Table Of ContentWORLD’S #1 ACADEMIC OUTLINE
Essential tool for the student, national and state exams & the practicing field provider
Essential Concepts themselves. They speak to honor, integrity, Medico-Legal Issues – There may be no loose objects in the
and diligence. ambulance that can impact a patient or
• Safety of the field provider is of utmost • The code of ethics adopted by physicians Regional, State & Federal Agencies crewmember in the event of a collision.
concern. also applies to paramedics. • Regionally, paramedics may be bound to – A patient’s right to safe transport exists
• Always use personal protective equipment – In 1948, the World Medical Association local protocols. regardless of the provider’s assessment of
(PPE) suitable to the incident. (WMA) adopted the “Oath of Geneva.” • Statewide, services likely have licensing and what constitutes an emergency.
– At minimum, wear protective gloves dur- – Primum non nocere. (First, do no harm.) certification requirements. – Patients with medical conditions should
ing all patient contact. – Be truthful and honest with patients and • Federally, insurance laws (Medicare/ not be allowed to walk or otherwise exert
– PPE may include face masks and even coworkers. Medicaid) and HIPAA regulations apply. themselves in such a way that could con-
full body hazmat suits with respirators. Duty to Act Regulatory Agencies ceivably make their condition worse.
• Paramedics respond to incidents at routine Standard of care: Any paramedic is expect- • There are federal and state laws governing • The ability to deviate to a more serious call
locations (bedside) and extreme locations ed to practice with the same level of training medication. may be determined by regional or state
(e.g., mountains and industrial plants). The and competence as similar paramedics with- – Controlled substance laws may include spe- protocols.
steps needed to ensure paramedics remain in similar EMS systems. Failure to perform cial reporting and inventory requirements. • Patient destination is based on:
injury free may run from requesting lifting according to the standard of care is considered • State or regional councils may regulate the – Patient choice
assistance to acquiring complex rigging negligence. review and promulgation of protocols (com- – Local protocols (e.g., stroke centers,
and equipment. pliance investigations).
• In negligence cases, paramedics are usu- trauma centers, and neonatal care)
Injury Prevention Licensing & Certifications
ally subject to legal action under tort law – Severity of the condition
• Always ask for lifting assistance. Back inju- (a civil suit brought on behalf of the patient) • Paramedics may be licensed or certified. – Distance to the closest appropriate facility
ries end careers. rather than criminal law. – Certification: Grants recognition after Patient Refusal of Transport
• When lifting patients, bend at the knees, – Elements that must be proven for the meeting predetermined qualifications.
• In most systems, a patient has the right to
not at the waist. plaintiff to prevail: – Licensing: State or federal granting of
• Maintain a good support base; space your » Duty to act: The plaintiff must estab- legal authority. refuse transport under certain criteria.
feet widely enough to ensure stability. lish that the paramedic had a legal duty • Much confusion exists regarding the differ- – The patient must have the capacity to
• Never twist while lifting a patient. to respond. ence. States often refer to certifications in understand the nature of their condition
• Always make sure that your lifting power is » Breach of duty: The paramedic must be their licensure processes. along with the risks and benefits of refus-
balanced. Never have more lifting power on found to have violated the level of care. – Most paramedics practice under strict al versus transport. Patients with behav-
one side of a patient than the other. There are three types of breaches: guidelines per their locality. ioral emergencies (e.g., suicidal ideation
• Employ multiple rescuers for steep ■ Malfeasance: Performing a wrongful – Some paramedics feel licensure is more and delusions) may lack the capacity to
prestigious; this is subjective. refuse care.
inclines. act.
Good Samaritan Laws – The patient must be legally competent to
• Use equipment such as powered ■ Misfeasance: Performing a legal act
stretchers for additional assistance. in a wrongful manner. • Good Samaritan laws: Laws that exempt refuse care (e.g., adults and legally eman-
Stress Reduction ■ Nonfeasance: Failure to perform the individuals from legal liability following cipated minors).
attempts to give reasonable care/aid to a • A patient’s refusal must be fully informed.
• Stress is a hidden “injury” that ends careers. correct action.
person in distress. The paramedic must provide the patient
• Over time, the continual bombardment of » A harm or loss has occurred.
stressful situations takes its toll, resulting » Proximate cause: Proof that the para- • Federal laws may exist. with facts concerning their condition and
ihne aar tl orastse oanf dsl beleopo dan pdre asspupreet, iatne,d i innccrreeaasseedd Medicmale Ddiicre ccatuisoend the harm or loss. • Tnwehhgeelrsigeebe lnya cwtehs,e c dpriromo vniinodate lr pm irsoi fstlceaocgntr adanugtcaltyi,n vosirto ilgsasrtuoinesgss • tDmhoue csrtui samklwse noayft srt ehbfeeu swiinnetlgel rcdaaocrcteiu.omn ewnetelld. .Refusals
irritability. All EMS systems have a physician medical the rights of others. Check your local laws. • Paramedics should follow local protocols.
• Deal with stress by recognizing it and seek- director. • On-duty professionals may not be pro- • A parent or legal guardian may refuse care
ing help from stress counselors. • Retrospective direction: Occurs after an tected under these laws.
for a minor as long as these criteria are met.
Death & Dying EMS call when the medical director reviews Patient Restraint
Resuscitation & Cessation of
Paramedics are called to scenes where loved amnadn ccoem onm tehnet sc aolnl. the paramedic’s perfor- • Restraints are reserved for violent patients Resuscitation
ones have died and resuscitative efforts are who may do harm to you or themselves.
• Prospective direction: Occurs before or • States may have legal guidelines under
(or become) fruitless. • Physical restraints: Extremity ties and
during the call. This direction usually takes which a paramedic may initiate resuscitation
• When talking to families: straps. Use soft restraints with frequent
– Use direct words when appropriate (e.g., “I one of two forms: perfusion assessments. and cease resuscitation once started.
am very sorry for your loss. We’ve done all – Online medical control: The physician • Chemical restraints: Injectable pharmaco- – States may provide guidance in the form
we could but we were unable to save him.”). and paramedic communicate during the logic agents. of healthcare proxy or MOLST (Medical
– Always tell the truth. call (by radio or phone) to decide a • Restraints must be used cautiously and with Orders for Life-Sustaining Treatment)
• Remain with the family and assist as best proper course of action. detailed documentation. forms or the equivalent.
you can. – Offline medical control: The physician • It is very important to follow state and local – States may have specific protocols for
takes an active role in developing para- guidelines when restraining a patient. Restraint ceasing resuscitation once started if
• Responses can vary from thanks to anger.
medic protocols and standing orders laws vary widely between jurisdictions. various advanced measures have been
These are normal parts of the grief process.
(written medical guidelines for the para- Patient Transport unsuccessful.
Health & Nutrition
medic to follow for common patient • Patients generally have a right to safe transport. • Resuscitation is a state-specific area of para-
Maintain a healthy diet and lifestyle. This is conditions). – Patients must be fully secured to the ambu- medicine.
key to remaining an active participant in this Continuing Research lance cot using state, regional, and/or – Refer carefully to state and regional guide-
physically and mentally demanding field.
• Paramedics often take part in medical manufacturer-recommended methods. lines and protocols.
• Get regular weight training and cardiovas-
research. – The cot must be safely secured in the – Document in accordance with the defined
cular exercise.
• Continuing research is critical to advance ambulance. guidelines.
