Emergency Medical Response Textbook
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Cezar Alexander GuevaraEmergency Medical Response Textbook
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Cezar Alexander GuevaraEmergency Medical Response
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Emergency Medical Response
The emergency care procedures outlined in this textbook reflect the standard of
knowledge and accepted emergency practices in the United States at the time this
textbook was published. It is the reader’s responsibility to stay informed of changes
in emergency care procedures.
The materials in this program, including all content, graphics, images, logos and
downloadable electronic materials (as applicable), are copyrighted by, and the
exclusive property of, The American National Red Cross (“Red Cross”). Unless
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Published by The StayWell Company, LLC
Printed in the United States of America
ISBN: 978-1-58480-692-9
Acknowledgments
This textbook is dedicated to the thousands of employees and volunteers of the American Red Cross who
contribute their time and talent to supporting and teaching lifesaving skills worldwide and to the thousands of
course participants and other readers who have decided to be prepared to take action when an emergency strikes.
The care steps outlined in this textbook are consistent with the:
• 2015 International Consensus on CPR and Emergency Cardiovascular Care (ECC) Science with Treatment
Recommendations.
• 2015 American Heart Association Guidelines Update for CPR and ECC.
• 2015 American Heart Association and American Red Cross Guidelines Update for First Aid.
This course meets or exceeds National Emergency Medical Services Education Standards Emergency Medical
Responder Instructional Guidelines.
American Red Cross Scientific Advisory Council
Guidance for the Emergency Medical Response program was provided by members of the American Red Cross
Scientific Advisory Council.
The Council is a panel of nationally recognized experts drawn from a wide variety of scientific, medical and
academic disciplines. The Council provides authoritative guidance on first aid, CPR, emergency treatments,
rescue practices, emergency preparedness, aquatics, disaster health, nursing, education and training.
For more information on the Scientific Advisory Council, visit redcross.org/science.
Emergency Medical Response Content Direction
The American Red Cross team for this edition included:
Jonathan Epstein Joshua Rowland
Senior Director Product Manager
Science & Content Development Healthcare Product Management
Acknowledgments | iii
Table of Contents
UNIT 1:
PREPARATORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Chapter 1 The Emergency Medical Responder. . . . . . . . . . . . . . . . . . . . 2
Chapter 2 The Well-Being of the Emergency
Medical Responder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Chapter 3 Medical, Legal and Ethical Issues. . . . . . . . . . . . . . . . . . . . . 44
Chapter 4 The Human Body . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Chapter 5 Lifting and Moving Patients. . . . . . . . . . . . . . . . . . . . . . . . . . 84
UNIT 2:
ASSESSMENT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
Chapter 6 Scene Size-Up. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
Chapter 7 Primary Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144
Chapter 8 History Taking and Secondary Assessment . . . . . . . . . . . 172
Chapter 9 Communication and Documentation. . . . . . . . . . . . . . . . . . 211
UNIT 3:
AIRWAY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 224
Chapter 10 Airway and Ventilation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225
Chapter 11 Airway Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 258
Chapter 12 Supplemental Oxygen. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281
UNIT 4:
CIRCULATION. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293
Chapter 13 Circulation and Cardiac Emergencies. . . . . . . . . . . . . . . . 294
UNIT 5:
MEDICAL EMERGENCIES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 337
Chapter 14 Medical Emergencies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 338
Chapter 15 Poisoning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 364
Chapter 16 Environmental Emergencies. . . . . . . . . . . . . . . . . . . . . . . . . 387
Chapter 17 Behavioral Emergencies. . . . . . . . . . . . . . . . . . . . . . . . . . . . 422
iv | Emergency Medical Response
UNIT 6:
TRAUMA EMERGENCIES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 436
Chapter 18 Shock . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 437
Chapter 19 Bleeding and Trauma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 444
Chapter 20 Soft Tissue Injuries. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 463
Chapter 21 Injuries to the Chest, Abdomen and Genitalia . . . . . . . . 483
Chapter 22 Injuries to Muscles, Bones and Joints . . . . . . . . . . . . . . . 497
Chapter 23 Injuries to the Head, Neck and Spine . . . . . . . . . . . . . . . . 529
UNIT 7:
SPECIAL POPULATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 555
Chapter 24 Childbirth. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 556
Chapter 25 Pediatrics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 579
Chapter 26 Older Adults and Patients with Special
Healthcare or Functional Needs. . . . . . . . . . . . . . . . . . . . 599
UNIT 8:
EMS OPERATIONS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 614
Chapter 27 EMS Support and Operations . . . . . . . . . . . . . . . . . . . . . . . . 615
Chapter 28 Access and Extrication . . . . . . . . . . . . . . . . . . . . . . . . . . . . 635
Chapter 29 Hazardous Materials Emergencies. . . . . . . . . . . . . . . . . . 646
Chapter 30 Incident Command and Multiple-Casualty
Incidents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 657
Chapter 31 Response to Disasters and Terrorism . . . . . . . . . . . . . . . . 672
Chapter 32 Special Operations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 694
GLOSSARY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 706
SOU RCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 731
PHOTO CREDITS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 734
INDEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 735
Table of Contents | v
Detailed Table of Contents
UNIT 1: PREPARATORY Patient Consent and Refusal of Care. . . . . . . . 48
1 The Emergency Medical Other Legal Issues. . . . . . . . . . . . . . . . . . . . . . . . . . 55
Responder . . . . . . . . . . . . . . . . . . . . . . 2 Confidentiality and Privacy. . . . . . . . . . . . . . . . . . 56
You Are the Emergency Medical Special Situations. . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Responder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Putting It All Together. . . . . . . . . . . . . . . . . . . . . . . 59
Key Terms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
You Are the Emergency Medical
Learning Objectives. . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Responder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
The EMS System. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 4 The Human Body . . . . . . . . . . . . . . . . 60
Emergency Medical Responder. . . . . . . . . . . . . . 9 You Are the Emergency Medical
Putting It All Together. . . . . . . . . . . . . . . . . . . . . . . 14 Responder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Key Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Learning Objectives. . . . . . . . . . . . . . . . . . . . . . . . . 61
2 The Well-Being of the Emergency
Medical Responder . . . . . . . . . . . . . 15 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
You Are the Emergency Medical Medical Terminology. . . . . . . . . . . . . . . . . . . . . . . . 62
Responder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Anatomical Terms. . . . . . . . . . . . . . . . . . . . . . . . . . 63
Key Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Body Systems. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
Learning Objectives. . . . . . . . . . . . . . . . . . . . . . . . . 17 Putting It All Together. . . . . . . . . . . . . . . . . . . . . . 83
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 You Are the Emergency Medical
Preventing Disease Transmission. . . . . . . . . . . . 19 Responder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
Emotional Aspects of Emergency
Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 5 Lifting and Moving Patients. . . . . . . 84
Stress Management. . . . . . . . . . . . . . . . . . . . . . . . . 34 You Are the Emergency Medical
Incident Stress Management. . . . . . . . . . . . . . . . 35 Responder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
Putting It All Together. . . . . . . . . . . . . . . . . . . . . . . 36 Key Terms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
You Are the Emergency Medical Learning Objectives. . . . . . . . . . . . . . . . . . . . . . . . . 86
Responder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Skill Objectives. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
SKILL SHEET 2-1: Removing Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
Disposable Latex-Free Gloves. . . . . . . . . . 38 Role of the Emergency Medical
ENRICHMENT: Health of the Responder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
Emergency Medical Responder . . . . . . . . . 40 Principles of Moving Patients. . . . . . . . . . . . . . . . 87
Emergency Moves. . . . . . . . . . . . . . . . . . . . . . . . . . 90
3 Medical, Legal and Ethical Nonemergency Moves. . . . . . . . . . . . . . . . . . . . . . 92
Issues. . . . . . . . . . . . . . . . . . . . . . . . . 44
Equipment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
You Are the Emergency Medical
Responder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 Patient Positioning and Packaging
for Transport. . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
Key Terms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Medical Restraint. . . . . . . . . . . . . . . . . . . . . . . . . 100
Learning Objectives. . . . . . . . . . . . . . . . . . . . . . . . . 46
Putting It All Together. . . . . . . . . . . . . . . . . . . . . 102
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 You Are the Emergency Medical
Legal Duties . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 Responder. . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
vi | Emergency Medical Response
SKILL SHEET 5-1: Clothes Drag. . . . . . . . . 103 Responsiveness. . . . . . . . . . . . . . . . . . . . . . . . . . . 149
SKILL SHEET 5-2: Blanket Drag. . . . . . . . 104 Airway Status. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
SKILL SHEET 5-3: Shoulder Drag. . . . . . . 106 Breathing Status. . . . . . . . . . . . . . . . . . . . . . . . . . 153
SKILL SHEET 5-4: Ankle Drag . . . . . . . . . . 107 Circulatory Status. . . . . . . . . . . . . . . . . . . . . . . . . 157
SKILL SHEET 5-5: Firefighter’s Drag. . . . 108 Identifying Life Threats. . . . . . . . . . . . . . . . . . . . 161
SKILL SHEET 5-6: Firefighter’s Shock. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
Carry. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109 Putting It All Together. . . . . . . . . . . . . . . . . . . . . 161
SKILL SHEET 5-7: Pack-Strap Carry . . . . . 111 You Are the Emergency Medical
SKILL SHEET 5-8: Walking Assist. . . . . . . . 113 Responder. . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
SKILL SHEET 5-9: Two-Person SKILL SHEET 7-1: Primary
Seat Carry. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . 162
SKILL SHEET 5-10: Direct Ground SKILL SHEET 7-2: Jaw-Thrust
Lift. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 (Without Head Extension)
Maneuver. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
SKILL SHEET 5-11: Extremity Lift. . . . . . . . 117
SKILL SHEET 7-3: Using a
Resuscitation Mask—Adult,
UNIT 2: ASSESSMENT Child and Infant. . . . . . . . . . . . . . . . . . . . . . . 166
6 Scene Size-Up . . . . . . . . . . . . . . . . 120 SKILL SHEET 7-4: Using a
Resuscitation Mask—Head,
You Are the Emergency Medical Neck or Spinal Injury Suspected:
Responder. . . . . . . . . . . . . . . . . . . . . . . . . . . . 120 Jaw-Thrust (Without Head Extension)
Key Terms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 Maneuver—Adult or Child. . . . . . . . . . . . . . 168
Learning Objectives. . . . . . . . . . . . . . . . . . . . . . . 121 ENRICHMENT: Glasgow Coma Scale. . . . 170
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
Dispatch Information . . . . . . . . . . . . . . . . . . . . . . 122 8 History Taking and Secondary
Assessment . . . . . . . . . . . . . . . . . . . 172
Safety. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
You Are the Emergency Medical
Mechanism of Injury and Nature Responder. . . . . . . . . . . . . . . . . . . . . . . . . . . . 172
of Illness. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
Key Terms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173
Additional Resources. . . . . . . . . . . . . . . . . . . . . 134
Learning Objectives. . . . . . . . . . . . . . . . . . . . . . . . 174
Putting It All Together. . . . . . . . . . . . . . . . . . . . . 137
Skill Objectives. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174
You Are the Emergency Medical
Responder. . . . . . . . . . . . . . . . . . . . . . . . . . . . 137 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174
ENRICHMENT: Dealing with Hazards Obtaining the Focused/Medical
at the Scene. . . . . . . . . . . . . . . . . . . . . . . . . . 138 History. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174
Components of a Patient History. . . . . . . . . . . 176
7 Primary Assessment . . . . . . . . . . . 144 SAMPLE History. . . . . . . . . . . . . . . . . . . . . . . . . . 177
You Are the Emergency Medical The Secondary Assessment. . . . . . . . . . . . . . . 179
Responder. . . . . . . . . . . . . . . . . . . . . . . . . . . . 144 Detailed Physical Exam. . . . . . . . . . . . . . . . . . . . 182
Key Terms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 Obtaining Baseline Vital Signs. . . . . . . . . . . . . . 186
Learning Objectives . . . . . . . . . . . . . . . . . . . . . . 146 Ongoing Assessment. . . . . . . . . . . . . . . . . . . . . . 194
Skill Objectives. . . . . . . . . . . . . . . . . . . . . . . . . . . . 146 The Need for More Advanced Medical
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146 Personnel. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195
The Importance of the Scene Putting It All Together. . . . . . . . . . . . . . . . . . . . . 195
Size-Up. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146 You Are the Emergency Medical
General Impression of the Patient . . . . . . . . . 148 Responder. . . . . . . . . . . . . . . . . . . . . . . . . . . . 195
Detailed Table of Contents | vii
SKILL SHEET 8-1: How to Obtain a Skill Objectives. . . . . . . . . . . . . . . . . . . . . . . . . . . . 227
SAMPLE History. . . . . . . . . . . . . . . . . . . . . . 197
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227
SKILL SHEET 8-2: How to Perform
The Respiratory System. . . . . . . . . . . . . . . . . . . . 228
a Secondary Assessment for a
Responsive Trauma Patient. . . . . . . . . . . . 198 Respiratory Emergencies . . . . . . . . . . . . . . . . . . 229
SKILL SHEET 8-3: How to Perform Airway . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233
a Secondary Assessment for an
Unresponsive Patient Who Is Assessing Breathing. . . . . . . . . . . . . . . . . . . . . . 235
Breathing Normally. . . . . . . . . . . . . . . . . . . . 199 Artificial Ventilation. . . . . . . . . . . . . . . . . . . . . . . . 237
SKILL SHEET 8-4: Physical Exam. . . . . . . 200 Putting It All Together. . . . . . . . . . . . . . . . . . . . . 243
SKILL SHEET 8-5: How to Obtain You Are the Emergency Medical
Baseline Vital Signs. . . . . . . . . . . . . . . . . . . 202 Responder. . . . . . . . . . . . . . . . . . . . . . . . . . . . 243
SKILL SHEET 8-6: Taking and SKILL SHEET 10-1: Giving
Recording a Patient’s Blood Ventilations—Adult and Child. . . . . . . . . . 244
Pressure (by Auscultation). . . . . . . . . . . . . 204
SKILL SHEET 10-2: Giving
SKILL SHEET 8-7: Taking and Ventilations—Infant. . . . . . . . . . . . . . . . . . . . 246
Recording a Patient’s Blood
Pressure (by Palpation). . . . . . . . . . . . . . . . 207 SKILL SHEET 10-3: Giving Ventilations—
Head, Neck or Spinal Injury Suspected:
ENRICHMENT: Pulse Oximetry. . . . . . . . . . 209 Jaw-Thrust (Without Head Extension)
Maneuver—Adult and Child. . . . . . . . . . . . 248
9 Communication and SKILL SHEET 10-4: Giving Ventilations
Documentation. . . . . . . . . . . . . . . . . 211 Using a Bag-Valve-Mask Resuscitator—
One Responder. . . . . . . . . . . . . . . . . . . . . . . 250
You Are the Emergency Medical
Responder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211 SKILL SHEET 10-5: Giving Ventilations
Using a Bag-Valve-Mask
Key Terms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212 Resuscitator—Two Responders. . . . . . . . 251
Learning Objectives. . . . . . . . . . . . . . . . . . . . . . . 212
ENRICHMENT: Assessing Breath
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212 Sounds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252
Communicating Within the Emergency ENRICHMENT: Assisting the Patient
Communications System. . . . . . . . . . . . . . . 213 with Asthma. . . . . . . . . . . . . . . . . . . . . . . . . . . 253
Interpersonal Communication. . . . . . . . . . . . . . 217 SKILL SHEET 10-6: Assisting with
The Importance of Documentation. . . . . . . . . 219 an Asthma Inhaler. . . . . . . . . . . . . . . . . . . . . 255
Prehospital Care Report. . . . . . . . . . . . . . . . . . . 219
Transfer of Care. . . . . . . . . . . . . . . . . . . . . . . . . . . 222 11 Airway Management . . . . . . . . . . . 258
Special Situations. . . . . . . . . . . . . . . . . . . . . . . . . 223 You Are the Emergency Medical
Responder. . . . . . . . . . . . . . . . . . . . . . . . . . . . 258
Putting It All Together. . . . . . . . . . . . . . . . . . . . . 223
Key Terms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259
You Are the Emergency Medical
Responder. . . . . . . . . . . . . . . . . . . . . . . . . . . . 223 Learning Objectives. . . . . . . . . . . . . . . . . . . . . . . . 259
Skill Objectives. . . . . . . . . . . . . . . . . . . . . . . . . . . . 259
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259
UNIT 3: AIRWAY
Suctioning. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259
10 Airway and Ventilation. . . . . . . . . . 225
Breathing Devices. . . . . . . . . . . . . . . . . . . . . . . . . 261
You Are the Emergency Medical
Responder. . . . . . . . . . . . . . . . . . . . . . . . . . . . 225 Airway Adjuncts. . . . . . . . . . . . . . . . . . . . . . . . . . . 261
Key Terms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226 Airway Obstruction. . . . . . . . . . . . . . . . . . . . . . . . 263
Learning Objectives. . . . . . . . . . . . . . . . . . . . . . . . 227 Putting It All Together. . . . . . . . . . . . . . . . . . . . . 266
viii | Emergency Medical Response
You Are the Emergency Medical High-Quality CPR. . . . . . . . . . . . . . . . . . . . . . . . . 304
Responder. . . . . . . . . . . . . . . . . . . . . . . . . . . . 267 Automated External Defibrillation . . . . . . . . . . 310
SKILL SHEET 11-1: Using a Automated External Defibrillators. . . . . . . . . . 310
Mechanical Suctioning Device. . . . . . . . . 268
AED Precautions. . . . . . . . . . . . . . . . . . . . . . . . . . . 315
SKILL SHEET 11-2: Using a
Manual Suctioning Device. . . . . . . . . . . . . 270 AED Maintenance . . . . . . . . . . . . . . . . . . . . . . . . . 315
SKILL SHEET 11-3: Inserting Providing CPR/AED for Children
an Oral Airway. . . . . . . . . . . . . . . . . . . . . . . . 272 and Infants . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317
SKILL SHEET 11-4: Choking—Adult CPR/AED Differences for Infants. . . . . . . . . . 319
and Child. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 274 Putting It All Together. . . . . . . . . . . . . . . . . . . . . 324
SKILL SHEET 11-5: Choking—Infant. . . . 276 You Are the Emergency Medical
ENRICHMENT: Nasopharyngeal Responder. . . . . . . . . . . . . . . . . . . . . . . . . . . . 325
Airway. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 278 SKILL SHEET 13-1: CPR/AED—
SKILL SHEET 11-6: Inserting a Adult. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 326
Nasal Airway. . . . . . . . . . . . . . . . . . . . . . . . . . 279 SKILL SHEET 13-2: CPR/AED—
Child. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 329
12 Supplemental Oxygen. . . . . . . . . . . 281 SKILL SHEET 13-3: CPR/AED—
Infant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 333
You Are the Emergency Medical
Responder. . . . . . . . . . . . . . . . . . . . . . . . . . . . 281 ENRICHMENT: Preventing Coronary
Heart Disease . . . . . . . . . . . . . . . . . . . . . . . . 336
Key Terms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 282
Learning Objectives. . . . . . . . . . . . . . . . . . . . . . . 282
UNIT 5: MEDICAL EMERGENCIES
Skill Objectives. . . . . . . . . . . . . . . . . . . . . . . . . . . . 282
14 Medical Emergencies . . . . . . . . . . 338
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 282
You Are the Emergency Medical
Administering Supplemental Oxygen . . . . . . 283 Responder. . . . . . . . . . . . . . . . . . . . . . . . . . . . 338
Safety Precautions. . . . . . . . . . . . . . . . . . . . . . . . 288 Key Terms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 339
Putting It All Together. . . . . . . . . . . . . . . . . . . . . 289 Learning Objectives. . . . . . . . . . . . . . . . . . . . . . . 340
You Are the Emergency Medical Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 341
Responder. . . . . . . . . . . . . . . . . . . . . . . . . . . . 289
General Medical Complaints. . . . . . . . . . . . . . . 341
SKILL SHEET 12-1: Oxygen Delivery. . . . 290
Altered Mental Status. . . . . . . . . . . . . . . . . . . . . 341
Seizures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 343
UNIT 4: CIRCULATION Diabetic Emergencies. . . . . . . . . . . . . . . . . . . . . 346
13 Circulation and Cardiac Stroke. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 349
Emergencies. . . . . . . . . . . . . . . . . . 294
Abdominal Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . 351
You Are the Emergency Medical
Responder. . . . . . . . . . . . . . . . . . . . . . . . . . . . 294 Gastrointestinal Bleeding. . . . . . . . . . . . . . . . . . 353
Key Terms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 295 Hemodialysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 354
Putting It All Together. . . . . . . . . . . . . . . . . . . . . . 355
Learning Objectives. . . . . . . . . . . . . . . . . . . . . . . 296
You Are the Emergency Medical
Skill Objectives. . . . . . . . . . . . . . . . . . . . . . . . . . . . 296
Responder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 355
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297 ENRICHMENT: Basic Pharmacology. . . . . 356
The Circulatory System. . . . . . . . . . . . . . . . . . . . 297 ENRICHMENT: Blood Glucose
Cardiac Arrest. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 302 Monitoring. . . . . . . . . . . . . . . . . . . . . . . . . . . . 363
Detailed Table of Contents | ix
15 Poisoning. . . . . . . . . . . . . . . . . . . . . 364 17 Behavioral Emergencies. . . . . . . . 422
You Are the Emergency Medical You Are the Emergency Medical
Responder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 364 Responder. . . . . . . . . . . . . . . . . . . . . . . . . . . . 422
Key Terms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 365 Key Terms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 423
Learning Objectives. . . . . . . . . . . . . . . . . . . . . . . 366 Learning Objectives. . . . . . . . . . . . . . . . . . . . . . . 423
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 366 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 424
Poison Control Centers. . . . . . . . . . . . . . . . . . . . 367 Behavioral Emergencies. . . . . . . . . . . . . . . . . . . 424
How Poison Enters the Body. . . . . . . . . . . . . . 367 Psychological Emergencies . . . . . . . . . . . . . . . 426
Substance Abuse and Misuse. . . . . . . . . . . . . 371 Violence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 427
Putting It All Together. . . . . . . . . . . . . . . . . . . . . . 380 Providing Care for Behavioral
Emergencies. . . . . . . . . . . . . . . . . . . . . . . . . . 433
You Are the Emergency Medical
Responder. . . . . . . . . . . . . . . . . . . . . . . . . . . . 380 Putting It All Together. . . . . . . . . . . . . . . . . . . . . 434
ENRICHMENT: Administering Nasal You Are the Emergency Medical
Naloxone. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 381 Responder. . . . . . . . . . . . . . . . . . . . . . . . . . . . 435
ENRICHMENT: Administering
Activated Charcoal. . . . . . . . . . . . . . . . . . . . 382
UNIT 6: TRAUMA EMERGENCIES
ENRICHMENT: Carbon Monoxide
and Cyanide Poisoning. . . . . . . . . . . . . . . . 383 18 Shock . . . . . . . . . . . . . . . . . . . . . . . 437
You Are the Emergency Medical
Responder. . . . . . . . . . . . . . . . . . . . . . . . . . . . 437
16 Environmental Emergencies. . . . . 387
Key Terms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 438
You Are the Emergency Medical
Responder. . . . . . . . . . . . . . . . . . . . . . . . . . . . 387 Learning Objectives. . . . . . . . . . . . . . . . . . . . . . . 438
Key Terms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 388 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 438
Learning Objectives. . . . . . . . . . . . . . . . . . . . . . . 389 What Is Shock?. . . . . . . . . . . . . . . . . . . . . . . . . . . . 438
Skill Objectives. . . . . . . . . . . . . . . . . . . . . . . . . . . . 389 Why Shock Occurs. . . . . . . . . . . . . . . . . . . . . . . . 439
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 389 Types of Shock. . . . . . . . . . . . . . . . . . . . . . . . . . . . 439
Body Temperature. . . . . . . . . . . . . . . . . . . . . . . . . 390 Signs and Symptoms of Shock. . . . . . . . . . . . 440
People at Risk for Heat-Related Illnesses Providing Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . 442
and Cold-Related Emergencies. . . . . . . . 391 Putting It All Together. . . . . . . . . . . . . . . . . . . . . 442
Heat-Related Illnesses . . . . . . . . . . . . . . . . . . . . 391 You Are the Emergency Medical
