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PreparatoryEMS SystemsEMR Education StandardUses simple knowledge of the Emergency Medical Services (EMS) system, safety/well-being ofthe Emergency Medical Responder (EMR), medical/legal issues at the scene of an emergencywhile awaiting a higher level of care.EMR-Level Instructional GuidelineI. The Emergency Medical Services (EMS) SystemA. The Current EMS Systems1. Types of systems in EMSa. Fire-based-Fire Station Basedb. Third service-Private ambulance resource- ex. EVACc. Hospital-based2. Delivery may be different but the goal is the same – based uponcommunity needs/resourcesB. National Highway Traffic Safety Administration (NHTSA) Is Lead CoordinatingAgency- helps sets standards and protocols for EMSC. Access to the Emergency Medical Services1. Public Safety Access Point (PSAP)- call center-most have caller location-voice broadcasting system2. Most communities access through 9-1-1D. Education1. National Scope of Practice Model -What you are legally allowed to perform as a result of your traininga. Description of the professionb. Prehospital personnel levels2. National EMS Education StandardsE. Authorization to Practice1. State EMS officea. Determines scope of practiceb. Licenses prehospital personnel2. Medical oversight-Medical Director of one of the local Emergency/Trauma Departmentsa. Protocols/Standardsb. Quality improvement-CQI Continuous quality improvementc. Administratived. Online (direct communication) off line (standards and protocols)3. Local credentialing4. Employer policies and proceduresII. Roles, Responsibilities, and Professionalism of EMS PersonnelA. Roles and Responsibilities1. Maintain equipment readiness2. Safetya. Personalb Crewb. Patientc. Others on scene3. Provide scene evaluation and summon additional resources as needed4. Gain access to the patient5. Perform patient assessment6. Administer emergency medical care while awaiting arrival of additionalmedical resources7. Provide emotional supporta. Patientb. Patient familyc. Other responders8. Maintain continuity of carea. Definition-quality of care overtime-ongoing case management. Good notations-> proper report and documentationb. EMR is the first step in the EMS care ladder9. Maintain medical and legal standards and assure patient privacy10. Maintain community relationsB. Professionalism1. Characteristics of professional behaviora. Integrityb. Empathyc. Self-motivationd. Appearance and hygienee. Self-confidencef. Knowledge of limitationsg. Time managementh. Communicationsi. Teamworkj. Respectk. Tactl. Patient advocacym. Careful delivery of care2. Maintaining certificationa. Personal responsibilityb. Continuing educationc. Skill competencyd. Criminal implications- could revoke your license, need to work with a current license e. FeesIII. Quality ImprovementA. Dynamic System for Continually Evaluating and Improving Care1. Patient safety2. Significant – one of the most urgent health care challenges3. How errors happena. Skills-based failureb. Rules-based failure- not following rulesc. Knowledge-based failure-not properly trained4. How you can help reduce errorsa. Debrief callsb. Constantly question assumptionsc. Use decision aidsd. Ask for helpPreparatoryResearchEMR Education StandardUses simple knowledge of the EMS system, safety/well-being of the EMR, medical/legal issuesat the scene of an emergency while awaiting a higher level of care.EMR-Level Instructional GuidelineI. Impact of Research on EMR CareA. Research Findings Are Important to Identify What Should Be Changed in EMSAssessment and Management and to Improve Patient Care and Outcome (i.e. CPRguidelines change based on current research )B. Quality Assurance Research For An EMS System Can Improve Service DeliveryC. Data CollectionUse data (example response times) to improve emergency route access to patientsand to care facility (trauma centers and hospitalsPreparatoryWorkforce Safety and WellnessEMR Education StandardUses simple knowledge of the EMS system, safety/well-being of the EMR, medical/legal issuesat the scene of an emergency while awaiting a higher level of care.EMR-Level Instructional GuidelineI. Standard Safety PrecautionsA. Baseline Health Assessment1. Before working in health care, have a physical examination to determinebaseline health status2. Immunizations should be current while practicing in health carea. Tetanusb. Hepatitis Bc. Measles/mumps/rubella (German measles)d. Chicken pox (varicella)e. Influenza3. Screening for tuberculosis recommendedB. Hand washing-before and after each patient-C. Adherence to Standard Precautions/OSHA Regulation-PPE and Universal PrecautionsD. Safe Operation of EMS/Patient Care EquipmentE. Environmental Control-Stabilize scene and vehicleF. Occupational Health and Blood borne Pathogens1. Immunizations2. Sharps- dispose of appropriatelyII. Personal Protective EquipmentA. Exposure to Diseases Spread Through Blood or Body Fluids or by RespiratoryDroplets Are Best Prevented by the Use of Standard PrecautionsB. Standard Precautions1. Hand hygienea. The most important measure to prevent the spread of infectionb. Wash your hands after gloves are removedc. Hand cleansingi. soap and waterii. alcohol-based hand rubd. Cleanse hands with soap, and dry hands thoroughlye. Cleanse hands and other exposed skin immediately if they areexposed to contaminants, such as blood and body fluids or afteruse of the toilet2. Glovesa. Wear gloves for patient contacts where there is a risk of exposureto blood or body fluidsb. If EMR has a latex allergy use an alternative type of glove3. Eye protection or face shielda. Goggles or full-face shieldb. Use if there is a risk of splash or spray of body fluidsi. reduces risk of contamination of eyes, nose, or mouthii. examples include care of patients who area) bleeding profuselyb) delivering a baby4. Masksa. High-efficiency particulate air (HEPA) or N95 mask on EMRb. Surgical mask on patient5. Gowna. In situations with large amounts of blood or body fluids,disposable gown should be wornb. If clothing becomes contaminatedi. remove as soon as possibleii. shower as soon as possibleiii. wash clothes in a separate loadiv. preferably at work6. Sharps (needles)C. If an exposure occurs1. Clean the contaminated area thoroughly with soap and water2. If eyes are involved, flush with water for 20 minutes3. Report the exposure to the EMS providers who take over care of thepatient4. Report the exposure to the appropriate person identified in yourdepartment infection control plan5. Seek immediate follow-up care as identified in your department infectioncontrol plan6. Documenta. Time and date of the exposureb. Circumstances of the exposurec. Actions taken after the exposured. Other information required by your departmentD. Soiled equipment or vehicles1. Cleaning-after each call.2. Disinfection3. DisposalII. Stress ManagementA. Many EMS Situations Can Be Stressful for EMS Personnel1. Dangerous situations2. Physical and psychological demands3. Critically ill or injured patients4. Dead and dying patients5. Overpowering sights, smells, and sounds6. Multiple-patient situations7. Angry or upset patients, family, and bystandersB. EMR Should Be SupportiveC. During and Immediately After a Stressful Incident1. Administer appropriate medical care2. Cooperate with other personnela. Law enforcementb. Other EMS providers3. Be calm, supportive, and nonjudgmental4. Allow patients to express feelings, unless their behavior is harmful tothemselves or othersD. Recognize the Warning Signs of Personal Stress1. Difficulty sleeping and nightmares2. Irritability with coworkers, family, and friends3. Feelings of sadness, anxiety, or guilt4. Indecisiveness5. Loss of appetite6. Loss of interest in sexual activity7. Isolation8. Loss of interest in work9. Physical symptoms10. Feelings of hopelessness11. Alcohol or drug misuse or abuse12. Inability to concentrateE. Strategies to Manage Personal Stress1. Talk about your feelings2. See a professional counselor3. Make lifestyle changes that can reduce stress, such as dietary changes,limiting caffeine and alcohol intake, exercise, and the use of relaxationtechniquesF. Dealing With Death and Dying1. Attempt to resuscitate patients without a pulse or not breathing unless:a. Do Not Resuscitate (DNR) order that meets local guidelines ispresent at scene(signed by doctor, legal document)b. Obvious signs of deathi. tissue decay (putrefaction)ii. rigor mortisa) stiffening of joints that occurs after deathb) assess two or more joints to verifyiii. injuries not compatible with life(decapitation) lividity- pooling of blood and body fluids due to lack of circulation.c. Attempting resuscitation would endanger life of EMR2. How to assist grieving patients or family membersa. Responses to death and dying are very individualb. People do not always experience them all or in any particular orderi. denialii. angera) patient or family projects feelings of anger towardother people, especially those closest to themb) do not take anger personally, even though it mayseem to be directed toward youc) be alert to anger that may become physical andendanger you or othersiii. bargaininga) patient or family may attempt to negotiate with aspiritual being or even with EMS providers in aneffort to extend lifeb) be non-judgmental at this timeiv. depressiona) patient or family exhibits sadness and griefb) affected person is usually withdrawn, sad, and maycry continuallyc) allow the affected person to express his feelings andto help him understand that these are normalfeelings associated with deathv. acceptancea) patient or family ultimately accepts the situationand incorporates the experience into the activities ofdaily living in an effort to surviveb) use good listening skills and a non- judgmentalattitude in this phaseIII. Prevention of Response-Related InjuriesA. Exposure to Infectious Diseases1. How infectious diseases are spreada. Through the air by coughing(droplets or airborne)b. Direct contact with infected blood or body fluidIndirect contact- touching contaminated objectsVector- passed on from insectsc. Needle sticksd. Contaminated foode. Sexually transmitted2. Exposurea. Contact with blood or body fluids of a person with an infectiousdiseasei. patient’s blood gets into a cut on your handii. you are stuck with a needle used by a patientiii. bloody saliva splashes into your eyes or mouthb. Close contact with a person with an airborne disease (e.g.,influenza, tuberculosis, etc.)B. Injury Prevention1. Good personal habitsa. Sleepb. Nutritionc. Current immunization statusd. Fitness2. Safe response to vehicle collisionsa. Traffic hazardsb. Deployment of air bagsc. Power linesd. Vehicle stabilitye. Other hazardsi. fireii. leaking fluids(hazardous gas or gasoline/hazardous tankard truck fluid)f. Violent or potentially violent personsg. Risk factors for violenceh. Safe responsei. law enforcementii. awarenessiii. restraint3. Hazardous materiala. Definition(item/agent (biological, chemical, radiological and/or physical) that has the potential to cause harm to humans/animals/environment.b. Assess the scene for signs of hazardous materials if suspectedi. binocularsii. look for placards(signs on buildings with possible material hazards)iii. notify dispatchc. Do not approach the scene if you suspect a hazardous materialreleasei. remain uphill and upwind a safe distance from the sceneii. await specialized resourcesIV. Lifting and Moving PatientsA. Body Mechanics1. Keep back straight2. Maintain a firm grip on stretcher or patient3. Avoid twisting of the body4. Maintain firm footing5. Communicate next move clearly to partner or team6. Use good postureB. Know Your Own Physical Limitations1. Safe lifting of cots and stretchersa. Power liftb. Squat lift2. Carryinga. Determine the weight to be liftedb. Know your own limitationsc. Communicate with partner or teamd. Keep the weight close to your bodye. Flex at hips and bend at knees, not waist3. Reachinga. General guidelines(do not over reach as this will cause you to strain the muscles in your back)b. Correct reaching for log rolling4. Pushing and pulling techniques(easier to push than pull, keep arms close to body for both , feet hip width apart, bend with your knees)C. Emergency Moves1. Immediate danger to the patienta. Fire or danger of fireb. Close proximity of explosives or other imminent hazardsc. To gain access to others who need lifesaving cared. Cardiac arrest patient2. Types of emergency movesa. Pull toward the long axis of the body if possibleb. Clothing drag(pull by clothing across the back area)c. Blanket drag(blanket or sheet)d. Firefighter’s drag(patient seated, firefighter’s arms are under patient’s arms and then clasped around patient’s chest. Fire fighter bends their knees and drags patient backwards)e. Firefighter’s carry(patient over back with arms over fire fighter’s shoulders- patient is carried)3. Urgent movesa. Patients with altered mental statusb. Inadequate breathing or shockc. Other situations that are potentially dangerous to the patient4. Techniquesa. Direct ground liftb. Extremity liftc. Moving patients from a bed to stretcheri. direct carry(lift up and move)ii. draw sheet(slide using a sheet)D. Positioning Patients1. Position of comforta. Indications for use-Respiratory distress, chest painb. Techniques-assist or on stretcher2. Recovery position-side lying, left lateral a. Indications for use-post dictal(after seizure)b. Techniques-log roll3. Supinea. Indications for use-CPR/Maintaining c-spine/back boardingb. Techniques-log rollE. Restraint1. Consider medical or trauma as cause for altered mental status2. Restrain only if patient is a danger to self or othersa. When using restraints have police present if possibleb. Get approval from medical directionc. Follow local protocols3. If restraints must be used:a. Have adequate helpb. Plan your activitiesc. Use only the force necessary for restraintd. Estimate range of motion of patient’s arms and legs and staybeyond range until readye. Once decision has been made, act quicklyf. Have one EMR talk to patient throughout restrainingg. Approach with four persons, one assigned to each limb, all at thesame timeh. Secure limbs with equipment approved by medical directioni. Never secure a patient face down – have access to the airway at alltimesj. Consider the use of oxygen by non-rebreather maskk. Reassess airway, breathing, and circulation frequentlyl. Document indication for restraining patient and technique ofrestraintm. Avoid unnecessary force4. Types of restraints-wrist, ankle, belt , harnessPreparatoryDocumentationEMR Education StandardUses simple knowledge of the EMS system, safety/well-being of the EMR, medical/legal issuesat the scene of an emergency while awaiting a higher level of care.EMR-Level Instructional GuidelineI. Recording Patient FindingsA. Prehospital Care Report1. Functions-record of care2. Continuity of care3. Administrative-admissions and insurance4. Legal documentB. Document1. Time of events2. Assessment findings3. Emergency medical care provided4. Changes in the patient after treatment5. Observations at the scene6. Dispositiona. Refused careb. Care turned over toPreparatoryEMS System CommunicationEMR Education StandardUses simple knowledge of the EMS system, safety/well-being of the EMR, medical/legal issuesat the scene of an emergency while awaiting a higher level of care.EMR-Level Instructional GuidelineI. CommunicationsA. Call for ResourcesB. Transfer Care of Patient1. When other EMS personnel arrive on scene, identify yourself and give averbal reporta. Current patient conditionb. Patient’s age and sexc. Chief complaint/mechanism of injuryd. Brief, pertinent history of what happenede. How you found the patientf. Major past illnessesg. Vital signsh. Pertinent findings of the physical exami. Emergency medical care given and response to careC. Interact Within the Team Structure1. Communication concerning the patient and scene toa. Law enforcementb. Other respondersPreparatoryTherapeutic CommunicationEMR Education StandardUses simple knowledge of the EMS system, safety/well-being of the EMR, medical/legal issuesat the scene of an emergency while awaiting a higher level of care.EMR-Level Instructional GuidelineI. Principles of Communicating With Patients in a Manner That Achieves a PositiveRelationshipA. Factors for Effective Communication1. Introductiona. Selfb. Partners/teamc. Patient introduction2. Privacy-HIPPA3. Interruptions-minimal4. Physical environmenta. Lightingb. Noises and outside interferencec. Distracting equipmentd. Distance-be near the patiente. Equal seating, eye level5. Note-taking-you may forget informationB. Interviewing Techniques1. Using questionsa. Open-ended questions-allows them to elaborateb. Closed or direct questions-use for patients with difficulty breating/ in painc. One question at a time-may confuse patient or miss informationd. Choose language the patient understands-plain English avoid too many medical terms they may not understand.2. Hazards of interviewing THINGS NOT TO DOa. Providing false assurance or reassuranceb. Giving advicec. Leading or biased questionsd. Talking too