• Always eat and hydrate well.
the field of paramedicine. It:
– Beware of defaulting to fast food during – Helps validate current patient care stan- Terminology & Documentation • Abbreviations are helpful for charts and
a busy shift, as it is packed with calories, dards (protocols) reports. Judicious use of abbreviations makes
salt, and unhealthy fats. Save fast food – Helps validate new standards and med- • Proper use of medical terminology will:
reports easier to write and sounds more pro-
for emergencies. ical devices – Sound professional
– Your diet should be low in fat and salt. – Allows for data collection to improve – Garner respect fessional. See our Medical Abbreviations &
Focus on fruits, vegetables, lean meats, EMS systems nationally – Improve documentation Acronyms QuickStudy guide.
and grains. • Before any research is undertaken, the • Most medical terms derive from Latin or Greek. Documentation
– Snack on nuts and fruit between meals. medical director confers with a review – The list is too extensive to include every term. • All documentation consists of narratives of
Ethics body—often called an Internal Review See our Medical Terminology: The Basics events and actions.
• Ethics: Standards that dictate how mem- Board (IRB)—to ensure that safety and and Medical Terminology: The Body • It is critical that documentation be clear and
bers of a professional group should conduct data reporting requirements are met. QuickStudy guides. concise.
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Terminology & Documentation (continued)
– Documentation reports your interaction » May be used by physicians to under- Assessment, Plan) is used by paramedics History, Assessment, Rx (treatment),
with your patient: what you saw, what you stand the events leading to the patient’s and hospital professionals alike. Transport) is widely used by paramedics.
did, and how things changed. chief complaint – Subjective: Anything the patient, family, – Chief complaint: Why the patient called
– Document any pertinent information— » May be referred to years later for crim- or bystanders tell you that you cannot EMS.
even if it is negative. inal or civil litigation physically observe (e.g., “I have chest – History: The history of the present illness
pain.”).
» Pertinent positive information: “The ■ Without clear documentation, you and the patient’s medical history.
– Objective: What you can see, hear, and feel.
patient has a gunshot wound to the left may not remember all events when – Assessment: Your assessment of the
– Assessment: Your assessment of the
shoulder.” asked to testify under oath. patient; what is causing the illness or patient’s condition.
» Pertinent negative information: ■ Documentation affects lives both at injury. – Rx (treatment): Clear documenta-
“There is no exit wound.” the time of service and years later if – Plan: What you did for the patient (e.g., tion of what you did and any resul-
– Documentation becomes a permanent called to court. interventions and transport decisions). tant changes.
part of the patient’s medical record. SOAP Documentation Format CHART Documentation Format – Transport: Where the patient was trans-
Documentation: • The SOAP format (Subjective, Objective, • The CHART format (Chief complaint, ported and why.
Body Systems Overview – Bone: Stores minerals, provides Muscular System Urinary System Systems Regulating the Acid-
support, and allows for attach- The muscular system: The urinary system: Base Balance
Cell Structure ment of tendons. • Provides for body movement • Eliminates dissolved waste Bicarbonate Buffer System
• Cells are the fundamental com- – Cartilage: Flexible; gel matrix • Includes cardiac muscle and • Regulates blood volume and pressure • The fastest acting system, the bicar-
ponents of all organs and tissues. found in the nose, ears, and smooth muscle • Controls electrolyte concentrations bonate buffer system is driven by
• The cytoplasmic membrane (cell joints. Nervous System • Is responsible for acid-base bal- the amount of CO2 in the blood.
membrane) encloses organelles. – Blood: Fluid matrix with red The nervous system: ance and acidity (pH) of the blood – This system follows the chem-
– Mitochondria: Produces ener- and white blood cells. • Controls voluntary muscles • Consists of the kidneys, ureters, ical equation
gy and synthesizes ATP. – Loose: Fibers are loosely inter- • Provides sensory information to .
bladder, and urethra
– Golgi apparatus: Packages pro- twined; found in adipose (fat). the brain (e.g., touch and vision) Acid-Base Balance » H2CO3 is carbonic acid, which
teins and lipids. – Dense: Found in tendons and • Affects involuntary muscle control is a weak acid that can move
–– ERinbdoosopmlaess:m Syinct herseizteisc purloutemin:. Bodyli gSaymsteenmts.s Re(per.go.d, ubcretaivthe iSnygs)tem • Aamciodu-nbta soef hbyadlarnogceen r e(Hfe+r)s itoon st hine taonwd aCrOd 2 p(lreoftd suidcet ioofn e qoufa tHio2nO)
Intercellular membrane system Circulatory System Male the body. or produce hydrogen ions and
that synthesizes and transports The circulatory system: The male reproductive system: • Acid-base balance is critical for bicarbonate ions (right side
protein. • Consists of the heart, veins, arter- • Is responsible for sperm production the human body. of equation).
– Nuclear membrane: Surrounds ies, and capillaries • Consists of multiple tissues and – Base = alkalinity; acid = acidity. » ↔: The reaction can proceed
the nucleus. • Moves blood through all body organs including the penis, testes, – The measurement for acid/base in both directions.
– Nucleus: Contains the genetic systems vas deferens, seminal vesicles, and in the body is pH. ■ The direction the equation
material of the cell. • Is a closed system prostate gland – pH ranges from 0 to 14. favors is influenced by the
– Centrioles: Helps with cell Digestive System Female – A neutral pH is 7.0. concentration of the sub-
division/reproduction. • The digestive system controls the The female reproductive system: – Acids have a pH less than 7.0. strates. Excess CO2 leads to
– Cytoplasm: Liquid material digestion and absorption of nutri- • Is responsible for oocyte (egg) – Bases have a pH greater than 7.0. acidosis—the body takes
within the cell. ents for distribution to all body • pCroondsuiscttsi oonf amnudl gtiepsltea ttiiosnsues and – pH is a logarithmic scale. stote tphse tloef td troiv ree stthoer ee bqaulaatniocen.
• Cells form tissues, tissues form systems. organs including the vagina, – A normal human body pH is Respiratory System
organs, organs form systems, and • Digested food is absorbed by the from 7.35 to 7.45.
organ systems form organisms. villi in the intestines and trans- Reustpeirruast,o farlyl oSpyiasnte tmubes, and ovaries • Typical conditions that can make • Aeqsu CatOio2n b utoiwldasr d(f oarcciidnogs itsh)e,
THiussmuaen Ts yhpaevse four primary tissue • fAerlsroed k innotow cnir caus ltahtieo nG.I tract or T• hIes rreessppiornatsoibrlye sfyosrt epmro:viding oxy- tinhcel buodde:y more acidic (pH < 7.35) tdheee pbero rdeysp iorradtieornss tfoa “sbtelorw/ off”
t•y pEthepsei. tbhoedliya al:n Cd oinveterrs ntahle o srugrafnasc.e of s–y saHtgeoumlsl,o, siwtto comorngascaihns,ts ss: mMofa:olul itnht,e esstoinpehs-, • giCdeoenn ftsroios amtsn odtfh r teeh mbe ooludvniynggs, c aairrbwoany sd, iaonxd- ––– LMLuivenedgri cofaarti ilkouinrdesney disease • CAeqOsu 2Ca atOinod2n d rteeoscwtroaerraed sb eaasll ak(nfaocleorc.siins)g, tthhee
gall bladder, bile ducts, and anus.