Cold-Related Emergencies. . . . . . . . . . . . . . . . 396 Responder. . . . . . . . . . . . . . . . . . . . . . . . . . . . 443
Preventing Heat-Related Illnesses
and Cold-Related Emergencies. . . . . . . . 400 19 Bleeding and Trauma. . . . . . . . . . . 444
Anaphylaxis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 400 You Are the Emergency Medical
Bites and Stings. . . . . . . . . . . . . . . . . . . . . . . . . . . 403 Responder. . . . . . . . . . . . . . . . . . . . . . . . . . . . 444
Water-Related Emergencies. . . . . . . . . . . . . . . . 410 Key Terms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 445
Putting It All Together. . . . . . . . . . . . . . . . . . . . . . 414 Learning Objectives. . . . . . . . . . . . . . . . . . . . . . . 446
You Are the Emergency Medical Skill Objectives. . . . . . . . . . . . . . . . . . . . . . . . . . . . 446
Responder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 414 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 446
SKILL SHEET 16-1: Administering Incidence/Significance of Trauma. . . . . . . . . 446
an Epinephrine Auto-Injector. . . . . . . . . . . 415
Trauma System. . . . . . . . . . . . . . . . . . . . . . . . . . . . 447
ENRICHMENT: Lightning. . . . . . . . . . . . . . . . . 418
Multi-System Trauma. . . . . . . . . . . . . . . . . . . . . . 447
ENRICHMENT: SCUBA and Free Diving
Emergencies. . . . . . . . . . . . . . . . . . . . . . . . . . 420 Perfusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 447
x | Emergency Medical Response
Bleeding. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 448 22 Injuries to Muscles, Bones
and Joints. . . . . . . . . . . . . . . . . . . . 497
Dressings and Bandages. . . . . . . . . . . . . . . . . . 449
You Are the Emergency Medical
External Bleeding. . . . . . . . . . . . . . . . . . . . . . . . . 451
Responder. . . . . . . . . . . . . . . . . . . . . . . . . . . . 497
Internal Bleeding. . . . . . . . . . . . . . . . . . . . . . . . . . 455
Key Terms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 498
Putting It All Together. . . . . . . . . . . . . . . . . . . . . 456
Learning Objectives. . . . . . . . . . . . . . . . . . . . . . . 499
You Are the Emergency Medical
Skill Objectives. . . . . . . . . . . . . . . . . . . . . . . . . . . . 499
Responder. . . . . . . . . . . . . . . . . . . . . . . . . . . . 456
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 499
SKILL SHEET 19-1: Using Direct
Pressure to Control External Musculoskeletal System. . . . . . . . . . . . . . . . . . . 499
Bleeding. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 457 Injuries to Muscles, Bones and
SKILL SHEET 19-2: Using a Joints. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 500
Commercial Tourniquet with Splinting. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 505
a Windlass. . . . . . . . . . . . . . . . . . . . . . . . . . . . 458
Putting It All Together. . . . . . . . . . . . . . . . . . . . . . 513
ENRICHMENT: Mechanisms of
Injury—The Kinematics of Trauma. . . . . 459 You Are the Emergency Medical
Responder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 513
SKILL SHEET 22-1: Applying a Rigid
20 Soft Tissue Injuries . . . . . . . . . . . . 463 Splint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 514
You Are the Emergency Medical SKILL SHEET 22-2: Applying a Sling
Responder. . . . . . . . . . . . . . . . . . . . . . . . . . . . 463 and Binder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 516
Key Terms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 464 SKILL SHEET 22-3: Applying an
Learning Objectives. . . . . . . . . . . . . . . . . . . . . . . 464 Anatomic Splint. . . . . . . . . . . . . . . . . . . . . . . . 518
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 465 SKILL SHEET 22-4: Applying a Soft
Splint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 520
Skin and Soft Tissue Injuries. . . . . . . . . . . . . . . 465
ENRICHMENT: Agricultural and
Closed Wounds . . . . . . . . . . . . . . . . . . . . . . . . . . . 466
Industrial Emergencies. . . . . . . . . . . . . . . . 522
Open Wounds. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 467
Burns. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 473
23 Injuries to the Head, Neck
Putting It All Together. . . . . . . . . . . . . . . . . . . . . 482 and Spine . . . . . . . . . . . . . . . . . . . . 529
You Are the Emergency Medical You Are the Emergency Medical
Responder. . . . . . . . . . . . . . . . . . . . . . . . . . . . 482 Responder. . . . . . . . . . . . . . . . . . . . . . . . . . . . 529
Key Terms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 530
21 Injuries to the Chest, Abdomen Learning Objectives. . . . . . . . . . . . . . . . . . . . . . . 530
and Genitalia . . . . . . . . . . . . . . . . . 483
Skill Objectives. . . . . . . . . . . . . . . . . . . . . . . . . . . . 530
You Are the Emergency Medical
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 530
Responder. . . . . . . . . . . . . . . . . . . . . . . . . . . . 483
Anatomy of the Head, the Neck
Key Terms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 484
and the Spine. . . . . . . . . . . . . . . . . . . . . . . . . 531
Learning Objectives. . . . . . . . . . . . . . . . . . . . . . . 484
Injuries to the Head. . . . . . . . . . . . . . . . . . . . . . . . 531
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 485
Injuries to the Neck and Spine. . . . . . . . . . . . . 539
Anatomy of the Chest, Abdomen
Putting It All Together. . . . . . . . . . . . . . . . . . . . . 542
and Genitalia. . . . . . . . . . . . . . . . . . . . . . . . . . 485
You Are the Emergency Medical
Chest Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 485
Responder. . . . . . . . . . . . . . . . . . . . . . . . . . . . 542
Abdominal Injuries. . . . . . . . . . . . . . . . . . . . . . . . . 492
SKILL SHEET 23-1: Controlling
Genital Injuries. . . . . . . . . . . . . . . . . . . . . . . . . . . . 495 Bleeding from an Open Head
Putting It All Together. . . . . . . . . . . . . . . . . . . . . 496 Wound. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 543
You Are the Emergency Medical SKILL SHEET 23-2: Caring for Foreign
Responder. . . . . . . . . . . . . . . . . . . . . . . . . . . . 496 Bodies in the Eye . . . . . . . . . . . . . . . . . . . . . 545
Detailed Table of Contents | xi
SKILL SHEET 23-3: Bandaging Assessing Pediatrics. . . . . . . . . . . . . . . . . . . . . . 583
an Eye with an Injury from an Common Problems in Pediatric
Impaled Object. . . . . . . . . . . . . . . . . . . . . . . . 546 Patients. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 588
SKILL SHEET 23-4: Spinal Motion The Emergency Medical Responder’s
Restriction Using Manual Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 597
Stabilization. . . . . . . . . . . . . . . . . . . . . . . . . . . 547
Putting It All Together. . . . . . . . . . . . . . . . . . . . . 597
ENRICHMENT: Removing Helmets
and Other Equipment. . . . . . . . . . . . . . . . . . 548 You Are the Emergency Medical
Responder. . . . . . . . . . . . . . . . . . . . . . . . . . . . 598
ENRICHMENT: Cervical Collars and
Backboarding. . . . . . . . . . . . . . . . . . . . . . . . . 551
SKILL SHEET 23-5: Immobilizing 26 Older Adults and Patients
a Head, Neck or Spinal Injury. . . . . . . . . . 553 with Special Healthcare or
Functional Needs. . . . . . . . . . . . . . 599
You Are the Emergency Medical
UNIT 7: SPECIAL POPULATIONS Responder. . . . . . . . . . . . . . . . . . . . . . . . . . . . 599
24 Childbirth . . . . . . . . . . . . . . . . . . . . 556 Key Terms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 600
You Are the Emergency Medical Learning Objectives. . . . . . . . . . . . . . . . . . . . . . . 600
Responder. . . . . . . . . . . . . . . . . . . . . . . . . . . . 556
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 601
Key Terms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 557
Older Adult Patients. . . . . . . . . . . . . . . . . . . . . . . 601
Learning Objectives. . . . . . . . . . . . . . . . . . . . . . . 558
Patients with Special Healthcare
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 558 or Functional Needs. . . . . . . . . . . . . . . . . . . 608
Anatomy and Physiology of Pregnancy. . . . 558 Putting It All Together. . . . . . . . . . . . . . . . . . . . . 613
Normal Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . 559 You Are the Emergency Medical
Birth and Labor Process. . . . . . . . . . . . . . . . . . . 560 Responder. . . . . . . . . . . . . . . . . . . . . . . . . . . . 613
Preparing for Delivery. . . . . . . . . . . . . . . . . . . . . 563
Delivery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 564 UNIT 8: EMS OPERATIONS
Caring for the Newborn and 27 EMS Support and Operations. . . . . 615
Mother. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 565 You Are the Emergency Medical
Complications During Pregnancy. . . . . . . . . . 569 Responder. . . . . . . . . . . . . . . . . . . . . . . . . . . . 615
Complications During Delivery. . . . . . . . . . . . . 571 Key Terms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 616
Putting It All Together. . . . . . . . . . . . . . . . . . . . . 574 Learning Objectives. . . . . . . . . . . . . . . . . . . . . . . 616
You Are the Emergency Medical Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 616
Responder. . . . . . . . . . . . . . . . . . . . . . . . . . . . 575 Roles of the EMR in the
ENRICHMENT: More Complications EMS System. . . . . . . . . . . . . . . . . . . . . . . . . . 617
During Pregnancy and Delivery. . . . . . . . 576 Phases of a Response. . . . . . . . . . . . . . . . . . . . . 617
Air Medical Transport Considerations. . . . . . 622
25 Pediatrics. . . . . . . . . . . . . . . . . . . . 579 Emergency Vehicle Safety. . . . . . . . . . . . . . . . . 627
You Are the Emergency Medical Leaving the Scene . . . . . . . . . . . . . . . . . . . . . . . . 632
Responder. . . . . . . . . . . . . . . . . . . . . . . . . . . . 579
EMS Equipment. . . . . . . . . . . . . . . . . . . . . . . . . . . 632
Key Terms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 580
Putting It All Together. . . . . . . . . . . . . . . . . . . . . 633
Learning Objectives. . . . . . . . . . . . . . . . . . . . . . . 580
You Are the Emergency Medical
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 581 Responder. . . . . . . . . . . . . . . . . . . . . . . . . . . . 633
Anatomical Differences . . . . . . . . . . . . . . . . . . . 581 ENRICHMENT: Operational Safety
Child Development. . . . . . . . . . . . . . . . . . . . . . . . 582 and Security Measures. . . . . . . . . . . . . . . . 634
xii | Emergency Medical Response
28 Access and Extrication . . . . . . . . . 635 Stress at an MCI. . . . . . . . . . . . . . . . . . . . . . . . . . . 670
You Are the Emergency Medical Communication . . . . . . . . . . . . . . . . . . . . . . . . . . . 671
Responder. . . . . . . . . . . . . . . . . . . . . . . . . . . . 635 Putting It All Together. . . . . . . . . . . . . . . . . . . . . 671
Key Terms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 636 You Are the Emergency Medical
Learning Objectives. . . . . . . . . . . . . . . . . . . . . . . 636 Responder. . . . . . . . . . . . . . . . . . . . . . . . . . . . 671
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 636
Fundamentals of Extrication 31 Response to Disasters and
and Rescue Operations. . . . . . . . . . . . . . . 637 Terrorism. . . . . . . . . . . . . . . . . . . . . 672
Vehicle Stabilization. . . . . . . . . . . . . . . . . . . . . . . 641 You Are the Emergency Medical
Responder. . . . . . . . . . . . . . . . . . . . . . . . . . . . 672
Gaining Access . . . . . . . . . . . . . . . . . . . . . . . . . . . 642
Key Terms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 673
Extrication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 644
Learning Objectives. . . . . . . . . . . . . . . . . . . . . . . 673
Putting It All Together. . . . . . . . . . . . . . . . . . . . . 645
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 674
You Are the Emergency Medical
Responder. . . . . . . . . . . . . . . . . . . . . . . . . . . . 645 Preparing for Disasters and Terrorist
Incidents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 674
Incident Management. . . . . . . . . . . . . . . . . . . . . 674
29 Hazardous Materials
Emergencies. . . . . . . . . . . . . . . . . . 646 The Role of the Emergency Medical
Responder. . . . . . . . . . . . . . . . . . . . . . . . . . . . 677
You Are the Emergency Medical
Responder. . . . . . . . . . . . . . . . . . . . . . . . . . . . 646 Disaster Response. . . . . . . . . . . . . . . . . . . . . . . . 677
Key Terms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 647 WMD (Chemical, Biological,
Radiological/Nuclear and
Learning Objectives. . . . . . . . . . . . . . . . . . . . . . . 647
Explosive Incidents). . . . . . . . . . . . . . . . . . 680
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 647
Response to a CBRNE WMD
Hazardous Materials. . . . . . . . . . . . . . . . . . . . . . . 647 Incident. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 686
HAZMAT Incidents. . . . . . . . . . . . . . . . . . . . . . . . 649 Providing Self-Care and Peer Care
Scene Safety and Personal Protective for Nerve Agents. . . . . . . . . . . . . . . . . . . . . . 689
Equipment. . . . . . . . . . . . . . . . . . . . . . . . . . . . 652 Putting It All Together. . . . . . . . . . . . . . . . . . . . . 690
Contamination and Decontamination. . . . . . 654 You Are the Emergency Medical
Putting It All Together. . . . . . . . . . . . . . . . . . . . . 656 Responder. . . . . . . . . . . . . . . . . . . . . . . . . . . . 691
You Are the Emergency Medical ENRICHMENT: Preparing
Responder. . . . . . . . . . . . . . . . . . . . . . . . . . . . 656 for a Public Health Disaster—
Pandemic Flu. . . . . . . . . . . . . . . . . . . . . . . . . 692
ENRICHMENT: Personal Preparedness. . 693
30 Incident Command and
Multiple-Casualty Incidents . . . . . 657
You Are the Emergency Medical 32 Special Operations . . . . . . . . . . . . 694
Responder. . . . . . . . . . . . . . . . . . . . . . . . . . . . 657 You Are the Emergency Medical
Key Terms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 658 Responder. . . . . . . . . . . . . . . . . . . . . . . . . . . . 694
Learning Objectives. . . . . . . . . . . . . . . . . . . . . . . 658 Key Terms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 695
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 659 Learning Objectives. . . . . . . . . . . . . . . . . . . . . . . 695
National Incident Management Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 695
System. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 659 Hazardous Terrain. . . . . . . . . . . . . . . . . . . . . . . . . 699
Multiple-Casualty Incidents. . . . . . . . . . . . . . . . 661 Confined Space. . . . . . . . . . . . . . . . . . . . . . . . . . . 700
Triage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 662 Crime Scene. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 701
Detailed Table of Contents | xiii
Fireground Operations. . . . . . . . . . . . . . . . . . . . . 702 Glossary. . . . . . . . . . . . . . . . . . . . . . . . 706
Special Events and Standby. . . . . . . . . . . . . . . 703 Sources. . . . . . . . . . . . . . . . . . . . . . . . . . 731
Putting It All Together. . . . . . . . . . . . . . . . . . . . . 704 Photo Credits. . . . . . . . . . . . . . . . . . . . 734
You Are the Emergency Medical
Index. . . . . . . . . . . . . . . . . . . . . . . . . . . 735
Responder. . . . . . . . . . . . . . . . . . . . . . . . . . . . 705
xiv | Emergency Medical Response
Key Features
The American Red Cross Emergency Medical Response program is designed to be a flexible training solution and
is part of a comprehensive suite of high-quality health and safety training programs offered by one of the most
respected brands in the world.
This program has been completely revised to reflect the latest science in first aid, CPR and cardiovascular care.
The course has also been redesigned to align with updated EMS Educational Standards.
This Emergency Medical Response textbook has also been revised with instructors’ and participants’ needs in
mind. The new affordable, user-friendly training materials enrich the learning experience for EMRs at every level.
The new course includes:
An interactive course format featuring rescue scenarios and hands-on exercises.
Fully updated participant materials, including a textbook and workbook.
7 PRIMARY
ASSESSMENT
You Are the Emergency Medical Responder
Your rescue unit arrives at a scene to find a distraught mother who says, “I can’t wake
my baby up.” The infant appears to be unconscious and is turning blue. How would you
respond? What are your immediate priorities? What should you do first?
You Are the Emergency Medical
Responder
At the start of each chapter, readers will find a
unique, real-life scenario description that features
an emergency involving different EMRs. Readers are
asked to assess the situation and are prompted to
think about what should be done. These scenarios
help frame what will be discussed in the chapter, and
encourage the participant to start thinking about what
to do and the proper sequence in a given emergency.
A concluding scenario at the end of each chapter
builds on the opening scenario and allows readers to
apply the knowledge and skills gained to help answer
the questions posed.
Key Features | xv
KEY TERMS LEARNING OBJECTIVES
Agonal breaths: Isolated or infrequent gasping in Level of consciousness (LOC): A person’s After reading this chapter, and completing the class • Describe the methods used to assess
the absence of normal breathing in an unconscious state of awareness, ranging from being fully activities, you will have the information needed to: circulatory status.
person; can occur after the heart has stopped alert to unconscious; also referred to as • Explain the differences in obtaining a pulse in an
• Summarize the reasons for forming a general
beating. Agonal breaths are not normal breathing mental status. impression of the patient. adult, a child and an infant.
and are considered a sign of cardiac arrest. • Explain the need to assess a patient for
Minute volume: The amount of air breathed in a • Explain the purpose of the primary
(initial) assessment. external bleeding.
Airway: The pathway for air from the mouth and nose minute; calculated by multiplying the volume of
through the pharynx, larynx and trachea and into air inhaled at each breath (in mL) by the number • Describe methods for assessing a patient’s level of • Describe how to assess a patient for
the lungs. of breaths per minute. consciousness (LOC). severe bleeding.
• Explain the differences in assessing the LOC of an • Describe how to assess breathing rate and quality,
AVPU: Mnemonic describing the four levels of patient Perfusion: The circulation of blood through the pulse rate and quality, and skin appearance.
response: Alert, Verbal, Painful and Unresponsive. body or through a particular body part for the adult, a child and an infant.
purpose of exchanging oxygen and nutrients • Describe methods of assessing whether a patient • Describe how to establish priorities for care
Brachial artery: The main artery of the upper arm; is breathing. including recognition and management of shock.
with carbon dioxide and other wastes.
runs from the shoulder down to the bend of
• Distinguish a patient with adequate breathing from
the elbow. Primary (initial) assessment: A check for
a patient with inadequate breathing.
conditions that are an immediate threat to a
Breathing rate: Term used to describe the number patient’s life.
of breaths per minute.
Pulse: The beat felt from each rhythmic contraction
Capillary refill: A technique for estimating how of the heart. SKILL OBJECTIVES
the body is reacting to injury or illness by
checking the ability of the capillaries to refill Respiratory arrest: A condition in which there is
with blood. an absence of normal breathing. After reading this chapter, and completing the class • Demonstrate how to open the airway using the
activities, you should be able to: head-tilt/chin-lift maneuver and the jaw-thrust
Carotid artery: The major artery located on either Respiratory distress: A condition in which a (without head extension) maneuver.
side of the neck that supplies blood to the brain. person is having difficulty breathing or requires • Perform a primary assessment.
• Demonstrate how to use a resuscitation mask.
extra effort to breathe. • Demonstrate how to assess LOC.
CPR breathing barrier: Device that allows for
ventilations without direct mouth-to-mouth contact Signs: Term used to describe any observable
between the responder and the patient; includes evidence of injury or illness, such as bleeding or
resuscitation masks, face shields and bag-valve- unusual skin color.
mask (BVM) resuscitators.
Signs of life: A term sometimes used to INTRODUCTION THE IMPORTANCE
Cyanotic: Showing bluish discoloration of the describe normal breathing and a pulse in an
In previous chapters, you learned how to prepare OF THE SCENE SIZE-UP
skin, nailbeds and mucous membranes due to unresponsive patient.
for an emergency, the precautions to take when Once you recognize that an emergency has
insufficient levels of oxygen in the blood.
Stoma: A surgical opening in the body; a stoma may approaching the scene and how to recognize occurred and decide to act, always remember the
Glasgow Coma Scale (GCS): A measure of level be created in the neck following surgery on the a dangerous situation. You also learned about importance of sizing up the scene first. A primary
of consciousness (LOC) based on eye opening, trachea to allow the patient to breathe. your roles and responsibilities. As an emergency assessment should never occur until after the
verbal response and motor response. medical responder (EMR), you can make a scene size-up. The four main components to
Symptoms: What the patient reports experiencing, difference in an emergency—you may even save a consider during a scene size-up include:
Head-tilt/chin-lift maneuver: A common method such as pain, nausea, headache or shortness life. But to do this, you must learn how to provide
for opening the airway unless the patient is of breath. care for an injured or ill person, and set priorities 1. Scene safety.
suspected of having an injury to the head, neck for that care. 2. The mechanism of injury (MOI) or nature
or spine. Vital signs: Important information about the patient’s
condition obtained by checking respiratory rate, of illness.
When an emergency occurs, one of the most
Hypoxic: Having below-normal concentrations of pulse and blood pressure. 3. The number of patients involved.
essential aspects of your job is the primary
oxygen in the organs and tissues of the body. (initial) assessment. The primary assessment 4. The resources needed.
Jaw-thrust (without head extension) maneuver: is the process used to quickly identify those
A maneuver for opening the airway in a patient conditions that represent an immediate threat Ensuring Scene Safety
suspected of having an injury to the head, neck to the patient’s life, so that you may properly Always begin by making sure the scene is safe
treat them as they are found. An effective
the necessary or spine. and equipment, do not
training or nature of illness may be the only way you can for you, other responders, the patient(s) and
primary assessment includes creating a any bystanders, as discussed in Chapter 6.
approach the patient—summon the appropriate identify what occurred. general impression of the patient, checking for
personnel. Keep assessing the situation, and, Take the necessary precautions when working
responsiveness and checking airway, breathing in a dangerous environment. If you do not have
if conditions change, you then may be able to Recognizing Patients and circulatory status.
approach the patient. Remember, nothing is gained
by risking your safety. An emergency that begins When you size up the scene, look carefully for
with one injured or ill person could end up with two more than one patient. You may not see everyone
if you are hurt. at first. For example, in a motor-vehicle collision, 146 | Emergency Medical Response
an open door may be a clue that someone has left
the vehicle or was thrown from it. If one patient is
Determining Mechanism of Injury Chapter 7: Primary Assessment | 145
bleeding or screaming loudly, you may overlook
or Nature of Illness another patient who is unconscious. It is also easy
When attempting to determine the MOI or nature in an emergency situation to overlook small children
of illness, you must look around the scene for clues or infants if they are not crying.
to what caused the emergency and the extent of
Key Terms and Glossary Learning Objectives and
the damage (Fig. 7-1). Consider the force that may
have been involved in creating an injury. These Summoning More Advanced
considerations will help you to think about the Medical Personnel
possible types and extent of the patient’s injuries. At times, you may be unsure if more advanced
Skill Objectives
Take in the whole picture. How a motor vehicle medical personnel are needed. For example, the
is damaged or the presence of nearby objects, patient may ask you not to call an ambulance or
such as shattered glass, a fallen ladder or a spilled transport vehicle to avoid embarrassment about
A list of the key terms that most EMS personnel
medicine container, may suggest what happened. creating a scene. Your training as an EMR will help
If the patient is unconscious, determining the MOI you make the decision. As a general rule, summon
should be familiar with appears at the beginning These objectives represent the key material
of each chapter. These key terms are in boldface covered in the chapter, as well as the skills in
italics the first time they are explained in the which the participants will be trained.
chapter and also appear in the glossary.
Fig. 7-1: Search the scene for clues to determine what caused the emergency or injury and the
extent of the damage.
CRITICAL Primary assessment is essential to the job of an EMR to ensure proper care. patient or an unconscious medical patient, the Considerations for Older Adults
FACTS However, a scene size-up to evaluate safety, MOI or nature of illness, number of history will likely be performed after the physical Keep in mind that older people usually prefer
patients and resources needed should always be done first. exam. For a medical patient who is responsive, the to be addressed more formally, as in
history will likely be performed first. “Mr. Smith” or “Mrs. Smith.” Position yourself
To determine the MOI or nature of illness, check the scene for clues and consider at eye level with the patient and speak slowly.