muche. Interruptingf. Using “why” questions -patient may not know why, this type of questioning may become distressing to the patientPreparatoryMedical/Legal and EthicsEMR Education StandardUses simple knowledge of the EMS system, safety/well-being of the EMR, medical/legal issuesat the scene of an emergency while awaiting a higher level of care.EMR-Level Instructional GuidelineI. ConsentA. Conditions for Consent1. Decision-making capacitya. Intellectual capacityb. Age of majority (18 years old in most States)c. Ability to make decisionsd. May be impaired in cases ofi. intoxication (alcohol/drugs)ii. serious injury or illnessiii. mental incompetenceiv. legal incompetenceB. Expressed1. Patient gives permission for carea. Informed consent you have explained procedures and treatmentsb. Understanding implications of actionsC. Implied1. Inability to consent arising from medical condition ex.unconscious patient2. PediatricsD. Emancipated Minor1. Civil rights obtained by person below age of majority (i.e. marriage)2. Economic self-sufficiency3. Military serviceE. Pediatrics1. Parental control2. Courts assume parental control-if parent is not working in child’s best interestF. Refusal of Care1. Patients with decision-making capacity of legal age have a right to refusecare2. Follow local policies related to refusal of care3. If care is refused, tell the patienta. Treatment that is neededi. why it is neededii. alternative treatmentsb. Risks of refusing carec. That he may call EMS again if he changes his mindd. Follow local protocols related to refusal under supervision of EMR4. Notifya. Responding EMS providersb. Medical direction (if required in your local policies)5. Document the refusal according to local policya. Have patient sign refusal documentationb. Have a witness to patient’s signatureII. ConfidentialityA. Obligation to Protect Patient InformationB. Health Information Portability and Accountability Act (HIPAA)1. Description2. Protected health information (PHI)a. Identifies the patientb. Relates to physical health, mental health, and treatmentc. Can be written or verbal3. Permitted disclosures of PHI without written patient consenta. Treatment, payment, and operationsb. Special situationsi. mandatory reportingii. public healthiii. law enforcement (specific situations only)iv. certain legal situationsIII. Advanced DirectivesA. Do Not Attempt Resuscitation (DNAR) Order1. Terminal disease2. Medical futility (as discussed in the current International LiaisonCommittee on Resuscitation [ILCOR] consensus statement)B. Living Wills1. Advance directives indicating a patient’s wishes2. May not address the EMR in your StateC. Surrogate Decision-Makers1. Durable power of attorney for healthcare2. Healthcare proxy3. Next of kinIV. Types of Court CasesA. Civil (Tort)1. Abandonment-starting care and leaving patien at scene or with unqualified personell2. Negligencea. A failure to follow the standard of care causes or worsens thepatient’s injury or illness. Four elements needed to provei. duty to actii. breach of dutya) definition- failure to perform care needed performing care incorrectlyiii. harm (damage to patient)iv. proximate causation3. AbandonmentB. Criminal1. Assault-threat of harm/injury or treating a patient who is refusing2. Battery-actually causing harm/injury or treating patient after they refuseV. Evidence PreservationA. Emergency medical care of the patient is the EMR’s priorityB. Do not disturb any item at the scene unless emergency medical care requires itC. Observe and document anything unusual at the sceneD. Do not cut through bullet or knife holes in clothingE. Work closely with the appropriate law enforcement authoritiesVI. Statutory ResponsibilitiesA. Scope of Practice1. Definition-procedures, actions, processes that EMR permitted to perform under license 2. Authority to practice (Medical Practice Act as applicable)3. Professional responsibility-to carry out practices4. Duties to patient, medical director, and public5. Government and medical oversighta. Intended to protect the publicb. Role of medical oversighti. on-line medical direction-speaking with medical director for extra ordersii. off-line medical direction-standards and protocolsVII. Mandatory reportingA. Varies by StateB. Follow State requirementsC. Legally Compelled to Notify Authorities1. Abuse or neglect (child, elder, domestic)2. Some infectious diseases3. Certain crimesD. Legal Liability for Failure to Report-actions may be taken against your licenseE. Fully Document Objective FindingsVIII. Ethical PrinciplesA. Defined1. Morals – concept of right and wrong2. Ethics – branch of philosophy or study of morality3. Applied ethics – use of ethical valuesB. Decision-Making Models1. Do no harm2. In good faith3. Patient’s best interestAnatomy and PhysiologyEMR Education StandardUses simple knowledge of the anatomy and function of the upper airway, heart, vessels, blood,lungs, skin, muscles, and bones as the foundation of emergency care.EMR-Level Instructional GuidelineI. Anatomy and Body FunctionsA. Standard Anatomic Terms1. Patient-oriented directions (patient’s left and patient’s right)2. Anterior (front)and posterior (back)3. Midline, medial(towards the middle of body) lateral(towards the sides of the body), inferior (towards the foot of the body), superior (towards the head of the body)4. Pertains to the extremities Distal(furthest away from main stem of the body), proximal (part of the extremity that is closest to the main stem of the body)B. Skeletal System1. Componentsa. Skullb. Facec. Vertebral columnd. Thoraxi. Ribsii. Breastbonee. Pelvisf. Upper extremitiesg. Lower extremities2. JointsC. Muscular System1. FunctionD. Respiratory System1. Upper airwaya. Noseb. Mouth/teethc. Tongue/jawd. Throat/pharynxe. Voice box/larynxf. Epiglottis (flap of tissue that covers trachea-protects it from food and drink accidentally getting into trachea)g. Lower airwayi. trachea/windpipeii. bronchiiii. lungs and bronchiolesiv. alveoli (grapelike structure where gas exchange occurs in the pulmonary capillaries)h. Structures that support ventilationi. chest wallii. diaphragm (muscle separating lung cavities and abdominal cavity)iii. intercostal muscles (between ribs that allow for rib expansion and contraction during respiration)i. Functioni. ventilationii. respirationiii. alveolar/capillary gas exchange2. Circulatory Systema. Hearti. chambers(atrium collect blood and pumps it into ventricles, ventricles pump to (right side to lung tissue) and (left side to body).ii. coronary arteriesb. Blood vesselsi. arteries-go away from the heart- pump harder to get blood and nutrients to bodyii. veins—go towards heart- carries deoxygenated blood back to pick up oxygeniii. capillaries- smallest vessels in body where gas and nutrient exchange occurs.c. Bloodi. red blood cellsii. other blood cellsiii. plasmad. Functioni. blood flowii. tissue/cell gas exchangeiii. blood clotting3. Skina. Structuresi. epidermis outer layerii. dermis second layeriii. subcutaneous layer innermost layerb. Functions of the skini. protectionii. temperature controlII. Life Support ChainA. Fundamental Elements1. Oxygenationa. Alveolar/capillary gas exchangeb. Cell/capillary gas exchange2. Perfusiona. Oxygenb. Glucosec. Removal of carbon dioxide and other waste products3. Cells need oxygen and glucose to make energy so they can perform theirfunctionsB. Issues Impacting Fundamental Elements1. Composition of ambient air (room air) Oxygen 20-21%2. Patency of the airway3. Mechanics of ventilationPage 20 of 1274. Regulation of respiration5. Transport of gases6. Blood volume7. Effectiveness of the heart as a pump8. Blood vessel size and resistanceIII. Age-Related Variations for Pediatrics Body is not as mature as teen or young adult and Geriatrics Body does not function as well as it used to, breaking down more likely to have diseases/illness Page 21 of 127Medical TerminologyEMR Education StandardUses simple medical and anatomical terms.EMR-Level Instructional GuidelineI. Medical TerminologyA. Recognizes Simple Medical Prefixes, Suffixes, and Combining Words Such As1. Cardio- cardiac/heart2. Neuro-nervous3. Hyper- above normal4. Hypo-below normal5. Naso-nasal/nose6. Oro-oral7. Arterio- arteries8. Hemo-blood9. Therm-thermal10. Vaso-vessels11. Tachy- fast12. Brady-slowPage22 of 127PathophysiologyEMR Education StandardUses simple knowledge of shock and respiratory compromise to respond to life threats.EMR-Level Instructional GuidelineI. Respiratory CompromiseA. Impaired Airway, Respiration, or Ventilation1. Airwaya. Movement of oxygenated air into and out of lungs is blockedb. Possible causesi. foreign body airway obstructionii. tongue blocks airway in unconscious patientiii. blood or secretionsiv. swellingv. trauma to the neck2. Respirationa. Inadequate oxygen in air that is breathed inb. Possible causesi. low oxygen environmentii. poison gasesiii. infection of the lungsiv. illness that narrow the airway and cause wheezing (ex. asthma)v. excess fluid in the lungsvi. excess fluid between the lungs and blood vesselsvii. poor circulation3. Ventilationa. Rate or depth of breathing is not adequateb. Insufficient volume of air moved into and out of lungsc. Possible causesi. unconscious or altered level of consciousnessii. injury to the chestiii. poisoning or overdoseiv. diseasesII. ShockA. Impaired Blood Flow to the Organs and Cells1. Hearta. Rate is too slow or very fast both will cause a decrease in blood flow to the tissuesb. Contractions are too weakc. Related to heart disease, poisoning, excessive rate, or depth ofartificial ventilationPage 23 of 1272. Blood vesselsa. Unable to constrictb. Related to neck fractures with spinal cord injury, infection, oranaphylaxis3. Blooda. Decrease in the amount of blood or blood components in the bloodvesselsb. Related to bleeding, vomiting, diarrhea, or burnsPage 24 of 127Life Span DevelopmentEMR Education StandardUses simple knowledge of age-related differences to assess and care for patients.EMR-Level Instructional GuidelineI. Infancy (Birth to 1 Year)A. Physiology1. Vital signsa. Normal heart rate in newborns is between 140 and 160b. Normal respiratory rate in newborns is between 40 and 60 anddrops to 30-40 after first few minutes of lifec. Average systolic blood pressure increases from 70 mmHg at birthto 90 mmHg at 1 year2. Weighta. Normally 3.0-3.5 kg at birth3. Pulmonary systema. Airways are more easily obstructedb. Infants are primarily nose breathers until 4 weeksc. Rapid respiratory rates lead to rapid heat and fluid loss4. Nervous systema. Strong, coordinated suck and gagb. Well flexed extremitiesc. Extremities move equally when infant is stimulatedII. Toddler (12 to 36 Months) and Pre-School Age (3 to 5)A. Physiological1. Vital signsa. Normal heart rate is between 80 and 130 beats per minute intoddlers and between 80 and 120 beats per minute in preschool-agechildrenb. Normal respiratory rate is between 20 and 30 breaths per minute inboth toddlers and preschool-age childrenc. Normal systolic blood pressure is between 70 and 100 mmHg intoddlers and between 80 and 110 mmHg in preschool-age childrend. Normal temperature is between 96.8 and 99.6 degrees Fahrenheit2. Nervous systemIII. School-Age Children (6 to 12)A. Physiological1. Vital signsa. Normal heart rate is between 70 and 110 beats per minuteb. Normal respiratory rate is between 20 and 30 breaths per minutePage 25 of 127c. Normal systolic blood pressure is between 80 and 120 mmHgd. Normal temperature is 98.6 degrees Fahrenheit2. Bodily functionsa. Loss of primary teeth and replacement with permanent teeth beginsIV. Adolescence (13 to18)A. Physiological1. Normal heart rate is between 55 and 105 beats per minute2. Normal respiratory rate is between 12 and 20 breaths per minute3. Normal systolic blood pressure is between 80 and 120 mmHgV. Early Adulthood (20 to 40)A. Physiological same as belowVI. Middle Adulthood (41 to 60)A. Physiological1. Normal heart rates average 70 beats per minute2. Normal respiratory rate average 16 to 20 breaths per minute3. Normal blood pressure average 120/80 mmHg4. Vision and hearing become less effective5. Cardiovascular health becomes a concern6. Cancer strikes in this age group often7. Weight control becomes more difficult8. Menopause in women in late forties and early fiftiesB. Psychological1. Approach problems more as challenges than threats2. Empty-nest syndrome3. Often burdened by financial commitments to elderly parents as well asyoung adult childrenVII. Late Adulthood (61 and Older)A. Physiological1. Normal vital signs are dependant on the patient’s physical and healthstatus2. Cardiovascular function changesa. Circulation efficiency decreasesb. Tachycardia not well toleratedc. Functional blood volume decreases3. Respiratory systema. Chest wall weakensb. Gas exchange through alveoli is diminishedc. Lung capacity is diminishedPage 26 of 127Public HealthEMR Education StandardHas an awareness of local public health resources and the role EMS personnel play in publichealth emergencies.EMR-Level Instructional GuidelineI. Basic Principles of Public HealthA. EMS Interface With Public Health1. EMS is a public health systema. EMS provides a critical public health functionb. Collaborations with other public health agencies2. Roles for EMS in public healtha. Health prevention and promotioni. primary prevention—preventing disease developmenta) vaccinationb) educationii. secondary prevention—preventing the complications and/orprogression of diseaseiii. health screeningsb. Disease surveillancei. EMS providers are first line care giversii. patient care reports may provide information on epidemics of disease3. Injury preventiona. Safety equipmentb. Educationi. car seat safetyii. seat belt useiii. helmet useiv. driving under the influencev. fallsvi. firePage 27 of 127PharmacologyPrinciples of PharmacologyEMR Education StandardUses simple knowledge of the medications that EMR may self-administer or administer to a peerin an emergency.EMR-Level Instructional GuidelineTake note of the statement belowNo knowledge related to the competency is applicable at this level.Page 28 of 127PharmacologyMedication AdministrationEMR Education StandardUses simple knowledge of the medications that EMR may self-administer or administer to a peerin an emergency.EMR-Level Instructional GuidelineI. Self-Administration (Intramuscular Injection by Auto injector)A. Advantages-readily able to administerB. Disadvantages- may not be focused to administerC. Techniques take out of case, uncap, stab into muscle, vacuum action allows medication to dispense out of syringeII. Peer Administration (Intramuscular Injection by Auto injector)A. Advantages readily able to administerB. Disadvantages may not be focused to administerC. Techniques take out of case, uncap, stab into muscle, vacuum action allows medication to dispense out of syringePage 29 of 127PharmacologyEmergency MedicationsEMR Education StandardUses simple knowledge of the medications that EMR may self-administer or administer to a peerin an emergency.EMR-Level Instructional GuidelineThe EMR must know the names, effects, indications, routes of administration, and dosages forall of the following emergency medications.I. Specific Medications (i.e. Chemical Antidote Autoinjector Devices) single dose, life saving drug. Same action as auto injection for epi pen. Administer into thigh or buttocksPage 30 of 127Airway Management, Respiration, and Artificial VentilationAirway ManagementEMR Education StandardApplies knowledge (fundamental depth, foundational breadth) of anatomy and physiology toassure a patent airway, adequate mechanical ventilation, and respiration while awaiting EMSresponse for patients of all ages.EMR-Level Instructional GuidelineI. Airway AnatomyA. Upper Airway Tract1. Nose2. Mouth and oral cavitya. Alternate airway, especially in emergency OPA, NPA, ET Tube(airway tube that requires intubationb. Entrance to the digestive systemc. Also involved in the production of speechd. Tongue3. Jaw4. Throat/pharynxa. Oropharynxb. Epiglottisc. Larynx/voice boxi. vocal cordsii. thyroid cartilage attaches the thyroid gland in front of the larynx/voice boxiii. cricoid cartilageB. Lower Airway Tract1. Trachea/windpipea. Hollow tube which passes air to the lower airwaysb. Supported by cartilage rings2. Bronchia. Hollow tubes which further divide into lower airways of the lungsb. Supported by cartilage3. Lungsa. Bronchiolesi. thin hollow tubes leading to the alveoliii. remain open through smooth muscle toneb. Alveolii. the end of the airwayii. millions of thin walled sacs looks like grapesiii. each alveolus surrounded by capillary blood vesselsiv. site where oxygen and carbon dioxide (waste) areexchangedPage 31 of 127II. Airway AssessmentA. Signs of Adequate Airway1. Airway is open, can hear and feel air move in and out2. Patient is speaking in full sentences3. Sound of the voice is normal for the patientB. Signs of Inadequate Airway1. Unusual sounds are heard with breathing (i.e. stridor or snoring)2. Awake patient is unable to speak or voice sounds hoarse3. No air movement4. Apnea5. Airway obstructiona. Tongue partial