• Nervous: Allows communication respiratory muscles – Low blood sugar body orders slower respirations
– Solid organs: Pancreas and
bstertuwcteuernes /afunndc tcioonnst trhorlo uogf hb eoledcy- Endolicvreinr.e System STkheel esktaelle Stayls styesmtem: • –T yDpiechayl dcroantidointions that increase Retnoa rle Stayisnt eCmO2 and restore balance.
trical signals propagated via • Consists of 206 bones, ligaments, alkalinity (pH > 7.45): • The renal system is a slow, long-
sodium and potassium ion • The endocrine system produces and cartilage – Medications term approach to acid-base balance.
exchange across cell membranes. hormones that control cell functions. • Provides: – High altitudes • Kidneys excrete extra bicarbonate
• Muscle: Contractile tissue. • Major endocrine glands: – Support – Lack of oxygen if the body is too alkaline. They
–– CmSmaursodcoileat.ch:: MFyooucnadrd iiunm h (ohlleoawrt-) –––– AHOPadyvnpracerorniteeahasla s(lfaemmuasle) –– »LP erToveteenrcadtgoieon nas ncdo nmnoevcet mtoe bnotne. • –Bd elIocnroecdar seeaascs)i edfrdiot ym p:irnocdruecatsieosn (poHr Otebhxoecdrr yBe tuiesf efteoxrtoir naag ch iySddyicrso.tegemns ions if the
walled organs such as blood – Parathyroid » Ribs protect the heart and decreased elimination of acids • An acid-base imbalance can have
lungs. metabolic and respiratory causes.
vessels and intestines; respon- – Pineal – Decreased production or
– Storage (calcium and other – Metabolic acidosis: Bicarb low,
saicbtilvei tifeosr. involuntary body –– PTeitsuteitsa (rmyale) – mBlionoedr aclesl al npdro ldipuicdtsi)on – iMncertaebaoselidc eplriomciensasteison of bases – pRHes lpoiwra, tPoarCyO a2c hidigohs.is: Bicarb
– Skeletal: Connects through – Thymus » Marrow produces red blood • Blood alkalinity increases (pH normal, pH low, PaCO2 high.
tendons to bone; allows for vol- – Thyroid cells, white blood cells, and increases) from: – Metabolic alkalosis: Bicarb
untary movements of the body. Integumentary System platelets. – Decreased production or high, pH high, PaCO2 low.
• Connective: Multiple types. The integumentary system: – Production of osteocalcin, increased elimination of acids – Respiratory alkalosis: Bicarb
– Lymphatic: Formed by reticu- • Consists of the skin, nails, hair, which is involved in insulin – Increased production or normal, pH high, PaCO2 low.
lar fibers; densely packed with and glands secretion and sensitivity as well decreased elimination of bases – Pearl of wisdom: When PaCO2
lymphocytes. • Is the largest body system as fat storage – Metabolic processes is high, respirations are rapid.
Physiology & cardiac contractility, water and Allergic Reactions – Decrease in blood pressure • Albuterol
Pathophysiology salt balance, and blood pressure. (Anaphylaxis) – Urticaria (hives) • Parenteral steroids
• Typical symptoms: Low blood • An allergic reaction happens when – Angioedema (facial swelling) • Pressors (e.g., dopamine
Adrenal Insufficiency pressure, pain in muscles and the body considers a substance – Peripheral vasodilatation and norepinephrine)
• An adrenal insufficiency occurs joints, dizziness, and sweating. (allergen) harmful. – Itchy skin Hypoglycemia
when the adrenal glands cannot – A crisis occurs in a stress situ- • The immune system reacts by – Nausea, vomiting, and diarrhea • Hypoglycemia: Low blood
produce (primary type) or are not ation when the body cannot releasing antibodies (typically • Allergic reactions can be life- glucose that can result in an
signaled by the pituitary gland to supply necessary hormones. immunoglobulin-E). threatening (anaphylaxis). altered mental status or brain dys-
produce (secondary type) enough – Treatment is generally to – Immunoglobulins trigger mast Treatment function. Typically includes:
cortisol and aldosterone. administer a parenteral steroid cells to release histamines. • Oxygen – Disorientation
• Cortisol: A critical stress hor- (e.g., hydrocortisone or • Symptoms of an allergic reaction: • Parenteral epinephrine – Memory loss
mone that is vital to maintaining methylprednisolone). – Difficulty breathing (wheezing) • Diphenhydramine – Strange behavioral patterns
2
– Loss of muscle control Symptoms Neonatal Emergencies muscle movement (jerking) and shock) by raising the heart rate
• Hypoglycemia is typical in dia- • SLUDGEM (mnemonic): • Assess airway. If necessary, clear then stiffness and constricting blood vessels to
betic emergencies and insulin Salivation, lacrimation, urination, secretions and supply blow-by Febrile maintain homeostasis.
overdose. defecation, gastric upset, emesis, oxygen only if clinically indicated. A febrile seizure: • Be wary if the heart rate is higher
Treatment miosis (constricted pupils) • Clamp/cut the umbilical cord. • Typically occurs in children than the systolic blood pressure.
• Oral glucose (if gag reflex is intact) • Bradycardia, bronchorrhea, and • Newborns are prone to hypother- • Is often the result of a rapid change Note: Patients on beta or calcium
• Parenteral glucose bronchospasm (“killer Bs”) mia. Prevent heat loss by supplying in body temperature blockers may not exhibit an increase
• Glucagon Treatment blankets, increasing the tempera- Treatment for Severe in heart rate and will have lower
Bronchospasm • Oxygen ture of the ambulance, and cover- Manifestations compensatory mechanisms.
• Bronchospasm: Respiratory • Atropine ing the newborn’s head. • Administer oxygen if clinically • When shock progresses to
distress that: • Pralidoxime • Provide tactile stimulation for indicated. uncompensated shock, the body
– Is caused by spasms in the lower • Benzodiazepines breathing. • Protect the patient from harm. is no longer able to correct to nor-
respiratory tract Safety • Assess circulation. Provide circu- • Parenterally administer a benzo- mal perfusion.
– May be triggered by asthma and If nerve agents or broad area expo- latory support if needed. diazepine. Treatment
allergens sures are suspected: • Record the APGAR (activity, – Although IM or IV administra- Treatment of shock includes deter-
Treatment • Ensure the scene is safe. pulse, grimace, appearance, res- tion is preferred, rectal admin- mining the type of shock. Treatments
• Oxygen • Wear appropriate hazmat gear. pirations) score at one and five istration is sometimes used with may include:
• Beta agonists such as albuterol • Follow MCI protocols. minutes. children. In these cases: • Oxygen administration (use cau-
• Beta antagonists such as ipratropium • Move patients to a cold zone per • Obtain IV/IO or umbilical access » Dosages must be adjusted. tion in cardiogenic shock with an
• Epinephrine protocols. if necessary. » Onset of action is much slower. MI)
• Steroids OB (Obstetric) Emergencies Pain Management – Intranasal administration is • Volume replacement with crystal-
• Magnesium sulphate Eclamptic Seizures Paramedics are often authorized to possible with some drugs. loids or other volume replacement
Hyper/Hypothermia Typically preceded by preeclamptic pTrreoavtidmee mntedications to control pain. S• ySnycnocpoepe (a.k.a. fainting): The spurobtsotaconlcses depending on local
• Hyper/hypothermia: Occurs symptoms:
• Acetaminophen sudden loss of consciousness. – Use care to avoid disseminated
when the body temperature is too • High blood pressure • Ibuprofen • Near syncope (a.k.a. presyncope): intravascular coagulopathy,
high (hyper) or too low (hypo). • Increased blood protein levels in • Ketorolac The feeling you may faint. hypothermia, and acidemia.