Under ideal circumstances, patients will be able
the force that may have been involved. Older patients may sometimes appear
to tell you themselves all you need to know about confused. This can be caused by conditions
what happened and any related medical issues. such as dementia or Alzheimer’s disease. It
Help relieve the patient’s anxiety by explaining who can also be the result of an acute medical
you are and that you are there to help. Also ask the condition and may not be typical behavior for
Chapter 7: Primary Assessment | 147 patient’s name and use it. Always obtain consent that person. Make sure the patient can see
before touching or providing care to a patient. and hear you, as an older patient may have
vision or hearing problems. Allow time for
Pediatric Considerations the older patient to respond. Always treat the
If a child or an infant does not respond to patient with dignity and respect (Fig. 8-1).
your questions, it does not always mean the
child or infant is unable to respond. Children Sources of information may also be all around
and infants may be frightened of you or the you. Be sure to check the patient for a medical
situation, may not understand the question or identification tag or bracelet, or other medical
may not be able to speak. Position yourself information sources, such as wallet cards or mobile
at or below eye level with the child to avoid phone apps. Other hints include the presence of
being intimidating. Do not separate the medication containers, medical equipment or a
child from a parent or legal guardian, unless service animal. If you are in the patient’s home,
absolutely necessary. you should also look for a Vial of Life label on
the outside of the refrigerator door—it signifies
Necessary information cannot always be obtained that a vial or container, such as a sealable plastic
from the patient. The patient may be unconscious, bag, contains vital medical information and has
disoriented, agitated or otherwise uncooperative, been placed on the top shelf of the refrigerator
or the patient may not understand and/or speak door. Some people keep their medications in the
English. In these cases, interviews with family, refrigerator, so it also is a good idea to look for
friends, caregivers, bystanders or public safety these items.
personnel may be helpful.
Critical Facts Pediatric Considerations and
Considerations for Older Adults
Brief summaries of crucial parts of the chapter are
called out for quick and easy reference. Focus on considerations in the pediatric and older
adult populations EMRs should be aware of when
responding to an emergency.
Fig. 8-1: Always treat older patients with dignity and respect.
Chapter 8: History Taking and Secondary Assessment | 175
xvi | Emergency Medical Response
The primary assessment helps to identify any life-
stable patients every 15 minutes, or as deemed threatening conditions so they can be cared for
appropriate by the patient’s condition. rapidly. Problems that are not an immediate threat The amount of effort a conscious patient puts into Breathing very shallow respirations. The patient
can become serious if you do not recognize them breathing can be observed by watching to see if is likely not receiving an adequate supply
Newborn Considerations and provide care. By following the proper steps the patient is using the accessory muscles—the of oxygen.
The APGAR scoring system is the universally when conducting the primary assessment, you muscles in the neck, between the ribs and/or the Breathing increasingly slow. Oxygen intake
accepted method of assessing a newborn at will give the patient with a serious injury or illness abdomen—to breathe. Nasal flaring is another will be dropping and the patient is likely not
1 minute after birth, at 5 minutes after birth the best chance for survival. Before you proceed indication of difficulty breathing, as is the tripod receiving an adequate supply of oxygen.
and again at 10 minutes after birth. APGAR with a primary assessment, be certain to size up position, where the patient sits and leans forward,
bracing both arms on knees or an adjacent surface
Tolerant of assisted ventilation. For those who
stands for Appearance, Pulse, Grimace, the scene to make sure there are no dangers to are not tolerant of assisted ventilation, you can
Activity and Respiration. The term APGAR you, the patient and bystanders, and to consider for support to aid breathing. use a “blow-by” technique. Refer to Chapter 12
also stands for the person who developed it, the MOI, nature of illness, the number of patients Administer supplemental oxygen or provide for more information.
Virginia Apgar, MD. For more information on involved and additional resources you may need. ventilations as appropriate, based on local
assessing a newborn, refer to Chapter 24. It is important to remember that the respiratory
protocols, if the patient is having trouble breathing. status of a patient can change suddenly
The essential aspects to the primary assessment
This would be necessary if the patient is: (Table 7-3).
are making a general impression of the patient and
SHOCK checking responsiveness, airway, breathing and Unresponsive. Monitor the patient’s airway If the patient is not breathing normally and
circulation. Determine if there are any immediate to ensure that respirations are continuing and
If the patient shows signs of shock, you will need has no pulse and the cause is the result of a
threats to life, such as the presence of severe, are effective.
to provide care for shock during the primary drowning, give 2 ventilations prior to beginning
life-threatening bleeding, or an absence of Hypoxic. Pale, cool, clammy, moist skin is an CPR. Provide ventilations using a resuscitation
assessment. In order to determine whether shock
breathing or pulse. early sign of inadequate oxygenation. mask or BVM. These CPR breathing barriers
should be treated immediately, watch for:
Although this plan of action can help you decide Cyanotic. The patient is not receiving can help protect against disease transmission
Decreased responsiveness.
what care to provide in any emergency, providing adequate oxygen. This is a clear but late sign when performing CPR or giving ventilations to
Unresponsiveness to verbal commands. care is not an exact science. Because each
of inadequate oxygenation. The mouth, lips and a patient.
A heart rate that is too fast or too slow. nailbeds would appear blue in color.
emergency and each patient is unique, an emergency
Skin signs of shock. may not occur exactly as it did in a classroom setting.
Table 7-3:
A weak or no radial pulse (brachial pulse Even within a single emergency, the care needed
for infants). may change from one moment to the next. Respiratory Status and Providing Care
SIGNS RESPIRATORY STATUS PROVIDING CARE
You Are the Emergency Medical Responder
• Normal rate and depth of breathing • Breathing is adequate • Monitor breathing for any changes
As you begin a primary assessment, you verify that the infant is unconscious. What are your
• Absence of abnormal breath sounds • Administer supplemental oxygen, if
next steps in the primary assessment? Should you call for more advanced medical personnel? • Air moves freely in and out of the chest available, based on local protocols
Why or why not? • Normal skin color
• Rate and/or depth of breathing is • Breathing is inadequate • Assist ventilations
Chapter 7: Primary Assessment | 161 slower or faster than normal range • Breathing is either slow • Administer supplemental oxygen, if
• Breathing is shallow or shallow available, based on local protocols
• There are no breath sounds or breath • Patient is moving some
sounds are diminished air in and out of the chest
• Breathing is noisy: crowing, stridor, • Breathing is not enough
snoring, gurgling or gasping to sustain life
• Cyanosis (blue or gray skin color)
• Decreased minute volume
• The chest does not rise • Patient is not breathing • Provide ventilation
• No evidence of air moving in through • Administer supplemental oxygen, if
mouth or nose available, based on local protocols
• There are no breath sounds
CRITICAL It is important to remember that the respiratory status of a patient can change
FACTS suddenly.
154 | Emergency Medical Response Chapter 7: Primary Assessment | 155
Putting It All Together Tables
A wrap-up for each chapter, touching on the key Clear, visual presentation of certain key information.
objectives and points covered.
Never move a joint that is painful, red or swollen.
Skill Sheet Service Animals Handle the patient’s joints carefully, supporting
the areas above and below the joint when you
A service animal is any guide dog, signal dog move them.
Skill Sheet 7-2 or other animal individually trained to provide
assistance to an individual with a disability. Cancer
Jaw-Thrust (Without Head Extension) These animals are considered service animals
under the Americans with Disabilities Act
Cancer is the abnormal growth of new cells that
can spread and crowd out or destroy other body
Maneuver (ADA), whether or not they have been licensed
or certified by a state or local government.
tissues in the form of a malignant tumor, which
is a solid mass or a growth of abnormal cells
NOTE: Always follow standard precautions when providing care. that can grow anywhere in the body. Malignant
Service dogs perform some of the functions tumors can spread to other parts of the body,
After sizing up the scene and establishing that the patient is unresponsive, lying face-up and a head, and tasks that the individual with a disability growing quickly and invading and destroying other
neck or spinal injury is suspected: cannot perform independently. These dogs body tissue.
receive special training to help assist patients
with many different types of disabilities, such Typically, cancer is treated according to the type
as visual impairment, limited mobility, balance and location of the cancer, and whether or not it
STEP 1 problems, autism, seizures, or other medical has spread. The three most common approaches
Kneel above the patient’s head. problems like low blood sugar or psychiatric to treatment are surgery, chemotherapy and
disabilities. Services include retrieving objects, radiation. Common side effects of chemotherapy
pulling wheelchairs, opening and closing doors, include nausea, diarrhea, loss of hair and extremely
turning light switches off and on, barking when dry skin. Many people will experience skin burns,
help is needed, finding another person, leading fatigue, and possibly nausea and vomiting with
the person to the handler, assisting with radiation treatment; others may experience
▼ balance and counterbalance, providing deep hair loss as a result of the radiation treatment.
pressure and many other individual tasks.
When providing care for a person being treated
STEP 2 A service animal is not a pet and can be identified for cancer, infection control is important because
by either a backpack or special harness. By chemotherapy and radiation affect a person’s
Put one hand on each side of the patient’s head, with
law, service animals must be allowed into most immune system. Strict hand-washing guidelines
your thumbs near the corners of the mouth pointed
toward the chin. establishments. EMRs should not handle the and standard precautions must be taken. Never
service animal unless absolutely required. Never provide care for a patient who is receiving cancer
separate the patient from the service animal, as treatment if you have a cold or flu.
this could cause stress, agitation and anxiety to
both parties which can complicate patient care. A patient receiving chemotherapy or radiation
▼ It could also become a safety issue. treatment may feel tired. Skin changes and rashes
from some drugs or burns from radiation treatment
are common, so be gentle.
STEP 3
Use your elbows for support if needed. Cerebral Palsy
Cerebral palsy is the name given to a group of
▼ disorders affecting a person’s ability to move and
maintain balance and posture. It does not get
STEP 4 worse over time, although symptoms can change
over a patient’s lifetime.
Slide your fingers into position under the angles of the patient’s jawbone.
■ For a child or an infant, only use two or three fingers of each hand. Cerebral palsy causes damage to the part of
the brain that controls the amount of resistance
▼ to movement in a muscle (muscle tone), which
allows you to keep your body in specific postures
or positions.
STEP 5
Without moving the patient’s head, apply downward pressure with your thumbs and lift the jaw. Cystic Fibrosis
NOTE: If the patient’s lips close, pull back the lower lip with your thumbs.
Cystic fibrosis (CF) is an inherited disease of the
A service animal has been individually trained to
provide assistance to an individual with a disability. mucous and sweat glands, affecting the lungs,
Never separate an individual from their service animal. pancreas, liver, intestines, sinuses and sex organs.
CF causes mucus to become thick and sticky,
Chapter 7: Primary Assessment | 165
610 | Emergency Medical Response Chapter 26: Older Adults and Patients with Special Healthcare or Functional Needs | 611
Skill Sheets Sidebars
Step-by-step visual directions for performing Supplementary information that enriches
specific skills that participants will need to know participant knowledge and understanding
in order to provide appropriate care. of the chapter material.
Key Features | xvii
ENRICHMENT
Glasgow Coma Scale
The Glasgow Coma Scale (GCS) is a tool used to assess a patient’s LOC (Table 7-6). Originally intended to
assess LOC following a head injury, it is now considered valuable for primary and ongoing assessments of any
medical or trauma patient.
A GCS score is based on three parameters: eye opening (E), verbal response (V) and motor response (M).
The total score will range from 3 to 15 (E+V+M = 3–15), with 3 representing coma or death and 15 representing
a fully awake and alert patient. A GCS score of 8 or less indicates severe brain injury, 9–12 indicates moderate
brain injury and 13–14 indicates mild brain injury.
For patients more than 5 years of age, use the standard scale. For children under the age of 5, the verbal
responses must be adjusted using the Pediatric Glasgow Coma Scale (PGCS) (Table 7-7).
Table 7-6:
Glasgow Coma Scale
RESPONSE STATUS SCORE
Eye Opening (E) Spontaneous 4 points
Opens to verbal command 3 points
Opens to pain 2 points
No response 1 point
Verbal Response (V) Oriented and speaks 5 points
Confused conversation, but able to answer questions 4 points
Inappropriate responses, words discernible 3 points
Incomprehensible speech or sounds 2 points
No response 1 point
Motor Response (M) Obeys verbal commands 6 points
Purposeful movement to painful stimulus 5 points
Withdraws from pain (flexion) 4 points
Abnormal flexion from pain 3 points
Extension in response to pain 2 points
No response 1 point
170 | Emergency Medical Response
Enrichment
Areas of additional information and skills
participants will find valuable.
xviii | Emergency Medical Response
Health Precautions and Guidelines
During Training
The American Red Cross has trained millions of people in first aid, CPR and AED using manikins as training aids.
The Red Cross follows widely accepted guidelines for cleaning and decontaminating training manikins. If these
guidelines are adhered to, the risk of any kind of disease transmission during training is extremely low.
To help minimize the risk of disease transmission, you should follow some basic health precautions and guidelines
while participating in training. You should take additional precautions if you have a condition that would increase
your risk or other participants’ risk of exposure to infections. Request a separate training manikin if you:
Have an acute condition, such as a cold, sore throat or cuts or sores on your hands or around your mouth.
Know that you are seropositive (have had a positive blood test) for hepatitis B surface antigen (HBsAg), which
indicates that you are currently infected with the hepatitis B virus.*
Know that you have a chronic infection as indicated by long-term seropositivity (long-term positive blood tests)
for HBsAg* or a positive blood test for anti-HIV, that is, a positive test for antibodies to HIV, the virus that causes
many severe infections, including AIDS.
Have had a positive blood test for hepatitis C virus.
Have a type of condition that makes you extremely likely to get an infection.
To obtain information about testing for individual health status, go to the Centers for Disease Control and Prevention
website (cdc.gov).
After a person has had an acute hepatitis B infection, they will no longer test positive for HBsAg but will test
positive for the hepatitis B antibody (anti-HBs). People who have been vaccinated against hepatitis B will also test
positive for anti-HBs. A positive test for anti-HBs should not be confused with a positive test for HBsAg.
If you decide that you should have your own manikin, ask your instructor if they can provide one for you. You will
not be asked to explain why you made this request. The manikin will not be used by anyone else until it has been
cleaned according to the recommended decontamination procedures. Because the number of manikins available
for class use is limited, the more advance notice you give, the more likely it is that you can be provided with a
separate manikin.
*People with hepatitis B infection will test positive for HBsAg. Most people infected with hepatitis B virus will get better in time.
However, some hepatitis B infections will become chronic and linger for much longer. People with these chronic infections will
continue to test positive for HBsAg. Their decision to participate in CPR training should be guided by their physician.
Health Precautions and Guidelines During Training | xix
GUIDELINES
In addition to taking the precautions regarding manikins, you can protect yourself and other participants from
infection by following these guidelines:
Wash your hands thoroughly before participating in class activities.
Do not eat, drink, use tobacco products or chew gum during class when manikins are used.
Clean the manikin properly before use.
For some manikins, cleaning properly means vigorously wiping the manikin’s face and the inside of its mouth
with a clean gauze pad soaked with either a fresh solution of liquid chlorine bleach and water (1/4 cup of sodium
hypochlorite per gallon of tap water) or rubbing alcohol. The surfaces should remain wet for at least 1 minute
before they are wiped dry with a second piece of clean, absorbent material.
For other manikins, cleaning properly means changing the manikin’s face. Your instructor will provide you with
instructions for cleaning the type of manikin used in your class.
Follow the guidelines provided by your instructor when practicing skills such as clearing a blocked airway with
your finger.
PHYSICAL STRESS AND INJURY
Successful course completion requires full participation in classroom and skill sessions, as well as successful
performance during skill and knowledge evaluations. Because of the nature of the skills in this course, you
will participate in strenuous activities, such as performing CPR on the floor. If you have a medical condition or
disability that will prevent you from taking part in the skill practice sessions, please tell your instructor so that
accommodations can be made.
If you are unable to participate fully in the course, you may audit the course and participate as much as you can
or desire but you will not be evaluated. To participate in the course in this way, you must tell the instructor before
training begins. Be aware that you will not be eligible to receive a course completion certificate.
xx | Emergency Medical Response
UNIT 1
Preparatory
1 The Emergency Medical Responder�������������������������2
2 The Well-Being of the Emergency
Medical Responder������������������������������������������������������ 15
3 Medical, Legal and Ethical Issues�������������������������� 44
4 The Human Body �������������������������������������������������������� 60
5 Lifting and Moving Patients�������������������������������������� 84
1 THE EMERGENCY
MEDICAL
RESPONDER
You Are the Emergency Medical Responder
A terrified mother pulls her child from the bottom of a pool while a neighbor calls
9-1-1 for help. You are the first to arrive at the scene and see the neighbor trying to
breathe air into the boy’s limp body. The mother looks to you helplessly. How would
you respond?
KEY TERMS
Advanced emergency medical technician (AEMT): Licensure: Required acknowledgment that the
A person trained to give basic and limited advanced bearer has permission to practice in the licensing
emergency medical care and transportation for state; offers the highest level of public protection;
critical and emergent patients who access the may be revoked at the state level should the bearer
emergency medical services (EMS) system. no longer meet the required standards.
Certification: Certification is achieved by obtaining Local credentialing: Local requirements EMRs
and maintaining the National EMS Certification (or must meet in order to maintain employment
state certification), taking an approved EMS course or obtain certain protocols so that they
and meeting other requirements; this does not grant may practice.
the right to practice as licensure may in some states.
Medical direction: The monitoring of care provided
Direct medical control: A type of medical direction, by out-of-hospital providers to injured or ill
also called “on-line,” “base-station,” “immediate” persons, usually by a medical director.
or “concurrent medical control”; under this type
of medical direction, the physician speaks directly Medical director: A physician who provides
with emergency care providers at the scene of oversight and assumes responsibility for the
an emergency. care of injured or ill persons provided in out-of-
hospital settings.
Emergency medical responder (EMR): A person
trained in emergency care who may be called on Paramedic: An allied health professional whose
to give such care as a routine part of their job primary focus is to give advanced emergency
(paid or volunteer) until more advanced emergency medical care for critical and emergent patients
medical services (EMS) personnel take over; who access the EMS system. Paramedics may
EMRs are often the first trained professionals to also give nonemergency, community-based care
respond to emergencies. based on state and local community paramedicine
Emergency medical services (EMS) system: or mobile integrated healthcare programs.
A network of community resources and medical
Prehospital care: Emergency medical care
personnel that provides emergency medical care
provided before a patient arrives at a hospital
to people who are injured or suddenly fall ill.
or medical facility.
Emergency medical technician (EMT): A person
Protocols: Standardized procedures to be followed
who gives basic emergency medical care and
when providing care to injured or ill persons.
transportation for critical and emergent patients
who access the EMS system; EMTs are typically Scope of practice: The range of duties and skills that
authorized to function after completing local and are allowed and expected to be performed when
state certification requirements; formerly referred necessary, according to the professional’s level of
to as EMT-Basic. training, while using reasonable care and skill.
Indirect medical control: A type of medical
Standing orders: Protocols issued by the medical
direction, also called “off-line,” “retrospective” or
director allowing specific skills to be performed
“prospective” medical control; this type of medical
or specific medications to be administered in
direction includes education, protocol review and
certain situations.
quality improvement for emergency care providers.
LEARNING OBJECTIVES
After reading this chapter, and completing the class • Define who an emergency medical responder
activities, you will have the information needed to: (EMR) is.
• Summarize the history and origins of the • List the roles and responsibilities of an EMR.
emergency medical services (EMS) system. • Describe the personal characteristics and
• Describe the components of an EMS system, and professional behavior expected of an EMR.
discuss factors related to “right to practice.” • Discuss medical oversight.
• Explain the different levels of EMS training. • Discuss factors related to the “right to practice.”
• Discuss the continuity of care and the importance
of working with other responders.
Chapter 1: The Emergency Medical Responder | 3
INTRODUCTION By taking this course, you will gain the knowledge,
skills and confidence to provide appropriate care
The emergency medical services (EMS) when you are called upon to help a person who
system, along with its front-line-trained emergency has sustained an injury or sudden illness. You
medical responders (EMRs), plays a vital role in the will learn how to assess a patient’s condition and
health and safety of the population. By providing how to recognize and care for life-threatening
emergency services rapidly and effectively, EMRs emergencies. You will also learn how to minimize
save many lives and minimize damage caused a patient’s discomfort and prevent further
by injuries. complications until more advanced medical
The role of the EMR can vary, however, depending personnel take over.
on the state and the location of practice. It is
important for every EMR to understand the role of
practice and any limitations, to be able to provide THE EMS SYSTEM
timely and skillful care. History and Origins
As an EMR, you provide a link between the first In the early 1960s in the United States,
actions of bystanders and more advanced care. An firefighters in some regions were taught how
EMR is a person trained in emergency care, paid or to perform CPR and basic first aid. There were
volunteer, who is often summoned to provide initial two reasons for this. First, it prepared them to
care in an emergency (Fig. 1-1). provide emergency care to colleagues injured in
action. Second, because firefighters are based
As the first trained professional on the scene, in communities all across the country, they were
your actions are often critical. They may determine a practical choice to be available to answer
whether a seriously injured or ill person survives. emergency calls.
Fig. 1-1: As the first trained professional on the scene, an EMR’s actions are often critical.
CRITICAL As the first trained professional on the scene, your actions are often critical. They
FACTS may determine whether a seriously injured or ill person survives or has a long-term
disability.
4 | Emergency Medical Response
Although some firefighters received training in not a subset of a fire or police department. Many
CPR and first aid, there was no organized EMS large cities employ the third-service model.
network in the early 1960s. This meant that there Other systems: These include other police and
was no standardized or regulated training to ensure private systems that do not fit one of the models
comparable emergency care education between above, such as a private corporate response
the different regions. system servicing an industrial complex.
This patchwork of resources resulted in response At each of these levels, the delivery of care may
times and quality of care that differed between be different, but the goal is always the same:
locations. Also, by not having a directed, formal to provide care according to community needs
EMS system, educational requirements differed and resources.
by location.
Regulating Agencies
In 1966, the National Academy of Sciences/
National Research Council (NAS/NRC) Working with federal partners, the National
documented the problem in a white paper that Highway Traffic Safety Administration’s (NHTSA)
found the quality of emergency care in the Office of EMS advances a national vision for
United States to be dismal. Entitled “Accidental EMS through projects and research, fosters
Death and Disability: The Neglected Disease of collaboration among federal agencies involved
Modern Society,” the white paper criticized both in EMS planning, measures the health of the
ambulance services and hospital emergency nation’s EMS systems, and delivers the data
departments. In response to this white paper, EMS leaders need to help advance their systems.
in 1973, the U.S. Congress enacted the Its mission is to reduce death and disability
Emergency Medical Services Act, which by providing leadership and coordination to
created a multi-tiered, nationwide system of the EMS community in assessing, planning,
emergency healthcare. Among other things, developing and promoting comprehensive,
the legislation called for standardized training evidence-based emergency medical services and
within the EMS system. 9-1-1 systems.
In addition to NHTSA’s oversight of the EMS
system, each state and territory has a lead EMS
The EMS System Today office of its own. These can fall under the individual
Types of Systems state health or public safety department. In some
Today, several types of EMS services operate in states, the EMS office is independent.
the United States:
State EMS agencies are responsible for the overall
Fire-based services: These services are planning, coordination and regulation of the EMS
operated directly by a local, county or regional system within the state as well as licensing or
fire-rescue department. Approximately half of certifying EMS providers.
all communities in the United States depend on
Their responsibilities may include leading statewide
fire departments to provide emergency services.
trauma systems; licensing and certifying EMS
Private services: These are for-profit and not- services, vehicles and personnel; developing
for-profit companies that have been hired (often and enforcing statewide protocols for EMS
on a contract basis) by local governmental providers in addition to the national requirements;
agencies to perform EMS services in specific administering or coordinating regional EMS
geographic areas. programs; operating or coordinating statewide
Hospital-based services: These services are communications systems; coordinating and
those that are backed up, monitored and run by distributing federal and state grants; and
a local hospital. planning and coordinating disaster and mass
Third services: These are provided by casualty responses, as well as homeland security
community-based EMS departments that are medical initiatives.
CRITICAL State EMS agencies are responsible for the overall planning, coordination and
FACTS regulation of the EMS system within the state as well as licensing or certifying
EMS providers.
Chapter 1: The Emergency Medical Responder | 5
Components of an EMS System 4. Transportation. Safe and reliable transportation
is needed for patients to reach end destinations.