obstructionb. Foodc. Vomitd. Bloode. Teethf. Foreign bodyC. Swelling Due to Trauma or InfectionIII. Techniques of Assuring a Patent Airway (refer to current American Heart Associationguidelines)A. Manual Airway Maneuvers1. Head tilt/chin lifta. Purpose-open airwayb. Indications-patient not breathing- checking for patient respiration, administer respirationsc. Contraindications- spinal cord injuriesd. Complications- trauma to mouth/nse/tracheae. Procedure edge of palm on patient’s forehead, tilt back while lifting the chin along the jaw bonef. Limitation2. Jaw thrust maneuver keeping spinal cord in a neutral position, use thumbs to jut jaw bone forwarda. To open airway when cervical spine injury is suspectedb. Procedure use thumbs to jut jaw bone forwardc. If airway is not open and jaw thrust maneuver does not open it, usehead tilt/chin lift maneuver3. Modified chin lifta. Purposeb. Indicationsc. Contraindicationsd. Complicationse. Proceduref. LimitationB. Mechanical Airway Devices1. Oropharyngeala. Purpose air passage opening through the mouthb. Indications helps to allow air flow, keeping tongue from blocking airwayc. Contraindications-patient is becoming consciousd. Complicationse. Procedure measure OPA from edge of lips to the angle of the jaw, insert turned up or sideways, as it is inserted, twist the OPA to turn it down towards pharynx f. Limitation mouth/ pharynx injury. Once patient becomes conscious, patient will start gaging.C. Relief of Foreign Body Airway ObstructionD. Upper Airway Suctioning1. Purpose clear airway of fluid and small particles2. Indications unconscious patients/semi conscious who is vomiting3. Contraindications mouth trauma4. Complications5. Procedurea. mechanically powered suction devicesi. purpose clear airway of fluid and small particlesii. indication unconscious patients/semi- conscious who is vomitingiii. contraindications mouth traumaiv. complicationsv. procedure attach tubing, turn machine on, test for suction by putting your thumb over valve hole, put tube into patient’s mouth rotating tube around mouth while placing finger over the opening to allow for suction. Do not suction for 5-10 seconds- no more than15 seconds maximum.vi. limitationb. hand-powered suctioni. purpose clear airway of fluid and small particlesii. indication- battery operated is not available, unconscious patients/semi conscious who is vomitingiii. contraindications mouth traumaiv. complicationsv. procedure attach tubing, turn machine on, test for suction by putting your thumb over valve hole, put tube into patient’s mouth rotating tube around mouth while placing finger over the opening to allow for suction. Do not suction for 5-10 seconds- no more than15 seconds maximum.vi. limitation takes slightly longer because you have to pump it manually6. LimitationIV. Consider Age-Related Variations in Pediatric and Geriatric PatientsPage 33 of 127Airway Management, Respiration, and Artificial VentilationRespirationEMR Education StandardApplies knowledge (fundamental depth, foundational breadth) of anatomy and physiology toassure a patent airway, adequate mechanical ventilation, and respiration while awaiting EMSresponse for patients of all ages.EMR-Level Instructional GuidelineI. Anatomy of the Respiratory SystemA. Includes All Airway Anatomy Covered in the Airway Management SectionB. Additional Respiratory System Anatomy1. Chest cage (includes ribs and muscles)a. Intercostal musclesb. DiaphragmC. Vascular Structures That Support Respiration1. Pulmonary capillariesa. Picks up oxygen from the alveolib. Releases carbon dioxide (waste) to the alveoli2. Heart and blood vesselsa. Circulates unoxygenated blood to lungs to pick up oxygenb. Circulates oxygenated blood from lungs though heart to cells of thebodyII. Physiology of RespirationA. Pulmonary Ventilation1. Ventilation is defined as the movement of air into and out of the lungs2. Patients with adequate ventilation are moving normal or near-normalvolumes of air into and out of the lungsB. Oxygenation1. Refers to the amount of oxygen dissolved in blood and body fluids2. Blood that is almost fully saturated with oxygen might be described aswell-oxygenated bloodC. Respiration1. The process by which the body captures and uses oxygen and disposes ofcarbon dioxide2. External respiration3. Internal respiration4. Cellular respirationa. Each cell of the body performs a specific functionPage 34 of 127b. Oxygen and sugar are essential to produce energy for cells toperform their functionc. Produce carbon dioxide as a waste productIII. Pathophysiology of RespirationA. Pulmonary Ventilation1. Interruption of nervous control Causesa. Drugsb. Traumac. Muscular dystrophy2. Structural damage to the thorax3. Bronchoconstriction4. Disruption of airway patencya. Infectionb. Trauma/burnsc. Foreign body obstructiond. Allergic reactionse. Unconsciousness (loss of muscle tone)B. OxygenationC. Respiration1. External respirationa. Deficiencies due to closed environmentsb. Deficiencies due to toxic or poisonous environments2. Internal respiration3. Cellular respirationa. Ineffective Circulation Causesi. shockii. cardiac arrestIV. Assessment of Adequate and Inadequate Respiration (refer to current American HeartAssociation Guidelines)A. Unresponsive Patient1. Medical patientsa. Open and maintain the airway using head-tilt, chin-lift technique2. Trauma patientsa. Open and maintain the airway using modified jaw thrust techniquewhile maintaining manual cervical stabilizationB. Responsive Patient1. If the patient speaks, the airway is functional but may still be at riska. Foreign body or substances in the mouth may impair the airwayand must be removedi. finger sweep (solid objects)ii. suction (liquids)2. If the upper airway becomes narrowed, inspiration may produce a highpitchedwhistling sound known as stridora. Foreign bodyPage 35 of 127b. Swellingc. Trauma3. Airway patency must be continually reassessed4. Breathing statusa. Normal adult breathingb. Abnormal adult breathingi. characteristicsa) the respiratory rate is too fast or too slow for the ageof the patientii. managementa) administer oxygen to all patients with abnormal breathingb) consider assisting breathing with a bag-mask with supplemental oxygen ifi) unresponsiveii) skin is blue (cyanotic) in colorc) rate issuesi) breathing is too fast for the age of the patientii) breathing is too slow for the age of the patient(a) does verbal or painful stimulusincrease the rate to normal?(b) assist breathing with a bag-maskwith supplemental oxygen(c) treat patients who are occasionallygasping as if they were not breathing at alliii) breathing is absentiv) assist ventilation with a pocket mask or bagmask with supplemental oxygeniii. chest rise and fall is shallowiv. breathing is noisya) gurgling noise without secretions in the mouthb) wheezingv. effort of breathinga) accessory muscles using all or some of these to help breathei) neckii) between ribsiii) abdomenb) nasal flaringc) tripod positionV. Management of Adequate and Inadequate RespirationA. Assure Patent Airway (techniques described in Airway Management section)B. Techniques for Assuring Adequate RespirationsPage 36 of 127VI. Supplemental Oxygen TherapyA. Portable Oxygen Cylinder1. Cylinder sizea. D – 350 litersb. E – 625 liters2. Regulators3. Assembly and use of cylinders4. Changing a cylindera. Safe residual for operation is 200 psi5. Securing and handling cylindersB. Oxygen Delivery Devices1. Nasal cannulaa. Purpose-low flow oxygenb. Indications minor injury, anxious patient or if patient cannot tolerate the non -rebreather maskc. Procedure attach to flowmeter , place prongs in patients nose and loop tubing around patient’s ear (not neck)d. Limitation only can be dialed up to 6 liters, more oxygen is needed if patient is in more distress/ major trauma, patient must be breathing adequately on their own.2. Non-Rebreather (NRB) Maska. Purpose deliver high flow oxygenb. Indications- chest pain/ respiratory distress etc.c. Procedure- place on flowmeter of oxygen tank, turn flowmeter to between 10-15 liters per min. , fill reservoir ? by placing finger over one way valve , then place mask on patient’s face and secure with strapd. Limitation- patient must be breathing adequately on their own.VII. Consider Age-Related Variations in Pediatric and Geriatric PatientsPage 37 of 127Airway Management, Respiration, and Artificial VentilationArtificial VentilationEMR Education StandardApplies knowledge (fundamental depth, foundational breadth) of anatomy and physiology toassure a patent airway, adequate mechanical ventilation, and respiration while awaiting EMSresponse for patients of all ages.EMR-Level Instructional GuidelineI. Assessment of Adequate and Inadequate VentilationA. Adequate1. Respiratory rate is normal2. Respiration depth is normal3. Effort of breathing is normalB. Inadequate1. Abnormal work (effort) of breathinga. Muscles between ribs pull in on inhalationb. Nasal flaringc. Excessive use of abdominal muscles to breathd. Sweatinge. Sitting upright and leaning forward (tripod position)f. Fatigue from work of breathing2. Abnormal breathing soundsa. Stridorb. Wheezing heard when patient breathes3. Depth of breathinga. Shallowb. Markedly increased4. Rate of breathinga. Very slowb. Very fast5. Chest wall movement or damagea. Paradoxical flailing chest movements (broken ribs) segment will move opposite of the rest of rib cage.b. Splinting patient holding chest area due to painc. Penetrating (knife, gun)d. Asymmetric one side moves in or out unevenly to the opposite side6. Irregular respiratory patternII. OxygenationA. Adequate1. Mental status considered normal for patient2. Skin color normalPage 38 of 127B. Inadequate1. Ambient air (room air) is abnormala. Enclosed spaceb. High altitudec. Poison gas2. Mental status considered abnormal or altered for patient3. Skin color/mucosa is not normala. Cyanosis condition of being blueb. Pallor pale/ with out colorc. Mottling bluish with marble/ purpleIII. Management of Adequate and Inadequate VentilationA. Patients With Adequate VentilationB. Patients With Inadequate Ventilation1. May be conscious or unconscious2. EMR must assist ventilation during respiratory distress/failurea. Pocket maski. purpose to oxygenate patient that is viable with lifeii. indications Shallow breathing, bradypnea (slow breathing) apnea (no breaths), dyspnea (difficulty breathing)iii. procedure- Open airway (head tilt chin lift, jaw thrust) create E-C seal on appropriately sized mask, breathe into mask. Watch for patient chest rise and fall. 2 breaths after every 30 chest compressions or if patient has a pulse and is not taking adequate breaths- breath into mask as patient is taking a breath to assist their respirations.iv. limitation- facial/mouth damage, large amounts of secretions in mouth (you will need to suction)v. pocket mask with oxygen outleta) advantages-adds oxygen to the breaths being deliveredb) oxygen flow rate-15 liters per minute (flow meter)b. Bag-valve-mask with reservoiri. purpose to oxygenate patient that is viable with lifeii. indications Shallow breathing , bradypnea (slow breathing) apnea (no breaths), dyspnea (difficulty breathing)iii. procedure Use BVM connected to Oxygen, create E-C seal on appropriately sized mask, squeeze bag every five seconds( allowing the BVM to re-inflate) Watch for patient chest rise and fall. iv. limitation- facial/mouth damage, large amounts of secretions in mouth (you will need to suction)v. indicationsa) apnea(no breaths)b) cardiac arrest- patient would have apnea, see above for others indicationsvi. procedurea) see manufacturer’s instructions for the specificdeviceb) explain the procedure to the patientc) place the mask over the patient’s nose and mouthd) initially assist at the rate at which the patient hasbeen breathinge) squeeze the bag each time the patient begins toinhalef) adjust the rate and the delivered tidal volumevii. limitationsa) requires oxygenb) difficult to maintain adequate mask seal with one rescueroperationPage 39 of 127c) must have bag-valve-mask device availabled) may interfere with timing of chest compressionsduring CPRe) must monitor to assure full exhalationf) inadequate mask sealg) difficult to accomplish in combative/hypoxicpatientsc. Sellick’s maneuver (cricoid pressure)i. use during positive pressure ventilationii. reduces amount of air in stomachiii. procedurea) identify cricoid cartilageb) apply firm backward pressure to cricoid cartilagewith thumb and index fingeriv. do not use ifa) patient is vomiting or starts to vomitb) patient is responsivec) breathing tube has been placed by advanced levelprovidersIV. Ventilation of an Apneic PatientA. To Oxygenate and Ventilate the PatientB. Indications1. No breathing is noted2. Occasional gasping breathing is notedC. Monitoring PatientD. Limitation See above limitations for the BVM(bag-valve-mask)V. Differentiate Normal Ventilation From Positive Pressure VentilationA. Air Movement1. Normal ventilationa. Creates negative pressure inside the chestb. Air is sucked into lungs2. Positive pressure ventilation with pocket mask or bag-mask-air is under pressure by a mechanical device, designed to improve the exchange of air between lungs and atmosphere. It delivers artificial respiration with their breath and inbetween their breaths. Ex. CPAP machineB. Blood Movement1. Normal ventilationa. Blood returns to the heart from the bodyb. Blood is pulled back to the heart during normal breathing2. Positive pressure ventilationa. Blood return to the heart is decreased when lungs are inflatedb. Less blood is available for the heart to pumpc. Amount of blood pumped out of the heart is reducedC. Esophageal Opening Pressure1. Normal ventilationa. Esophagus remains closed during normal breathingb. No air enters the stomachPage 40 of 1272. Positive pressure ventilation with a pocket mask or bag-maska. Air is pushed into the stomach during ventilationb. Excess air in stomach may lead to vomitingD. Excess Rate or Depth of Ventilation Using Pocket Mask or Bag-Mask Can Harmthe Patient as ventilating too fast or too deep may cause low blood pressure,vomiting, or decreased blood flow when the chest is compressed during CPRVI. Consider Age-Related Variations in Pediatric and Geriatric PatientsPage 41 of 127Patient AssessmentScene Size-UpEMR Education StandardUse scene information and simple patient assessment findings to identify and manage immediatelife threats and injuries within the scope of practice of the EMR.EMR-Level Instructional GuidelineI. Scene SafetyA. Common Scene Hazards1. Environmental2. Hazardous substancesa. Chemicalb. Biological3. Violencea. Patientb. Bystandersc. Crime scenes4. Rescuea. Motor-vehicle collisionsi. extrication hazardsii. roadway operation dangersb. Special situationsB. Evaluation of the Scene1. Is the scene safe?a. Yes -- establish patient contact and proceed with patientassessment.b. No -- is it possible to quickly make the scene safe?i. Yes – assess patientii. No -- do not enter any unsafe scene until minimizinghazardsc. Request specialized resources immediatelyII. Scene ManagementA. Impact of the Environment on Patient Care1. Medicala. Determine nature of illnessb. Hazards at medical emergencies2. Traumaa. Determine mechanism of injuryb. Hazards at the trauma scenePage 42 of 1273. Environmental considerationsa. Weather or extreme temperaturesb. Toxins and gasesc. Secondary collapse and fallsd. Unstable conditionsB. Addressing Hazards1. Protect the patienta. After making the scene safe for the EMR, the safety of the patientbecomes the next priorityb. If the EMR cannot alleviate the conditions that represent a healthor safety threat to the patient, move the patient to a saferenvironment2. Protect the bystandersa. Minimize conditions that represent a hazard for bystandersb. If the EMR cannot minimize the hazards, remove the bystandersfrom the scene3. Request resourcesa. Multiple patients need additional ambulancesb. Fire hazard need fire departmentc. Traffic or violence issues need law enforcement4. Scan the scene for information related toa. Mechanism of injuryb. Nature of the illnessC. Violence1. EMRs should not enter a scene or approach a patient if the threat ofviolence exits2. Park away from the scene and wait for the appropriate law enforcementofficials to minimize the dangerD. Need for Additional or Specialized Resources1. A variety of specialized protective equipment and gear is available forspecialized situationsa. Chemical and biological suits can provide protection againsthazardous materials and biological threats of varying degreesb. Specialized rescue equipment may be necessary for difficult orcomplicated extricationsc. Ascent or descent gear may be necessary for specialized rescuesituations2. Only specially trained responders should wear or use the specializedequipmentE. Standard Precautions1. Overviewa. Based on the principle that all blood, body fluids, secretions,excretions (except sweat), non-intact skin, and mucous membranesmay contain transmissible infectious agentsPage 43 of 127b. Includes a group of infection prevention practices that apply to allpatients, regardless of suspected or confirmed