Total body weakness6. Dizziness7. Possible unconsciousness1. Move to cool place2. Keep @ rest3. Remove enough clothing to cool the patient without chilling him (watch for shivering)4. Fan the patients skin5. Give the conscious patient fluids with electrolytes. 6. Do not try to administer fluids to an unconscious patient7. Treat for shock but do not cover to the point of overheating patient8. 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 Stroke1. Deep breaths and shallow breathing2. 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 seen1. Cool the patient in any manner rapidly. Remove from heat source. 2. Remove patients 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 patients neck5. Immediate transport6. Delayed transport: Find a tub or container. Immerse patient up to the face in cooled water. Constantly monitor to prevent drowning7. Monitor vital signs throughout process

ConditionMuscle CrampsWeaknessBreathingPulseSkinPerspirationLoss of Consciousness

Heat CrampsVariesVariesMoist-warmHeavySeldom

Heat ExhaustionRapid shallowWeakCold clammyHeavySometimes

Heat StrokeDeep, then shallowFull RapidDry-hotLittle or noneOften



Typical 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 other possible source of the poisoning

1. Noticeable bites and stings on the skin2. Blotchy skin3. Localized pain or itching4. Numbness 5. Muscle cramps, chest tightening & joing pains6. Burning sensation7. Difficulty of brerathing and abnormal pulse rate8. Excessive saliva formation, profuse sweating9. Weakness/ collapse10. Headaches/Dizziness11. Chills and fever12. Nausea and vomiting13. Redness14. Swelling or blistering15. Anaphylaxis1. CAB treat for shock2. Follow insect bites and sting protocol in your local EMS3. Remove jewelry from affected limb4. Immobilized the affected part, if allowed by your protocol, apply cold compress5. Transport in semi-sitting position for conscious patient and recovery position for unconscious patient

Snake bites1. Bite on the skin2. Discoloration, pain, swelling, at area. Slow to develop from 30 min to hours3. Rapid pulse and labored breathing4. Progressive general weakness5. Blurring of vision6. Nausea and vomiting7. Seizures8. Drowsiness of unconsciousness1. Locate the fang marks and clean the site with soap and water2. Remove any jewelry from the bitten extremity3. Keep the bitten extremity immobilized4. Apply light contracting band above the bitten part if allowed by local protocol5. Transport and monitor the patient

Pit Viper Has pit in maxillary bone Eliptical pupil Triangular headTissue NecrosisMinimal None Swelling Pain

Moderate Progressive swelling1. Safety BSI2. Supine3. Open and maintain airway4. Immobilize injured limb and maintain it.


Coral Snake Red on yellow kill a fellow; Red on black venom lack Thin Small rounded1. Calm Victim2. O23. Proximal constricting band (+/-)4. Clean bandage wound5. Immobilize bitten area6. Watch constricting bands


Dog bitesVery common street emergency especially in rural areas

Areas of the body most commonly bitten: Head Neck Upper ExtremitiesPercentageFace 11%Trunk 7%Upper extremity 28%Lower extremity 31%

Children Necrosis

1. Necrosis2. Hemoglobinuria3. Hypotension4. Possibility of deathSupportive care

Scorpion ( Centuroides sculpturatus)1. Airway management2. Look out for cardiac dysrrhytmias

Sting ray1. CAB2. Flush with water3. Immerse in warm water

JellyfishHypotensionVinegar 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 scalding6. Transport

Scorpion/Lion/StonefishStonefish being the most poisonous of them7.

Sea Urchins8.




Causes:Rip CurrentsActive drowning: Conscious Thrashing Vertical in H2O Unable to call for help Body maybe low in H2O

Step 1 Victim goes under, water enters the airway. Coughing and gasping victim swallows water Step 2 A small amount enters the larynx and causes laryngospasm Breathing ceases and metabolic acidosis occurs. Dry drowning (10 15% of gases) Step 3 Laryngeal muscles became severely hypoxic and relax allowing air and water to enter the lungs. (Wet drowning) Triggers peripheral airway resistance and constriction of the pulmonary vessels > Stiff Lung lung ceases to be compliant. Step 4 Victems hypercarbic/hypoxic drive further stimulate inhalation of water which mixes with air and chemical resident in the lungs to form a froth. Brain damage and death follows

Stages of water rescue: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

Stages of management of drowning1. Do not enter unless trained in water rescue2. Ensure open airway and attempt rescue breathing3. Continue rescue breathing and remove from the water4. Check pulse, if no pulse, start chest compression5. Transport6. If given the opportunity positive pressure ventilation using PEEP to dry the lungs.

Diving Emergencies

Boyles law As pressure increase, volume decreases As pressure decreases, volume increases

Daltons law P1= P(O2) + P(N2) + P(X) Total pressure of gas mix is sum of partial pressure of its components

Henrys law Pressure of a gas in liquid is proportional to its pressure in the atmosphere 1 atm 34 ft water

What to find out about a diving emergency1. Type of diving and the Type of Equipment2. Diving activity (photographing, fishing)3. Number of dives made the past 72 hours with each has4. 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 spaces

Descent 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 spacesLung 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 edemaLung Squeeze1. No PPV or PEEP 2. 100% O2 NRM3. IV4. Keep patient sitting up5. TRANSPORT to hosp

AscentPOPS (Pulmonary Overpressure Syndrome)Burst lungCould cause: Pneumothorax/Tension Pneumothorax Pneumomediastinum Subcutaneous emphysema Arterial Air Embolism Pneumomediastinum/ Subcutaneous emphysema Fullness of his throat Dysphagia Dyspnea Substernal chest pain Subcutaneous air palpable above clavicles Crunching noise synch with heart beat

Dysbaric Air Embolism - Symptoms occurs within seconds or minutes after surfacing. Air bubbles coalesce into larger and larger bubbles as they travel through the veins > Cornoray arteries > MI or Cerebral artery > just like Stroke Pneumothorax/Tension Pneumothorax Tracheal deviation Unequal breath sounds Hyper resonance on the affected side Pneumomediastinum/ Subcutaneous emphysema Bed rest and oxygen therapy POPS 100% O2 NRM Dont give PEEP to POPS keep patient quiet transport him to hospital. If in doubt of AIR EMBOLISM > go to hyperbaric chamber facility

Decompression Sickness

Narcosis (Narcs/Rapture of the deep)Not dangerous but can impair the divers judgment.Accumulation of nitrogen in the tissues > increase pressure > increase amount of dissolved nitrogen in the tissues > anesthetic effect > martini effectAscend slowly to alleviate martini effect.

Type I DS

DS of the skinMost common but least reported1. Pruritis2. SQ emphysema3. Mottled rashes1. 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

DS of the joints (musculoskeletal)1. Deep, dull aches in muscle/joints2. Movement worsen pain3. Fatige4. Inflating cuff will relieve pain


DS of the CNS4-10 min ruleBrain involvement1. Paresthesia2. Seizure3. Spinal cord involvement4. Paralysis 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

CHOKES1. Chest pain2. Dry cough3. Dyspnea 4. 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