NHTSA Technical Assistance Program This includes adequate and functioning
Assessment Standards transportation services for the area, which gives
As part of its role to oversee the national EMS all citizens equal access to emergency care.
system, NHTSA has designated 10 components 5. Facilities. EMS systems must have a range of
that make up an effective EMS system and has appropriate receiving institutions available to
identified a method of assessing those areas. meet the various and acute needs of injured
NHTSA’s statewide EMS Technical Assistance or ill persons. Depending on the patient’s
Program allows states to request a team of outside age and condition, these can range from the
experts, a Technical Assistance Team (TAT), to hospital emergency department to specialty
conduct a comprehensive assessment of each centers such as trauma, burn, stroke or
statewide EMS program. The assessment provides pediatric centers.
an overview of the current program in comparison
6. Communications. EMS systems must have
to a set of standards. This evaluation outlines the
a designated communications number to
program’s strengths and weaknesses, as well as
be used by the public to get help and by
recommendations for improvement. Almost all
members of the emergency response team to
states and territories have utilized this process, and
communicate effectively. Generally, 9-1-1 is
states may also request a reassessment by making
used, although there are areas that must use a
joint requests to their state Highway Safety Office
non-9-1-1 or seven- or 10-digit number.
and NHTSA Regional Office. By measuring the
progress of EMS systems against the standard set 7. Public information and education. The EMS
by NHTSA, states can ensure the EMS system is system should offer information and education
effective nationwide. to the public on prevention of injury and illness
and appropriate use of the EMS system.
NHTSA’s 10 components, also known as its Technical 8. Medical direction (also known as medical
Assistance Program Assessment Standards, include: oversight). EMS systems are required to have
a physician act as medical director, overseeing
1. Regulation and policy. State agencies have
their operations.
regulations and policies in place that govern
their EMS systems. The regulations and 9. Trauma systems. As part of the EMS system,
policies regarding the EMS system vary among each state is required to have a system that
states. As an EMR, you are responsible for ensures timely and effective direction of
knowing and understanding the applicable patients to the appropriate receiving facilities,
regulations and policies in your state depending on the level of care required.
of practice. 10. Evaluation. Improvement in care and
2. Resource management. To ensure that all assessment of the care provided are obtained
patients are able to receive the required care, through evaluation and upgrading of the EMS
all states must have central control of EMS system, which is governed by each state.
resources. State EMS oversight includes
ensuring that EMS personnel have adequate
training, and providing the equipment necessary Levels of EMS Training
to provide emergency care throughout the state. National EMS Education Agenda for
Equipment includes vehicles for transportation the Future: A Systems Approach
as well as tools and supplies necessary to The need for standards in EMS care was identified
provide care. back in the 1960s. At that time, the National
3. Human resources and training. All EMS Standard Curricula (NSC) were developed by the
personnel must be trained to adequate levels, U.S. Department of Transportation (DOT) and
with the basic level being that of an EMR. NHTSA, in response to a mandate by Congress.
Each state has its own rules and regulations Between 1966 and 1973, NSC were developed for
regarding extra training or skills. For this, the EMT-Basics, Intermediates and Paramedics. These
agencies have to monitor training programs, curricula standardized aspects such as course
and these programs must be re-evaluated on planning and structure, objectives, lessons, content
a regular basis. and hours of instruction.
6 | Emergency Medical Response
Access to the EMS System
Mobile 9-1-1: Hundreds of Millions Served
The 9-1-1 service was created in the United • Callers should not program their mobile phone
States in 1968 as a nationwide telephone to automatically dial 9-1-1 when one button,
number for the public to use to report such as the “9” key, is pressed. Mobile 9-1-1
emergencies and request emergency assistance. calls often occur when autodial keys are
It gives the public direct access to an emergency pressed unintentionally. This causes problems
communications center called a public safety for PSAPs.
answering point (PSAP), which is responsible for • Callers should turn off the autodial 9-1-1 feature
taking appropriate action. if the mobile phone came preprogrammed with
it already turned on. They can check their user
The numbers 9-1-1 were chosen because they manual to find out how.
best fit the needs of the public and the telephone • Callers should lock their keypad when they
companies. They are easy to remember and dial, are not using the mobile phone. This action
and they have never been used as an office, area or prevents accidental calls to 9-1-1.
service code. Most of the population and geography
of the United States is covered by some type of The next generation of 9-1-1 systems—NG911—
9-1-1 service. Today, an estimated 240 million calls is now being implemented across the nation
are made to 9-1-1 each year in the United States. In to create a faster, more flexible, resilient and
many areas, 70 percent or more are from a wireless scalable system that allows 9-1-1 to keep up with
device. People who call 9-1-1 using a mobile phone communication technology used by the public.
should remember the following tips, to assist the NG911 is a system that allows digital information
PSAP in finding their location: (e.g., audio, photos, video, text messages) to flow
• Callers should tell the call taker the location of seamlessly from the public, through the 9-1-1
the emergency right away. network, and on to emergency responders. While
• They should then give the call taker the mobile many of these new functions are not currently
phone number so that they can call back if available in most states, progress is being
the call gets disconnected. This is especially made rapidly.
important if callers do not have a contract for
service with a mobile phone service provider,
because in these cases
dispatch centers will have no
way of obtaining the mobile
phone number and may be
unable to contact them.
• Callers should learn to use the
designated number in their
state for highway crashes or
other non-life-threatening
incidents, if there is one.
States often reserve specific
numbers for these types
of incidents. For example,
“#77” is the number used for
highway crashes in a number
of states. The number to
call for non-life-threatening
incidents in each state may People who call 9-1-1 with a mobile phone should immediately tell the call taker
be located in the front of the the emergency location and the mobile phone number in case the call gets
phone book or found online. disconnected. Photo: D. Hammonds/Shutterstock.com.
Chapter 1: The Emergency Medical Responder | 7
In 1996, the NHTSA and the Health Resources Education Program Accreditation and the
and Services Administration (HRSA) published a National EMS Certification.
document entitled the EMS Agenda for the Future
(the Agenda). The purpose of this document was The National EMS Education Standards replaced
to create a common vision for the future of EMS the NSC and set minimum learning objectives for
systems. The document was designed to be each level of practice. National EMS Certification
used by national, state and local governments, as now is available for all levels of providers and
well as by private organizations, in order to guide entails a standardized examination process
planning, decision making and policy around to ensure entry-level competence of EMS
EMS care. providers.
One of several areas addressed in the Agenda National Scope of Practice
was the EMS education system. NHTSA, along The scope of practice of an EMR is defined
with more than 30 EMS-related organizations, as the range of duties and skills that the EMR is
implemented steps to address the education allowed and expected to perform when necessary,
section of the Agenda. The plan for this while using reasonable care and skill according
implementation was entitled the National EMS to the EMR’s level of training. While the scope of
Education and Practice Blueprint (known as practice does not have regulatory authority, it does
the Blueprint), and represents an important provide guidance to states. The EMR is governed
component of the EMS education system. The by legal, ethical and medical standards. Since
purpose of this document was to establish practices may differ by region, responders must
nationally recognized levels of EMS providers be aware of the variations that exist for their level
and scopes of practice, a framework for of training, certification and/or licensure in their
future curriculum-development projects, and region. Whenever the national scope of practice is
a standardized way for states to handle legal updated for any level of EMS responder, responder
recognition and reciprocity. duties and skills will be impacted.
In 1998, a group under the NHTSA met to
develop procedures to revise the Blueprint Professional Levels of EMS
and developed a document entitled the EMS Certification or Licensure
Education Agenda for the Future: A Systems There are four nationally recognized levels of
Approach (the Education Agenda). The Education training for prehospital emergency care, including:
Agenda proposed an education system with
five components: 1. Emergency medical responder (EMR).
EMRs have the basic knowledge and skills
1. National EMS Core Content needed to provide emergency care to people
2. National EMS Scope of Practice Model who are injured or who have become ill. They
3. National EMS Education Standards are certified to provide care until a more highly
4. National EMS Education Program Accreditation trained professional—such as an EMT—takes
over. EMR is the initial training level within the
5. National EMS Certification
EMS system.
The main benefit of this systematic approach 2. Emergency medical technician (EMT).
was the resulting consistency of instructional EMTs have the next highest level of training.
quality it would achieve through the system’s An EMT gives basic emergency medical care
three main components: the National EMS and transportation for critical and emergent
Education Standards, the National EMS patients who access the EMS system. EMTs are
CRITICAL The scope of practice of an EMR is defined as the range of duties and skills that the
FACTS EMR is allowed and expected to perform when necessary, while using reasonable
care and skill according to the EMR’s level of training and the terms of certification
and/or licensure in the location where they practice.
An EMR’s responsibilities are to ensure safety, gain safe access to the patient,
determine threats to the patient’s life, summon more advanced medical personnel
and assist them as needed, and provide needed care for the patient.
8 | Emergency Medical Response
typically authorized to function after completing are recognized and certified to provide emergency
local and state certification requirements; care to the general public until more advanced
formerly referred to as EMT-Basic. medical personnel take over.
3. Advanced emergency medical technician
Some occupations, such as law enforcement
(AEMT). AEMTs receive more training than
and firefighting, require personnel to respond to
EMTs, which allows them to give basic and
and assist at the scene of an emergency. These
limited advanced emergency medical care and
personnel are dispatched through an emergency
transportation for critical and emergent patients
number, such as 9-1-1, and often share common
who access the EMS system, such as insertion
communications networks. When someone
of IVs, the administration of a limited number of
dials 9-1-1, this will contact police, fire or
emergency medications and insertion of some
EMS personnel. These are typically considered
advanced airway devices. This level of care used
public safety personnel. However, EMRs do not
to be called EMT-Intermediate.
necessarily work for public safety agencies.
4. Paramedic. Paramedics have more in-depth People in many occupations other than public
training than AEMTs, including more knowledge safety are called to help in the event of an injury
about performing physical exams. They may or sudden illness, such as:
perform more invasive procedures than any
other prehospital care provider. Paramedics Athletic trainers.
are considered allied health professionals whose Camp leaders.
primary focus is to give advanced emergency
medical care for critical and emergent patients.
Emergency management personnel.
They may also give nonemergency, community- First aid station members.
based care based on state and local community Industrial response teams.
paramedicine or mobile integrated healthcare Lifeguards.
programs. This level of care used to be called Ski patrol members.
EMT-Paramedic.
In an emergency, these people are often required
to provide the same minimum standard of care
Working with Other Responders as traditional EMRs. Their duty is to assess the
and Continuity of Care patient’s condition and provide necessary care,
Continuity of care in an emergency situation can make sure that any necessary additional help has
be compared to a course of action. As an EMR, been summoned, assist other medical personnel
you are often the first on the scene and begin the at the scene and document their actions.
course of action. While providing care, you will
collect all the information you require to pass on to Responsibilities
the next level of personnel when they arrive or to
the receiving facility if you are providing transport. To be an EMR means to accept certain
A smooth transition of care depends on the proper responsibilities beyond providing care. Since you
and thorough relay of information. will often be the first trained professional to arrive
at many emergencies, your primary responsibilities
As an EMR, you will be working and communicating center on safety and early emergency care. Your
with other medical personnel including EMTs, major responsibilities are to:
AEMTs and paramedics as well as other public
safety personnel, emergency management, home Ensure safety for yourself and any bystanders.
healthcare providers and others. Your first responsibility is not to make the
situation worse by getting hurt or letting
bystanders get hurt. By making sure the scene
EMERGENCY MEDICAL is safe as you approach it, you can avoid
unnecessary injuries.
RESPONDER
Gain safe access to the patient. Carefully
Who Is an EMR? approach the patient unless the scene is
An EMR is a person trained in emergency care too dangerous for you to handle without
who may be called on to provide such care as help. Electrical or chemical hazards, unsafe
a routine part of their job, whether that job is structures and other dangers may make
voluntary or paid. EMRs have a duty to respond to it difficult to reach the patient (Fig. 1-2).
the scene of a medical emergency and to provide Recognize when a rescue requires specially
emergency care to the injured or ill person. They trained emergency personnel.
Chapter 1: The Emergency Medical Responder | 9
Fig. 1-2: One of an EMR’s major responsibilities is gaining safe access to the patient.
Determine any threats to the patient’s life. Check In addition to these major responsibilities, you have
first for immediate life-threatening conditions, secondary responsibilities that include:
and care for any you find. Next, look for other
conditions that could threaten the patient’s life Summoning additional help, such as special
or health if not addressed. rescue teams and utility crews, when needed.
Summon more advanced medical personnel as Controlling or directing bystanders or asking
needed. After you quickly assess the patient, them for help.
notify more advanced EMS personnel of the Taking additional steps, if necessary, to protect
situation, if someone has not done so already. bystanders from dangers, such as traffic or fire.
Provide needed care for the patient. Remain with Recording what you saw, heard and did at
the patient and provide whatever care you can the scene.
until more advanced medical personnel take over. Reassuring the patient’s family or friends.
Assist more advanced medical personnel.
Transfer your information about the patient Maintaining Certification
and the emergency to more advanced medical As an EMR, you have an obligation to remain up-to-
personnel. Tell them what happened, how you date on the knowledge, skills and use of equipment
found the patient, any problems you found and needed for you to fulfill your role competently and
any care you provided. Assist them as needed effectively. Your employer should provide you with
within your level of training, and help with care the requirements for your area. Some areas require
for any other patients. When possible, try to a higher level of knowledge for their EMRs, above
anticipate the needs of those providing care. and beyond the basic requirements.
CRITICAL As an EMR, you have an obligation to remain up-to-date on the knowledge, skills and
FACTS use of equipment needed for you to fulfill your role competently and effectively.
10 | Emergency Medical Response
Continuing Education Personal Characteristics and
The field of healthcare, particularly emergency care, Professional Behavior
changes quickly as newer and better techniques The responsibilities of EMRs require that they
and methods are discovered. EMRs must keep up- demonstrate certain characteristics. These include:
to-date on all of the new developments that affect
them and the care they provide. As an EMR, you Maintaining a caring and professional attitude.
will be required to participate in various types of Injured or ill people are sometimes difficult to
continuing education (CE) programs as outlined by work with. Be compassionate; try to understand
the certifying body and your region. their concerns and fears (Fig. 1-3). Realize that
anger shown by an injured or ill person often
Criminal Implications results from fear. A lay responder who helps
at the emergency may also be afraid. Try to be
The National EMS Scope of Practice Model
reassuring. Even though lay responders may
places limitations on your scope of practice
not have done everything perfectly, be sure
to ensure that what you do is in the interest of
to thank them for taking action. Recognition
public protection and safety. Standards for EMR
and praise help to affirm their willingness to
education, certification, licensure and credentialing
act. Also be careful about what you say. Do
are all mechanisms that set the parameters of
not volunteer distressing news about the
practice. Criminal implications may arise for you if
emergency to the patient or to the patient’s
you perform procedures that are outside of what
family or friends.
you are trained to do, what you are certified as
competent to do, what you are legally licensed to Controlling your fears. Try not to reveal your
do or what you have been credentialed (authorized anxieties to the patient or bystanders. The
by a medical director) to do. presence of blood, vomit, unpleasant odors,
or torn or burned skin is disturbing to most
EMRs must not be placed in situations in which people. You may need to compose yourself
they are expected to perform procedures they have before acting. If you must, turn away for a
not been sufficiently trained to do or for which they moment and take a few deep breaths before
have insufficient experience. There are also criminal providing care.
implications for falsification of care or training Presenting a professional appearance.
records, or for allowing your certification to lapse This helps ease a patient’s fears and
and continuing to practice. inspires confidence.
Keeping your knowledge and skills up-to-
Fees date. Involve yourself in continuing education,
One of your areas of responsibility is paying professional reading and refresher training.
required fees. There is a fee to obtain licensure Maintaining a safe and healthy lifestyle. Job
and recertification, and there may be fees for stresses can adversely affect your health.
certain exams. You will also be required to As an EMR, it is important to maintain a safe
obtain continuing education units (CEUs) to and healthy lifestyle both on and off the job.
maintain your knowledge and skills. Fees vary Exercise, diet and common sense safety
widely from state to state and are usually your practices can help you manage physical,
responsibility, though employers may sometimes mental and emotional stress, and may help
assist with them. you be more effective as an EMR.
CRITICAL As an EMR, you have a responsibility to control your fears, present a professional
FACTS appearance, keep your knowledge and skills up-to-date, and maintain a safe and
healthy lifestyle.
Medical direction is the process by which a physician directs the care provided by
out-of-hospital providers to injured or ill people. Usually this monitoring is done by a
medical director, who assumes responsibility for the care provided.
Chapter 1: The Emergency Medical Responder | 11
Fig. 1-3: An EMR should be compassionate and reassuring. Photo: courtesy of Captain Phil Kleinberg, EMT-P.
Medical Direction Other procedures that are not covered by
standing orders require EMRs to speak directly
Medical Director with the physician. This contact can be made
Medical direction is the process by which a via mobile phone, radio or telephone following
physician directs the care provided by out-of- local requirements. This kind of medical direction
hospital providers to injured or ill people. Usually is called direct medical control, or “online”
this monitoring is done by a medical director, medical direction (Fig. 1-4).
who provides oversight and assumes responsibility
for the care provided. The physician also oversees Right to Practice
training and the development of protocols
(standardized procedures to be followed when Legislation and Scope of Practice
providing care to injured or ill people). EMRs must follow state regulations that determine
what they can and cannot do. Each state has
very specific laws and rules governing how
Medical Control
EMS personnel may practice in the out-of-
Since it is impossible for the medical director to be hospital setting.
present at every incident outside the hospital, the
physician directs care through standing orders. State EMS Office Oversight
Standing orders allow EMS personnel to provide
EMRs must be licensed or certified through the
certain types of care or treatment without speaking
state EMS office, the licensing or certifying agency,
to the physician. This kind of medical direction is
before being allowed to work in that state. EMRs
called indirect medical control. Indirect medical
should be familiar with these laws and regulations.
control, or “offline” medical direction, includes
Typical legal concerns and issues are addressed
education, protocol review and quality improvement
in Chapter 3.
for emergency care providers.
12 | Emergency Medical Response
Medical Direction Certification
Medical direction is provided by the medical Certification is achieved by obtaining and
director, who assumes responsibility for maintaining the National EMS Certification (or
care provided. state certification), taking an approved EMS course
and meeting other requirements. This does not
grant you the right to practice as licensure may
Levels of Credentialing in some states. EMS personnel generally need to
There are three aspects to credentialing of recertify every 2 years, to ensure that they maintain
EMRs, all with the goal of protecting the public: a high degree of competency by re-affirming their
certification, licensure and local credentialing. knowledge, skills and abilities as well as learning
any new skills or information.
Licensure
Licensure is an acknowledgement that the
bearer has permission to practice in the licensing
state. It is the highest level of public protection,
which is granted at the state level. It is generally
a requirement, with a few exceptions, for work
on federal land or in the military. States often
have requirements in addition to those required
for certification, before they grant licensure. The
state is the final authority for public protection;
therefore, states can revoke state licensure
if appropriate.
Local Credentialing
Often, EMS providers must meet local
credentialing requirements in order to maintain
employment or obtain certain protocols so that
they may practice. Most employers also have
additional requirements as part of an orientation
program that would be similar to a local
credentialing process.
Administrative Requirements
EMRs must follow any policies and procedures
based on national, state, local or employer
requirements. For example, the Health Insurance
Portability and Accountability Act (HIPAA)
is national; protocols can be state or local;
and specifics of uniform (e.g., level of training
and credentialing recognition) could be
employer requirements.
Research
The field of emergency care and emergency
medicine is constantly evolving. Quality
improvement (QI), or continuous quality
improvement (CQI), based on research, allows
for continuing assessment and reassessment
of all aspects of the EMS system. This includes
Fig. 1-4: Procedures that are not covered by standing orders
require EMRs to speak directly with the physician. This is called viewing and evaluating the system internally, from
direct medical control. the personnel’s and administration’s point of view,
Chapter 1: The Emergency Medical Responder | 13
and also externally, from the public’s point of view. The primary role of an EMR is to provide
It also entails keeping personnel and equipment emergency care at the scene, while working
up-to-date with the latest standards of care, with other services and healthcare personnel.
ensuring that personnel are adequately trained It is important to understand that the role of the
and skilled in using new knowledge. EMR does not stop at providing care. EMRs
must continue to grow and learn along with the
One example is the continuous evaluation of CPR field. They must remain certified and retain their
procedures. As new recommendations come about licensure in order to practice in their chosen
and become the recognized standard through an state and, as such, must maintain the necessary
evidence-based guidelines process, EMS systems standards as outlined by that state.
across the country must ensure that employees
and volunteers are up-to-date and comfortable To be an effective EMR, you must not only be able
performing new techniques. The goal of an EMS to keep up the professional side of your work, but
system is to provide the highest quality of care your personal side. EMRs have a responsibility
possible throughout the country, equally accessible to remain fit and healthy in order to perform their
to all citizens. Through research, QI programs can duties accordingly. This means maintaining a
assess whether that goal is being met. healthy lifestyle, and being aware of your choices
and how they would and could affect your
PUTTING IT ALL TOGETHER performance on the job.
Since the EMS system was established in the The size and scope of the EMS system in each
United States, it has undergone significant state may vary according to population, needs and
changes as it has grown and adapted to citizens’ resources. However, all systems have some things
needs. However, this growth needs to continue in common: namely, their need for certification and
as the field of emergency and prehospital care licensure, and their goal of providing equal access
continues to evolve. to prehospital care to all citizens.
14 | Emergency Medical Response
2
THE WELL-BEING
OF THE EMERGENCY
MEDICAL
RESPONDER
You Are the
Emergency Medical
Responder
Your police unit responds to a
call for a medical emergency
involving a man who has
collapsed in front of a school
building. When you and your
partner arrive, you see that
the man is bleeding from the
mouth and face. Vomit and
blood are on the ground around
him. “His face hit the ground
when he fell,” a bystander says.
The man does not appear to
be breathing. How would you
respond, and what can you do
to protect yourself from possible
disease transmission?
KEY TERMS
Acute: Having a rapid and severe onset, then Exposure: An instance in which someone is exposed
quickly subsiding. to a pathogen or has contact with blood or
OPIM or objects in the environment that contain
Adaptive immunity: The type of protection from disease-causing agents.
disease that the body develops throughout a
lifetime as a person is exposed to diseases or Exposure control plan: Plan in the workplace
immunized against them. that outlines the employer’s protective
measures to eliminate or minimize employee
AIDS: A disease of the immune system caused by exposure incidents.
infection with HIV.
Hepatitis: An inflammation of the liver most
Antibodies: A type of protein found in blood or commonly caused by viral infection; there are
other bodily fluids; used by the immune system to several types including hepatitis A, B, C, D and E.
identify and neutralize pathogens, such as bacteria
and viruses. HIV: A virus that weakens the body’s immune
system, leading to life-threatening infections;
Bacteria: One-celled organisms that can cause causes AIDS.
infection; a common type of pathogen.
Homeostasis: A constant state of balance or
Biohazard: A biological agent that presents a hazard well-being of the body’s internal systems that is
to the health or well-being of those exposed. continually and automatically adjusted.
Bloodborne: Used to describe a substance carried Immune system: The body’s complex group of body
in the blood (e.g., bloodborne pathogens are systems that is responsible for fighting disease.
pathogens carried through the blood).
Indirect contact: Mode of transmission of a disease
Bloodborne pathogens: Infectious microorganisms caused by touching a contaminated object.
that are present in human blood or other potentially
infectious materials (OPIM) and can cause disease Infection: A condition caused by disease-producing
in humans. microorganisms, called pathogens or germs, in
the body.
Body substance isolation (BSI) precautions:
Protective measures to prevent exposure to Infectious disease: Disease caused by the invasion
communicable diseases; these precautions define of the body by a pathogen, such as a bacterium,
all body fluids and substances as infectious. virus, fungus or parasite.
Chronic: Persistent over a long period of time. Innate immunity: The type of protection from
disease with which humans are born.
Critical incident stress: Stress triggered by
involvement in a serious or traumatic incident. Lividity: Purplish color in the lowest-lying parts
of a recently dead body, caused by pooling
Direct contact: Mode of transmission of pathogens of blood.
that occurs through directly touching infected
blood or OPIM, or other agents such as chemicals, Meningitis: An inflammation of the meninges,
drugs or toxins. the thin, protective coverings over the brain and
spinal cord; caused by virus or bacteria.