infection status, inany healthcare delivery settingc. Universal precautions were developed for protection of healthcarepersonneld. Standard precautions focus on protection of patients and healthcare professional2. Implementationa. The extent of standard precautions used is determined by theanticipated blood, body fluid, or pathogen exposurei. hand washingii. glovesiii. gownsiv. masksv. protective eyewear3. Personal protective equipmenta. Personal protective equipment includes clothing or specializedequipment that provides some protection to the wearer fromsubstances that may pose a health or safety riskb. Wear PPE appropriate for the potential hazardi. steel-toe bootsii. helmetsiii. heat-resistant outerweariv. self-contained breathing apparatusv. leather glovesPage 44 of 127Patient AssessmentPrimary AssessmentEMR Education StandardUse scene information and simple patient assessment findings to identify and manage immediatelife threats and injuries within the scope of practice of the EMR.EMR-Level Instructional GuidelineI. Primary Survey/Primary AssessmentA. The Primary Survey Quickly Attempts to Identify Those Conditions ThatRepresent an Immediate Threat to the Patient’s LifeB. Level of Consciousness1. While approaching the patient or immediately upon patient contact,attempt to establish level of consciousnessa. Speak to the patient and determine the level of responseb. EMR should identify himself or herselfc. EMR should explain that he or she is there to help2. Patient response (AVPU)a. Alerti. the patient appears to be awakeii. the patient acknowledges the presence of the EMRb. Responds to verbal stimulii. the patient opens his/her eyes in respond to the EMR’svoiceii. the patient responds appropriately to a simple commandc. Responds to painful stimulii. the patient neither acknowledges the presence of the EMRnor responds to loud voiceii. patient responds only when the EMR applies some form ofirritating stimulusa) pinch the patient’s earb) trapezius squeezec) others-sternal rubd. Unresponsive (patient does not respond to any stimulus)C. Airway Status (refer to the current American Heart Association Guidelines)1. Unresponsive medical patient open and maintain the airway with head-tilt,chin-lift technique2. Unresponsive trauma patient open and maintain the airway with modifiedjaw thrust technique while maintaining manual cervical stabilization3. Responsive patienta. Foreign body or substances in the mouth may impair the airwayand must be removedPage 45 of 127i. finger sweep (solid objects)ii. suction (liquids)b. If the upper airway becomes narrowed, inspiration may produce ahigh-pitched whistling sound known as stridori. foreign bodyii. swellingiii. traumac. Airway patency must be continually reassessedD. Breathing Status1. Normal adult breathinga. Characteristicsi. the respiratory rate will not be too fast or too slowii. breathing will produce a visible chest rise and falliii. breathing will be quietiv. the adult will not be expending much energy to breathb. Continue maintaining airway, if needed2. Abnormal adult breathinga. Characteristics noisy, irregular, too shallow, too deepb. Managementi. administer oxygen to all patients with abnormal breathingii. consider assisting breathing with a bag-mask withsupplemental oxygen ifa) unresponsiveb) skin is blue (cyanotic) in coloriii. rate issuesa) breathing is too fast for the age of the patientb) breathing is too slow for the age of the patienti) does verbal or painful stimulus increase the rate to normal?ii) assist breathing with a bag-mask with supplemental oxygeniii) treat patients who are occasionally gasping as if they were not breathing at allc) breathing is absentd) assist ventilation with a pocket mask or bag-mask with supplemental oxygenc. Chest rise and fall is shallowd. Breathing is noisyi. gurgling noise without secretions in the mouthii. wheezinge. Effort of breathingi. accessory musclesa) neckb) between ribsc) abdomenii. nasal flaringiii. tripod positionPage 46 of 127E. Circulatory Status1. Is a radial pulse present?a. Yesi. normalii. adult heart rate 60-100/miniii. fastiv. adult heart rate greater than 100/minv. slowvi. adult heart rate less than 60/minvii. irregular pulseviii. may be normal or abnormalb. No radial pulse – assess for carotid pulsei. if carotid pulse present,ii. lay patient flat and elevate feet 8-12 inchesiii. no carotid pulse,iv. begin CPR2. Is any major bleeding present?a. Yes –b. control the bleedingc. No3. Is the patient maintaining adequate blood flowa. Skin colori. pinkii. assess palms of hands in dark-skinned patientsiii. pale skin may indicatea) low body temperatureb) blood lossc) shock (poor blood flow)d) poor blood flow to a body partiv. blue (cyanotic skin) may indicatea) problem with airway, ventilation, respirationb) poor blood flowb. Skin temperaturei. cool skin may indicatea) low body temperatureb) shockc. Skin moisturei. dry or slightly moistii. wet or sweaty skin may indicatea) physical exertionb) severe painc) shockd. Capillary refill (children)i. press on the skin and releaseii. color should return to area depressed within two secondsiii. color return in more than two seconds may indicate shockPage 47 of 1274. Treat for shock in primary survey ifa. Unresponsive to verbalb. Heart rate too fast or too slowc. Skin signs of shock are present5. Management of shocka. Administer oxygen by non-rebreather mask at 15 liters per minute(if available)b. Lay patient flatF. Identifying Life Threats1. Assess patient and determine if the patient has a life-threatening conditiona. Unstable: treat life-threatening conditions as soon as they arediscoveredb. Stable: assess nature of illness or mechanism of injuryG. Assessment of Vital FunctionsII. Begin Interventions Needed to Preserve LifePage 48 of 127Patient AssessmentHistory-TakingEMR Education StandardUse scene information and simple patient assessment findings to identify and manage immediatelife threats and injuries within the scope of practice of the EMR.EMR-Level Instructional GuidelineI. Determining the Chief ComplaintA. The Chief Complaint Is a Very Brief Description of the Reason for SummoningEMS to the Scene1. In the best of circumstances, the patient will be able to answer allquestions about his or her own chief complaint and medical history2. In other cases, this information may be obtained froma. Familyb. Friendsc. Bystanderd. Public safety personnele. Medical identification jewelry or other medical informationsourcesII. Mechanism of Injury or Nature of IllnessA. Mechanism of Injury1. Forces that caused an injury2. May help predict presence of injuriesB. Nature of Illness1. Ask patient, family, or bystanders why EMS was called2. Look for clues in environmenta. Hot or cold environmentb. Presence of drugs or poisonsIII. Associated Signs and SymptomsA. Ask the Patient to Describe the Current Problem1. Sign – any medical or trauma assessment finding that can be seen, felt, orheard by the EMRa. Listening to blood pressureb. Seeing an open woundc. Feeling skin temperature2. Symptom – any medical or trauma condition that is described to the EMRby the patienta. “I’m having trouble breathing”Page 49 of 127b. “I have a headache”c. “My chest hurts”B. Events Leading to the Illness or InjuryIV. Age-Related Variations for Pediatric and Geriatric Assessment and ManagementA. Pediatric1. Assess infant pulse at brachial artery2. Capillary refill is a reliable assessment of adequate blood flow in infantsand children six and younger3. Use distracting measures to gain trust4. See Special Patient Population section (Pediatrics)B. Geriatric1. Obtain eye glasses and hearing aids2. Expect history to take more time3. See Special Patient Population section (Geriatrics)Page 50 of 127Patient AssessmentSecondary AssessmentEMR Education StandardUse scene information and simple patient assessment findings to identify and manage immediatelife threats and injuries within the scope of practice of the EMR.EMR-Level Instructional GuidelineI. Performing a Rapid Full-Body ScanA. General Approach to the Secondary Assessment1. Examine the patient systematically2. Place special emphasis on areas suggested by the chief complaint3. Many patients view a physical exam with apprehension and anxiety—theyfeel vulnerable and exposeda. Maintain professionalism throughout the physical examb. Display compassion towards your patient and family membersII. Focused Assessment of PainA. The EMR Should Complete a Secondary Assessment on All Patients Followingthe Primary AssessmentB. Exam May Focus on Specific Area Based on Patient Complaint (i.e. injury orillness)C. As the EMR Discovers Specific Signs and Symptoms, There May Be SpecificRelevant Questions That the EMR Should Ask. This Material Is Described inSpecific Lessons in the Medical and Trauma SectionsD. Perform a Physical Examination to Gather Additional Information1. Compare one side of the body to the other2. Inspect (look) and palpate (feel) for the following signs of injurya. Deformitiesb. Contusionsc. Abrasionsd. Penetratinge. Burnsf. Tendernessg. Lacerationsh. Swelling3. Briefly assess the body from head to toea. Headi. facial symmetryii. drainage or bleedinga) noseb) earsiii. objects or swelling in moutha) vomit, bloodb) teethPage 51 of 127b. Necki. stomaii. open woundsiii. accessory muscles of breathingc. Chesti. rise and fallii. effort of breathingiii. accessory muscles of breathingiv. open woundsv. symmetryd. Abdomeni. painii. scarsiii. protruding organs (evisceration-organ outside of body)iv. pregnancye. Pelvisf. All four extremitiesi. symmetryii. circulationa) pulsesb) colorc) capillary refilliii. sensationiv. movement4. Immediately treat life-threatening problems found in secondary surveyIII. Assessment of Vital SignsA. Obtain a Complete Set of Vital Signs After Managing Life-Threatening ProblemsFound in Primary SurveyB. Vital Signs Provide a Starting Point for Judging the Effectiveness of PrehospitalTherapy.1. Respiratory rate2. Pulsea. Rate - calculation methodb. Rhythmc. Strengthd. Locationi. common locationsii. relationship of pulse to perfusion3. Blood pressurea. Measures force of blood against the walls of the arteryb. Reported as systolic blood pressure over diastolic blood pressure inmmHgi. systolic blood pressurea) force exerted against the arteries when the heart iscontractingPage 52 of 127b) normal adult systolic blood pressure 100-120ii. diastolic blood pressurea) force exerted against the arteries when the heart isbetween contractionsb) normal adult diastolic blood pressure 60-80c. Techniquei. equipmenta) blood pressure cuff sizesb) stethoscopeii. positioninga) position of the patient resting, may be sitting or laying down b) position of the arm resting on a surface with antecubital space facing upiii. measurementa) auscultation- listening with stethoscopeb) palpation- feeling radial while using a b/p cuff(sphygmomanometer) d. Relationship of blood pressure to perfusion lower B/P the lower the perfusion. Too high of B/P can also lower perfusion.IV. Special Considerations for Pediatric and Geriatric PatientsA. Normal Vital Signs by AgeB. See Special Patient Populations SectionPage 53 of 127Patient AssessmentMonitoring DevicesEMR Education StandardNo standard exists at this level for this information.EMR-Level Instructional GuidelinePage 54 of 127Patient AssessmentReassessmentEMR Education StandardUse scene information and simple patient assessment findings to identify and manage immediatelife threats and injuries within the scope of practice of the EMR.EMR-Level Instructional GuidelineI. How and When to ReassessA. Identify and Treat Changes in the Patient’s Condition in a Timely Manner1. Monitor the patient’s condition2. Monitor the effectiveness of interventionsB. Reassess at Regular Intervals1. Unstable patient every 5 minutes, but more often if indicated by patientcondition2. Stable patient every 15 minutes or as deemed appropriate by the patient’sconditionC. Reassessment includes1. Primary assessment2. Vital signs3. Chief complaint4. InterventionsD. Compare to the Baseline Status of That Assessment Component1. Level of consciousness2. Airway3. Breathinga. Reassess the adequacy of breathingb. Monitor breathing rate, depth, and effort4. Circulation adequacya. Checking both carotid and radial pulsesb. Skin color, temperature, and moistureE. Vital Signs1. Repeat vital signs as necessarya. Blood pressure, pulse, and respirationF. Chief Complaint1. Constantly reassess the patient’s chief complaint or major injury(s)a. Pain remains the sameb. Pain getting worsec. Pain getting better2. Ask if there are new or previously undisclosed complaintsPage 55 of 127G. Interventions1. Reassess the effectiveness of each intervention performed2. Consider the need for new interventions or modifications to care alreadybeing providedII. Age-Related Considerations for Pediatric and Geriatric AssessmentPage 56 of 127MedicineMedical OverviewEMR Education StandardRecognizes and manages life threats based on assessment findings of a patient with a medicalemergency while awaiting additional emergency response.EMR-Level Instructional GuidelineI. Overview of Medical ComplaintsA. Assessment1. Follow a systematic assessment approacha. Scene size-upb. Primary assessmentc. History-takingd. Secondary assessmente. ReassessmentB. Manage life-threatening problems as they are discoveredPage 57 of 127MedicineNeurologyEMR Education StandardRecognizes and manages life threats based on assessment findings of a patient with a medicalemergency while awaiting additional emergency response.EMR-Level Instructional GuidelineI. Review of Anatomy and Functions of the Brain, Spinal Cord, and Cerebral Blood VesselsII. Altered Mental Status (can be caused by the following)A. Inadequate oxygenation or ventilationB. Poisoning or overdoseC. InfectionD. Head injuryE. Behavioral illnessF. Diabetic conditionsIII. SeizuresA. Causes -injury, high fever, electrical conduction disturbance to brain tissue, diseases (epilepsy, mitochondrial disorder, brain tumor, etc.)B. Assessment Findings1. Spasms, muscle contractions2. Bite tongue, increased secretions3. Sweating4. Cyanosis5. Unconscious gradually increasing level of consciousness6. Shaking or tremors and no loss of consciousness7. Incontinent-loss of control of bladder sphincter and rectal sphincter8. Amnesia of event- patient does not remember the event but may remember the time preceding the seizure (how they felt of what the smelled or heard)C. Management1. Safety of patient/position-recovery position- left side lying2. ABCs, consider nasopharyngeal airway3. Oxygen/suction4. Assist ventilation if indicated5. Emotional supportIV. StrokeA. Causes1. Hemorrhage2. ClotB. Assessment Findings and Symptoms1. Confused, dizzy, weakPage 58 of 1272. Decreasing or increasing level of consciousness3. Combative, uncooperative, or restless4. Facial droop, inability to swallow, tongue deviation5. Double vision or blurred vision6. Difficulty speaking or absence of speech7. Decreased or absent movement of one or more extremities8. Headache9. Decreased or absent sensation in one or more extremities or other areas ofbody10. ComaC. Management of Patient With Stroke Assessment Findings or Symptoms1. Scene safety and PPE2. ABCs/position3. Oxygen/suction4. Emotional supportPage 59 of 127MedicineAbdominal and Gastrointestinal DisordersEMR Education StandardRecognizes and manages life threats based on assessment findings of a patient with a medicalemergency while awaiting additional emergency response.EMR-Level Instructional GuidelineI. Define Acute Abdomen-sudden or severe abdominal pain is a medical emergencyII. Organs of the Abdominopelvic CavityA. StomachB. IntestinesC. EsophagusD. SpleenE. Urinary bladderF. LiverG. Gall bladderH. PancreasI. KidneysJ. Reproductive organsIII. Assessment and SymptomsA. Techniques1. Inspection2. PalpationB. Normal findings1. Soft2. Non-tenderC. Abnormal findings1. Nausea, vomiting, diarrheaa. Excessiveb. Blood in emesis or stool2. Pain3. Signs of shock4. FeverIV. General Management for Patients With Abdominal PainA. Scene safety and PPEB. Airway, ventilatory, and circulationC. Position of comfortD. Emotional supportPage 60 of 127V. Specific Acute Abdominal ConditionsA. Gastrointestinal Bleeding1. Causes- appendicitis , peptic ulcer, pancreatitis, diverticulitis, pyelonephritis, ruptured spleen, kidney stone, sickle cell anemia, etc. 2. Assessment findings and symptomsa. Bloody vomit (color is red or looks like coffee grounds)b. Blood in stool (color is red or black)c. Signs of shock3. Managementa. Standard precautionsb. Airway –c. suction if neededd. Oxygenation/ventilationi. administer oxygenii. assist with ventilation if indicatede. PositionVI. Consider Age-Related Variations for Pediatric and Geriatric Assessment andManagementA. Pediatrics -- vomiting/diarrhea can cause shockB. Geriatric -- abdominal pain may be related to heart attackPage 61 of 127MedicineImmunology -Immune System EMR Education StandardRecognizes and manages life threats based on assessment findings of a patient with a medicalemergency while awaiting additional emergency response.EMR-Level Instructional