• Hyperthermia symptoms progress urine • Fentanyl Causes • Infusion of pressors (e.g., dopa-
ftrioonm t oh ehaet actr satmropkse t.o heat exhaus- • Swelling • Morphine • Vasovagal reflex mine, epinephrine, and norep-
Heat Cramps • Weight gain due to fluid retention • Ketamine • Psychogenic reaction inephrine)
• Can occur postpartum (typically • Nitrous oxide • Prolonged standing • Stopping the source of the shock
• Symptoms: within 48 hours but can be longer) Opioid Overdose • Cardiac abnormalities (brady/ (e.g., controlling the bleeding)
– Sweating Treatment Presents with tachy dysrhythmias, myocardial • Administering agents to help the
– Marmussc,l ele cgrsa, manpds ,a tbydpoicmalelyn in the • Benzodiazepines • Decreased breathing infarction (MI)) clotting mechanism (e.g.,
• Heat cramps result from exposure • Magnesium sulphate • Unresponsiveness or minimal • Drugs tranexamic acid (TXA) given par-
to a hot environment, mild dehy- Prolapsed Cord responsiveness • Respiratory insufficiencies enterally and locally applied
dration, and electrolyte loss. A prolapsed cord occurs when the • Pinpoint pupils (miosis) • Hypoglycemia topical hemostats)
umbilical cord precedes birth, plac- Treatment Assessment Sepsis
Heat Exhaustion
ing the fetus at risk for decreased • Administer naloxone. • Perform a patient assessment. Sepsis:
• Symptoms:
– Sweating perfusion. • Support breathing with O2. • Obtain vital signs, 12-lead ECG, • When severe, can lead to septic
Management • Consider poly-drug overdose. blood glucose measurement, and shock, which is a life-threatening
– Muscle cramps
– Spasms of large muscle groups • Place the patient in a knee-chest • Treat symptomatically. a pulse oximetry. condition
– Nausea or Trendelenburg position. Seizures • Perform any other assessments as • Is generally the result of a bacte-
– Vomiting • Place a gloved hand in the vagina Seizures: necessary. rial infection
– Weakness to reduce pressure on the cord. • Present as alterations in con- Shock • Can be life-threatening, especially
– Weak/thready and rapid pulse • Cover the cord with wet dressing. sciousness with or without muscle • Shock results in poor perfusion to with comorbidities (young and
– Severe dehydration Avoid manipulation. activity the body with potentially life- elderly people and people with other
– Electrolyte loss • Provide rapid transport. • Are caused by abnormal brain threatening complications. concurrent medical conditions)
Heat Stroke Nuchal Cord activity • Types of shock: Presents with
• Heat stroke: The most serious • A nuchal chord occurs when the • Are sometimes preceded by an – Cardiogenic: Related to car- • A concomitant history (e.g., a UTI
aura, which is some type of sen- diac disturbances, congestive
form of hyperthermia, it includes umbilical cord is wrapped around or recent surgery)
sory hallucination heart failure (CHF), and myo-
both “classic” (nonexertional) the baby’s neck. • An abnormally high or low temp-
• Sometimes end with a postictal cardial infarction (MI).
and exertional heat stroke. • Typical management is similar to erature
phase—characterized by initial – Distributive: Relative hypovo-
• Symptoms: prolapsed cord; treat per local confusion and fatigue with a slow lemia resulting from a dilation • Low ETCO2
– Decompensated volume loss protocol. return to normal mental status in blood vessels. Some causes: • High serum lactate levels
–– IbSneoavdbeyir lefilt ueyli etdocst srwoleyatte dimueb taola lnoscse of V• aBglieneadl iBnlge medaiyn gbe caused by: SAi msimplpel Pe apratritailal seizure: »» AAdnraepnhayll ainxsisufficiency ••• LACoaltwredr bieadlco moadbe nnpotraremls ssautalritetuiess
– Altered mental status – Placenta previa • Affects only a limited portion of » Sepsis • Lowered urine output
Treatment of Hyper/Hypothermia – Placenta abruption the brain » Drugs • Rapid heart rate
– Ruptures • May produce auditory, olfactory, – Hypovolemic: Caused by a low Treatment
• Consider discussion with online • Bleeding may be life-threatening and visual disturbances volume of vascular fluid typi-
medical control if feasible. to both the mother and fetus. • May cause muscle disturbances in cally because of trauma with • Fluid boluses
• Monitor for dysrhythmias. Treat • Treatment is generally supportive limited parts of the body external or internal bleeding. • Pressor administration by infusion
per protocol. to the condition. Complex Partial – Obstructive: Caused by an Stroke
Hyperthermia: Ectopic Pregnancy A complex partial seizure: obstruction to normal blood A.k.a. a cerebral vascular accident
• Cool the patient with sprays and fans. • Frequently originates in the tem- flow. Causes: (CVA), a stroke can be ischemic or
• Restore electrolytes (usually oral, An ectopic pregnancy: poral lobe of the brain » Cardiac tamponade hemorrhagic.
if possible and applicable). • Occurs when the fetus grows out- • May present with communica- » Pulmonary embolism An ischemic stroke:
• Administer intravenous (IV) fluids. side the uterus, most often in a tions disturbances, blank stare, lip » Tension pneumothorax • Is caused by an embolus
Hypothermia: fallopian tube smacking, and twitching • Generally, all forms of shock result • Reduces perfusion to part of the
• Rewarming • Is a potentially life-threatening Generalized in symptoms associated with poor brain
• Hot packs condition A generalized seizure: perfusion (e.g., low blood pres- Hemorrhagic stroke: Bleeding
Caution: Local vasodilation Symptoms • Results from excessive brain activ- sure, altered mental status, car- caused by a trauma or aneurysm,
may cool the body’s core. • Early signs are pelvic pain and ity in both hemispheres diac abnormalities, lowered urine which puts pressure on the brain and
Nerve Agent & possible light vaginal bleeding. • May present with anything from output, and rapid heart rate). decreases perfusion.
Organophosphate Poisoning • There may be referred pain to the subtle changes to rhythmic jerking • Specific symptoms may occur, Symptoms
Poisoning: shoulder, flank, or neck with and stiffening of muscles such as chest pain with a myo- • Loss of function or weakness on
• May occur through ingestion, inha- excessive bleeding. Tonic-Clonic cardial infarction (MI) and one side of the body or part of one
lation, and skin (dermal) contact • If ruptured, signs of hypovolemic A tonic-clonic seizure: difficulty breathing with an MI side of the body
• Acts to “deactivate” acetylcholin- shock occur. • Is the most recognized type of seizure or embolism. • Loss of proprioception
esterase, effectively causing a Treatment • May present with rapid uncon- • The body tries to compensate as • Facial droop
parasympathetic storm • Treat for shock. sciousness followed by generalized shock progresses (compensated • Dysphasia
3
• Altered mental status Provide supportive treatment for – Magnesium sulphate (for Treatment – Is a critical paramedic skill
• Abnormalities in anything con- life-threatening conditions as torsades de pointes) Note: Follow AHA guidelines. » Practice is essential.
trolled by the brain appropriate. – Lidocaine Treatment depends on severity. – Allows early detection of ST
Note: It is very important to deter- Cardiac Emergencies • If patient is unstable, consider: • Transcutaneous pacing elevation MIs (STEMI)
mine the exact time of symptom Acute Coronary Syndrome – Cardioversion with pre- • Atropine • Myocardial infarction (MI)
onset. (ACS) sedation and/or analgesia as • Epi infusion progressions:
Treatment with SVT • Dopamine infusion – Ischemia: Peaked T-waves or
ACS represents a spectrum of
• Establish an IV. disease and includes angina, A-Fib/A-Flutter • Norepinephrine infusion inversions.