Disease-causing agent: A pathogen or germ that
can cause disease or illness (e.g., a bacterium Methicillin-resistant Staphylococcus aureus
or virus). (MRSA): A staph bacterium that can cause
infection; difficult to treat because of its resistance
Droplet transmission: Mode of transmission to many antibiotics.
of pathogens that occurs when a person
inhales droplets from an infected person’s Multidrug-resistant tuberculosis (MDR TB):
cough or sneeze; also known as respiratory A type of tuberculosis (TB) that is resistant to
droplet transmission. some of the most effective anti-TB drugs.
Engineering controls: Control measures that Needlestick: A penetrating wound from a needle
eliminate, isolate or remove a hazard from the or other sharp object; may result in exposure to
workplace; things used in the workplace to help pathogens through contact with blood or OPIM.
reduce the risk of an exposure.
(Continued )
16 | Emergency Medical Response
KEY TERMS continued
Occupational Safety and Health Administration these precautions assume that all body fluids,
(OSHA): Federal agency whose role is to promote secretions and excretions (except sweat) are
the safety and health of American workers by potentially infective.
setting and enforcing standards; providing training,
outreach and education; establishing partnerships; Stress: The body’s normal response to any situation
and encouraging continual process improvement that changes a person’s existing mental, physical
in workplace safety and health. or emotional balance.
Opportunistic infections: Infections that strike Sudden death: An unexpected, natural death;
people whose immune systems are weakened. usually used to describe a death from a sudden
cardiac event.
Other potentially infectious materials (OPIM):
Materials, other than blood, that can cause illness; Tuberculosis (TB): A bacterial infection that usually
these materials include body fluids such as semen attacks the lungs.
and vaginal secretions.
Universal precautions: A set of precautions
Pandemic influenza: A respiratory illness caused designed to prevent transmission of HIV,
by virulent human influenza A virus; spreads easily hepatitis B virus (HBV) and other bloodborne
and sustainably, and can cause global outbreaks pathogens when providing care; these precautions
of serious illness in humans. consider blood and OPIM of all patients
potentially infectious.
Passive immunity: The type of immunity gained
from external sources such as from a mother’s Vector-borne transmission: Transmission of
breast milk to an infant. a pathogen that occurs when an infectious
source, such as an animal or insect bite or sting,
Pathogen: A term used to describe a germ; a penetrates the body’s skin.
disease-causing agent (e.g., bacterium or virus).
Virus: A common type of pathogen that depends
Personal protective equipment (PPE): All on other organisms to live and reproduce; can be
specialized clothing, equipment and supplies that difficult to kill.
keep the user from directly contacting infected
materials; includes gloves, gowns, masks, shields Work practice controls: Control measures that
and protective eyewear. reduce the likelihood of exposure by changing the
way a task is carried out.
Standard precautions: Safety measures, including
BSI and universal precautions, taken to prevent
occupational-risk exposure to blood and OPIM;
LEARNING OBJECTIVES
After reading this chapter, and completing the class • Describe the steps an emergency medical
activities, you will have the information needed to: responder (EMR) should take for personal
protection from bloodborne pathogens.
• Describe how the immune system works.
• Describe the procedure an EMR would use to
• Identify ways in which diseases are transmitted disinfect equipment, work surfaces, clothing and
and give an example of how each transmission leather items.
can occur.
• Explain the importance of documenting an
• Describe diseases that cause concern and how exposure incident and post-exposure follow-
they are transmitted. up care.
• Describe conditions that must be present for • Explain how the OSHA standard for bloodborne
disease transmission. pathogens influences your actions as an EMR.
• Explain the importance of standard precautions. • Acknowledge the importance of knowing how
• Identify standard precautions to protect yourself various diseases are transmitted.
against disease transmission.
(Continued )
Chapter 2: The Well-Being of the Emergency Medical Responder | 17
LEARNING OBJECTIVES continued
• Demonstrate the proper techniques for placing and • List possible emotional reactions an EMR may
removing personal protective equipment (PPE). experience when faced with trauma, illness, death
• Use appropriate PPE and properly remove and and dying.
discard the protective garments, given a scenario • Explain the importance of understanding the
in which potential exposure takes place. response to death and dying and communicating
• Identify the signs and symptoms of critical effectively with the patient’s family.
incident stress. • Describe the steps an EMR might take when
• Describe actions an EMR could take to reduce or approaching the family of a dead or dying patient.
alleviate stress. • Recognize possible reactions of the EMR’s family
• Describe reactions a person might have when to the responsibilities of an EMR.
confronted with the dying process or actual death • Communicate with empathy to patients and their
of another individual. family members and friends.
INTRODUCTION
The demands on an emergency medical responder
(EMR) can be significant and are physical,
emotional and mental in nature. To meet these
demands, it is essential to take good care of
yourself, by making healthy choices that promote
your own physical, emotional and mental well-
being. These choices will benefit not only you but
also the patients and families you assist as you
carry out your work each day.
Bloodborne pathogens, such as bacteria
and viruses, are present in blood and other
potentially infectious materials (OPIM)
and can cause disease when certain conditions
are present. Being aware of disease-causing
agents, how they are spread, and their signs and
symptoms will help you prevent exposure to these
illnesses and recognize them. It is also important
for you to keep immunizations up-to-date to protect
against vaccine-preventable diseases and wear
proper personal protective equipment (PPE) while
providing care (Fig. 2-1).
EMRs must also look after their mental and
emotional health. A serious injury, sudden illness or
death can have an emotional impact on everyone
involved: patients, family, friends, bystanders,
EMRs and others. The degree of impact varies from Fig. 2-1: Prevent exposure to bloodborne pathogens by wearing
person to person. The way one person responds to personal protective equipment, such as disposable latex-
free gloves.
a stressful situation can differ substantially from the
response of another person in a similar situation.
need to provide emotional support. Being able
At times, you may encounter a patient who is to understand some of what a patient feels when
experiencing an emotional crisis. Besides providing coping with an injury or illness is an important part
care for a specific injury or illness, you may also of what you do as a responder.
18 | Emergency Medical Response
PREVENTING DISEASE The body may have difficulty fighting infection
caused by bacteria. The body’s ability to fight
TRANSMISSION infection depends on its immune system.
To help prevent disease transmission, you need to In people with healthy immune systems,
understand how infections occur, how diseases a bacterial infection is often avoided. When
spread from one person to another and what an infection is present, healthcare providers
you as an EMR can do to protect yourself and may prescribe antibiotic medications that either
others. Infectious diseases can be spread kill the bacteria or weaken them enough for
from infected people and from animals, insects the body to get rid of them. Commonly used
or objects that have been in contact with them. antibiotics include penicillin, erythromycin
EMRs must protect themselves and others from and tetracycline.
infectious diseases.
Unlike bacteria, viruses depend on other
organisms to live and reproduce. Viruses cause
How Infection Occurs many diseases, including the common cold
Disease-Causing Agents (caused by the rhinovirus). Once in the body,
The disease process begins when a pathogen viruses may be difficult to eliminate because
(germ) gets into the body. When pathogens very few medications are effective against viral
enter the body, they sometimes can overpower infections. While there are some medications that
the body’s natural defense systems and cause kill or weaken viruses, the body’s immune system
illness. Bacteria and viruses cause most infectious is the main defense against them.
diseases. Other disease-causing pathogens
Some infections, such as measles, malaria,
include fungi, protozoa, rickettsia, parasitic worms,
HIV and yellow fever, affect the entire body.
prions and yeasts.
Others affect only one organ or system of
Bacteria are everywhere. They do not depend the body—for example, the virus that causes
on other organisms for life and can live outside the common cold, which occurs in the upper
the human body. Most bacteria do not infect respiratory tract. Table 2-1 identifies some
humans. Those that do may cause serious diseases and conditions caused by each of
illness, such as bacterial meningitis and tetanus. the types of pathogenic agents.
Table 2-1:
Pathogens and the Diseases and Conditions They Cause
PATHOGEN DISEASES AND CONDITIONS
Viruses Hepatitis, measles, mumps, chicken pox, meningitis, rubella, influenza, warts, colds, herpes,
HIV (which causes AIDS), genital warts, smallpox, avian flu, Ebola, Zika
Bacteria Tetanus, meningitis, scarlet fever, strep throat, tuberculosis, gonorrhea, syphilis, chlamydia,
toxic shock syndrome, Legionnaires’ disease, diphtheria, food poisoning, Lyme disease,
anthrax
Fungi Athlete’s foot, ringworm, histoplasmosis
Protozoa Malaria, dysentery, cyclospora, giardiasis
Rickettsia Typhus, Rocky Mountain spotted fever
Parasitic worms Abdominal pain, anemia, lymphatic vessel blockage, lowered antibody response, respiratory
and circulatory complications
Prions Creutzfeldt-Jakob disease (CJD) or bovine spongiform encephalopathy (mad cow disease)
Yeasts Candidiasis (also known as “thrush”)
Chapter 2: The Well-Being of the Emergency Medical Responder | 19
The Body’s Natural Defenses have, such as the skin and mucous membranes
The body has a series of natural defenses that in the nose, throat and gastrointestinal tract that
prevent infectious microorganisms from entering. The prevent most diseases from entering our bodies.
body depends on intact skin and mucous membranes Adaptive immunity develops throughout
in the mouth, nose and eyes to keep infectious our lives as we are exposed to diseases or are
microorganisms out. When the skin is damaged, immunized against them.
infectious microorganisms can enter through Passive immunity is immunity we gain from
openings, such as cuts or sores. Mucous membranes external sources such as from a mother’s breast
in the mouth, nose and eyes also work to protect milk to an infant.
the body from intruding infectious microorganisms,
often by trapping them and forcing them out through How Diseases Spread
a cough or sneeze. However, mucous membranes Exposure to blood and OPIM occurs across a
are less effective than skin at keeping bloodborne wide variety of occupations. Healthcare workers,
pathogens out of the body. If these barriers fail and emergency response personnel, public safety
a germ enters the body, the body’s immune system personnel and other workers can be exposed to
begins working to fight the disease. blood and OPIM through injuries from needles and
other sharps devices, as well as by direct and
The immune system’s basic tools are antibodies indirect contact with skin and mucous membranes.
and white blood cells. Special white blood cells
travel around the body and identify invading For any disease to spread, including bloodborne
pathogens. Once they detect a pathogen, white diseases, all four of the following conditions must
blood cells gather around it and release antibodies be met:
that fight infection.
1. A pathogen must be present.
These antibodies attack the pathogens and weaken 2. A sufficient quantity of the pathogen to cause
or destroy them. Antibodies usually can rid the body disease must be present.
of pathogens. However, once inside the body, some 3. A person must be susceptible to the pathogen.
pathogens can thrive and, under ideal conditions,
4. The pathogen must pass through the correct
multiply and overwhelm the immune system.
entry site (e.g., eyes, mouth and other mucous
This combination of preventing pathogens from membranes or skin pierced or broken by
entering the body and destroying them once they needlesticks, bites, cuts, abrasions and
enter is necessary for good health (homeostasis). other means).
Sometimes, however, the body cannot fight off
To understand how infections occur, think of these
infection. When this occurs, an invading pathogen
four conditions as pieces of a puzzle (Fig. 2-2). All
can become established in the body, causing
of the pieces must be in place for the picture to be
infection, which may range from mild to serious
complete. If any one of the conditions is missing,
and brief (acute) to long-lasting (chronic). Fever
an infection cannot occur.
and exhaustion are often a sign and symptom that
the body is fighting off an infection. Other common Bloodborne pathogens, such as hepatitis B,
signs and symptoms include headache, nausea hepatitis C and HIV, spread primarily through
and vomiting. direct or indirect contact with infected blood or
OPIM (see Table 2-2). While these diseases can
There are three different types of human immunity:
be spread by sexual contact through infected body
innate, adaptive and passive.
fluids, such as vaginal secretions and semen, these
Innate immunity is the type of protection with body fluids are not usually involved in occupational
which we are born. The term “innate immunity” transmission. Hepatitis B, hepatitis C and HIV are
also refers to the natural barriers our bodies not spread by food or water or by casual contact
CRITICAL Intact skin, as well as mucous membranes in the mouth, nose and eyes, are part of
FACTS the body’s natural defenses to help keep infectious microorganisms out.
For any disease to spread, pathogens must be present in sufficient quantity and
pass through the broken skin or mucous membrane of a susceptible person.
20 | Emergency Medical Response
Present Entry
Site
Susceptible
Quantity
Fig. 2-2: To understand how infections occur, think of the four necessary conditions as pieces of a puzzle.
Table 2-2:
How Bloodborne Pathogens Are Transmitted
MODE OF INFECTIVE
DISEASE SIGNS AND SYMPTOMS
TRANSMISSION MATERIAL
Hepatitis B Jaundice, fever, dark urine, clay-colored bowel Direct and indirect Blood, semen
movements, fatigue, abdominal pain, loss of appetite, contact
nausea, vomiting, joint pain
Hepatitis C Jaundice, fever, fatigue, dark urine, clay-colored stool, Direct and indirect Blood, semen
abdominal pain, loss of appetite, nausea, vomiting, contact
joint pain
HIV May or may not be signs and symptoms in early stage; Direct and Blood, semen,
late-contact stage symptoms may include fever, possibly indirect vaginal fluid
headache, fatigue, diarrhea, skin rashes, night sweats, contact
loss of appetite, swollen lymph glands, significant
weight loss, white spots in the mouth or vaginal
discharge (signs of yeast infection) and memory or
movement problems
such as hugging or shaking hands. The highest risk Direct Contact
of occupational transmission is unprotected direct Direct contact transmission occurs when infected
or indirect contact with infected blood. blood or OPIM from one person enters another
Disease-causing germs can also cause infection person’s body at a correct entry site (Fig. 2-3). For
through contaminated food or water. In this way, example, direct contact transmission can occur
germs can spread to many people through a through infected blood splashing in the eye or from
single source, such as sometimes occurs with directly touching the OPIM of an infected person.
Escherichia coli (E. coli); this type of infection is The infected blood or OPIM then enters the body
referred to as food poisoning. through a correct entry site.
Chapter 2: The Well-Being of the Emergency Medical Responder | 21
Fig. 2-3: Bloodborne pathogens can be transmitted by direct Fig. 2-4: Bloodborne pathogens can be transmitted by indirect
contact when an uninfected person directly touches the blood or contact when an uninfected person touches an object that
OPIM of an infected person. contains the blood or OPIM of an infected person.
Indirect Contact
Some bloodborne pathogens are also transmitted
by indirect contact (Fig. 2-4). Indirect contact
transmission can occur when a person touches an
object that contains the blood or OPIM of an infected
person, and that infected blood or OPIM enters the
body through a correct entry site. These objects
include soiled dressings or equipment and work
surfaces contaminated with an infected person’s
blood or OPIM. For example, indirect contact
can occur when a person picks up blood-soaked
bandages with a bare hand and the pathogens enter
through a break in the skin on the hand.
Respiratory Droplet and Vector-Borne
Transmission
Other pathogens, such as the flu virus, can
enter the body through droplet transmission
Fig. 2-5: Some pathogens enter the body through droplet
(Fig. 2-5). This occurs when a person inhales transmission, when a person inhales droplets propelled from an
droplets propelled from an infected person’s infected person’s cough or sneeze. Photo: courtesy of Michelle
cough or sneeze from within a few feet. A person Lala Clark.
can also become infected by touching a surface
recently contaminated by infected droplets
and then touching the eyes, mouth or nose
with contaminated hands. Vector-borne
transmission of diseases, such as malaria, rabies
and West Nile virus, occurs when an infectious
source, such as an animal or insect bite or a sting,
penetrates the body’s skin (Fig. 2-6).
Risk of Transmission
Infectious diseases have widely varying levels of risk
of transmission. Hepatitis B, hepatitis C and HIV
share a common mode of transmission—direct or
indirect contact with infected blood or OPIM—but
they differ in the risk of transmission. Workers who
Fig. 2-6: Vector-borne transmission occurs when an insect bite
have received the hepatitis B vaccine and have or sting penetrates the body’s skin. Photo: © Shutterstock.com/
developed immunity to the virus are at virtually Dmitrijs Bindemanis.
22 | Emergency Medical Response
no risk for infection by the hepatitis B virus (HBV).
For an unvaccinated person, the risk for infection
from a needlestick or cut exposure to hepatitis
B-infected blood can be as high as 30 percent,
depending on several factors. In contrast, the risk
for infection after a needlestick or cut exposure
to hepatitis C-infected blood is about 2 percent,
and the risk of infection after a needlestick or
cut exposure to HIV-infected blood is less than
1 percent.
Diseases That Cause Concern
Hepatitis A, B, C, D and E
Fig. 2-7: Later-stage symptoms of hepatitis B include jaundice,
Hepatitis is a type of liver disease. Hepatitis which causes a yellowing of the skin and eyes. Photo: courtesy of
A is caused by the hepatitis A virus (HAV). This CDC/Dr. Thomas F. Sellers, Emory University.
disease is spread primarily through food or water
that has been contaminated by stool from an
is the hepatitis B vaccine. This vaccine, given in
infected person.
a series of three doses, provides immunity to the
HAV is transmissible by: disease. Scientific data show that hepatitis B
vaccines are safe for adults, children and infants.
Eating food prepared by someone with HAV who There is no confirmed evidence indicating that the
did not wash hands after using the bathroom. hepatitis B vaccine causes chronic illnesses.
Engaging in certain sexual activities, such as
The hepatitis B vaccination series must be made
oral-anal contact with someone who has HAV.
available to all employees who have occupational
Changing a diaper and then not washing hands.
exposure, usually within 10 working days of initial
Drinking water that has been contaminated. assignment, after completing appropriate training.
HAV causes inflammation and swelling of the liver. However, employees may decide not to have the
The patient may feel ill, with flu-like symptoms, or vaccination. If an employee decides not to be
may experience no symptoms at all. Symptoms vaccinated, the person must sign a form affirming
of HAV usually disappear after several weeks. this decision. However, if an employee who initially
This disease rarely causes permanent damage or declines hepatitis B vaccination decides to accept
chronic illness. the vaccination at a later date, the employer
must make the hepatitis B vaccination available
HAV can be prevented with the hepatitis A vaccine, at that time, so long as the standard still covers
which is a series of two injections administered the employee.
at least 6 months apart. The most effective
prevention, though, is healthy habits. Always wash Hepatitis C is a liver disease caused by the
your hands thoroughly before preparing food, hepatitis C virus (HCV). It is the most common
after using the toilet and after changing a diaper. chronic bloodborne infection in the United States.
International travelers should be careful about Its symptoms are similar to those of hepatitis B
drinking tap water. infection, including fever, fatigue, abdominal pain,
loss of appetite, nausea, vomiting, dark urine,
Hepatitis B is a liver infection caused by HBV. clay-colored stool, joint pain and jaundice. There
Hepatitis B may be severe or even fatal and it can is no vaccine against hepatitis C and no treatment
be in the body for up to 6 months before symptoms available to prevent infection after exposure. For
appear. These may include flu-like symptoms such these reasons, hepatitis C is more serious than
as fever, fatigue, abdominal pain, loss of appetite, hepatitis B. Hepatitis C is the leading cause of
nausea, vomiting and joint pain, as well as dark liver transplants.
urine and clay-colored bowel movements. Later-
stage symptoms include jaundice, which causes a Hepatitis D is a serious liver disease caused by
yellowing of the skin and eyes (Fig. 2-7). the hepatitis D virus (HDV) and relies on HBV to
replicate. It is uncommon in the United States. It is
Medications are available to treat chronic transmitted through contact with infectious blood,
hepatitis B infection, but they do not work for similar to how HBV is spread. There is no vaccine
everyone. The most effective means of prevention for hepatitis D.
Chapter 2: The Well-Being of the Emergency Medical Responder | 23
Hepatitis E is caused by the hepatitis E virus Coughing up blood or bloody sputum (phlegm
(HEV). It is commonly transmitted via the fecal- from inside the lungs).
oral route and is associated with ingestion of Weakness and/or fatigue.
drinking water contaminated with fecal material in
countries with poor sanitation. It occurs primarily
Fever and chills.
in adults. The potential for HEV transmission from Night sweats.
contaminated food is still under investigation, TB must be treated properly or it can lead to death.
and there is no evidence of transmission by It can usually be cured with several medications
percutaneous (through the skin) or sexual over a long period of time. Patients with latent
exposures. There is currently no FDA-approved (asymptomatic) TB can take medicine to prevent
vaccine for hepatitis E. development of active TB.
HIV/AIDS Multidrug-Resistant Tuberculosis
HIV is the virus that causes AIDS. HIV attacks Multidrug-resistant tuberculosis (MDR TB)
white blood cells and destroys the body’s ability is TB that is resistant to at least two of the most
to fight infection. This weakens the body’s immune effective anti-TB drugs, isoniazid and rifampicin.
system. Infections that strike people with weakened These drugs are the ones most widely used to treat
immune systems are called opportunistic TB. MDR TB is more likely to occur in patients who:
infections. Some opportunistic infections
that occur in patients with AIDS include severe Do not take their TB medicine regularly or who
pneumonia, tuberculosis, Kaposi’s sarcoma and do not take all of the prescribed medication.
other unusual cancers. Get active TB, after having taken medication to
treat it in the past.
People infected with HIV may not feel or appear
sick. A blood test, however, can detect the Come from areas of the world where MDR TB
is prevalent.
HIV antibody. When an infected person has a
significant drop in a certain type of white blood Spend time with someone known to have
cell or shows signs of having certain infections MDR TB.
or cancers, the patient may be diagnosed as
having AIDS. These infections can cause fever, Meningitis
fatigue, diarrhea, skin rashes, night sweats, loss Meningitis is a contagious meningococcal
of appetite, swollen lymph glands and significant infection that attacks the meninges, the protective
weight loss. In the advanced stages, AIDS is coverings that surround the brain and spinal cord.
a very serious condition. Patients with AIDS Several different bacteria can cause meningitis,
eventually develop life-threatening infections from but a virus can also cause it. The bacteria are
which they can die. Currently, there is no vaccine transmitted from person to person through droplets.
against HIV. Close and prolonged contact (e.g., kissing, sneezing
or coughing on someone) and living in close
Tuberculosis quarters or dormitories (e.g., military or student
Tuberculosis (TB) is an infection caused by a housing) facilitates the spread of the disease.
bacterium called Mycobacterium tuberculosis. Meningitis can infect anyone but is more commonly
The bacteria usually attack the lungs, but they may found in those who have compromised immune
also damage other parts of the body such as the systems and have trouble fighting infections.
brain, kidneys or spine. TB is spread through the air The most common symptoms are stiff neck, high
when an infected person coughs, sneezes or talks. fever, light sensitivity, confusion, headache, nausea,
Anyone exposed to TB should be tested. People sleepiness and vomiting. Bacterial meningitis is
with a weakened immune system are more likely a serious infection; even when diagnosed early
to get TB. and properly treated, 5 to 10 percent of patients
Symptoms of TB in the lungs may include: die, typically within 24 to 48 hours of the onset
of symptoms. Bacterial meningitis may result in
A bad cough lasting 3 weeks or longer. brain damage, hearing loss or learning disability in
A pain in the chest. 10 to 20 percent of patients and sometimes death.
Viral meningitis is less severe and usually resolves
Weight loss.
without specific treatment.
Loss of appetite.
24 | Emergency Medical Response
Bacterial meningitis is potentially fatal and is a of susceptible persons who are within 3 feet of
medical emergency. Admission to a hospital or infected people. Transmission can also occur
health center is necessary. There are vaccines through direct contact or indirect contact with
available to prevent meningitis and antibiotics with respiratory secretions—for example, when touching
which to treat it. surfaces contaminated with influenza virus and
then touching the mouth, nose or eyes.
Community-Associated MRSA Pandemic influenza (or pandemic flu) is
Methicillin-resistant Staphylococcus aureus a virulent human influenza A virus. The term
(MRSA) is a type of bacterium. As one of the staph “pandemic” refers to a worldwide epidemic
bacteria, like other kinds of bacteria, it frequently occurring over a wide geographic area that affects
lives on the skin and in the nose without causing a large number of people. Pandemic flu causes a
any health problems. It only becomes a problem global outbreak, or pandemic, of serious illness in
when it is a source of infection. These bacteria humans. Because there is little natural immunity,
can be spread from one person to another through the disease spreads easily from person to person.
casual contact or contaminated objects. Infections
with MRSA are more difficult to treat than ordinary Although we do not know for sure when the next
staph infections because they are resistant to pandemic influenza will strike or that it would
many types of antibiotics, the medications used to present in the same way as seasonal influenza, it
treat bacterial infections. Infections can occur in is helpful to be aware of the symptoms of seasonal
wounds, burns and sites where tubes have been influenza in order to plan for a pandemic flu. The
inserted into the body. best defense is to take steps to prevent disease
transmission, such as frequent hand washing.