GuidelineI. IntroductionA. Anaphylaxis Definition (Allergy- reaction to a substance that is usually harmless versus anaphylaxis-severe allergic reaction that may be a life threat)B. Common Substances That Cause Anaphylaxis (peanuts, shellfish, etc.)II. Assessment FindingsA. Respiratory system -- severe respiratory distress, wheezingB. Cardiovascular -- rapid pulse, low blood pressureC. Skin -- pale, red, or cyanotic; hives, itching, swelling around eyes, mouth, tongueD. Other -- altered mental status, nausea, vomitingIII. ManagementA. Maintain AirwayB. Administer Oxygen high flow.C. Position usually of comfortD. VitalsE. Remove Allergen If PossibleF. Ask If Patient Has Used His/Her Epinephrine Auto injectorIV. Consider Age-Related Variations for Pediatric and Geriatric Assessment andManagementPage 62 of 127MedicineInfectious DiseasesEMR Education StandardRecognizes and manages life threats based on assessment findings of a patient with a medicalemergency while awaiting additional emergency response.EMR-Level Instructional GuidelineI. Infectious Disease AwarenessA. Definitions1. Infectious disease-easily spread throughout population2. Communicable disease-easily spread throughout populationB. Transmission Routes1. Direct contact -touching the person or their body fluids.2. Airborne/ Droplets- Coughing and sneezing3. Blood borne4. Other body fluids5. Indirect- touching a contaminated object (toys, clothing, silverware, etc.)6. Vector- passed on by insects.7. Foodborne C. Standard Precautions (Review content in Preparatory: Workforce Safety)II. Equipment Decontamination (Review Content in Preparatory: Workforce Safety)Page 63 of 127MedicineEndocrine DisordersEMR Education StandardRecognizes and manages life threats based on assessment findings of a patient with a medicalemergency while awaiting additional emergency response.EMR-Level Instructional GuidelineI. Diabetic ConditionsA. Introduction1. Definition of termsa. Diabetesb. Low blood glucosec. High blood glucose2. Role of glucose – fuel for body cells to produce energy3. High blood glucosea. History and Assessment findingsi. Onset—slow changes in mental statusii. Rapid breathing, sweet smell on breathiii. Dehydration, skin pale, warm and dryiv. Weakness, nausea, and vomitingv. Weak and rapid pulsevi. Increased urination, appetite, thirstvii. Medical alert identificationb. Managementi. ABCsii. positioniii. oxygeniv. emotional support4. Low blood glucosea. History and assessment findingsi. onset—rapid changes in mental statusii. bizarre behavior, tremors, shakingiii. sweating, hungeriv. rapid full pulse, rapid shallow respirationsv. seizures, coma- late stagevi. medical identification jewelry or informationb. Managementi. ABCsii. oxygenc. Emotional supportPage 64 of 127II. Age-Related Variations for Pediatric and Geriatric Assessment and ManagementA. Pediatrics – seizuresB. Geriatrics -- strokesPage 65 of 127MedicinePsychiatricEMR Education StandardRecognizes and manages life threats based on assessment findings of a patient with a medicalemergency while awaiting additional emergency response.EMR-Level Instructional GuidelineI. Define- relating to mental illness or its treatmentII. AssessmentA. General AppearanceB. SpeechC. SkinD. Posture/GaitE. Mental StatusF. Mood, Thought, Perception, Judgment, Memory, and AttentionIII. Behavioral ChangeA. Factors That May Alter a Patient’s Behavior—May Include Situational Stresses,Medical Illnesses, History, Psychiatric Problems, Alcohol or Drugs, Patient NotTaking Psychiatric MedicationB. Common Causes of Behavioral Alteration1. Low blood sugar2. Lack of oxygen3. Shock4. Head trauma5. Mind altering substances6. Psychiatric7. Excessive cold8. Excessive heat9. Brain infection10. Seizure disorders11. Poisoning or overdose12. Withdrawal from drugs or alcoholC. Behavioral Emergencies That Can Be a Danger to the EMR, Patient or Others1. Agitation2. Bizarre thinking and behavior (i.e. hallucinations, paranoia)3. Danger to self—self-destructive behavior, suicide attempt4. Danger to others—threatening behavior, violence, weaponsD. Assessment for Suicide Risk1. DepressionPage 66 of 1272. Risk factors/signs or symptomsa. Has the patient said or done anything that would indicate thepossible risk of suicide or violence to self or others?b. Certain cultural and religious beliefs3. Important questionsa. How does the patient feel?b. Are you thinking about hurting or killing yourself or anyone else?c. Is patient a threat to self or others?d. Is there a medical problem?e. Is there trauma involved?f. Does the patient have any weapons on self or in purse?g. Interventions?IV. Methods to Calm Behavioral Emergency PatientsA. Acknowledge That the Person Seems Upset. Restate That You Are There to HelpB. Inform the Patient About What You Are DoingC. Ask Questions in a Calm, Reassuring VoiceD. Maintain a Comfortable DistanceE. Encourage the Patient to State What Is Troubling HimF. Do Not Make Quick MovesG. Respond Honestly to Patient’s QuestionsH. Do Not Threaten, Challenge, or Argue With Disturbed PatientsI. Tell the Truth; Do Not Lie to the PatientJ. Do Not “Play Along” With Visual or Auditory Disturbances of the PatientK. Involve Trusted Family Members or FriendsL. Be Prepared to Stay at Scene for a Long Time; Always Remain With the PatientM. Avoid Unnecessary Physical Contact; Call Additional Help if NeededN. Use Good Eye ContactO. Avoid Threatening PosturesP. Other Assessment Techniques to Keep in Mind1. Always try to talk patient into cooperation2. Do not belittle or threaten patients3. Be calm and patient4. Reassure the patient5. Lower distressing stimuli, if possible6. Avoid restraints unless necessary7. Treat the patient with respect8. Protect the patient and yourselfV. Emergency Medical CareA. Scene Size-Up, Personal SafetyB. Establish Rapport1. Interviewing techniquesa. Acknowledge that you are listening byi. noddingii. stating phrases such as, “go on” or “I understand”Page 67 of 127b. Be supportive and empathetici. “I understand that made you angry, sad, upset, etc.”c. Limit interruptionsd. Respect patient’s territory, limit physical touch2. Avoid threatening actions, statements, and questions3. Approach slowly and purposefullyC. Patient Assessment1. Ability to make decisions2. Delusions, hallucinations3. Unusual worries, fears4. Anxiety, depression, elation, agitationD. Calm the Patient—Do Not Leave the Patient Alone, Unless Unsafe Situation;Consider Need for Law EnforcementE. Assist Other EMS Responders With Restraint If NecessaryVI. Consider Age-Related Variations for Pediatric and Geriatric Assessment andManagementA. Pediatric Behavioral Emergencies -- teenage suicide concernsB. Geriatrics -- suicide issues/depression commonPage 68 of 127MedicineCardiovascularEMR Education StandardRecognizes and manages life threats based on assessment findings of a patient with a medicalemergency while awaiting additional emergency response.EMR-Level Instructional GuidelineI. Chest PainA. Causes1. Decrease in blood supply to part of the heart musclea. Heart attack -- death of heart muscleb. Angina -- temporary or incomplete interruption of blood supply toheart muscle2. Assessment and management of both conditions is the same for EMRB. Assessment1. Chest discomfort/pain [OPQRST-onset, provoking event, quality, radiating, severity (scale of 1-10) time (how long has it been happening]2. Paina. Character and location of discomforti. Quality -- what does the discomfort feel like?ii. Location -- where is the discomfort?iii. Severity -- consider pain scaleb. Does the discomfort go anywhere else (radiate) in your body?i. Armsii. Backiii. Neckiv. Jawv. Stomach3. Shortness of breath may occura. During activity/exerciseb. At restc. Worse when lying flat4. Skina. Coldb. Wet/sweaty5. Other findingsa. Nausea or vomitingb. Lightheadedness6. Vital signsa. Blood pressureb. Pulsec. Respirations (rate of breathing)Page 69 of 127C. Management1. High-concentration oxygen2. Place in position of comfort3. Encourage the patient to rest4. Ask if patient has taken any medicine for paina. Aspirinb. NitroglycerinII. Consider Age-Related Variations for Pediatric and Geriatric Patients for Assessment andManagement of Cardiac CompromiseA. Pediatric1. Heart problems often related to congenital heart condition2. Cardiac arrest is often caused by a primary respiratory problemB. Geriatric -- may not have chest discomfort with heart attackIII. Cardiac Arrest (Refer to Shock and Resuscitation section)Page 70 of 127MedicineToxicologyEMR Education StandardRecognizes and manages life threats based on assessment findings of a patient with a medicalemergency while awaiting additional emergency response.EMR-Level Instructional GuidelineI. IntroductionA. Define Poisoning- when a substance interferes with normal body functions after being swallowed, inhaled, injected, or absorbedB. National Poison Control Center1. Role- assist public with guiding them what to do in case of an incident of poising 2. When to call- any suspicion of poisoning3. National Telephone Number 1-800-222-1222II. Carbon Monoxide PoisoningIII. Poisoning by Nerve AgentsA. Define Nerve Agents- chemicals that disrupt the mechanisms by which nerves transfer messages to organs.B. Exposure Routes1. Inhaled gas2. Absorbed through skin3. Ingested from liquid or foodC. Onset of Signs and SymptomsD. Assessment Findings1. Salivation, lacrimation (tearing), urination, defecation, emesis, pupilconstriction2. Blurred or dim vision3. Difficulty breathing4. Slow or fast heart rate5. Muscle twitching, weakness or paralysis6. Slurred speech7. Sweating8. Seizures9. Loss of consciousness10. DeathE. General Management Considerations1. Scene safety/special resources2. Remove patient from contaminated environment as soon as safely possible3. PPE4. Decontamination by appropriately trained personnel if indicated5. Remove clothingPage 71 of 1276. Airway control7. Oxygenate and ventilate8. Position9. Administer nerve agent antidote auto injector kit to self or other rescuer ifindicated and availableIV. Nerve Agent Antidote Autoinjector KitA. Types1. Mark I -- two autoinjector syringes each contain a separate druga. Atropineb. Pralidoxime chloride2. DuoDotea. One autoinjector syringe that contains both atropine andpralidoxime chlorideb. FDA-approved 2007B. Administer a Nerve Agent Autoinjector Kit If1. You or a peer has serious signs or symptoms that indicate the presence ofnerve agent poisoning2. You are authorized to do so by medical directionC. Do Not Give the Nerve Agent Autoinjector Kit If1. Mild signs and symptoms such as tearing or runny nose are the only signsof nerve agent poisoning present2. Drugs in the nerve agent autoinjector kita. Atropinei. Increases heart rateii. Dries secretionsiii. Decreases gastric upsetiv. Dilates pupilsb. 2-PAM Chloride (pralidoxime chloride)i. Muscle twitchingii. Difficulty breathingD. Administration of MARK I ? Kit1. Wear appropriate PPE2. Confirm that serious signs and symptoms of nerve agent poisoning arepresent3. Confirm correct drug4. Check expiration date5. Grasp the atropine syringe6. Remove the protective yellow cap7. Press the green end of the injector very firmly against the outer aspect ofthe patient’s upper leg (thigh) at a 90 degree angle8. Hold for 10 seconds9. Check for the presence of a needle at the tip to ensure the drug wasinjected10. Dispose of syringe appropriately11. Grasp the pralidoxime chloride syringePage 72 of 12712. Remove the gray protective cap13. Press the black end of the injector firmly against the outer aspect of thepatient’s upper leg (thigh) at a 90 degree angle14. Hold for 10 seconds15. Check for the presence of a needle at the tip to ensure the drug wasinjected16. Dispose of syringe appropriately17. Reassess the patient’s signs and symptomsE. Administration of the DuoDote? Kit1. Wear appropriate PPE2. Confirm that serious signs and symptoms of nerve agent poisoning arepresent3. Confirm correct drug4. Check expiration date5. Grasp the syringe with your dominant hand6. Remove the gray protective cap7. Press the green (needle) end of the injector very firmly against the outeraspect of the patient’s upper leg (thigh) at a 90 degree angle8. Hold for 10 seconds9. Check for the presence of a needle at the green tip to ensure the drug wasinjected10. Dispose of syringe appropriately11. Reassess the patient’s signs and symptomsV. Consider Age-Related Variations for Pediatric and Geriatric Assessment andManagementA. Pediatric1. Toddler-aged prone to ingestion of toxic substances2. Adolescent prone to experimentation with drugs of abuseB. Geriatric1. Medication errors are common for many reasons2. May cause life threatening conditionsPage 73 of 127MedicineRespiratoryEMR Education StandardRecognizes and manages life threats based on assessment findings of a patient with a medicalemergency while awaiting additional emergency response.EMR-Level Instructional GuidelineI. Anatomy of the Respiratory SystemA. Upper AirwayB. Lower AirwayC. Lungs and Accessory StructuresII. Normal Respiratory EffortA. Assessment Findings and Symptoms and Management for Respiratory Conditions1. Respiratory distress2. Shortness of breath3. Restlessness4. Increased pulse rate5. Changes in respiratory rate or rhythm6. Skin color changes7. Abnormal sounds of breathing (i.e. wheezing)8. Inability to speak9. Accessory muscle use10. Altered mental status11. Abdominal breathing12. Coughing13. Tripod positionB. Management of Respiratory Distress1. ABCs, position2. Oxygen/suction3. Emotional supportIII. Consider Age-Related Variations for Pediatric and Geriatric Assessment andManagementA. Pediatric1. Upper airway obstruction may be caused by respiratory infections2. Lower airway disease may be caused by birth problems or infectionsB. Geriatrics—Pneumonia and Chronic ConditionsPage 74 of 127MedicineHematologyEMR Education StandardRecognizes and manages life threats based on assessment findings of a patient with a medicalemergency while awaiting additional emergency response.EMR-Level Instructional GuidelineNo knowledge related to the competency is applicable at this level.Page 75 of 127MedicineGenitourinary/RenalEMR Education StandardRecognizes and manages life threats based on assessment findings of a patient with a medicalemergency while awaiting additional emergency response.EMR-Level Instructional GuidelineI. HemodialysisA. Hemodialysis1. Used to eliminate water and wastes from the body when the kidneys fail2. Dialysis machine is connected to an access site at fistula, shunt, or accessportB. Special Considerations for Hemodialysis Patients1. Do not obtain BP in the arm with the dialysis fistula or shuntC. Life-Threatening Emergencies Associated With Dialysis Patients1. Low blood pressure2. Nausea/vomiting3. Irregular pulse, cardiac arrest4. Bleeding from the access site5. Difficulty breathingD. Management of a Patient with a Dialysis Emergency1. Maintain airway2. Administer oxygen3. Assist ventilation if indicated4. Stop bleeding from shunt if present5. Positiona. Flat if signs of shockb. Upright if difficulty breathingPage 76 of 127MedicineGynecologyEMR Education StandardRecognizes and manages life threats based on assessment findings of a patient with a medicalemergency while awaiting additional emergency response.EMR-Level Instructional GuidelineI. Vaginal bleedingA. Causes-miscarriage, trauma, menses, post deliveryB. Assess for signs of shockC. Presence of painD. Management1. Standard precautions2. Administer oxygen3. PositionPage 77 of 127MedicineNon-Traumatic Musculoskeletal DisordersEMR Education StandardRecognizes and manages life threats based on assessment findings of a patient with a medicalemergency while awaiting additional emergency response.EMR-Level Instructional GuidelineNo knowledge related to the competency is applicable at this level.Page 78 of 127MedicineDiseases of the Eyes, Ears, Nose, and ThroatEMR Education StandardRecognizes and manages life threats based on assessment findings of a patient with a medicalemergency while awaiting additional emergency response.EMR-Level Instructional GuidelineI. NosebleedA. Causes1. Trauma2. Medicala. Drynessb. High blood pressureB. General Assessment Findings and Symptoms1. Pain or tenderness2. Bleeding from nose3. Vomits swallowed blood4. Can block airway if patient is unresponsiveC. Techniques to Stop Bleeding in Conscious Patient If No Risk of Spine Injury1. Sit patient up and lean forward2. Pinch the nostrils together firmly3. Tell patient not to sniffle or blow nosePage 79 of 127Shock and ResuscitationEMR Education StandardUses assessment information to recognize shock, respiratory failure or arrest, and cardiac arrestbased on assessment findings and manages the emergency while awaiting additional emergencyresponse.EMR-Level Instructional GuidelineI. Ethical Issues in ResuscitationA. Withholding Resuscitation Attempts1. Irreversible death2. Do Not Resuscitate (DNR) ordersII. Anatomy and Physiology ReviewA. Respiratory System1. Fresh oxygen to enter the lungs and blood supply2. Respiratory waste products to leave the blood and lungsB. Cardiovascular System1. Heart – four chambersa. When the heart contracts, a wave of blood is