• Check blood sugar to rule out unstable angina, and anginal • A-fib: Heart beats in an irregu- • Glucagon in suspected beta or – Injury: ST segment elevation,
hypoglycemia. equivalents. larly irregular rhythm. calcium blocker overdose usually with signs of ischemia.
• Defer oxygen application Signs & Symptoms – Atria are in fibrillation. This • Calcium chloride/gluconate in – Infarct: Presence of clini-
depending on oxygen satu- • Acute onset of weakness may result in an accelerated suspected calcium blocker over- cally significant Q-waves.
ration. • Chest pain ventricular response with dose 1. Prepare the patient.
• Transfer the patient to a stroke • Shortness of breath associated decompensation. Cardiac Arrest A. Expose the chest and
center capable of providing • Radiating pain (e.g., down the • A-flutter: Similar to a-fib but Note: Treat per current AHA extremities.
appropriate care. arm and into the jaw) the atria produce regular flutter guidelines. B. Ensure skin is clean and
Abdominal Pain Not OB- • Diaphoresis waves. • Perform high-quality CPR and dry.
Related • Anxiety – Waves often conduct to the ventilations with oxygen. C. Remove hair from elec-
• There is a very long differential • Abnormal vital signs ventricles with a 2:1, 3:1, etc. • Perform rhythm analysis. trode areas.
diagnosis of causes. Treatment ratio resulting in rapid ven- – If asystole: Provide epineph- 2. Apply electrodes.
• Goals: • 12-lead ECG: Acquisition, tricular response (a common rine or vasopressin. A. Place limb electrodes on
– Improve patient comfort. interpretation, and early atrial rate is 300 with a ven- – If v-fib or pulseless v-tach: the limbs, not the torso.
– Identify life-threatening notification tricular rate of 150—a 2:1 Provide defibrillation. B. Place chest leads on inter-
conditions. • Oxygen if saturation is low conduction). • Other medications (depending costal reference lines.
• Evaluate possible causes. – Use with caution in myocar- • Due to their rapid rates, a-fib on underlying cause): V1: Fourth space to right of
Possible Signs & Symptoms and a-flutter can often be mis- – Sodium bicarb the sternum
dial infarctions (MIs).
Perforated, Ischemic, taken for an SVT. – Atropine V2: Fourth space to left of
Necrotic Bowel • Aspirin • Rapid ventricular response can – Amiodarone the sternum
• Severe pain, especially with • Nitroglycerin (NTG) result in: – Calcium chloride/gluconate V3: Diagonally between V2
palpation • Analgesics (e.g., fentanyl and – Poor ejection fraction – Magnesium sulphate and V4
• Bloody stool morphine) – Poor cardiac perfusion – Lidocaine V4: Fifth space along the
• Nausea and vomiting • Fluids or pressors if blood pres- – Chest pain • The reversible causes of cardiac midclavicular line
• Fever sure is low – Radiating pain (e.g., down arrest can be remembered as V5: Fifth space along the
• Abdominal distension Transport to a percutaneous into the arm and into the jaw) the four Hs and four Ts. anterior axillary line
Abdominal Aortic coronary intervention (PCI) cen- – Low blood pressure – The Hs: Hypothermia, (same level as V4)
Aneurysm ter if applicable. – Nausea, weakness, and hyperkalemia, hypoxia, V6: Fifth space along the mid-
• Pulsatile abdominal mass Complete a thrombolytic check- diaphoresis hypovolemia, H+ (acidosis). axillary line (save level
• Back pain with or without chest list. – Shortness of breath – The Ts: Toxins, thrombus, as V4)
pain Supraventricular Tachycardia – Anxiety tension pneumothorax, tam-
• Past history (SVT) – Abnormal vital signs ponade (cardiac).
• Unequal femoral or distal pulses With a SVT, the heart beats in a • The paramedic must deter- Congestive Heart Failure
Appendicitis regularly regular, fast rhythm. An (Pulmonary Edema)
mine if the patient is stable or
• Right lower quadrant pain on SVT originates in the atria (nar- unstable. Congestive heart failure most V1 V2
palpation; periumbilical pain row complex QRS). – Stable patients may benefit commonly occurs when the left V3V4 V5 V6
• Fever Signs & Symptoms side of the heart can’t keep up with
from:
• Nausea and vomiting • Acute onset of weakness » Valsalva maneuver (if the the right side.
• Loss of appetite • Chest pain or palpitations rhythm is actually an SVT) • This results in increased pul- 3. Acquire a 12-lead.
Acute Cholecystitis (Gall • Shortness of breath » Diltiazem monary vessel pressure. A. Patient must be still.
Bladder) • Radiating pain (e.g., down into » Metoprolol • Increased pressure pushes fluid B. Leads must be tension free.
• Fever the arm and into the jaw) » Amiodarone across the alveolar membrane C. A clean (no artifact) 12-
• Past history • Diaphoresis » Fluid bolus into the lungs. lead is essential for good
• Nausea and vomiting • Anxiety – Unstable patients may ben- Signs & Symptoms STEMI interpretation.
• Right upper-quadrant pain • Abnormal vital signs efit from: • Acute onset of weakness 4. Interpret the 12-lead.