When MRSA occurs in groups of people who have
not been recently hospitalized or have not had a
medical procedure, this type of MRSA is referred to Protecting Yourself from Disease
as community-associated MRSA (CA-MRSA). For Transmission
example, it can occur among young people who have An EMR may be exposed to many other illnesses,
cuts or wounds and who are in close contact with viruses and infections. Keep immunizations
one another, such as members of a sports team. current, have regular physical checkups and be
knowledgeable about other pathogens. For more
Influenza information on infectious diseases and illnesses
of concern, contact the Centers for Disease
Seasonal influenza is a respiratory illness caused
Control and Prevention (CDC) at (800) 232-4636
by both human influenza A and human influenza
(800-CDC-INFO) or visit the website at cdc.gov.
B viruses, which can be transmitted from person
You may also refer to your organization’s exposure
to person. Most people have some immunity to
control officer.
influenza and there is a vaccine available.
Seasonal influenza usually has a sudden onset, Exposure Control Plan
with symptoms of fever (usually high), headache, Federal Occupational Safety and Health
extreme tiredness, dry cough, sore throat, runny Administration (OSHA) regulations require
or stuffy nose and muscle aches. Abdominal employers to have an exposure control plan.
symptoms such as nausea, vomiting and diarrhea The exposure control plan is a written plan
may also be present, but these symptoms occur outlining the protective measures the employer will
more often in children than in adults. take to eliminate or minimize employee exposure
Influenza is transmitted from person to person incidents. The exposure control plan should include
via large virus-laden droplets from coughing exposure determination, methods for implementing
or sneezing. These large droplets settle on the other parts of the OSHA standard (e.g., ways of
mucosal surfaces of the upper respiratory tracts meeting the requirements and recordkeeping) and
CRITICAL Exposure control plans, as required by OSHA, contain policies and procedures
FACTS that help employers eliminate, minimize and properly report employee exposure
incidents.
Chapter 2: The Well-Being of the Emergency Medical Responder | 25
procedures for evaluating details of an exposure Engineering controls.
incident. The exposure control plan guidelines Work practice controls.
should be available to employees and should
specifically explain what they need to do to prevent
Proper equipment cleaning.
the spread of infectious diseases. Spill cleanup procedures.
Immunizations Personal Protective Equipment
Before working as an EMR, you should have a Personal protective equipment (PPE)
physical examination to determine your baseline is equipment that is appropriate for your job
health status. Your immunizations should be current duties and should be available in your
while practicing in healthcare and should include workplace and identified in the exposure control
protection against: plan. PPE includes all specialized clothing,
equipment and supplies that keep you from
Tetanus, diphtheria, pertussis. directly contacting infected materials. These
Hepatitis B. include, but are not limited to, CPR breathing
Measles/mumps/rubella (German measles). barriers, disposable (single-use) latex-free gloves,
gowns, masks, shields and protective eyewear
Chicken pox (varicella).
(Fig. 2-8).
Influenza.
Meningococcal (meningitis).
Disposable Latex-Free Gloves
In addition to immunizations, it is recommended Wear disposable, latex-free nitrile gloves for all
that you be screened for TB and have an annual patient contact when providing care to injured or
tuberculin test. ill people. There are powder-free gloves available
as well as disposable latex-free gloves made of
vinyl. However, nitrile gloves are preferred and
Standard Precautions offer the greatest protection from bloodborne
Standard precautions are safety measures pathogens. For information on glove removal, refer
taken to prevent occupational-risk exposure to to Skill Sheet 2-1.
blood and OPIM such as body fluids containing
visible blood. Standard precautions combine body
Eye Protection
substance isolation (BSI) precautions and universal
precautions and assume that all body fluids may Safety glasses with side shields may be worn
be infective. for eye protection. Use goggles or a full-face
shield if there is a risk of splash or spray of body
Universal precautions are OSHA-required fluids. These reduce the risk of contamination
practices of control to protect employees of the mouth, nose or eyes. Examples of when
from exposure to blood and OPIM. These these are necessary are when a patient is
precautions require that all human blood and bleeding profusely, when delivering a baby, when
OPIM be treated as if known to be infectious suctioning and when providing ventilatory support
for hepatitis B, hepatitis C, HIV or other (e.g., bag-valve-mask [BVM] resuscitator or
bloodborne pathogens. resuscitation mask).
Body substance isolation (BSI) precautions
are a group of measures to prevent exposure to CPR Breathing Barriers
pathogens. This approach to infection control can CPR breathing barriers include resuscitation
be applied through the use of: masks (pocket masks), shields and BVMs. CPR
breathing barriers help protect you against disease
PPE. transmission when performing CPR or giving
Proper hand hygiene. ventilations to a patient.
CRITICAL Standard precautions are safety measures to prevent occupational-risk exposure to
FACTS blood and OPIM. These assume that all body fluids may be infective.
26 | Emergency Medical Response
Fig. 2-8: Personal protective equipment.
The History of Isolation Precautions
Isolation precautions have evolved over the last the need to avoid contact with all moist and
few decades, in response to the expansion of potentially infectious body substances, even if
healthcare delivery from a mostly primary care blood was not present. Another difference from
hospital setting to a wide range of settings, as universal precautions was that BSI precautions
well as our understanding of new pathogens and did not specify hand washing after glove
how they spread. removal unless there was visible soiling.
While isolation precautions were already in In 1996, the Healthcare Infection Control
place in the early 1980s, new guidelines, called Practices Advisory Committee (HICPAC)
universal precautions, were developed in the mid- blended the major features of universal and BSI
1980s in response to the HIV/AIDS epidemic. precautions in a broader guideline referred to
These precautions dictated the application of as standard precautions, directing healthcare
blood and OPIM precautions to all patients, workers to apply these precautions to all
whether or not they were known to be infected. patients at all times. Standard precautions
These precautions included such measures address some gaps in the earlier guidelines,
as hand washing immediately following glove by including three transmission-based
removal, handling of needles and other sharps categories of precautions: airborne, droplet
devices, and PPE to protect healthcare and contact.
personnel from mucous membrane exposures.
Today, standard precautions constitute the
In 1987, new precautions were developed, called primary strategy to prevent healthcare-
BSI precautions, which shared some features associated infection among patients and
with universal precautions but emphasized healthcare personnel.
Chapter 2: The Well-Being of the Emergency Medical Responder | 27
Masks Wash your hands with soap and running water,
A mask is a personal protective device worn and dry your hands thoroughly. Wash your hands
on the face that covers at least the nose and and other exposed skin immediately if exposed to
mouth, and reduces the wearer’s risk of inhaling contaminants, such as blood and OPIM. Always
hazardous airborne particles (including dust wash hands after using the restroom and before
particles and infectious agents such as TB), and after handling food. Use alcohol-based hand
gases or vapors. A high-efficiency particulate sanitizers when soap and running water are not
air (HEPA) or N95 mask filters out at least available, but wash your hands with soap and water
95 percent of airborne particles, and is therefore as soon as it is practical.
given a “95” rating. Respirators that filter out at
least 99 percent receive a “99” rating. Those Hand-Washing Tips
that filter at least 99.97 percent (essentially To ensure you wash your hands correctly, follow
100 percent) receive a “100” rating. Remember these steps:
that masks must be fit-tested to be effective. Place
a surgical mask on the patient if you suspect an Wet hands with warm water.
airborne disease. Apply soap to hands.
Rub hands vigorously for at least 20 seconds,
Gowns covering all surfaces of the hands and fingers.
Wear a disposable gown in situations with large Use soap and warm running water. Scrub nails
amounts of blood or OPIM. If your clothing by rubbing them against the palms.
becomes contaminated, remove it and shower as Rinse hands with water.
soon as possible. Wash the clothes in a separate Dry hands thoroughly with a paper towel.
load, preferably at work. Turn off the faucet using the paper towel.
Hand Hygiene In addition to washing your hands frequently, keep
your fingernails less than one-quarter of an inch
Hand washing is the most effective measure
long and avoid wearing artificial nails.
to prevent the spread of infection (Fig. 2-9). By
washing your hands often, you physically remove
disease-causing germs you may have picked up from Hand Sanitizer and Hand-Washing
other people, animals or contaminated surfaces. In Stations
addition, jewelry, including rings, should not be worn At some outdoor events or workplaces, for
where the potential for risk of exposure exists. example on a farm or at a fair, the only source
of clean water may be a portable hand-wash
Wash your hands frequently. When practical, wash station. These stations consist of a supply of
your hands before providing care and always after soap and potable water, and a bucket, cooler
providing care—whether or not gloves are worn. or other container with a turn-spout that allows
Local protocols may vary and should be followed. the water to run over your hands to rinse soap
away. The stations also include a catch bucket
to catch the wastewater, and an ample supply of
paper towels.
Alcohol-based hand sanitizers allow you to cleanse
your hands when soap and water are not readily
available and your hands are not visibly soiled. If
your hands contain visible matter, you should use
soap and water instead. When using an alcohol-
based hand sanitizer:
Apply the product to the palm of one hand.
Rub hands together.
Rub the product over all surfaces of the hands
and fingers until hands are dry.
Fig. 2-9: Hand washing is the most effective way to prevent the Wash your hands with soap and water as soon
spread of infection. as they are available.
28 | Emergency Medical Response
Engineering and Work Practice
Controls
Engineering controls are control measures that
isolate or remove a hazard from the workplace.
In other words, engineering controls are objects
used in the workplace to help reduce the risk of
an exposure incident. Examples of engineering
controls include:
Sharps disposal containers (Fig. 2-10).
Self-sheathing needles.
Safer medical devices, such as sharps with
engineered sharps injury protections or Fig. 2-10: Biohazard containers, such as those used for sharps
needleless systems. disposal, are one type of engineering control.
Use of biohazard containers and labels, and
posting of signs at entrances to areas where
infectious materials may be present. Placing sharps items (e.g., needles, scalpel
blades) in puncture-resistant, leak-proof and
PPE. labeled containers, and having the containers at
Biohazard containers are marked with a biohazard the point of use.
symbol—typically, a three-sided design in bright, Avoiding splashing, spraying and splattering
fluorescent orange or orange-red, with lettering or droplets of blood or OPIM when performing
symbols in a contrasting color. This symbol warns all procedures.
of potential infection hazards. The origin of the Removing and disposing of soiled protective
biohazard symbol dates back to the 1960s. It was clothing as soon as possible.
created out of a need for a standardized, unique Cleaning and disinfecting all equipment and
symbol to use as a warning symbol in response to work surfaces possibly soiled by blood or OPIM.
accidental infections that occurred as a result of
biomedical research. These unfortunate incidents
Washing your hands thoroughly with soap and
water immediately after providing care, using
were viewed as preventable. The symbol’s a utility or restroom sink (not one in a food
development was spearheaded by Charles preparation area).
Baldwin, an environmental health engineer at
Dow Chemical Corporation. The symbol that was Not eating, drinking, smoking, applying
cosmetics or lip balm, handling contact lenses,
eventually chosen best met the criteria that were
or touching your mouth, nose or eyes when you
tested in development of the symbol. It is easy to
are in an area where you may be exposed to
recognize, has three sides so it can be identified
infectious materials.
from any angle, and can be easily stenciled for
labeling purposes. The symbol was soon adopted Using alcohol-based sanitizers where hand-
by the National Institutes of Health, the CDC washing facilities are not available.
and OSHA. Vehicle and Equipment Cleaning
Work practice controls reduce the likelihood of and Disinfecting
exposure by changing the way a task is carried out. After providing care, the equipment and surfaces
These are the methods of working that help reduce you used should always be cleaned and disinfected
the risk of an exposure incident. Examples of work or properly disposed of (Fig. 2-11). Handle all soiled
practice controls include: equipment, supplies and other materials with care
CRITICAL Engineering controls, such as biohazard containers and PPE, are control measures
FACTS that isolate or remove a hazard from the workplace.
Work practice controls reduce the likelihood of exposure by changing the way
tasks, such as disposal of sharps items or soiled clothing, are carried out.
Chapter 2: The Well-Being of the Emergency Medical Responder | 29
approximately 1½ cups of liquid chlorine bleach to
1 gallon of water (1 part bleach per 9 parts water,
or about a 10 percent solution), and allow it to
stand for at least 10 minutes. Other commercial
disinfectant/antimicrobial solutions are available
and may have different set times. Follow local
protocols and manufacturer’s instructions.
Use appropriate material to absorb the
solution, and dispose of it in a labeled
biohazard container.
Scrub soiled boots, leather shoes and other
leather goods such as belts with soap, a
brush and hot water. If you wear a uniform
to work, wash and dry it according to the
manufacturer’s instructions.
Clean and disinfect the vehicle according to
standard procedures. Wear appropriate PPE
(disposable gown and gloves) during the cleaning
process and discard after use. Thoroughly clean and
disinfect all surfaces that may have come in contact
with the patient or materials that may have become
contaminated while providing care for the patient
(e.g., stretcher, rails, control panels, floors, walls,
work surfaces). Use an Environmental Protection
Agency (EPA)-registered hospital disinfectant and
follow manufacturer’s recommendations.
Fig. 2-11: Always clean and disinfect the equipment you use
after providing care. Photo: courtesy of Terry Georgia. If an Exposure Occurs
Exposure incidents involve contact with blood or
until it is properly cleaned and disinfected. Place OPIM—for example, a patient’s blood gets into a
all used disposable or single-use items in labeled cut on your hand, you are stuck with a needle used
biohazard containers. Place all soiled clothing in on a patient, or bloody saliva splashes into your
marked plastic bags for disposal or washing. mouth or eyes. You may also be exposed when
in unprotected, close contact with someone who
Take the following steps to clean up spills: has an airborne disease involving exposure to
aerosolized, respiratory droplets (e.g., coughing,
Wear disposable latex-free gloves and other
sneezing), such as with a patient infected with
PPE when cleaning spills.
influenza (including pandemic flu), TB or MDR TB.
Clean up spills immediately or as soon as
possible after the spill occurs.
What to Do If You Are Exposed
If the spill is mixed with sharp objects, such as
If you are exposed, take the following
broken glass and needles, do not pick these
steps immediately:
up with your hands. Use tongs, a broom and
dustpan or other similar items. Clean the contaminated area thoroughly with
Dispose of the absorbent material used to soap and water. Wash needlestick injuries, cuts
collect the spill in a labeled biohazard container. and exposed skin with soap and water.
Flood the area with a fresh disinfectant solution. Flush splashes of blood and OPIM to the mouth
Use a commonly accepted disinfectant of and nose with water.
CRITICAL If you are exposed to blood or OPIM, immediately take the appropriate steps, such
FACTS as cleaning contaminated areas, as part of a proper exposure control plan.
30 | Emergency Medical Response
If the eyes are involved, irrigate with clean water, OSHA regulations regarding bloodborne
saline or sterile irrigants for 20 minutes. pathogens have placed specific responsibilities on
Seek immediate follow-up care as identified in employers for protection of employees, including:
your department exposure control plan.
Identifying positions or tasks covered by
the standard.
Reporting Exposures
Following any exposure incident:
Creating an exposure control plan to minimize
the possibility of exposure and making the plan
easily accessible to employees.
Report the exposure incident to the appropriate
person identified in your employer’s exposure Developing and putting into action a written
control plan (often the infection control officer) schedule for cleaning and decontaminating at
immediately and to the emergency medical the workplace.
services (EMS) providers who take over care Creating a system for easy identification of
of the patient. This step can be critical to the soiled material and its proper disposal.
success of post-exposure treatment. Developing a system of annual training for all
Write down what happened. Include the covered employees.
time and date of the exposure as well as the Offering the opportunity for employees to get
circumstances of the exposure, any actions the hepatitis B vaccination at no cost.
taken after the exposure and any other
information required by your employer.
Establishing clear procedures to follow for
reporting an exposure.
Creating a system of recordkeeping.
OSHA Regulations In workplaces where there is potential exposure
OSHA has issued regulations about on-the- to injuries from contaminated sharps, soliciting
job exposure to bloodborne pathogens. OSHA input from non-managerial employees with
determined that employees are at risk when potential exposure regarding the identification,
exposed to blood or OPIM. OSHA therefore evaluation and selection of effective engineering
requires employers to reduce or remove hazards and work practice controls.
from the workplace that may place employees in If a needlestick injury occurs, recording the
contact with infectious materials. appropriate information in the sharps injury
log, including:
OSHA regulations and guidelines apply to
employees who may come into contact with yyThe type and brand of device involved in
blood and OPIM that could cause an infection. the incident.
These regulations apply to you as an EMR yyThe location of the incident.
because you are expected to provide emergency yyA description of the incident.
care as part of your job. In 2001, in response to
passage of the federal Needlestick Safety and
Maintaining a sharps injury log in such a way
that protects the privacy of employees.
Prevention Act, OSHA revised the Bloodborne
Pathogens Standard 29 CFR 1910.1030. These Ensuring confidentiality of employees’ medical
records and exposure incidents.
guidelines may help you and your employer meet
the OSHA bloodborne pathogens standard
to prevent transmission of serious diseases. Needlestick Safety and Prevention Act
(For additional information on the Bloodborne Blood and OPIM have long been recognized
Pathogens Standard 29 CFR 1910.1030, visit as potential threats to the health of employees
OSHA’s website at www.osha.gov/SLTC/ who are exposed to these materials through
bloodbornepathogens/standards.html.) penetration of the skin. Injuries from contaminated
CRITICAL Per OSHA regulations, employers are required to remove items that might put
FACTS employees in contact with infectious materials.
OSHA regulations regarding bloodborne pathogens have placed specific
responsibilities on employers for protection of employees. These include creating
exposure control plans, scheduling decontamination and cleaning of the workplace,
training on OSHA regulations and free hepatitis B vaccinations.
Chapter 2: The Well-Being of the Emergency Medical Responder | 31
needles and other sharps have been associated Critically injured or ill people. Responding to a
with an increased risk of disease from more call to help someone who is critically injured or ill
than 20 infectious agents. The most serious can be highly stressful because of the possibility
pathogens are hepatitis B, hepatitis C and HIV. of not being able to save the patient.
Needlestick and other sharps injuries resulting in Death and dying patients. Death is disturbing to
exposure to blood or OPIM are a concern because most people, but the feelings of powerlessness
they happen frequently and can have serious at not being able to save someone’s life may also
health effects. bring about tremendous guilt and grief.
In 2001, OSHA revised the Bloodborne Overpowering sights, smells and sounds.
Pathogens Standard 29 CFR 1910.1030. The Disturbing sights, strong smells and sounds
revised standard clarifies the need for employers that are upsetting to the EMR may accompany
to select safer needle devices and to involve scenes of illness and accidents, especially those
employees in identifying and choosing these that are severe.
devices. Needleless systems are one option to Multiple-patient situations. All of the above
reduce the possibility of accidental needlestick situations can occur when a single person
injuries and possible infection. The updated is injured or ill, but the effects are magnified
standard also requires employers to maintain a in a multiple-casualty incident, which can be
log of injuries from contaminated sharps. (For truly overwhelming.
additional information on the Needlestick Safety Angry or upset patients, family and bystanders.
and Prevention Act, visit OSHA’s website at In an emotionally charged situation, tempers may
www.osha.gov/SLTC/bloodbornepathogens/ flare, adding to the intensity of the situation.
standards.html.)
During stressful situations, cooperate with
Also, be aware of any areas, equipment or other personnel responding to the situation. It
containers that may be contaminated. Biohazard is important that you handle the situation in a
warning labels are required on any container professional manner when dealing with public
holding contaminated materials, such as used safety responders, other EMS providers, the
gloves, bandages or trauma dressings. Post patient and the family.
signs at entrances to work areas where infectious
materials may be present. Death and Dying
Experiencing the dying process is difficult for
EMOTIONAL ASPECTS most people. The following measures may help the
patient and family deal with the dying process:
OF EMERGENCY CARE
Stressful Situations Recognize that the patient’s and the family’s
needs include dignity, respect, sharing,
EMRs experience an extraordinary number communication, privacy and control.
of stressful situations beyond what others
may encounter. Some of the more powerful Allow the patient and the family to express rage,
anger and despair.
situations include:
Listen empathetically and remain calm and
Dangerous situations. Fires, scenes of violent nonjudgmental.
crime, agricultural accidents and other emergency Do not falsely reassure.
scenes all involve a certain measure of danger.
Use a gentle tone of voice.
Physical and psychological demands. Some
Let the patient and the family know that
rescues, such as extrications, may place everything that can be done to help will be done.
substantial physical burdens on the EMR;
others, such as rescuing an abused child, may Use a reassuring touch, if it is appropriate.
involve extraordinary psychological demands. Comfort the patient and the family.
CRITICAL Measures such as listening empathetically, speaking gently, and allowing anger or
FACTS despair to be expressed may help the patient and family cope with the dying process.
32 | Emergency Medical Response
Resuscitation personnel immediately to provide care. If you are in
You may be summoned to an emergency in which doubt about the validity of the advance directives,
one or more people have died or are dying. The cause attempt to resuscitate the patient. (For more
could be natural, accidental or intentional. Though information on advance directives, POLST forms
your responses will vary according to the situation, and DNR orders, refer to Chapter 3.)
you must recognize that death will have an emotional
impact on you, as well as on others involved. Individual Responses to Death
You may be in a situation in which you think a Dying is part of the living process. Death affects
person has been dead for a while and you are everyone, and the way we respond varies widely.
unsure whether you should attempt to resuscitate Be prepared to handle your feelings and the
that person. The general rule is to always attempt feelings of others. Remember that reactions to
to resuscitate a patient without a pulse or normal death and dying range from anxiety to acceptance.
breathing except in the following situations: How well you and others handle the situation will
depend on both personal feelings about death and
A valid do not resuscitate (DNR) order or a the nature of the incident.
Physician Orders for Life-Sustaining Treatment
(POLST) form that meets local guidelines One of the most disturbing emergency situations
is present at the scene and directs not to is sudden death. Sudden death generally refers
attempt resuscitation. to an unexpected, natural death. It is commonly
used to describe death resulting from an abrupt
Obvious signs of death are present in the patient.
cardiac event, but it also describes a death that
These signs include tissue decay (putrefaction);
occurs within a few hours after an abrupt onset of
rigor mortis (stiffening of joints that occurs after
symptoms in an otherwise healthy person. Sudden
death; assess two or more joints, such as the
death of an infant can be especially disturbing
fingers and jaw, to verify); obvious mortal wounds
to new parents, though it is difficult for anyone
(injuries clearly not compatible with life, such as
involved. EMRs can never fully prepare themselves
decapitation); or dependent lividity (purplish
for an emergency involving sudden death.
color in the lowest-lying parts of a recently dead
body, due to pooling of blood).
The situation is so dangerous (such as a Stages of Grief
gunman on the scene) that attempting to There will be times you are called to assist grieving
resuscitate the patient would endanger your life. patients or family members. There are some
predictable responses to grief, though people do
To determine that a person is dead, the patient not always experience them in any particular order.
is often placed on a heart monitor and vital signs Keep in mind that everyone’s reaction to death and
are assessed by more advanced EMS personnel. dying is unique and not everyone will experience
When it is determined that the patient has no every stage of grief, nor will everyone experience
electrical activity of the heart and no respirations grief in the same order.
and blood pressure, the person may be declared
dead. This may occur after prolonged resuscitation Remain nonjudgmental throughout the grieving
attempts, or it may occur immediately if one of the process. The stages of grieving include:
above conditions is present.
Denial. The patient or family member denies the
Some patients may have advance directives, seriousness of the situation in order to buffer the
POLST forms or DNR orders, which are written pain of the event.
legal documents saying that they do not wish to be Anger. The patient or family member projects
resuscitated or kept alive by mechanical means. In feelings of anger toward other people, especially
most instances, you should honor the wishes of the those closest to the individual. Do not take
patient if they are expressed in writing. However, anger personally, even though it may seem to be
since state and local laws about these situations directed toward you. Be alert to anger that may
vary, you should summon more advanced medical become physical and endanger you or others.
CRITICAL Denial, anger, bargaining, depression and acceptance are the five stages of grief.