sent through thearteriesb. Pumps blood to the lungs to pick up oxygenc. Pumps blood around the bodyi. to deliver oxygen and nutrients to the tissuesii. to remove waste products from the tissues2. Vascular Systema. Arteries carry blood to tissuesb. Veins carry blood to heartc. Heart contraction can be felt as a pulse.i. carotidii. femoraliii. radialiv. brachiald. VeinsIII. Respiratory FailureA. Many Causes1. Respiratory infection2. Heart failure3. Chronic respiratory illness4. TraumaB. If Untreated, Can Lead to Respiratory Arrest1. No spontaneous respiration2. If not treated, quickly leads to cardiac arrestPage 80 of 127C. Signs and Symptoms1. Altered mental status2. Cyanosis3. Inadequate depth and rate of breathingIV. Cardiac ArrestA. If the Heart Stops Contracting, No Blood Will FlowB. The Body Cannot Survive When the Heart Stops1. Brain damage begins 4-6 minutes after the patient suffers cardiac arrest2. Damage becomes irreversible in 8-10 minutesC. Cardio-pulmonary resuscitation (CPR)1. Artificial ventilation oxygenates the blood2. External chest compressions squeezes the heart and simulates acontraction3. Oxygenated blood is circulated to the brain and other vital organsV. ResuscitationA. System Components to Maximize Survival1. Early accessa. Public education and awarenessi. rapid recognition of a cardiac emergencyii. rapid notification before CPR starts – "phone first"b. 911-pre-arrival instructions and dispatcher directed CPR2. Early CPRa. Lay publici. familyii. bystandersb. Emergency Medical Responders3. Early Defibrillation4. Early Advanced CareB. Basic Cardiac Life Support (refer to the current American Heart Associationguidelines)1. Adult CPR and foreign body airway obstruction2. Child CPR and foreign body airway obstruction3. Infant CPR and foreign body airway obstructionC. Airway Control and Ventilation1. Basic airway adjuncts-OPA and NPA are inserted to help with ventilation2. Ventilationa. Delivery of excessive rate or depth of ventilation reduces bloodreturn to the right side of the heartb. educes the overall blood flow that can be generated with CPRD. Chest Compressions1. Factors which decrease effectivenessa. Compression that are too shallowb. Slow compression ratec. Sub-maximum recoild. Frequent interruptionsPage 81 of 127VI. Automated External Defibrillation (AED) (refer to the current American HeartAssociation guidelines)A. AdultB. ChildC. InfantD. Special AED Situations1. Pacemaker- do not place over2. Wet patients- remove from wet area or dry patient off3. Transdermal medication patches- remove patch and wipe off medicineVII. Shock (Poor Perfusion)A. Results From Inadequate Delivery of Oxygenated Blood to Body TissuesB. Can Be a Result of1. Severe bleeding or loss of fluid from the body2. Failure of the heart to pump enough oxygenated blood3. Abnormal dilation of the blood vesselsC. Signs and Symptoms1. Extreme thirst2. Restlessness, anxiety3. Rapid, weak pulse4. Rapid, shallow respirations5. Mental status changes6. Pale, cool, moist skin7. Decreased blood pressure (late sign)D. Patient Assessment1. Complete a scene size-up2. Perform a primary assessment3. Obtains a relevant history4. Perform secondary assessment5. Perform a reassessmentE. Management1. Manual in-line spinal stabilization, as needed2. Comfort, calm, and reassure the patient while awaiting additional EMSresources3. Do not give food or drink4. Airway control (i.e. adjuncts)5. Breathinga. Oxygen administration (high concentration)b. Assist ventilation, as needed6. Circulationa. Attempt to control obvious uncontrolled external bleedingb. Position patient appropriately for all agesc. Keep patient warm - attempt to maintain normal body temperatured. Treat any additional injuries that may be presentPage 82 of 127TraumaTrauma OverviewEMR Education StandardUses simple knowledge to recognize and manage life threats based on assessment findings for anacutely injured patient while awaiting additional emergency medical response. This level ofprovider does not transport patients, but should be able to identify and categorize trauma patientsand activate the appropriate trauma system response.EMR-Level Instructional GuidelineI. Identification and Categorization of Trauma PatientsA. Entry-level students need to be familiar with:1. National Trauma Triage Protocola. Centers for Disease Control and Prevention. Guidelines for FieldTriage of Injured Patients: Recommendations of the NationalExpert Panel on Field Triage. MMWR 2008:58 RR-1:1-35.b. contains the National Trauma TriageProtocols and additional instructional materials.Page 83 of 127TraumaBleedingEMR Education StandardUses simple knowledge to recognize and manage life threats based on assessment findings for anacutely injured patient while awaiting additional emergency medical response.EMR-Level Instructional GuidelineI. BleedingA. General Considerations1. Use standard precautions to reduce risk of exposure to blood or bodyfluids2. Estimation of severity of blood loss based ona. Signs and symptomsb. General impression of the amount of blood lossc. Usually unreliable3. Uncontrolled bleeding or significant blood loss leads to shock andpossibly deathB. Types of external bleeding1. Arteriala. Blood spurts from the woundb. Bright, red bloodc. May be difficult to control because of high pressure in arteriesd. As blood pressure drops, spurting may decrease2. Venousa. Blood flows as a steady streamb. Darker red than arterial bloodc. Bleeding from a vein can be severed. In most cases it is easier to control than arterial bleeding due to thelower venous pressure3. Capillarya. Blood oozes from capillariesb. Bleeding often clots spontaneouslyC. Internal Bleeding1. Injured or damaged internal organsa. May lead to extensive, concealed bleedingb. May cause unexplained shock2. Injuries to the extremities may lead to serious internal blood loss fromlong bone fractures3. Signs and Symptomsa. Discolored, painful, tender, swollen, or firm tissueb. Increased respiratory ratePage 84 of 127c. Increased pulse rated. Pale, cool skine. Nausea and vomitingf. Thirstg. Mental status changes4. Specific Injuries (i.e. nosebleed)a. Causesi. traumaii. medicala) drynessb) high blood pressureb. General assessment findings and symptomsi. pain or tendernessii. bleeding from noseiii. vomitiv. swallowed bloodv. can block airway if patient is unresponsivec. Techniques to stop bleeding in conscious patient if no risk of spineinjuryi. sit patient up and lean forwardii. pinch the nostrils together firmlyiii. tell patient not to sniffle or blow nose5. Management of bleeding soft tissue injuriesa. Expose the woundi. control the bleedinga) apply fingertip pressure (use flat part of fingers)directly on the point of bleedingb) large wounds may require sterile gauze and directhand pressure if fingertip pressure does not controlbleedingc) if bleeding oozes through dressing, do not lift off;apply another gauze dressing on top of the first andcontinue to apply pressured) consider other measures for bleeding control basedon local guidelinesii. prevent further contaminationiii. apply sterile dressing to the wound and bandage securely in place with tape or roller gauzeb. Keep patient warmc. Position patient flat on backd. Do not give food or drink if shock is suspectede. Treat other injuriesPage 85 of 127TraumaChest TraumaEMR Education StandardUses simple knowledge to recognize and manage life threats based on assessment findings for anacutely injured patient while awaiting additional emergency medical response.EMR-Level Instructional GuidelineI. Chest TraumaA. Sucking Chest Wound1. Open wounds of the chesta. May hear gurgling sound from wound as patient breathes inb. Bubbling in blood around the wound2. Apply an air tight (occlusive dressing)a. Vaseline gauzeb. Plastic wrapc. Foil3. Secure with tape on three sides4. Position of comfort if no spinal injury suspectedB. Impaled Objects in Chest1. Do not remove the impaled object unless it interferes with chestcompressions2. Manually secure the object3. Expose the wound area4. Control bleeding5. Use a bulky dressing to stabilize the objectPage 86 of 127TraumaAbdominal and Genitourinary TraumaEMR Education StandardUses simple knowledge to recognize and manage life threats based on assessment findings for anacutely injured patient while awaiting additional emergency medical response.EMR-Level Instructional GuidelineI. Abdominal TraumaA. Eviscerations – Open Injury With Organs Sticking Out of the Wound1. Do not replace organs2. Cover with thick moist dressingB. Impaled Objects in Abdomen1. Do not remove the impaled object2. Manually secure the object3. Expose the wound4. Control bleeding5. Use bulky dressing to stabilize the objectPage 87 of 127TraumaOrthopedic TraumaEMR Education StandardUses simple knowledge to recognize and manage life threats based on assessment findings for anacutely injured patient while awaiting additional emergency medical response.EMR-Level Instructional GuidelineI. Fractures and DislocationsA. Fractures1. Introductiona. Isolated fractures are not usually life-threatening; however,fractures of the pelvic bones or the femurs may result in seriousblood loss2. Typesa. Open – bone that is broken and a break in the continuity of the skinhas occurred either as a result of the broken bone ends or by theforces which caused the fractureb. Closed – bone that is broken but does not produce a break in thecontinuity of the skinB. Dislocations1. Definition – a dislocation occurs when a separation occurs between twobones at their joint2. Can be extremely painfulC. Signs and Symptoms -- may be extremely difficult to distinguish a fracture from adislocation1. Deformity or angulation2. Pain and tenderness3. Grating4. Swelling5. Bruising (discoloration)6. Exposed bone ends7. Joint locked into position8. Impaired function or circulationD. Emergency Medical Care of Bone Injuries1. After life threats have been controlled, allow patient to remain in aposition of comfort2. Apply cold pack to area of painful, swollen, deformed extremity to reduceswelling and pain3. Manual extremity stabilizationa. Goal is to prevent movement of the extremityb. Support above and below an injuryPage 88 of 127c. Cover open wounds with a sterile dressingd. Pad to prevent pressure and discomfort to the patiente. When in doubt, manually stabilize the injuryf. Do not intentionally replace the protruding bonesg. Amputationi. limb or part of a limb is severedii. bleeding may be controlled easily or be difficult to controliii. find the severed body part to send to the hospitaliv. place in a sealed plastic bagv. place plastic bag in a bowl with ice and watera) do not allow the amputated part become saturatedwith waterb) never place amputated part directly on icePage 89 of 127TraumaSoft Tissue TraumaEMR Education StandardUses simple knowledge to recognize and manage life threats based on assessment findings for anacutely injured patient while awaiting additional emergency medical responseEMR-Level Instructional GuidelineI. AbrasionA. Outermost layer of skin is scraped offB. PainfulC. SuperficialD. No bleeding or small amount of blood oozes from woundII. LacerationA. Cut or Break in SkinB. May Occur Alone or With Other Soft Tissue InjuriesC. Caused by Forceful Impact With Sharp ObjectD. Bleeding May Be SevereIII. Penetration/PunctureA. Caused by Sharp Pointed ObjectB. May Be Little or No External BleedingC. Internal Bleeding May Be SevereD. Exit Wound May Be PresentE. Examples1. Gun shot wound2. Stab woundIV. Impaled ObjectA. Object That Creates the Puncture Wound Remains EmbeddedB. Leave in Place Unless It Is in the Cheek With Uncontrolled BleedingC. Apply Pressure Around the Object and Secure in PlaceD. Avoid MovementV. Foreign Body in EyeA. Dirt, Dust, or ChemicalB. Signs and Symptoms1. Pain, tearing, redness2. Vision may be blurredPage 90 of 127C. Treatment1. Standard precautions2. Lay patient flat3. Tilt head to affected side so debris or chemical does not flow intounaffected eye4. Hold eye lid open with gloved handa. Apply pressure to bones around the eye while holding lid openb. Never press on the eye itself5. Flush for at least 15 minutes with water or normal salineVI. BurnsA. Severity1. Determined by several factorsa. Depth of burnb. Extent of burnc. Respiratory involvementd. Part of body burnede. Cause of burni. thermalii. chemicaliii. electrical2. Deptha. Superficial involves only the outer layer of the skini. painii. redness of the skiniii. swellingb. Partial thickness involves the outer and middle layer of the skini. deep intense painii. reddeningiii. blisters or moist appearancec. Full thickness extends through all layers of the skini. white, yellow, tan, brown or charred appearanceii. leathery feeliii. no pain in those areasa) Usually there is pain in surrounding areas with otherdepth of burns3. Extent of burna. How much of the body surface is burnedb. Has a large influence on whether the patient developsi. shockii. other complications related to burnsc. Rule of nines4. Special management considerationsa. Stop the burning process with brief application of clean roomtemperature water or salinePage 91 of 127b. Remove smoldering clothing and jewelryi. some clothing may have melted to the skinii. if you meet resistance when removing clothing, leave inplacec. Continually monitor the airway and breathingd. Burned in an enclosed space or on the face could be high risk ofswelling of the airway or other breathing problemse. Cover the burned area with a dry, clean dressingi. do not apply any ointment, lotion, or antisepticii. do not break blistersiii. keep the patient warmf. Chemical burnsi. scene safetyii. gloves and eye protectioniii. brush off dry powderiv. flush with copious amounts of waterv. consider eye burns if there is a splash injury and flush with waterg. Electrical burnsi. scene safety -- never touch a patient in contact with anelectric sourceii. often internal damage more severe than external injuriesappeariii. patient may be in cardiac arrest when EMR arrivesh. Infant and child considerationsi. skin covers greater body surface area in relation to the totalbody sizeii. greater fluid and heat lossiii. keep environment warm when possibleiv. consider possibility of child abuseVII. Dressings and BandagesA. Function1. Control bleeding2. Absorb drainage3. Prevent contaminationB. Dressings1. Usually sterile2. Typesa. Sterile gauze padsb. Non-stick gauze padsc. Occlusive dressingsd. Trauma dressingsC. Bandages1. Hold dressings in place2. Typesa. Adhesive bandagesPage 92 of 127b. Roller gauzei. elasticii. non-elasticc. TapeD. Application1. Dressings-check pulse motor and sensory before and after-not too tight unless applying a pressure dressing needed for bleeding control2. Bandages-check pulse motor and sensory before and after-not too tight unless applying a pressure dressing needed for bleeding controlPage 93 of 127TraumaHead, Facial, Neck, and Spine TraumaEMR Education StandardUses simple knowledge to recognize and manage life threats based on assessment findings for anacutely injured patient while awaiting additional emergency medical response.EMR-Level Instructional GuidelineI. Head, Face, Neck, and Spine TraumaA. Injuries to the Brain and Skull1. Head injuriesa. Open injuries may present with bleedingb. Closed injury may present with swelling or depression of skullbonesc. Brain injury may lead to altered consciousness with airway andbreathing problems2. Scalp injuriesa. May bleed more than expected because of the large number ofblood vessels in the scalpb. Control bleeding with direct pressurec. Severe bleeding from the scalp can cause shock in infants andyoung children3. Injury to the braina. Injury of brain tissue or bleeding inside the skull may increasepressure on the brainb. Altered mental status4. Special Management Considerationsa. Maintain airway/ ventilation/oxygenationb. Primary assessment with manual in-line spinal stabilization shouldbe done on scenec. Monitor the patient’s mental statusd. Dress and bandage open wound as indicated in the emergencymedical care of soft tissue injuriesB. Injuries to the Spine1. Mechanism of injurya. Motor vehicle crashesb. Pedestrian – vehicle collisionsc. Fallsd. Blunt traumae. Penetrating trauma to head, neck, or torsof. Motorcycle crashesg. HangingsPage 94 of 127h. Springboard or platform diving accidentsi. Unresponsive trauma patients2. Signs and symptomsa. Tenderness in the area of injuryb. Pain associated with movingi. do not ask the patient to move to try to find a pain responseii. do not move the patient to test for a pain responsec. Pain independent of movement or palpationd. Numbness, weakness, or tingling in the arms or legse. Unable to feel or move below the suspected level of injuryf. Loss of feeling or movement in the upper or lower extremitiesg. Difficulty breathing or shallow breathingh. Loss of bladder and/or bowel controli. If the patient can walk, move, and feel arms and legs it does notrule out the possibility of injury to the bones of the spine or to thespinal cord3. Assessing the patient with a possible spine injurya. Responsive patienti. manually stabilize head and neck in the position