Pyelonephritis (UTI, Kidney Treatment » Cardioversion per AHA • Chest pain A. STEMI is evident if:
Infection) • Vagal (Valsalva) maneuver; protocols • Radiating pain (e.g., down the i. ST elevation is 1 mm
• Dysuria hard cough » Sedation and/or analgesia arm and into the jaw) or more in two or more
• Hematuria • Shortness of breath contiguous leads
• If patient is stable, consider: prior to conversion
• Fever • Diaphoresis ii. Rule out STEMI impos-
– Adenosine Warning: Some contraindica-
• Nausea and vomiting • Anxiety ters such as:
– Diltiazem tions to medication therapy are
• Back and/or flank pain • Abnormal vital signs a) Ventricular rhythms
– Amiodarone Wolff-Parkinson-White (WPW)
• Feeling of urinary urgency • Wet lung sounds bilaterally, (e.g., pacers and
Renal Colic (Kidney Stones) Warning: Some contraindications syndrome, second- and third- starting in bases and working v-tach)
• Flank pain on one side; gener- are Wolff-Parkinson-White degree heart block, sick sinus up as the condition worsens b) Left ventricular hyper-
ally severe (WPW) syndrome, second- or syndrome, severe hypotension, Presents with trophy (LVH)
• Nausea and vomiting third-degree heart block, sick and cardiogenic shock. • An increased blood pressure c) Left bundle branch
• Hematuria sinus syndrome, severe hypoten- Bradycardia (Slow Heart Rate) (from anxiety) block (LBBB) unless
Peritonitis (Bacterial or sion, and cardiogenic shock. Bradycardia is classically defined • A cough and frothy sputum presumed new
Fungal Inflammation of • If patient is unstable: as a heart rate under 60. • Pitting pedal edema d) Early repolarization
Peritoneal Lining) – Cardioversion per AHA • “Slow” is relative to the patient. • A past history and diagnosis e) Pericarditis
• Abdominal tenderness protocol • Patients who are physically fit Treatment 5. Leads V1 and V2: Septal wall
• Diarrhea – Consider pre-sedation and/ may have resting heart rates • Nitroglycerin and nitroglycerin 6. Leads V3 and V4: Anterior
• Thirst or analgesia with: under 60 as normal. paste wall
• Fever » A benzodiazepine • Generally, only treat patients • Furosemide 7. Leads V5, V6, aVL, and I:
• Weakness and fatigue » Fentanyl or morphine when they are symptomatic. • Pressors (if blood pressure is Lateral wall
• Loss of appetite Ventricular Tachycardia Signs & Symptoms low) such as norepinephrine or A. Use the acronym SAL:
• Bloating With a ventricular tachycardia, • Acute onset of weakness dopamine i. S: V1 and V2
• Inability to pass stool or gas the heart beats in a regularly • Chest pain • Sitting patient upright—legs ii. A: V3 and V4
Treatment regular, fast rhythm. It originates • Radiating pain (e.g., down into over the side of a cot if possible iii. L: V5, V6, aVL, and I
• IV access in the ventricles (wide complex the arm and into the jaw) • Oxygen 8. Leads II, III, and aVF:
• Pain management QRS). • Shortness of breath • Continuous positive airway Inferior wall
• Antiemetic medications Treatment • Diaphoresis pressure (CPAP) Note: It is possible to move leads
In all cases, continually assess the • If patient is stable, consider: • Anxiety 12-Lead Interpretation to view the right side and poste-
patient’s vital signs. – Amiodarone • Abnormal vital signs • A 12-lead interpretation: rior walls.
4
Physiology & Pathophysiology (continued)
(cid:31)(cid:30)(cid:29)(cid:28)(cid:27)(cid:26)(cid:25)(cid:24)(cid:23)(cid:22)(cid:24)(cid:21)(cid:20)(cid:22)(cid:25)(cid:19)(cid:18)(cid:23)(cid:19)(cid:24)(cid:17)(cid:29)(cid:26)(cid:26)(cid:24)(cid:16)(cid:21) (cid:31)(cid:30)(cid:29)(cid:28)(cid:27)(cid:26)(cid:25)(cid:24)(cid:23)(cid:22)(cid:24)(cid:21)(cid:20)(cid:19)(cid:25)(cid:18)(cid:23)(cid:17)(cid:25)(cid:27)(cid:19)(cid:29)(cid:26)(cid:24)(cid:16)(cid:15) capnography the gold stan-
dard for ETT placement.
I aVR V1 V4 I aVR V1 V4 – Provides real-time waveform
of exhaled CO2 that can be
II aVL V2 V5 used to determine normal
II aVL V2 V5 versus abnormal conditions
III aVF V3 V6 such as bronchospasm and
leaky endotracheal (ET) tube
V III aVF V3 V6 – Allows the paramedic to:
» View the efficacy of treat-
II Note: Reciprocal changes (ST segment depression) may be evident ments related to respira-
tory conditions
in opposing lead groups.
V » Assess correct ventilation
Trauma Note: Room temperature normal • Be prepared for emergent intu- • Do not overventilate/oxygenate in head injured, intubated,
General Trauma Guidelines saline is both acidic and promotes bation for inhalation injuries. head trauma victims. Target an chronic obstructive pulmo-
Consider these treatments for all hypothermia. – An airway edema can prog- ETCO2 within normal ranges, nary disease (COPD), con-
Burns ress rapidly, making intuba- per protocols. gestive heart failure (CHF),
trauma injuries.
• Provide assessment targeted to Categorization tion difficult. • Intubation may be required to and asthma patients
life threatening injures. • Superficial: First-degree burn. – Consider rapid sequence protect the airway. » Assess return of spontane-
– Profound bleeding: – Causes erythema, pain, and intubation if available. Spinal Trauma ous circulation (ROSC) in
Exsanguination can occur swelling Blast Injuries • Consider spinal immobilization cardiac arrest patients
quickly. Consider: • Partial thickness: Second- • Be safe! Identify any active when appropriate; minimize • Most monitors use the capno-
» Direct pressure degree burn. threats and delay entry into the morbidity from immobilization gram to report respiratory rate.
» Tourniquets – Serious burn that causes blis- hot zone until provider safety devices (e.g., rigid longboards). • Capnography is not the same as
■ Note the time of appli- tering and extends into upper is assured. • Remove helmets (e.g., motor- capnometry.
cation and rotate if dermal layers • An explosion can cause multi- cycle and football helmets). • Capnography should be used in
applicable. • Full thickness: Third-degree system trauma including: – Maintain stabilization of neck. conjunction with pulse oximetry.
» Hemostatic agents burn. – Chemical exposure – Maintain inline direction of • For all methods of airway con-
– Address airway and breathing – Very serious burn that – Burns neck. Use caution with uni- trol, ensure and document:
– iWas snhueeeunsr. oalpopgricoaplr aiastsee,s spmerefnotr.m etshoxrmteoneutdgimsh dedese eirpnmteora lmi nlautyose ctrliess,s uanesd, –– BtBralauruonmttr aaa)unmda/o (rp rpesesnuerter awtianvge – Irfoef rmmho (vefelomdo,te btuassl le) cppaaandddndionintg g. btoe – »C lTeahre, rbei lsahteorualld b breea ntho esopuignadss-
trauma tric sounds.
• Rapid but safe extrication may • Hands, feet, face, and genitalia maintain a neutral position
involve additional rescuers with involvement increase serious- Crush Injuries of the head and neck relative – Misting in tube
special training. ness of all burns. • Watch for signs of hyperkalemia to the torso. – Active EtCO2 monitoring
• Perform a thorough secondary Chemical (e.g., tall, peaked T-waves in an • Place patient in a cervical collar. – Active pulse oximetry
assessment, both anterior and • Consider hazmat precau- EKG and a wide QRS). This can Thoracic & Abdominal Trauma Noninvasive Methods of Airway
posterior. Patient should be in tions. Refer to the National be a fatal complication. • Expect possible spinal injury Control
a warm environment. Institute for Occupational • Consider treatment with: and treat accordingly. • Nasal cannula
• Transport to a designated trau- Safety and Health (NIOSH) – Calcium chloride or calcium • Secure impaled objects in place. • Simple and non-rebreather
ma center should be rapid but hazmat references. gluconate For Open Pneumothorax masks
safe. • Determine offending agents. – Albuterol • Apply occlusive dressing. Seal • Continuous positive airway
• Note any signs of alcohol or • Brush off dry substances. – Sodium bicarbonate but configure to allow for pres- pressure (CPAP)
drug usage. • Continuously flush with water Facial Trauma sure release on three sides. • Bag-valve mask (BVM)
• Special situations (e.g., decapi- if indicated. • Goal: Maintain the airway and • Monitor closely for tension Invasive Methods of Airway
tation, severe penetrating trau- • Some substances that react with preserve vision and teeth. pneumothorax, which presents Control
ma, and signs of rigor) may water: • Bleeding may be severe. with decreased breath sounds Endotracheal Intubation
dictate withholding resuscita- – Lime/lye • Collect any lost teeth. on one side, increased difficulty (ET tubes)
tive efforts in a trauma arrest. – Phenol – Avoid contact with the root. breathing, narrowing pulse pres- The gold standard, ET tubes:
• Continually monitor ECG, vital – Pure sodium, potassium, and Don’t wipe the tooth; pick it sure, jugular venous distention • Isolate the airway
signs, pulse oximetry, and cap- lithium metals up at the crown. (JVD), difficulty ventilating, and • Prevent aspiration from emesis
• nEostgarbalpishhy I(Vwsh wenit hap apprporporpiartiea)te. Th–e rOmthaelr alkali metals – Pnolarcme atol osathli nine fwohr otrlea nmspilokr ot.r • tCroacnhsiedael rd neeveiadtlieo dne.compression • Provide positive control of ven-
fluids. 1. Stop the burning process. – An alert patient can hold the if indicated. tilations and volume
• Consider analgesics. 2. Remove non-adherent coverings. tooth in their mouth with For Flail Chest • Allow for tracheal suctioning
• Consider ice packs to limit 3. Cover with a clean, dry, sterile patient saliva as the preserva- Flail chest: Paradoxical move- • Require specialized training and
swelling. dressing. tion medium. ment of chest wall due to “float- equipment to insert
• Be alert to emesis control in 4. Keep patient warm. Hypo- Eye Trauma • Involve a risk of esophageal
ing” ribs.