FACTS
Chapter 2: The Well-Being of the Emergency Medical Responder | 33
Bargaining. The patient or family member may An event like a serious injury, illness or death may
attempt to negotiate with a spiritual higher produce great stress in patients, family members
being or even with EMS providers in an effort to and EMRs. By learning how stress builds up,
extend life. how to identify its signs and symptoms, and
Depression. The patient or family member how to manage stress, you can help yourself
exhibits sadness and grief, is usually withdrawn and others cope with the stressful impact of an
and may cry continually. Allow the affected emergency situation.
person to express these feelings, and help
While providing care, you may encounter angry,
the patient or family member to understand
scared or violent patients and family members,
that these are normal feelings associated
especially when the patient is seriously injured or
with death.
ill. Personal feelings triggered by these situations
Acceptance. The patient or family member can affect you. Learn what to expect and how to
ultimately accepts the situation and incorporates assist patients, their families, yourself and others in
the experience into the activities of daily living, dealing with this stress.
in an effort to survive or to support a loved one.
Use good listening skills in this phase. Those involved in a serious injury, sudden
illness or death may face an emotional crisis.
Their reactions to the crisis will depend on a
Helping the Patient and the Family
number of factors and will differ from person
The care EMRs provide to patients often focuses to person. Often, reactions will come during or
on the patient’s physical needs, but care must immediately following the event, but in some
also include supporting patients and their families cases they may be delayed for hours, days or
through the emotions they may experience when even longer.
someone is injured or ill. In these situations, be
calm, supportive and nonjudgmental. Allow the
patient or family member to safely vent feelings. Warning Signs and Symptoms of
Personal Stress
STRESS MANAGEMENT As an EMR, be sure to note if you or those around
you are exhibiting any signs or symptoms of
What Is Stress? personal stress during or following a response.
Stress is the body’s normal response to any When interacting with patients and their families
situation that changes a person’s existing mental, during an emergency, you may hear them talk about
physical or emotional balance. Stress can result or exhibit certain signs or symptoms of stress.
from positive experiences, such as a wedding, or Warning signs and symptoms of stress include:
more difficult situations, such as responding to a
life-threatening emergency. Difficulty sleeping and nightmares.
Irritability with co-workers, family and friends.
Stress can arise from any situation or thought
that brings about feelings of frustration, anger
Feelings of sadness, anxiety or guilt.
or anxiety. Stress is unique to the individual; Indecisiveness.
what is stressful to one person may not be Loss of appetite.
so to another. Stress is a normal part of Loss of interest in sexual activity.
life. In small quantities, it can be positive, Isolation.
motivating people and helping them to be Loss of interest in work.
more productive. Too much stress or a strong
response to stress, however, can be harmful,
Feelings of hopelessness.
contributing to illnesses such as heart disease Alcohol or drug misuse or abuse.
or depression. Inability to concentrate.
CRITICAL When interacting with patients and their families, watch carefully for signs of stress,
FACTS which can include sleep disorders, loss of appetite, emotional and behavioral
changes, and drug abuse.
34 | Emergency Medical Response
INCIDENT STRESS Pre-Incident Education
MANAGEMENT To help EMRs cope with job-related stress before
An EMR’s job can be highly stressful, often it occurs, employers sometimes offer stress-
involving “critical incidents.” These emergencies management classes and crisis-mitigation training.
involve a serious injury or death. Critical incidents This preparation helps responders set expectations
are especially stressful if you feel you did and improve their ability to cope with stress.
something wrong or failed to do something even It is also a good idea to create a self-care plan
after responding exactly as you were trained. A that lays out how you will take care of your own
particular type of stress, called critical incident well-being while involved in emergency work. This
stress, can result from such a situation. It is should include mental health considerations. For
important to understand the powerful impact this example, your employer may offer prearranged
stress can have on you. professional counseling to help you cope with
The stress of the emergency can cause distress work-related stress.
or disruption in a person’s mental or emotional Finally, an EMR’s job often requires long hours,
balance. It can cause sleeplessness, anxiety, including weekends and evenings. To lower your
depression, exhaustion, restlessness, nausea, stress level, it is a good idea to arrange in advance
nightmares and other problems. Some effects for personal responsibilities such as care for
may appear right away and others only after days, children and older parents.
weeks or even months have passed. People
suffering from critical incident stress might not be
able to do their job well. Stress Management During
an Emergency
Closely monitor your performance and watch Pay attention to your own stress responses during
for the following signs and symptoms of critical an emergency, through continual self-monitoring.
incident stress reactions: In monitoring your stress, consider factors such as
stamina, expectations, prior traumatic experiences
Confusion
and eating habits. Partner with a colleague so that
Shortened attention span
you can help monitor each other’s stress levels
Poor concentration to determine when relief is necessary. If you feel
Denial your stress level rising to a concerning level, you
Guilt may need a second to step back from a situation,
Depression recollect your thoughts and then continue with care.
Anger
Change in interactions with others Post-Incident Stress Management
Increased or decreased eating To relieve stress, the following steps can help:
Uncharacteristic, excessive humor or silence
Any other unusual behavior Use quick relaxation techniques, such as deep,
slow breathing.
EMS Incidents Likely to Produce Stress Eat a good meal and avoid beverages
with caffeine.
Events that trigger critical incident stress are often
powerful and traumatic, and are usually outside Avoid alcohol or drugs.
of the range of what we consider normal human Review the event and clear up any uncertainties.
experiences on the job. This might include the Get enough rest.
death or serious injury of a co-worker, the death of Get involved in some type of physical exercise
a child or a multiple-casualty event. or activity, either alone or in a group.
CRITICAL The stress of critical incidents can be powerful for EMRs, and the effects may
FACTS be latent or immediate. Watch for signs, including guilt, poor concentration,
depression, or any uncharacteristic or unusual behavior.
Chapter 2: The Well-Being of the Emergency Medical Responder | 35
Follow-Up Some people think that participating in counseling
EMRs sometimes do not recognize how much is an admission of weakness. Quite the contrary is
the stress of what they do can affect their family true. Counseling should be—and in many areas
and friends. They sometimes complain that their is—a routine part of any overwhelming incident,
loved ones show a lack of understanding for such as an airline disaster. Counseling can help
what they do. Family members can experience in any situation, regardless of how minor you may
frustration because of an EMR’s unwillingness to think the event was. The most important thing you
share information and feelings about an incident. can do to minimize the effects of any emergency
EMRs do not always realize that family members is to express your feelings and thoughts after
and friends suffer fear of separation and are afraid the incident.
of being ignored for something “more exciting.”
An EMS career can be cut short by the invisible
dangers of unmanaged stress. By taking a serious
PUTTING IT ALL TOGETHER
look at your life and making necessary adjustments, In order to provide emergency care to others, it is
you can ensure a healthy balance in all the things important first to look after yourself. This includes
you choose to do. physical, emotional and mental health concerns.
If you begin to exhibit signs and symptoms of One of the ways EMRs must look after themselves
critical incident stress that do not seem to be is by preventing illness. Bloodborne pathogens—
going away after an emergency, work with your most commonly bacteria and viruses—are present
supervisor to arrange for professional counseling in blood and OPIM and can cause disease in
by a licensed mental health professional. humans. The bloodborne pathogens of primary
concern to EMRs are hepatitis B, hepatitis C and
HIV. These pathogens spread primarily through
When to Access Professional Help direct or indirect contact with infected blood
If you or a colleague show signs of critical or OPIM.
incident stress, work with your employer as
soon as possible to arrange for professional To prevent the spread of bloodborne pathogens
counseling by a licensed mental health and other diseases, EMRs should follow standard
professional. Do not wait until after an precautions. These precautions require that all
emergency to figure out where you should go blood and OPIM be treated as if known to be
if you begin to exhibit signs and symptoms of infectious. Apply these precautions by using PPE,
critical incident stress. frequently washing your hands, using engineering
controls, following work practice controls, properly
Incidents that could lead to a necessity to access cleaning and disinfecting equipment, cleaning
professional counseling by a licensed mental health up after spills, and properly disposing of used
professional include: disposable or single-use equipment.
Line-of-duty death or serious injury. If exposed to blood or OPIM, you should
Multiple-casualty incidents. immediately wash, flush or irrigate the exposed
Suicide of an emergency worker. area of your body and report the incident to
your supervisor.
Serious injury or death of children.
Events with excessive media attention. It is equally important that you attend to mental
Victims known to EMS personnel. and emotional health concerns in yourself and the
Events that have unusual impact on patients and families you are helping. An emotional
EMS personnel. crisis often results from an unexpected, shocking
and undesired event, such as the sudden loss of
Any disaster.
a loved one. Although people react differently in
Activation protocols vary from area to area. Your different situations, everyone experiences some or
employer should be able to supply you with all of the stages of grief. By considering the nature
information on how to access this service in of the incident, you can begin to prepare yourself to
your community. deal with its emotional aspects.
36 | Emergency Medical Response
Regardless of the nature of the event, the care understand that in some cases death is inevitable.
you provide to patients in any emotional crisis is In some situations, you may be overcome by
very similar. Your care involves both verbal and emotion. Remember that self-help involves sharing
nonverbal communication. It also requires you to your feelings with others.
You Are the Emergency Medical Responder
After EMS personnel assumed the care of your patient, you note that, in addition to the blood
and vomit on the ground, there is some blood on your disposable gloves and the mask of your
BVM. What steps would you follow to avoid coming in contact with the blood and OPIM? How
should the area be decontaminated?
Chapter 2: The Well-Being of the Emergency Medical Responder | 37
Skill Sheet
Skill Sheet 2-1
Removing Disposable Latex-Free Gloves
NOTE: To remove gloves without spreading germs, never touch your bare skin with the outside of
either glove.
STEP 1
Pinch the palm side of one glove on the outside near your wrist.
STEP 2
Pull the glove toward your fingertips, turning it inside out as you
pull it off your hand.
STEP 3
Hold the glove in the palm of your other (still-gloved) hand.
(Continued)
38 | Emergency Medical Response
Skill Sheet
Skill Sheet 2-1
Removing Disposable Latex-Free Gloves Continued
STEP 4
Carefully slip two fingers under the wrist of the other glove.
Avoid touching the outside of the glove.
STEP 5
Pull the glove toward your fingertips, turning it inside out as you pull it
off your hand. The other glove is now contained inside.
STEP 6
Dispose of the gloves (and any other PPE) properly in a
biohazard container.
Wash your hands thoroughly with soap and running water, if available. Otherwise, rub your hands
thoroughly with an alcohol-based hand sanitizer if they are not visibly soiled and then wash your
hands as soon as it is practical.
Chapter 2: The Well-Being of the Emergency Medical Responder | 39
ENRICHMENT
Health of the Emergency Medical Responder
Being an EMR is a rewarding experience, but it also can be physically, emotionally and mentally challenging.
Making healthy lifestyle choices benefits not only yourself, but also the patients who will rely on you in their
moments of need.
Physical Well-Being
Taking care of your body is a must for an EMR. There are situations you may face where physical strength and
stamina will be key components in successfully caring for patients or assisting other responders. There are
many factors to obtaining good physical well-being, and you should consider it your responsibility to address all
of them as part of a healthy lifestyle. Physical activity not only helps you keep fit but also is an effective way to
reduce stress.
Physical Fitness
Your physical well-being is one of the most important assets you hold to ensure that you are able to effectively
perform your job as an EMR (Fig. 2-12). Maintaining your own physical fitness is necessary for having the stamina
and strength to respond at the level required.
One of the key aspects of physical fitness is cardiovascular endurance. Be sure to get regular cardiovascular
training. According to the American College of Sports Medicine, approximately 30 minutes of physical activity per
day can help lower blood pressure and cholesterol and help you maintain a healthy weight. The more you exercise,
the better your endurance—resulting in better health, strength and stamina.
Muscle strength and flexibility are also important assets for EMRs to assist in day-to-day tasks. Strength
training develops strong bones, increases bone density and controls body fat. Strength training will also reduce
your risk of injury, as muscle protects your joints and helps you maintain flexibility and balance.
Fig. 2-12: Strength training develops strong bones, increases bone density and controls body fat.
40 | Emergency Medical Response
ENRICHMENT
Health of the Emergency Medical Responder continued
Stretching on a regular basis is the best way to maintain flexibility. Therefore, in tandem with your aerobic and
strength training, make sure to incorporate stretching as part of your daily workout routine.
Nutrition
Following basic nutrition strategies will help keep you fit, reduce stress and assist in maintaining your stamina
throughout the day. Choose an eating style that is low in saturated fat, sodium and added sugars and follow the
USDA MyPlate recommendations for a healthy diet (at choosemyplate.gov).
Sleep
Sleep deprivation is one of the most potentially dangerous challenges EMRs may face, as it affects your ability
to think clearly and can decrease your hand-eye coordination. This means you are less productive and may make
mistakes that can lead to injury or negatively affect the patients you treat. If you find yourself consistently feeling
drowsy, adjust your sleep schedule to ensure you are getting enough rest. Speak to your healthcare provider if
you are experiencing sleeplessness.
Disease Prevention
Emergency care personnel must take precautions against disease transmission by potentially infectious
substances. Make sure to protect yourself against disease transmission by following standard precautions and
using recommended PPE. Remember, hand washing is the most important way to prevent the spread of infection,
even if you were wearing gloves when possibly exposed.
Controlling risk factors for heart disease is the best way to minimize your chance of cardiovascular disease. Taking
steps to maintain a healthy lifestyle by not smoking, becoming more active, lowering stress in your life and eating a
healthy diet will dramatically reduce your risks.
Injury Prevention
As mentioned, strength training is a good start to helping prevent injury on the job. As an EMR, it is challenging to
keep your own safety in mind, especially when your patient is in a life-threatening situation. Trying to remain aware
of your surroundings, using proper lifting techniques, and following proper procedures and protocols will help
ensure your safety and that of your patient.
Sun Safety
According to the American Academy of Dermatology, 1 in 5 Americans will develop some form of skin cancer
during their lifetime. Remember when exposed to the sun to drink plenty of fluids and dress appropriately,
such as in long-sleeved shirts, pants, hats and sunglasses. Apply a broad-spectrum sunscreen that has a sun
protection factor (SPF) of 15 or higher and that is water resistant for at least 40 minutes. Broad-spectrum
sunscreens protect the skin from ultraviolet A (UVA) and ultraviolet B (UVB) rays, both of which cause cancer.
Reapply sunscreen every 2 hours, even on cloudy days, and especially when sweating or swimming. One
ounce of sunscreen is considered the amount needed to cover exposed areas of the body.
Mental Well-Being
There is no doubt that being an EMR is stressful (Fig. 2-13). The sense of responsibility for other people’s lives
can be overwhelming. Mental well-being, like physical well-being, is important to allow you to stay focused and be
prepared to deal with the day-to-day stress of your job.
Continued on next page
Chapter 2: The Well-Being of the Emergency Medical Responder | 41
ENRICHMENT
Health of the Emergency Medical Responder continued
Reducing Stress
If you find yourself feeling overwhelmed or indifferent
toward your job, irritable, angry, sarcastic or quick to argue,
chances are you are not coping well with the stress in your
life. It is important to find ways to help relieve your feelings
of stress before they begin to affect your job performance.
Three types of stress reactions are common to EMRs:
acute, delayed and cumulative. Recognizing the warning
signs of stress is imperative, as the earlier they are
identified, the easier they are to address. The warning signs
and symptoms include:
Irritability.
Lack of concentration.
Difficulty sleeping and nightmares.
Anxiety.
Indecisiveness.
Guilt or shame.
Loss of appetite and sexual desire.
Isolation.
Loss of interest in work.
If you feel stress affecting your life, it is important to get it
under control. These stress management techniques may
be helpful:
Fig. 2-13: Being an EMR can be overwhelming. Mental
well-being is important to help you prepare for the everyday
Reprioritize work goals and tasks. stress of the job.
Perform physical activity every day.
Make sure you eat at every meal and avoid fast food.
Share household chores with family members.
Practice relaxed breathing or muscle relaxation.
Put a positive spin on negative thoughts.
Personal Relationships
Finding work-life balance is always challenging and must be managed properly so you can enjoy a rewarding
personal life. Too much focus on work can place stress on your relationships. Often, when faced with difficulties
in your personal life, concentrating on your job can be difficult. This can lead to mistakes or injuries. Some
people throw themselves into work as a way to avoid dealing with relationship problems at home, which can lead
to burnout.
Discovering you are having difficulty coping with problems at home can be overwhelming. Counseling can
help you cope with conflict in your personal relationships and be better prepared to focus while on the job. Family
therapy and marriage counseling can help mend strained relationships, teach new coping skills, and improve
how you interact with family and partners. Counseling gives families the tools to communicate better, negotiate
differences, problem solve and even argue in a healthier way.
42 | Emergency Medical Response
ENRICHMENT
Health of the Emergency Medical Responder continued
Alcohol and Drug Problems
High levels of stress, anxiety or emotional pain can lead some people to drink alcohol to excess or use drugs.
In actuality, this increases stress.
Addiction is a complex problem, including both psychological and physical aspects. If you are addicted to a
drug, you will experience intense cravings for it, sometimes many times throughout the day. Your cravings for the
substance will persist in spite of the physical, psychological and social consequences it brings. You may find
yourself repeatedly trying to stop taking the drug, but being unable to do so because of the unpleasant reactions
to stopping, such as insomnia, anxiety and tremors. You may also find yourself rationalizing the need to do things
you would not normally do, such as stealing or lying, to continue drug use. Or, you may try to convince yourself
that you need the drug in order to cope with your problems. If you show any of the signs of addiction, seek help
immediately through addiction services in your community.
If you are a smoker, deciding to quit smoking will be one of the best and most responsible decisions you make
in your life. It will also be one of the most challenging. Speak to your healthcare provider for advice on quitting,
and remember the health benefits as a way to stay focused on your goal.
Health Risks and Assessments
Your employer may offer wellness tools, such as online health profiles, to help you identify health risks and
develop wellness goals through personalized health assessments. Take advantage of these and other tools that
may be offered to you in an effort to lead a healthier lifestyle.
Chapter 2: The Well-Being of the Emergency Medical Responder | 43
3 MEDICAL,
LEGAL AND
ETHICAL ISSUES
You Are the Emergency Medical Responder
A 20-year-old cyclist on a mountain bike team was temporarily unconscious after falling
off his bike during practice. As the athletic trainer for the team, you respond to the incident.
The injured cyclist is awake but complaining of dizziness and nausea. After assessing and
taking a history and baseline vital signs, you tell the cyclist to go home and rest. Was this
an appropriate response? Why or why not?
KEY TERMS
Abandonment: Ending the care of an injured or ill healthcare, who can make medical decisions on
person without obtaining that patient’s consent someone else’s behalf.
or without ensuring that someone with equal or
Implied consent: Legal concept that assumes a
greater training will continue care.
patient would consent to receive emergency care
Advance directive: A written instruction, signed if they were physically able or old enough to do so.
by the patient and a physician, that documents
In good faith: Acting in such a way that the goal is
a patient’s wishes if the patient is unable to
only to help the patient and that all actions are for
communicate their wishes.
that purpose.
Applied ethics: The use of ethics in decision
Legal obligation: Obligation to act in a particular
making; applying ethical values.
way in accordance with the law.
Assault: A crime that occurs when a person tries to
Living will: A type of advance directive that outlines
physically harm another in a way that makes the
the patient’s wishes about certain kinds of medical
person under attack feel immediately threatened.
treatments and procedures that prolong life.
Battery: A crime that occurs when there is unlawful
Malpractice: A situation in which a professional fails
touching of a person without the person’s consent.
to provide a reasonable quality of care, resulting in
Competence: The patient’s ability to understand the harm to a patient.
emergency medical responder’s (EMR’s) questions
Medical futility: A situation in which a patient has a
and the implications of decisions made.
medical or traumatic condition that is scientifically
Confidentiality: Protection of a patient’s privacy and accepted to be futile should resuscitation be
personal information. attempted and, therefore, the patient should be
considered dead on arrival.
Consent: Permission to provide care; given by an
injured or ill person to a responder. Moral obligation: Obligation to act in a particular way
in accordance with what is considered morally right.
Do no harm: The principle that people who intervene
to help others must do their best to ensure their Morals: Principles relating to issues of right and
actions will do no harm to the patient. wrong and how individual people should behave.
Do not resuscitate (DNR) order: A type of Negligence: The failure to provide the level of care
advance directive that protects a patient’s right to a person of similar training would provide, thereby
refuse efforts for resuscitation; also known as a causing injury or damage to another.
“do not attempt resuscitation (DNAR) order.”
Next of kin: The closest relatives, as defined by state
Durable power of attorney for healthcare: A law, of a deceased person; usually the spouse and
legal document that expresses a patient’s specific nearest blood relatives.
wishes regarding their healthcare; also empowers
Patient’s best interest: A fundamental ethical
an individual, usually a relative or friend, to speak on
principle that refers to the provision of competent
behalf of the patient should they become seriously
care, with compassion and respect for human dignity.
injured or ill and unable to speak for themselves.
Physician Orders for Life-Sustaining Treatment
Duty to act: A legal responsibility of some individuals
(POLST) form: Medical orders concerning end-
to provide a reasonable standard of emergency care.
of-life care to be honored by healthcare workers
Ethics: A branch of philosophy concerned with the during a medical crisis.
set of moral principles a person holds about what
Refusal of care: The declining of care by a
is right and wrong.
competent patient; a patient has the right to refuse
Expressed consent: Permission to receive the care of anyone who responds to an emergency
emergency care granted by a competent adult scene, either before or after care is initiated.
verbally, nonverbally or through gestures.
Standard of care: The criteria established for the
Good Samaritan laws: Laws that protect people extent and quality of an EMR’s care.
against claims of negligence when they give
Surrogate decision maker: A third party with the
emergency care in good faith without accepting
legal right to make decisions for another person
anything in return.
regarding medical and health issues through a
Healthcare proxy: A person named in a healthcare durable power of attorney for healthcare.
directive, or durable power of attorney for
Chapter 3: Medical, Legal and Ethical Issues | 45
LEARNING OBJECTIVES
After reading this chapter, and completing the class • Explain other legal issues including assault and
activities, you will have the information needed to: battery, abandonment and negligence.
• Define the legal duties of an emergency medical • Explain the importance, necessity and legality of
responder (EMR), including scope of practice and maintaining confidentiality about the condition,
the standard of care. circumstances and care of the patient.
• Define and discuss the ethical responsibilities of • Discuss the Health Insurance Portability and
an EMR. Accountability Act (HIPAA) Privacy Rule, including
instances where disclosure of information
• Describe the various forms of consent and explain is permitted.
the methods of obtaining consent.
• Describe the signs of obvious death.
• Explain the difference between expressed consent
and implied consent. • Understand the importance of and need for crime
scene/evidence preservation.
• Have a basic understanding of Good Samaritan laws.
• Understand the circumstances and general
• Discuss the implications of and steps to follow if a requirements of mandated reporting.
patient refuses care.
• Discuss advance directives, do not resuscitate
(DNR) orders and Physician Orders for Life-
Sustaining Treatment (POLST) forms, and explain
their implications on emergency medical care.
INTRODUCTION or area. The term “scope of practice” also refers to the
authority to practice, given by the state to individuals
This chapter addresses, in general terms, some of licensed or certified to practice in that state.
the medical, legal and ethical principles that relate
to emergency care. As an emergency medical
responder, it is your responsibility to keep yourself Standard of Care
up-to-date on laws and regulations that affect The public expects a certain standard of care
your duties. If you are unclear about any aspect from personnel summoned to provide emergency
of these laws and regulations, speak with your care. The standard of care is the criteria
employer, regulatory agency or a legal professional. established for the extent and quality of EMR care.
You should also follow any rules and guidelines
established by your employer or organization with When providing emergency care, EMRs are
which you are affiliated when you are acting as an expected to perform to at least the minimum
emergency medical responder. standard set forth by their training and protocols.
State laws and other authorities, such as national
organizations, may govern the actions of EMRs.
LEGAL DUTIES If your actions do not meet the set standards,
Scope of Practice and harm another person, you may be liable for
The emergency medical responder’s (EMR’s) scope negligence or malpractice.
of practice is defined as the range of duties and
skills an EMR is allowed and expected to perform Duty to Act
as appropriate. The scope of practice also defines
boundaries and distinctions within the healthcare While on duty, an EMR has an obligation to respond
system, ensuring that each level of provider operates to an emergency and provide care at the scene.
within a legally accepted range of duties and skills. This obligation is called a duty to act (Fig. 3-1). It
Scope of practice also draws a distinction between applies to public safety officers, certain government
these professionals and the layperson. employees, licensed and certified professionals,
and medical paraprofessionals while on duty. For
The EMR, like other out-of-hospital care providers, instance, members of a volunteer fire department
is governed by legal, ethical and medical guidelines. have a duty to act based on participation in the fire
Since practice may differ from state to state or in department. An athletic trainer has a duty to provide
regions of the same state, you must be aware of care to an injured athlete. Failure to fulfill these
variations existing for your level of training in your state duties could result in legal action.