foundii. mechanism of injuryiii. questions to aska) does your neck or back hurt?b) what happened?c) where does it hurt?d) can you move your hands and feet?e) can you feel me touching your fingers?f) can you feel me touching your toes?b. Unresponsive patienti. maintain airwayii. assist ventilation if inadequateiii. administer oxygeniv. stabilize head and neck manually in the position foundv. obtain information from others at the scene to determinemechanism of injury and patient’s mental status before theEmergency Medical Responder's arrivalc. Complicationsi. inadequate breathing effortii. paralysis4. Special management considerationa. Establish and maintain manual stabilizationi. maintain constant manual stabilizationii. may be released when additional EMS resources haveapplied a cervical collar and properly secured the patient’storso and head to a backboardPage 95 of 127b. Primary assessmenti. whenever possible, airway control should be done withoutmoving the patient's headii. whenever possible, artificial ventilation should be donewithout moving the headiii. assess pulse, movement, and feeling in all extremitiesPage 96 of 127TraumaNervous System TraumaEMR Education StandardUses simple knowledge to recognize and manage life threats based on assessment findings for anacutely injured patient while awaiting additional emergency medical response.EMR-Level Instructional GuidelineNo knowledge related to the competency is applicable at this level. Take necessary steps as stated abovePage 97 of 127TraumaSpecial Considerations in TraumaEMR Education StandardUses simple knowledge to recognize and manage life threats based on assessment findings for anacutely injured patient while awaiting additional emergency medical response.EMR-Level Instructional GuidelineI. Pregnant PatientA. Recognition1. Pregnant women who have suffered an injury should be evaluated by aphysician in the emergency roomB. Management1. If the woman is having any symptoms related to shock, high-concentrationoxygen should be administered2. Place pregnant patient in third trimester on her left side unless spinalinjury suspected then tilt spine board to the left after patient is fullysecured to the boardII. Pediatric PatientA. Recognition1. Heavy head with weak neck muscles in children increase risk of cervicalspine injury2. Accessory muscle use more prominent during respiratory distress3. Slow pulse rate indicates hypoxia4. Normal blood pressure may be present in compensated shock5. Shaken baby syndrome may cause brain traumaB. Management1. Manage hypovolemia and shock as for adults2. Prevent hypothermia in shock3. Transport to appropriate facility4. Pad beneath child from shoulders to hips during cervical immobilization toprevent flexion of the neck5. Ventilate bradycardic pediatric patientIII. Elderly PatientA. Recognition1. Changes in pulmonary, cardiovascular, neurologic, and musculoskeletalsystems make older patients susceptible to trauma2. Circulation changes lead to inability to maintain normal vital signs duringhemorrhage, blood pressure drops soonerPage 98 of 1273. Multiple medications are more common and may affect:a. Assessment, especially vital signsb. Blood clotting4. Skeletal changes cause curvature of the upper spine that may requirepadding during spinal immobilization5. Dentures may cause airway obstruction6. Falls are often the result of medical conditionsB. Management1. Suctioning is important in elderly patients due to decreased cough reflex2. Skeletal changes cause curvature of the upper spine that may requirepadding during spinal immobilization3. Prevent hypothermia4. Broken bones are commonPage 99 of 127TraumaEnvironmental EmergenciesEMR Education StandardUses simple knowledge to recognize and manage life threats based on assessment findings for anacutely injured patient while awaiting additional emergency medical response.EMR-Level Instructional GuidelineI. Environmental EmergenciesA. Exposure to Cold1. Generalized cold emergencya. Contributing factorsi. cold environmentii. wet environmentiii. windiv. age (very old/very young)v. medical conditionsvi. alcohol/drugs/poisonsb. Signs and symptoms of generalized hypothermiai. obvious exposureii. subtle exposurea) underlying illnessb) overdose/poisoningc) ambient temperature decreased (e.g., cool home ofelderly patient)iii. cool/cold skin temperaturea) place the back of your hand between the clothingand the patient's abdomen to assess the generaltemperature of the patientb) the patient experiencing a generalized coldemergency will present with cool or cold abdominalskin temperatureiv. shiveringv. decreasing mental status or motor functiona) Depends on the degree of hypothermiab) Poor coordinationc) Memory disturbances/confusiond) Reduced or loss of touch sensatione) Mood changesf) Less communicativeg) Dizzinessh) Speech difficultyPage 100 of 127i) Stiff or rigid posturej) Muscular rigidityk) Poor judgment – patient may actually removeclothingl) Complaints of joint/muscle stiffnessvi. Slow pulsec. Managementi. move to a warm environment as soon as possibleii. remove wet clothingiii. wrap patient in warm blanketsiv. handle gentlyv. assess pulses for 30-45 seconds to determine there is nopulse before starting CPRvi. if AED states that shock is indicated, defibrillate2. Local cold emergenciesa. Freezing or near freezing of a body partb. Usually occurs in fingers, toes, face, ears, and nosec. Signs and symptoms of local cold injuriesd. Local injury with clear demarcationi. early or superficial injurya) blanching of the skin – palpation of the skin inwhich normal color does not returnb) loss of feeling and sensation in the injured areac) skin is softd) if rewarmed, tingling sensationii. late or deep injurya) white, waxy skinb) firm or frozen feeling when palpatedc) swelling may be presentd) blisters may be presente) if thawed or partially thawed, the skin may appearflushed with areas of purple and blanching or maybe mottled and cyanotice. Special management considerationi. remove the patient from the cold environment.a) handle the patient extremely gentlyb) protect the patient from further heat lossc) do not allow the patient to walk or exert himselfd) do not re-expose to the colde) remove any wet clothing and cover the patient witha blanketii. do nota) break blistersb) rub or massage affected areac) apply heatd) rewarm if any chance of refreezingPage 101 of 127iii. the patient should not be given anything by moutha) coffee, tea, or smoking may worsen the conditionb) cover the patient with a blanket; keep the patientwarmiv. if early or superficial injurya) manually stabilize the extremity.b) cover the extremityv. if late or deep cold injurya) remove jewelryb) cover with dry clothing or dressingsB. Exposure to Heat1. Predisposing factorsa. Climatei. high ambient temperature reduces body's ability to loseheat by radiationii. high relative humidity reduces the body's ability to loseheat through evaporationb. Exercise and activity – can lose more than 1 liter of sweat per hourc. Age (very old/very young)d. Preexisting illness and/or conditionse. Drugs/medications2. Signs and symptomsa. Muscular crampsb. Weakness or exhaustionc. Sweating or dry skind. Dizziness or faintnesse. Rapid heart ratef. Altered mental status to unresponsive3. Special management considerationsa. Administer oxygen by non-rebreather maskb. Remove the patient from the hot environmentc. Remove excess clothingd. Place in a cool environment (air conditioned)e. Cool patient by fanning (may be ineffective in high humidity)f. Cool with cool cloths or ice packs (wrapped so they are not placed in contact with the skin)i. on neckii. under armpitsiii. on groing. If unconscious place in recovery positioni. maintain airwayii. assist ventilation if breathing inadequatePage 102 of 127C. Submersion1. Definitionsa. drowning – occurs when the patient’s airway is surrounded by aliquid that prevents her from breathing air; it may or may notcause death2. Contributing factors3. Severity4. Signs and symptomsa. Coughingb. Vomitingc. Difficulty breathingd. Respiratory arreste. Cardiac arrest5. Special management considerationsa. If patient is in water be aware of personal safetyb. Consider possibility of spine injuryi. if risk of spinal injury exists, manually stabilize the neckand spine Remove patient from waterii. if no risk of spinal injury exists and patient is breathinga) place in recovery positionb) administer oxygeniii. if no risk of spinal injury exists and patient is not breathing,follow American Heart Association guidelines for CPRc. Risk of vomiting is high and if patient vomitsi. roll on sideii. suction mouthPage 103 of 127TraumaMulti-System TraumaEMR Education StandardUses simple knowledge to recognize and manage life threats based on assessment findings for anacutely injured patient while awaiting additional emergency medical response.EMR-Level Instructional GuidelineI. Multi-System TraumaA. Patients Subjected to Significant Forces Have an Increased Risk for Injuries toMultiple Organs Within the Body at the Same TimeB. Multi-Trauma Patients Are at a Greater Risk of Developing ShockC. Suspect Multi-Systems Trauma in Any Patient Subjected to Significant ExternalForcesPage 104 of 127Special Patient PopulationsObstetricsEMR Education StandardRecognizes and manages life threats based on simple assessment findings for a patient withspecial needs while awaiting additional emergency response.EMR-Level Instructional GuidelineI. Anatomy and Physiology of organs related to deliveryA. Uterus/WombB. Baby/FetusC. Placenta/AfterbirthD. Amniotic Sac/Bag of WaterE. Vagina/Birth CanalII. Vaginal Bleeding in the Pregnant PatientA. Light Irregular Discharges of Small Amount of Blood “Spotting” May Be NormalB. More Bleeding May Indicate a Problem That Needs Physician’s AttentionC. Mucus With Small Amount of Blood Late in Pregnancy May Mean Delivery IsNearD. Any Other Bleeding Late in Pregnancy Is a Serious EmergencyE. General Assessment1. ABCs2. Vital signs initially and repeated periodically3. SAMPLE history and obstetric historyF. General Management1. Standard precautions2. Place patient on left side3. Ensure the patient places a sanitary pad over the vaginal opening4. Provide shock care5. Monitor airway and administer oxygen6. Save blood soaked pads in a plastic bag for examination at the hospital7. Offer support for the patient while awaiting EMT responseIII. General Assessment and Management of the Obstetrical PatientA. Signs of Labor1. Braxton Hicks/false labor contractions2. Bloody show3. Ruptured membranes4. Contractions regular and at closer intervalsB. Stages of Labor and Delivery1. First stage: onset of contractions until fetus enters the birth canalPage 105 of 1272. Second stage: fetus enters the birth canal until birth (is delivered)3. Third stage: placenta deliveryC. Assessment During Labor and Delivery1. Airway, breathing, circulation2. SAMPLE and obstetric historya. When is the baby due?b. First or later pregnancyc. Known complications (multiple births, etc.)d. Has experienced bloody show, water brokene. Contraction regularity, interval, and durationf. Other medical historyIV. Vital SignsV. Physical ExaminationA. Evaluating ContractionsB. Inspect for CrowningC. Preparation for Delivery1. Standard precautionsa. Glovesb. Gownc. Eye protection and face shield2. Collect supplies/OB kita. Towelsb. Sheetsc. Bulb syringed. Cord clampse. Sterile scissors or razorf. Sanitary padsg. Bag or basin for afterbirthh. Medical hazard bag3. Provide privacy for mother4. Position mother on back, hips elevated, knees bent, legs apart5. No internal vaginal examination6. Wait for EMTsVI. Steps If the EMR Needs to DeliverA. If Baby’s Head Is Seen at the Vaginal Opening (Crowning), Delivery Will OccurSoonB. Someone by Mother’s Head for SupportC. Wash Hands and Put on PPED. Support the Baby’s Head As It DeliversE. If Umbilical Cord Is Around the Baby’s Neck, Slip It Gently Over the HeadF. Support the Baby As He or She RotatesG. The Upper Shoulder Should Deliver Next as the Head Is Guided DownwardH. The Feet Should Deliver After ThatI. Keep the Head Lowered So Fluids Can Drain; Suction Mouth and NosePage 106 of 127J. Make Note of the Birth TimeK. Keep the Baby at the Level of the Birth CanalL. Clamp the Cord, Cut Only If Sterile Equipment AvailableM. Monitor the ABC’sN. Wait for the Afterbirth DeliveryVII. Care for the Baby (see Neonatal Care)VIII. Care for the MotherA. Some Bleeding is NormalB. Sanitary Pad Over Vaginal OpeningC. Massage the Uterus in a Circular Motion ContinuouslyD. Allow the Mother to NurseE. Provide Comfort, WarmthPage 107 of 127Special Patient PopulationsNeonatal CareEMR Education StandardRecognizes and manages life threats based on simple assessment findings for a patient withspecial needs while awaiting additional emergency response.EMR-Level Instructional GuidelineI. Initial Care of the NeonateA. Assessment1. Respirations2. Pulse3. Color4. Cry5. MovementB. Routine Care1. Support2. Dry3. Warm4. Position5. Airway6. StimulationPage 108 of 127Special Patient PopulationsPediatricsEMR Education StandardRecognizes and manages life threats based on simple assessment findings for a patient withspecial needs while awaiting additional emergency response.EMR-Level Instructional GuidelineI. General ConsiderationsA. Many Components of the Initial Evaluation Can Be Done by Careful ObservationWithout Touching the PatientB. When Appropriate, Utilize the Parent/Guardian to Help the Infant or Child BeMore Comfortable With Your Exam and TreatmentC. Communicating With Scared, Concerned Parents and Family Is Important WhenCaring for an Ill Infant or ChildD. Continue Assessment Until Care Is TransferredII. Assessment ProcessA. Scene Survey1. Evaluate the scene for safety2. Evaluate the scene for clues related to the chief complainta. Ingestions or toxic exposures: pills, medicine bottles, chemicals,alcohol, drug paraphernalia, etc.b. Child abuse: injury must be consistent with history given andphysical/developmental capabilities of the patientc. Note position and location in which patient is found3. Observe caregivers’ interactions with the childa. Are they appropriately concerned, angry or indifferent?b. Does the child seem comforted by them or scared by them?B. Patient Assessment1. Pediatric assessment triangle -- 15- to 30-second assessment of theseverity of the patient’s illness or injurya. Use prior to addressing “the ABCs”b. Does not require touching the patient; just looking and listeningi. appearancea) muscle toneb) interactivenessc) consolabilityd) eye contacte) speech or cryii. work of breathinga) abnormal airway noisePage 109 of 127i) wheezingii) stridoriii) gruntingb) abnormal positioning (i.e. tripoding)c) accessory muscle usei) chest wallii) nasal flaringiii. assess skin to see if it isa) Paleb) Mottledc) Cyanoticc. possible causes of abnormal findings abovei. respiratory distress of failureii. shockiii. cardiopulmonary failure or arrestiv. other abnormalityv. stable patient2. Airwaya. Obstructedi. open with airway maneuvers and airway adjunctsii. if indicated suction or remove fluids, blood, or foreignobjectsb. Maintainable on its own3. Ventilation/oxygenationa. Administer oxygen if inadequateb. Assist with ventilation if necessary4. Circulationa. Signs of shocki. pulse quality: strong or weakii. extremity skin temperature and active bleedingb. Position flatc. Maintain warmth5. Determine level of consciousnessa. AVPU scaleb. Assess pupils: dilated, constricted, reactive, or fixedc. Moving all extremities equally6. Exposurea. Examine for additional injuriesb. Promptly cover to prevent hypothermia; cover head as well7. Additional assessmenta. Historyi. symptoms and durationa) feverb) activity levelc) recent eating, drinking, and urine output historyd) history of vomiting, diarrhea, or abdominal painPage 110 of 127ii. medications taking and medication allergiesiii. past medical problems or chronic illnessesiv. key events leading to the injury or illnessb. Detailed physical exam—“Head to Toe”i. head: bruising, swellingii. ears: drainage suggestive of trauma or infectioniii. mouth: loose teeth, identifiable odors, bleedingiv. neck: abnormal bruisingv. chest and back: bruises, injuries, or rashesvi. extremities: deformities, swellings, or pain on movementI. Respiratory Distress/Failure/ArrestA. Introduction1. Tongue is larger2. Airways are smallerB. Pathophysiology1. Respiratory distress- difficulty2. Respiratory failure- not creating good gas exchange3. Respiratory arrest- stopped breathingC. Assessment1. History2. Physical findingsD. Upper Airway Obstruction1. Swelling of tissue2. Foreign body3. Secretions4. OtherE. Management1. Airway positioning (chin lift, jaw thrust)2. If upper airway is obstructed, use,age- and situation-appropriate airway clearance measures (finger sweep, backblows, suctioning, abdominal thrusts)3. Airway adjunct (oropharyngeal airways)4. Oxygen5. Assisted ventilation (bag valve mask)II. ShockA. Causes1. Trauma2. Infections3. Vomiting or diarrheaB. Assessment1. History2. Physical findingsa. Rapid heart rate and respiratory rateb. Weak or absent pulsePage 111 of 127c. Altered mental