motion-limited patients. Turn thermia can progress rapidly. • Consider placing a shield over insertion
• If indicated, position the patient
patient as a unit. TBSB both eyes to limit sympathetic Supraglottic Airway
with the flail side down.
• Consider that patients may be Estimate the percentage of total movement. This method:
• Provide manual stabilization of
on medications that would affect body surface burned (TBSB) • Do not replace avulsed globe. • Allows for quick insertion
the flail segment.
morbidity/mortality such as: using accepted methods such as Cover with moist, sterile saline. • Consider positive pressure • Does not fully protect the
– Blood thinners, which can the rule of nines. Jaw (Mandible) Trauma ventilations. patient from aspiration
cause excessive bleeding Treatment • Be alert for airway problems. Submersion Injuries • Has less potential to induce
– Beta or calcium channel • Administer IV therapy and flu- • Patient may not be able to con- trauma than direct laryngos-
blockers, which can dull the ids per the Parkland formula. trol oral secretions. • Begin resuscitative efforts as copy
cshoomcpkensatory response to – GTBivSeB .2–4 mL/kg/percent N• oHsaevbel esuecdt i(oEnp aivsatailxabisle). • eCaornlys iadse rp sopsisniballe/c.ervical immo- • Is often used as a backup when
• Blood pressure management is » Administer the first half in Squeeze nares together for a min- bilization. endotracheal (ET) intubation
targeted to adequate perfusion, the first 8 hours. imum of 10 to 15 minutes. • Consider hypothermia. fails
not normal pressures (permis- » Administer the second half Nose, Ear & Lip Avulsions Airway Cricothyrotomy (Needle &
Surgical)
sive hypotension). over the remaining 16 • Recover tissue. • Ultimate goal of airway man-
Warning: Normal pressures and hours. • Place tissue in sterile gauze, agement: Achieve and maintain • Cricothyrotomy requires special
excessive fluids can exacerbate – Consider lower doses in then in a plastic bag. a patent airway with good training. It is used as a means
exsanguination and disseminated patients who can’t tolerate • Place tissue on ice, but not in EtCO2 (capnography) and SpO2 of last resort to secure an airway.
intravascular coagulopathy large fluid boluses due to direct contact with it. values. • When performing cricothy-
(DIC). comorbid factors (e.g., con- Head Trauma • Capnography is a standard of rotomy:
• The trauma killers (after the gestive heart failure (CHF)). • Maintain cervical stabilization. care that: – Identify and surgically pierce
ABCs): • If inhalation cyanide poisoning • Repeat neurological examination. – Is useful to verify endotra- the cricothyroid membrane.
– Hypothermia is suspected, consider admin- • Monitor for signs of Cushing cheal tube (ETT) placement – Obtain airway access.
– Acidosis istering hydroxocobalamin and reflex, which indicate brain » As ETT is the gold standard Rapid Sequence Intubation
– Coagulopathy sodium thiosulfate. herniation. for airway control, so is (RSI)
5
Physiology & Pathophysiology (continued)
• Administer sedatives and paralyt- – Succinylcholine – Mallampati score • Follow the seven “Ps” of RSI: • Note and document the depth of
ics, such as: – Rocuronium – Thyromental (TM) distance Prepare, Preoxygenate, Pretreat, the tube.
– Thiopental – Vecuronium – Hyoid-mental (HM) distance Paralyze, Protect, Placement, • Continuously check tube place-
– Etomidate • RSIs require a very high level of • You must ensure that positive air- Post-intubation management ment.
– Ketamine training. way control will be obtained before Post-Intubation Management • Suction if required.
––– FMPeriondptiaoznofyolallm • Ydoecui dmeu isft acnla RssSifIy i sth ien daiircwataeyd .a nTdo sptaatriteinntg f.o Yro RuS wI; itlhl ebye wpailrl anloyzt ibneg a tbhlee • CSpoOn2t,i nanudo ubsrleya tmh osonuitnodrs .ETCO2, • Bif et hperye praergeadin t oc osnedscaitoeu tshnee pssa.tient
– Pancuronium determine this, use the: to breathe on their own. • Secure the advanced airway.
Pharmacology – Intramuscular (IM) injection Drug Math EX: Assume there is a 250 mL bag – 6,000 ÷ 8 hours =
– Subcutaneous (SQ) injection 1 gram = 1,000 mg of normal saline. 750 mL in 1 hour.
• A drug is any substance that has – Intraosseous infusion (IO) 0.1 gram = 100 mg Assume the medication is 400 mg – 750 ÷ 60 minutes in an hour
a physiological effect when intro- – Inhalation 0.01 gram = 10 mg or 10,000 mcg in a 1 mL vial. = 12.5 mL/min.
duced into the body. – Endotracheal intubation Bolus Dosing Put all 400 mg (1 mL) into the 250 cc • Use a 60-drop set and the for-
• Tnahme seasm. e drug can have multiple –– ISnutbrlainnagsuaall a addmmiinniissttrraattiioonn 1. Determine the patient’s weight bTahge. yield is 400 mg per 250 ml, or mula of dose × 60 ÷ yield.
in kilograms (kg) by dividing 1.6 mg/ml. • The yield is 1, so: 12.5 × 60 =
– Chemical: A description of a – Topical administration
the patient’s weight in pounds 3. Pick a drip set. Most infusion 750 gtt./min. or 750 ÷ 60 =
– dGtore uang ed’srr icuchg: e Tbmyhi ect haflie r cscoto mnmappmoaseni tygi oitvnhe.ant Int–e rIanctrtaicoanrsdiac injection EX:( Alb p.)a btiye n2t.2 i.s 160 lb. apderm 1i nmisLt r(a6t0i ogntt .s/emtsL a).re 60 gtt. 1p2ra.5c tgictta./l saepcp.!r Toahcihs ;i sy onuo tc aa n’t
formulated it. • Synergism: When two or more 160 ÷ 2.2 = 72.73 4. Calculate the drip rate for the effectively count 12 gtt./sec.
drugs together provide a physio- medicine: Dose × administration
– Official: The name a drug is logical effect over that of any of A 160 lb. patient is about 73 kg. set drip rate ÷ yield. • Switch to a 10 gtt./mL set and
listed under in the United States the drugs alone. 2. Determine the number of grams EX: 0.3 × 60 = 18 the number changes to dose ×
Pharmacopeia (USP). • Potentiation: When one drug (g) or milligrams (mg) you need. 18 ÷ 1.6 = 11.25 gtt./min. (round to 10 or 12.5 × 10, which is
– Trade: A brand name given by increases the effect of another. EX: A drug is dosed at 0.25 mg/kg. 11 gtt./min.) 125 gtt./min. or 125 ÷ 60 =
the manufacturers. The same • Addition: An increased effect of The patient weighs 73 kg. 0.3 mg/min. × 60 gtt./mL ÷ 1.6 mg/mL 2.1 gtt./sec.—much more practical!
drug can have multiple trade two drugs that have the same 0.25 × 73 = 18.25 mg mg and mL cancel, so you are left This same formula can be used for
names. action. You need approximately 18 mg. with gtt./min. any fluid bolus over time.
• Drugs may be derived from: • Antagonism: When the action of 3. Determine the concentration by Important: You must work in all the EX: You need to administer a 250 cc
– Minerals one drug is decreased by another reading the medication label. same units. Do not attempt to use bolus over 15 minutes.
– Csizheedm)ical compounds (synthe- Nodtreu: gD.rugs may chemically interact EmXe: aAn dsr tuhge rise 1a0re0 2m mg Lin o 2f flmuLid. Tinh itsh e msamillieg rfoarmmsu alna.d C moincvreorgtr eamvesr yitnh itnhge 250 ÷ 15 = 17 cc/min.
– Living organisms (e.g., plants, when given through the same IV vTaiakle a tnhde tchoonscee 2n mtraLt icoonn 2ta minL 1 ÷0 01 0m0g m. g to either milligrams or micrograms. With a 15 gtt. drip set, that’s 17 ×
animals, bacteria, and fungi) tubing and cause precipitates or (2 mL contains 100 mg) and multiply All fluids should be in milliliters. 15 = 255 gtt./min. or approximately
• Drug forms: Extracts, powders, other chemical reactions. This must it by 18 mg (the dose). Fluid Infusions 4 gtt./sec. (255 ÷ 60 = 4.3)
pills, capsules (including be avoided at all costs. Different IV (2 × 18) ÷ 100 = 0.36 (0.4 to round) Fluid infusions using the Parkland Note: In general, count and adjust
Pulvules), tablets, suppositories, lines may be used in these cases. So 0.4 mL should be drawn from the Formula: You may want to simply drip rates over a 10, 20, or 30 second
ointments, patches, solutions, Special Considerations vial and given to the patient. infuse a volume of fluid over time period. If the formula says to count
suspensions, tinctures, spirits, Special considerations must be taken Infusions without a drug mixed in. 2.5 drops per second in 20 seconds,
elixirs, milks, emulsions, and for the very young and the elderly. Infusions are generally calculated EX: Use the Parkland formula for an count 50 drops (2.5 × 20).
lotions. • Pediatric patients: There may be based on patient weight over time. 80 kg patient with burns on 50% of Continue adjusting the drip
Routes of Administration special dosing considerations or 1. Determine the dose. the total body surface area (TBSA). rate until accuracy is obtained.
• Enteral routes: Through the contraindications in some EX: Administer 5 mcg/kg per minute. Parkland states 2–4 mL/kg/TBSA. Warning: Before you admin-
mouth and rectum (inserted in patients. The patient weighs 60 kg. • Using 3 mL/kg/TBSA: 3 × 80 × ister any medication, you must be
the anus). These require the drug • Elderly patients: Some patients The dose is 300 mcg/min. (5 × 60). 50 = 12,000 mL of fluid thoroughly familiar with all dosages,
to be absorbed in the GI tract. may have comorbid factors such Convert micrograms to milligrams; • Administer the first half with- mechanisms of action, indications,
• Parenteral routes: Introduced as kidney or liver disease that 300 mcg/min. = 0.3 mg/min. in the first 8 hours. contraindications, patient allergies,
outside of the GI tract via: would affect the metabolism of a 2. Get the yield by mixing a vial of – 12,000 ÷ 2 = 6,000 mL in potential side effects, and drug math
– IV (bolus or an infusion over time) drug and its dosing. the medication in normal saline. the first 8 hours. calculations.
Behavioral Emergencies • Suicidal ideation: Thoughts of • The patient truly believes in their Note: A hyperglycemic event from » They may lack the ability or
suicide. delusion. Remain calm with the new onset diabetes can present means to purchase necessary
General Principals • Risk factors are much greater for patient; tell them you are there to similarly; check blood sugar. medications.
• It may be considered an emer- patients: help. No two situations will be the • Panic attack: The most common Approach patients carefully. Rule
gency when a patient presents – Who have attempted suicide in same. presentation. Talk the patient out any other underlying medical
symptoms of harm to themselves the past Subcategories down; be calm and reassuring. It’s
• oTrh oe tehmeresrgency might be organic – Wdruhgos a orer ualncdoehro tlhe influence of • Govrearnindfelauterd: Tsehnes ep oaft iwenotr thh.as an vuenrdye rilmyipnogr ptaantht otpoh ryusiloel ooguyt. any cPosnydcihtioosniss.
(caused by a physiologic issue) or – Who have experienced a recent • Erotomaniac: The person feels Schizophrenia Psychosis: A complete loss of touch
nonorganic (caused by a psychi- significant event (e.g., loss of a with reality.
that someone is in love with them. Schizophrenia:
• aAtlrwica iysss uche)e.ck medications. Look – lWovheod ohnaev eo rr deciveoivrceed) a recent • Jealous: The person feels that their • Is a long-term brain disorder com- Symptoms
for possible over/underdosing. diagnosis of a terminal illness significant other is unfaithful. prising a combination of inability • Delusions and hallucinations
• It is important to rule out any • Assessment of a suicidal patient • Somatic: The person believes to process thoughts, behavior, (auditory and/or visual)
physiological and underlying causes is the same as an assessment for they have some physical illness and/or emotions that leads to a • Garbled speech
(e.g., hypoglycemia, perfusion prob- any general medical patient. or disease. faulty perception of reality and • Inappropriate actions
lems, and substance intoxications) • Suicidal patients may be violent; • Persecutory: The person believes inappropriate actions Treatment
and treat accordingly. approach with caution and speak they or someone they know is • Is a poorly understood condition
• Use calm and understanding
• Treatment: in a calm voice. being persecuted. • Can be managed with medications
– Is generally focused on talking • Ask the patient if they have a plan Anxiety (often multiple) speech.
the patient down in mind; document accordingly. • Anxiety: Fear of future threats, – Patients may stop taking their • Be alert for violent behavior.
– May include sedation and/or Delusions real or imagined. medications and become Consider possible use of benzo-
restraints • Delusion: A false idea that renders • Phobias: Extreme anxiety reactions. unstable. diazepines or other approved
Suicidal Ideation a person unable to differentiate • Patients may present with rapid » They may feel they are sedation if necessary to pro-
• Suicide: Taking one’s own life by reality from imagination (when breathing, heart rates, diaphoresis, “cured” and don’t need fur- tect the patient and the care-
any means. taken to an extreme). and decreased ETCO2 levels. ther medication. givers.
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