statusd. Pale, cool, clammy skinC. Management1. Scene safety and standard precautions2. Open airway (protect spine if necessary)3. Oxygen4. Assist ventilations if necessary5. Chest compressions if necessary6. Control bleedingIII. SeizuresA. DescriptionB. Causes1. Fever2. Head trauma3. Epilepsy4. Low blood glucose5. PoisoningC. AssessmentD. Management1. Scene safety and standard precautions2. Place patient on the floor3. Loosen restrictive clothing4. Protect the patient from injury5. Nothing in the mouth and do not hold the patient down6. After seizure, place patient in recovery positionIV. Sudden Infant Death Syndrome (SIDS)A. Introduction1. Definition of SIDS2. Definition of Apparent Life Threatening Event (ALTE)3. Epidemiology and risk factorsB. Assessment1. Airway, breathing, pulse2. Signs of death3. Begin resuscitation if no indication of futilityC. Management1. Local EMS criteria for death in the field2. Notification of appropriate authorities3. Caregiver supportPage 112 of 127Special Patient PopulationsGeriatricsEMR Education StandardRecognizes and manages life threats based on simple assessment findings for a patient withspecial needs while awaiting additional emergency response.EMR-Level Instructional GuidelineI. Age-Associated ChangesA. Age Dependent and VariableB. Sensory Changes in Older Patients1. Visiona. Decreased visionb. Inability to differentiate colorsc. Decreased night visiond. Decreased ability to see close upe. Decreased depth perception2. Hearinga. Inability to hear high-frequency soundsb. Use of hearing aids3. Sense of touch and paina. Decreased sense of balanceb. Diminished pain perceptionc. Decreased ability to differentiate hot from coldd. Decreased tolerance of hot and coldC. Heart/Blood Vessels1. High blood pressure2. Increased risk of heart and stroke3. Heart is less able to beat faster when neededD. Lungs and Breathing1. Diminished breathing capacity2. Increased risk of infection of the lungs3. Decreased coughE. Stomach and Intestines1. Difficulty with digestion2. Difficulty chewing –3. increased risk of foreign body airway obstructionF. Brain and Nervous System1. Slower reflexes2. Decreased recent memoryPage 113 of 127G. Muscles and Bones1. Decreased bone density—easier to break2. Loss of strength and size of bone and musclesH. Other1. Increased risk of infections2. Decreased signs and symptoms of infection when presentII. Assessment and Care ImplicationsA. Assessment1. ABCsa. Airway may be difficult to assess and manage due to neck arthritisb. Dentures should not be removed unless they obstruct the airway orinterfere with ventilation if rescue breathing is neededc. Increased risk of airway obstructionsd. Pulse may be irregular due to heart rhythm problems that arecommon2. Speak slowly and distinctly at patient’s eye level with good lighting3. Give the patient time to respond unless the condition appears urgent4. Elderly may not show severe symptoms even if very ill5. Use family members if available, especially for base line mental status6. Reassess often as condition may deteriorate quicklyB. Care1. Handle gently as skin is fragile and can easily tear2. Reassurance is importantPage 114 of 127Special Patient PopulationsPatients With Special ChallengesEMR Education StandardRecognizes and manages life threats based on simple assessment findings for a patient withspecial needs while awaiting additional emergency response.EMR-Level Instructional GuidelineI. Recognizing and Reporting Abuse and NeglectA. Child Abuse1. Types of abusea. Neglectb. Physical abusec. Sexual abused. Emotional abuse2. Assessmenta. History or scene findings to concern for abuse or neglectb. Caregiver’s behaviorc. Physical findings3. Managementa. Reportingb. Safely transportingc. Role of child/adult protective services4. Legal aspects5. DocumentationB. Elder Abuse1. Types of abusea. Neglectb. Physical abusec. Sexual abused. Emotional abusee. Financial abuse2. Epidemiology3. Assessment4. Management5. Legal aspects6. DocumentationPage 115 of 127EMS OperationsPrinciples of Safely Operating a Ground AmbulanceEMR Education StandardKnowledge of operational roles and responsibilities to ensure patient, public, and personnelsafety.EMR-Level Instructional GuidelineThe intent of this section is to give an overview of emergency response to ensure the safety ofEMS personnel, patients, and others during EMS operations. This does not prepare the entry level student to be an experienced and competent rmation related to the clinical management of the patient during emergency response isfound in the clinical sections of the National EMS Education Standards and InstructionalGuidelines for each personnel level.I. Risks and Responsibilities of Emergency ResponseA. Apparatus and Equipment Readiness1. Inspect and service vehicles regularlya. Tire inflationb. Engine fluid levelsc. Warning devices in working order2. Appropriate safety equipment available and in working ordera. Personal protective equipmentb. Safety vestsB. Pre-Arrival Considerations1. All personnel are properly seated and use seat belts2. All equipment is appropriately secureda. Cab areab. Rear of ambulancesc. Compartment areas3. Consideration of use of lights and sirensa. Risk/benefit analysisb. Audible warning devicesi. asking for right-of-way of othersii. not to be used to clear trafficc. Visual warning devices – consider turning off upon arrival ifappropriate4. Respond with due regard5. High-risk situationsa. Intersectionsb. Highway accessPage 116 of 127c. Speedingd. Driver distractionsi. mobile computerii. global positioning systemsiii. mobile radioiv. vehicle stereov. wireless devicesvi. eating/drinkinge. Inclement weatherf. Aggressive driversg. Unpaved roadways (see Federal Highway Administrationdefinition)h. Responding alonei. FatigueC. Scene Safety1. Personala. First priority for all EMS personnelb. Appropriate personal protective equipment for conditionsc. Scene size-up2. Patienta. Keep them informed of your actionsb. Protect from further harm3. Control traffic flowa. Proper positioning of emergency vehiclesi. upwind/uphillii. protect sceneb. Use of lights and other warning devicesc. Setting up protective barrierd. Designate a traffic control person4. 360-degree assessment (traffic crashes and outdoor incidents)a. Downed electrical linesb. Leaking fuels or fluidsc. Smoke or fired. Broken glasse. Trapped or ejected patientsf. Mechanism of injuryD. Leaving the Scene1. Ensure all hazards have been mitigated2. Pick up and dispose of all equipment properly3. Turn scene over to appropriate authority prior to leavinga. Law enforcementb. Fire suppressionc. Highway departmentd. OtherPage 117 of 127EMS OperationsIncident ManagementEMR Education StandardKnowledge of operational roles and responsibilities to ensure patient, public, and personnelsafety.EMR-Level Instructional GuidelineInformation related to the clinical management of the patient within components of the IncidentManagement System (IMS) is found in the clinical sections of the National EMS EducationStandards and Instructional Guidelines for each personnel level.I. Establish and Work Within the Incident Management SystemA. Entry-Level Students Need to Be Certified in1. ICS-100: Introduction to ICS, or equivalent2. FEMA IS-700: NIMS, An IntroductionB. This Can Be Done as a Co requisite or Prerequisite or as Part of the Entry-LevelCoursePage 118 of 127EMS OperationsMultiple Casualty IncidentsEMR Education StandardKnowledge of operational roles and responsibilities to ensure patient, public, and personnelsafety.EMR-Level Instructional GuidelineThe intent of this section is to give an overview of operating during a multiple casualty incidentwhen a multiple casualty incident plan is rmation related to the clinical management of the patients during a multiple casualty incidentis found in the clinical sections of the National EMS Education Standards and InstructionalGuidelines for each personnel level.I. Multiple-Casualty Incidents (MCI)A. A Situation With Numerous Patients That Does Not Overwhelm the RoutineCapacity of the SystemII. Triage PrinciplesA. Primary Triage Used On-Scene to Rapidly Categorize Patient’s Condition1. Document location of patient and transport needs2. Triage tape or labels used3. Focus on speed to sort patients quicklyB. Patient Priority1. Immediatea. Airway and breathing difficultiesb. Uncontrolled or severe bleedingc. Decreased mental statusd. Patients with severe medical problemse. Shock (hypoperfusion)f. Severe burns2. Delayeda. Burns without airway problemsb. Major or multiple bone or joint injuriesc. Back injuries with or without spinal cord damage3. Holda. Minor painful, swollen, deformed extremitiesb. Minor soft tissue injuries4. DeceasedPage 119 of 127C. Triage Tagging/Labeling1. International agreement on color-coding and prioritiesa. Immediate Red Priority-1 (P-1)b. Delayed Yellow Priority-2 (P-2)c. Hold Green Priority-3 (P-3)d. Deceased Black Prority-0 (P-0)D. Triage Procedures1. Identify a triage officer (remains on-scene for duration of event)2. Request additional resourcesa. Personnelb. Equipment3. Perform triage of all patients4. Assign personnel and equipment to highest priority patientsE. Post-Traumatic and Cumulative Stress1. Should be part of post-incident standard operating procedure (SOP)2. Access to defusing during the multiple casualty incident3. Roles of debriefing for a multiple casualty incident4. Access to debriefingIII. Resource ManagementA. Triage Procedures1. Identify a triage officer (remains on scene for duration of event)2. Request additional resourcesa. Personnelb. Equipment3. Perform triage of all patients4. Assign personnel and equipment to highest priority patientsPage 120 of 127EMS OperationsAir MedicalEMR Education StandardKnowledge of operational roles and responsibilities to ensure patient, public, and personnelsafety.EMR-Level Instructional GuidelineThe intent of this section is to give an overview of operating safely in and around a landing zoneduring air medical operations and rmation related to the clinical management of the patient being cared for during air medicaloperations is found in the clinical sections of the National EMS Education Standards andInstructional Guidelines for each personnel level.I. Safe Air Medical OperationsA. Types1. Rotorcraft2. Fixed wingB. Advantages1. Specialized care – skills, supplies, equipment2. Rapid transport3. Access to remote areas4. Helicopter hospital helipadsC. Disadvantages1. Weather/environmental2. Altitude limitations3. Airspeed limitations4. Aircraft cabin size5. Terrain6. CostD. Patient Transfer1. Interacting with flight personnel2. Patient preparation3. Scene safetya. Securing loose objectsb. Approaching the aircraftc. Landing zoneE. Landing Zone Selection and PreparationF. Approaching the AircraftG. Communication IssuesPage 121 of 127II. Criteria for Utilizing Air Medical ResponseA. Indications for Patient Transport1. Medical2. Trauma3. Search and rescueB. Activation1. Local and State guidelines exist for air medical activationa. State statutesb. Administrative rulesc. City/county/district ordinance standardsPage 122 of 127EMS OperationsVehicle ExtricationEMR Education StandardKnowledge of operational roles and responsibilities to ensure patient, public, and personnelsafety.EMR-Level Instructional GuidelineThe intent of this section is to give an overview of vehicle extrication to ensure EMS personneland patient safety during extrication operations. This does not prepare the entry-level student tobecome a vehicle extrication expert or rmation related to the clinical management of the patient being cared for during vehicleextrication is found in the clinical sections of the National EMS Education Standards andInstructional Guidelines for each personnel level.I. Safe Vehicle ExtricationA. Role of EMS in Vehicle Extrication1. Provide patient care2. Perform simple extricationB. Personal Safety1. First priority for all EMS personnel2. Appropriate personal protective equipment for conditions3. Scene size-upC. Patient Safety1. Keep them informed of your actions2. Protect from further harmD. Situational Safety1. Control traffic flowa. Proper positioning of emergency vehiclesi. upwind/uphillii. protect sceneb. Use of lights and other warning devicesc. Setting up protective barrierd. Designate a traffic control person2. 360-degree assessmenta. Downed electrical linesb. Leaking fuels or fluidsc. Smoke or fired. Broken glasse. Trapped or ejected patientsf. Mechanism of injuryPage 123 of 1273. Vehicle stabilizationa. Put vehicle in “park” or in gearb. Set parking brakec. Turn off vehicle ignitiond. Cribbing/Chockinge. Move seats back and roll down windowsf. Disconnect battery or power sourceg. Identify and avoid hazardous vehicle safety componentsi. seat belt pretensionersii. undeployed air bagsiii. other4. Unique hazardsa. Alternative-fuel vehiclesb. Undeployed vehicle safety devicesc. HAZMAT5. Evaluate the need for additional resourcesa. Extrication equipmentb. Fire suppressionc. Law enforcementd. HAZMATe. Utility companiesf. Air medicalg. Others6. Extrication considerationsa. Disentanglement of vehicle from patientb. Multi-step processc. Rescuer-intensived. Equipment-intensivee. Time-intensivef. Access to patienti. simplea) try to open doorsb) ask patient to unlock doorsc) ask patient to lower windowsii. complexiii. toolsa) handb) pneumaticc) hydraulicd) otherE. Determine Number of Patients (implement local multiple casualty incidentprotocols if necessary)II. Use of Simple Hand ToolsA. HammerB. Center PunchPage 124 of 127C. Pry BarD. Hack SawE. Come-AlongIII. Special Considerations for Patient CareA. Removing Patient1. Maintain manual cervical spine stabilization2. Complete primary assessment3. Provide critical interventionsB. Assist With Rapid ExtricationC. Move Patient, Not DeviceD. Use Sufficient PersonnelE. Use Path of Least ResistancePage 125 of 127EMS OperationsHazardous Materials AwarenessEMR Education StandardKnowledge of operational roles and responsibilities to ensure patient, public, and personnelsafety.EMR-Level Instructional GuidelineInformation related to the clinical management of the patient exposed to hazardous materials isfound in the clinical sections of the National EMS Education Standards and InstructionalGuidelines for each personnel level.I. Risks and Responsibilities of Operating in a Cold Zone at a Hazardous Material or OtherSpecial IncidentA. Entry-Level Students Need to Be Certified in:1. Hazardous Waste Operations and Emergency Response (HAZWOPER)standard, 29 CFR 1910.120 (q)(6)(i) -First Responder Awareness LevelB. This Can Be Done as a Co requisite or Prerequisite or as Part of the Entry-LevelCoursePage 126 of 127EMS OperationsMass Casualty Incidents Due to Terrorism andDisasterEMR Education StandardKnowledge of operational roles and responsibilities to ensure patient, public, and personnelsafety.EMR-Level Instructional GuidelineThe intent of this section is to give an overview of operating during a terrorist event or during anatural or manmade rmation related to the clinical management of patients exposed to a terrorist event orinvolved in a disaster is found in the clinical sections of the National EMS Education Standardsand Instructional Guidelines for each personnel level.I. Risks and Responsibilities of Operating on the Scene of a Natural or Man-Made DisasterA. Role of EMS1. Personal safety2. Provide patient care3. Initiate/operate in an incident command system (ICS)4. Assist with operationsB. Safety1. Personala. First priority for all EMS personnelb. Appropriate personnel protective equipment for conditionsc. Scene size-upd. Time, distance, and shielding for self-protectione. Emergency responders are targetsf. Dangers of the secondary attack2. Patienta. Keep them informed of your actionsb. Protect from further harmc. Signs and symptoms of biological, nuclear, incendiary, chemicaland explosive (B-NICE) substancesd. Concept of “greater good” as it relates to any delaye. Treating terrorists/criminals3. 360-degree assessment and scene size-upa. Outward signs and characteristics of terrorist incidentsPage 127 of 127b. Outward signs of a weapons of mass destruction (WMD) incidentc. Outward signs and protective actions of biological, nuclear,incendiary, chemical, and explosive (B-NICE) weapons4. Determine number of patients (implement local multiple-casualty incident(MCI) protocols as necessary)5. Evaluate need for additional resources6. EMS operations during terrorist, weapons of mass destruction, disastereventsa. All hazards safety approachb. Initially distance from scene and approach when safec. Ongoing scene assessment for potential secondary eventsd. Communicate with law enforcement at the scene of an armedattacke. Initiate or expand incident command system as neededf. Perimeter use to protect rescuers and public from injuryg. Escape plan and a mobilization point at a terrorist incident7. Care of emergency responders on scenea. Safe use of an auto injector for self and peersb. Safe disposal of auto injector devices after activationDOT HS 811 077BJanuary 2009 ................
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