46 | Emergency Medical Response
CRITICAL The EMR’s scope of practice is defined as the range of duties and skills an EMR is
FACTS allowed and expected to perform as appropriate.
The public expects a certain standard of care from personnel summoned to provide
emergency care. The standard of care is the criteria established for the extent and
quality of EMR care.
While on duty, an EMR has an obligation to respond to an emergency and provide
care at the scene. This obligation is called a duty to act.
Good Samaritan Laws
The vast majority of states and the District of
Columbia have Good Samaritan laws that
protect people against claims of negligence when
they provide emergency care in good faith without
accepting anything in return. These laws, which
differ from state to state, may apply when an EMR
volunteers to assist in an emergency when not
on duty.
Although professional responders such as EMRs
are not usually considered Good Samaritans when
on the job, many states have other laws that protect
Fig. 3-1: While on duty, an EMR has a legal duty to act.
EMRs from negligence claims arising out of job
activities in some situations.
As an EMR, if you see a motor-vehicle crash while When a responder’s actions are willful or reckless,
you are off duty, in most states you do not have a however, these liability protections most likely will
legal obligation to stop (although you may have not apply.
a moral obligation). However, if you stop and Along with the lay public, Good Samaritan laws
begin to provide care, you are legally obligated to may protect off-duty EMRs who are providing
continue until the patient is turned over to someone emergency care in good faith. The laws do not
with an equal or a higher level of training. protect an individual from a claim that an act was
grossly negligent.
Competence
Good Samaritan laws vary from state to state. For
Competence refers to the patient’s ability more information, check your local and state laws
to understand the EMR’s questions and the or consult with a legal professional to see if, and
implications of decisions made. EMRs must when, Good Samaritan laws protect you.
obtain permission from competent patients before
beginning any care. To receive consent or refusal
of care, the EMR should determine competence. In Ethical Responsibilities
certain cases, such as those involving intoxication, As an EMR, you have an ethical obligation to carry
drug abuse or cognitive impairment such as out your duties and responsibilities in a professional
dementia or Alzheimer’s disease, the patient is not manner. This includes showing compassion when
considered competent. Some individuals, such as dealing with a patient’s physical and emotional
minors, are not competent to make decisions about needs, and communicating sensitively and willingly
their care as a matter of law. at all times. Try to avoid becoming satisfied with
CRITICAL If an EMR acts in a reasonable and prudent way consistent with the standard of care,
FACTS a negligence claim against the EMR will likely fail.
Chapter 3: Medical, Legal and Ethical Issues | 47
meeting minimum training requirements and instead in his treatise, Of the Epidemics. The treatise
strive to develop your professional skills and states, “Practice two things in your dealings with
knowledge. Doing so includes not only practicing and disease: either help or do not harm the patient.”
mastering the skills taught in this course, but seeking “Do no harm” has been brought into several
out further training and information, such as through trained and professional healthcare practices.
workshops, conferences, and supplemental or In essence, it means that people who intervene
continuing advanced medical educational programs. to help others must do their best to ensure
Your instructor may be able to provide ideas and their actions will do no harm to the patient or
information about opportunities in your area for patients. (For more information on the National
further education and professional development. Association of Emergency Medical Technicians’
Code of Ethics and EMT Oath, see naemt.org/
In addition to being the best you can be in about_ems/emtoath.aspx.)
providing care, be honest in reporting your actions
and the events that occurred when you respond Act in good faith: To act in good faith means to
act in such a way that the goal is only to help the
to an emergency. Make it a personal goal to be a
patient and that all actions are for that purpose.
person whom others trust and can depend on to
give accurate reports and provide effective care. Patient’s best interest: To act in the patient’s
best interest is a fundamental ethical principle
Address your responsibilities to the patient at that refers to providing competent care with
every emergency. Periodically, carry out a self- compassion and respect for human dignity.
review of your performance (e.g., patient care, This implies that the care one provides serves
communication, documentation) to help improve the integrity of the patient’s physical well-being
any areas of potential weakness or opportunities while at the same time respecting the patient’s
for professional growth. choices and self-determination.
Ethical responsibilities include the PATIENT CONSENT AND
following concepts:
REFUSAL OF CARE
Morals: Morals are a set of principles relating Individuals have a basic right to decide what can
to issues of right and wrong and how individual and cannot be done to their bodies; they have the
people should behave. To understand the legal right to accept or refuse care. Therefore,
morals of a society, you have to know what that to provide care to an injured or ill person, you
society believes. must first obtain the patient’s consent. Usually,
Ethics: Ethics is a branch of philosophy that the patient needs to tell you clearly that you have
deals with the set of moral principles a person permission to provide care.
holds about what is right and wrong.
To obtain consent, you must:
Applied ethics: The term “applied ethics”
refers to the application of ethical values in Identify yourself to the patient.
decision making.
Give your level of training.
Decision-Making Models Ask the patient whether you may help.
A decision-making model is a tool or technique to Explain what you observe.
assist you in making decisions. The term can also Explain what you plan to do.
refer to a set of principles which, when applied, Forms of Consent
lead to the desired decision. Some of those
principles include the following: Consent may be either directly expressed or
implied. There are also some special situations in
Do no harm: The phrase “do no harm” is which exceptions or alternate means of providing
attributed to Hippocrates and first appeared consent may apply.
CRITICAL Ethical responsibilities include morals, ethics and applied ethics.
FACTS
Individuals have the legal right to refuse or accept care. To obtain consent, you must
identify yourself, give your level of training, ask the patient whether you may help, and
explain what you observe and what you plan to do.
48 | Emergency Medical Response
Expressed Consent married, pregnant, a parent, a member of the
After you have provided the required information, armed forces or financially independent and living
the patient can give expressed consent either away from home.
verbally or through a gesture. If the patient is a
minor, the law requires that an EMR obtain consent Special Situations
from a parent or legal guardian, if one is available. In certain cases, such as those involving intoxication
The patient has the right to withdraw consent for and drug abuse, patients may not be considered
care at any time. If this should occur, step back and competent and therefore are unable to make
call for more advanced medical personnel. In some rational decisions or give expressed consent. In
circumstances, you may be asked to explain why such cases, call more advanced medical personnel
the person needs your care. and law enforcement personnel or have someone
call them. If possible, attempt to provide care,
To give expressed consent, a patient must be but do not endanger your personal safety. Always
competent. This means the patient must be able maintain a safe distance from potentially violent or
to understand the EMR’s questions as well as hostile patients.
the implications of accepting or refusing any
care that the EMR has proposed. The EMR If a patient appears to be mentally incompetent,
should ensure that the patient understands the the EMR should verify if there is a guardian present
condition and both the risks and benefits of the with the legal right to consent to treatment. A
proposed treatment. mentally incompetent patient who is seriously
injured or ill falls under implied consent when a
Implied Consent parent or legal guardian is not present.
Certain patients may not be able to give If an adult is legally incompetent—that is,
expressed consent. This includes patients determined by a court to be unable to handle
who are unconscious, have an altered level of personal or financial affairs, and under a legal
consciousness, such as confusion, or who are guardian’s care—you must also get that legal
mentally impaired. In these cases, the law assumes guardian’s consent to provide care. Summon a law
that the patient would give informed consent for enforcement officer if necessary.
emergency care if they were able to do so. This
legal concept is called implied consent.
Refusal of Care
Some injured or ill people may refuse care, even
Implied Consent and Minors those who may desperately need it. Even though
Remember, when the patient is a minor, an patients may be seriously injured or ill, you should
EMR is required by law to obtain permission to honor their refusal of care. Patients with
provide care from a parent or legal guardian, if decision-making capacity who are of legal age
one is available. However, if the condition is life have a right to refuse care. If this occurs, you must
threatening and a parent or legal guardian is not ensure that the person is competent and is able to
present, consent is implied. A minor is usually make rational, informed decisions.
considered anyone under the age of 18, unless the
person is an emancipated minor, but this varies Refusal of care does not have to be all or nothing.
by state. Patients can agree to receive part of the care
that an EMR has suggested, but refuse another
If you encounter a parent or legal guardian who part. For example, a patient could choose to be
refuses to allow you to provide care, try to explain assessed at the scene but refuse transport to the
the consequences of not caring for the patient. Use hospital, or agree to be transported to the hospital
terms the parent or legal guardian will understand. but not to be treated at the scene. They can also
If a law enforcement officer or more advanced decline care after it has been initiated.
medical personnel are not present, have someone
call. If necessary, call them yourself. Do not argue If a patient refuses care, be sure to:
with the parent or legal guardian. Doing so can
create a potentially unsafe situation. Follow local policies related to refusal of care.
Tell the patient what treatment is needed and
Emancipated minors are minors who have why. Explain the benefits of receiving treatment
been granted the legal rights to make their own as well as the risks of refusing treatment, and
decisions, such as consent for emergency or mention any reasonable alternative treatments
medical care. Examples include a minor who is that fall within the parameters of care.
Chapter 3: Medical, Legal and Ethical Issues | 49
Try again to convince the patient that the care Do Not Resuscitate Orders and
is needed or that the patient should consider Medical Futility
going to the hospital instead, but do not argue. If One type of advance directive, a do not resuscitate
possible, have a witness listen to and document (DNR) order, also called a “do not attempt
the refusal, to make it clear that you did not resuscitation (DNAR) order,” protects a patient’s right
abandon the patient. to refuse efforts for resuscitation (Fig. 3-3). These
Remind injured or ill persons that they can call orders, which differ from state to state, are usually
9-1-1 or the designated emergency number to written for people who have a terminal illness.
summon emergency medical services (EMS)
personnel again if the situation changes or if There must be written proof of a DNR order unless
they change their mind and decide to accept your state is one of the few that accepts verbal
care before you leave the scene. verification. If there is no proof of a DNR order, or
if you are not certain that it is valid or applicable in
Notify more advanced EMS personnel about
the current situation, you must act and provide care
the situation.
as you would in any similar situation where a DNR
Notify medical direction, if required by your
order does not exist. The exception to this is in
local protocols.
cases of medical futility or obvious death.
Document the patient’s refusal, according
to local policy. If the patient continues to The term medical futility is used to describe
refuse care, document any assessment you situations where emergency medical interventions,
performed and have the patient sign the refusal such as CPR, would not provide any likely benefit
documentation (Fig. 3-2). If the patient refuses to the patient. Be familiar with and follow local
to sign the form, have a family member, police protocols and medical control for these situations.
officer or bystander sign the form, verifying that If there is any doubt as to whether medical futility
the patient refused to sign. Also, have a family exists, treatment should be provided.
member, police officer or bystander sign the
form as a witness. A law enforcement officer is
preferable, if available. Living Wills
A living will, another kind of advance directive, is
Try one more time to persuade the patient to go
a legal document that outlines a patient’s wishes
to a hospital before leaving the scene.
about certain kinds of medical treatments and
procedures that prolong life. In the event that the
Advance Directives patient cannot communicate healthcare decisions,
An advance directive is a set of written this document may take effect.
instructions that describes a person’s wishes
about medical care. These instructions, signed As an EMR, you should follow a living will only if
by the patient and a physician, make a person’s you are sure that it is valid and applicable to the
intentions known while they are still capable of current emergency. If in doubt, or if the situation is
doing so and are used when the patient can no urgent and you do not have the time to assess the
longer make their own healthcare decisions. The living will, you must provide care until the matter
most common types of advance directives are has been clarified. More general than a DNR order,
do not resuscitate (DNR) orders, living wills and which refers only to the act of resuscitation, living
Physician Orders for Life-Sustaining Treatment wills can go further into dictating what may and
(POLST) forms. may not be done to a patient.
Many states have strict requirements for advance
directives and the circumstances in which Physician Orders for Life-Sustaining
they should be followed. You must be aware of Treatment Forms
your state and local laws governing advance A Physician Orders for Life-Sustaining
directives. Your state EMS office is a good Treatment (POLST) form, while not currently
source of this information. If you are providing available in all states, is a tool that complements
emergency medical responder services as an advance directive. Its primary purpose is
part of your employment or affiliation with an to document the types of treatments a patient
organization, you should also seek guidance wants or does not want in the case of a medical
from them. emergency. POLST forms are signed by the
50 | Emergency Medical Response
Lake-Sumter Emergency Medical Services
INFORMED REFUSAL RELEASE FORM
FORMA INFORMADA DEL LANZAMIENTO DE LA DENEGACIÓN
Date (Fecha): RUN #:
Name (Nombre): Street Address (Direccion de Calle):
City (Ciudad): State ( Estado): Zip: Age (Edad): Sex (Sexo): M F
Phone # (Numero de Telefono): ( ) Date of Birth (Fecha de Nacimiento):
Refusal of Care (Negación del cuidado)
I (the patient or patient's guardian) have been informed of:
Yo (el paciente o guardian del paciente) he estado informado de:
The reason I (the patient) should go to a hospital for further medical care; and
La razon qua yo (el paciente) debo de ir al hospital para mas tratamiento; y
The evaluation and/or treatment that will/may occur when I (the patient) arrive(s) at the hospital; and
De la evaluacion y/o tratamiento que va/o puede ocurrir quando yo (el paciente) Ilegue al hospital; y
The potential consequences and/or complications that may result in my (or patient guardian's) refusal to go to the hospital for further
emergency care; and
De las consecuencias potenciales y/o complicaciones qua pueden resultar de mi (o guardian del paciente) rechazamiento de ir al
hospital para tratamiento de emergencia; y
As a competent adult, I understand the above and I am responsible for making a rational decision on my (the patient's) behalf, and have been advised
that emergency medical care is necessary, and that refusal of recommended care and transport to a hospital may result in death or imperil my (the
patient's) health by increasing the opportunity for morbidity. Understanding the above, I (patient guardian) refuse to accept emergency medical care
and/or transport to a hospital facility, assume all risks and consequences resulting from my (patient guardian's) decision, and release Lake-Sumter EMS
from any and all liability resulting from my (patient guardian's) refusal. The patient(s) was/were advised that Lake-Sumter EMS stands ready to return at
any time and can be reached by dialing 911.
Como un adulto competente, yo comprendo antedicho y estoy capaz de hacer una decision racional en mi (el paciente) enteres, y estoy avisado que el
tratamiento de emergencia as necesario, y que mi rachazamlento para cuidame y transportaclon al hospital puede resultar en muerte o poner an pellgro
mi (el paciente) salud para aumentar la oportunidad de morbosidad. Comprendiendo lo antedicho, yo (guardian del paciente) me niego a aceptar
tratamiento de emergencia o transporte al hospital, asumi todos los peligros y consecuencias que resultan de mi (guardian del paciente) decision, y
suelto a Lake-Sumter EMS de algunas y todas obligaciones resultando de mi (guardian del paciente) rechazamiento. El paciente eralfue avisado que
Lake-Sumter EMS esta listo para volver al cualquier hora y puede alcanzarlos marcando 911.
Notice of Privacy Practices(Aviso de las prácticas de la aislamiento)
I hereby acknowledge that I have received a copy of the LSEMS Notice of Privacy Practices as required by Federal Law.
Reconozco por este medio que he recibido una copia del aviso de LSEMS de las prácticas de la aislamiento según los requisitos de ley federal.
Patient Initials(Iniciales):_________(required)
A copy of the LSEMS Notice of Privacy Practices was given to: Patient Authorized Representative
Patient Signature
(Firma del Paciente): X Date(Fecha):________________________
Print Name (Imprenta su Nombre):
Print Patient(s) under care of Guardian(Imprenta el paciente que esta al cuidado del guardian)
Name (Nombre): Age (Edad): Name (Nombre): Age (Edad):
Name (Nombre): Age (Edad): Name (Nombre): Age (Edad):
Signature of Guardian (Firma del Guardian): X
Print Guardian's Name (Imprenta el nombre del guardian del paciente):
WITNESS
(TESTIFICAR)
Signature (Firma): Print Name (Imprenta Nombre): ID:
Signature (Firma): Print Name (Imprenta Nombre): ID:
Effective: June 2003
Fig. 3-2: Refusal of care form. Form: courtesy of Lake-Sumter EMS.
Chapter 3: Medical, Legal and Ethical Issues | 51
State of Florida
DO NOT RESUSCITATE ORDER
(please use ink)
Patient’s Full Legal Name: ________________________________________________Date:____________________
(Print or Type Name)
PATIENT’S STATEMENT
Based upon informed consent, I, the undersigned, hereby direct that CPR be withheld or withdrawn.
(If not signed by patient, check applicable box):
Surrogate Proxy (both as defined in Chapter 765, F.S.)
Court appointed guardian Durable power of attorney (pursuant to Chapter 709, F.S.)
________________________________________________________________________________________________
(Applicable Signature) (Print or Type Name)
PHYSICIAN’S STATEMENT
I, the undersigned, a physician licensed pursuant to Chapter 458 or 459, F.S., am the physician of the
patient named above. I hereby direct the withholding or withdrawing of cardiopulmonary resuscitation
(artificial ventilation, cardiac compression, endotracheal intubation and defibrillation) from the patient
in the event of the patient’s cardiac or respiratory arrest.
________________________________________________________________________________________________
(Signature of Physician) (Date) Telephone Number (Emergency)
________________________________________________________________________________________________
(Print or Type Name) (Physician’s Medical License Number)
DH Form 1896, Revised December 2002
PHYSICIAN’S STATEMENT State of Florida
DO NOT RESUSCITATE ORDER
I, the undersigned, a physician licensed pursuant to Chapter 458
or 459, F.S., am the physician of the patient named above.
I hereby direct the withholding or withdrawing of cardiopulmonary
________________________________________________________________
resuscitation (artificial ventilation, cardiac compression,
Patient’s Full Legal Name (Print or Type) (Date)
endotracheal intubation and defibrillation) from the patient in the
event of the patient's cardiac or respiratory arrest. PATIENT’S STATEMENT
Based upon informed consent, I, the undersigned, hereby direct that CPR
be withheld or withdrawn. (If not signed by patient, check applicable box):
________________________________________________________ Surrogate
(Signature of Physician) (Date) Telephone Number (Emergency) Proxy (both as defined in Chapter 765, F.S.)
Court appointed guardian
Durable power of attorney (pursuant to Chapter 709, F.S.)
________________________________________________________
(Print or Type Name) (Physician’s Medical License Number)
________________________________________________________________
(Applicable Signature) (Print or Type Name)
DH Form 1896,Revised December 2002
Fig. 3-3: DNRs are usually written for people with a terminal illness. DNR: courtesy of Lake-Sumter EMS.
52 | Emergency Medical Response
CRITICAL Always honor a patient’s refusal of care. In cases of refusal, follow local policies;
FACTS tell the patient what treatment is needed and why; try to convince them, but do not
argue; remind the person that they can call EMS if the situation changes or they
change their mind; and notify more advanced EMS personnel as well as medical
direction, based on local protocols.
An advance directive is a set of written instructions that describes a person’s wishes
about medical care.
A DNR order protects a patient’s right to refuse efforts for resuscitation. It is usually
written for those who have a terminal illness. You must be aware of state and local
legislation and protocol in regard to DNR orders.
patient’s physician or other approved healthcare often accompany the directive. The phrasing
provider such as a physician’s assistant or nurse must be clear and understandable, with no room
practitioner, based on state rules or protocols. As for interpretation. It is vital that you review your
an EMR, it is important to understand how POLST particular state’s laws to see if advance directives,
forms are used in your area and which sections DNRs, POLST forms and/or living wills are
apply to prehospital care. permitted in your area of practice. Also, clarify
whether they require more than one healthcare
When assessing an advance directive, check provider to verify the patient’s condition, which is
for written physician’s instructions that most the case in some states.
What Is a Do Not Resuscitate Order?
DNR orders are intended to direct the care of a a physician’s signature. Issues surrounding DNR
patient in the specific setting of either respiratory orders are complex, and the laws and regulations
or cardiac arrest. DNR orders are very specific regarding them vary from state to state. For
orders that express a patient’s denial of consent these reasons, the American Red Cross
for specific interventions limited to CPR for either advises all professional and certified trained lay
respiratory or cardiac arrest. As such, they only responders to receive specific training from their
apply to the following specific interventions in the employer, agency or medical director. In addition,
setting of respiratory or cardiac arrest: responders are encouraged to check local laws
and regulations. However, there are some general
• Airway—positioning, adjuncts and intubations principles that all responders should be aware of
• Breathing—assisted ventilations and can use to guide their practice.
• Circulation—cardiac compressions,
defibrillation and cardiac arrest medications End-of-life care legislation is in place across
the country and serves as a mechanism to
Up to the point of either respiratory or cardiac address two equally valid, competing interests.
arrest, the DNR order would not apply and Specifically, it allows patients to be involved in
responders should provide the normal care for their own healthcare decision making and it
any conditions that they identify. protects healthcare personnel from liability for
honoring patients’ wishes. Ethical principles
In most states, a DNR order is a physician’s order require that responders respect a person’s right
not to resuscitate if a patient goes into cardiac to make decisions regarding their own healthcare.
or pulmonary (respiratory) arrest. It is part of the This usually involves obtaining the patient’s
prescribed medical treatment plan and must have consent. However, sometimes a patient is either
(Continued )
Chapter 3: Medical, Legal and Ethical Issues | 53
What Is a Do Not Resuscitate Order? continued
unconscious or otherwise incapacitated. In these EMS personnel when they arrive on scene; it is
cases, advance directives, such as healthcare designed to allow the patient to move between
proxies, living wills, DNR orders and POLST settings with one document.
forms, provide mechanisms by which individuals
can make their wishes known when they are
unable to speak for themselves. In addition, Can a DNR Order Be Revoked?
advance directives allow those responsible for
Review of individual state laws for specific
the care of others—such as a minor or an adult
criteria is necessary. Generally, the DNR order
lacking the capacity for decisions—to make
can be revoked at any time orally or in writing,
end-of-life decisions prior to the time when the
by physical destruction, by failure to present it,
decision is necessary. Of course, in the absence
or by the oral expression of a contrary intent by
of an applicable advance directive, consent for
the patient or the patient’s healthcare proxy. In
emergency treatment is implied.
the out-of-hospital setting, it may be difficult to
determine who the actual surrogate is and, likely,
How Do You Know If There the question has arisen because the patient is in
cardiac or respiratory arrest and cannot express
Is a DNR Order? their own wishes. If there is any doubt regarding
In most cases, the family, a caretaker or revocation of the DNR order or someone
healthcare provider will inform you that a DNR verbally requests revocation, begin normal
order is in place. care procedures.
A DNR order is written on a form developed, in
most states, by the individual state’s Department In What Healthcare Settings
of Health or state EMS office to identify patients Is the DNR Order Honored?
who do not wish to be resuscitated in the event
of respiratory or cardiac arrest. In the case of The DNR order is honored in most healthcare
inpatient admissions at hospitals and long-term settings, including hospices, adult family care
care facilities, the DNR order may be on a form homes, assisted living facilities, emergency
that complies with state laws and regulations departments, nursing homes, home health
but has been designed by the facility. In some agencies and hospitals. State laws further
states there are both hospital and inpatient provide that healthcare providers employed
forms. The properly completed form is signed in these healthcare settings may withhold or
by the competent patient or by the patient’s withdraw CPR if presented with a valid DNR
representative, and then signed by a licensed order and be immune from criminal prosecution
physician on a specific form developed and or civil liability. In addition, most state laws and
approved by the respective state. regulations allow DNR orders to be honored by
prehospital providers. In those instances where
Unless provided with clear written documentation the DNR order is presented to a prehospital
that meets legal requirements or unless your emergency medical provider in a setting
state laws and regulations allow acceptance of other than a healthcare facility, the form may
oral verification (which most states’ laws do not), be honored.
you must perform all procedures as you would in
the absence of a DNR order. Review of individual state and local laws as well
as local protocols is essential for compliance.
In some states, there is a patient ID device in the Direct questions regarding DNR orders to the
form of a bracelet or a smaller version of the form state regulating agency or state EMS office.
that can be worn on a chain around the neck or
clipped to a key chain or to clothing/bed so it In the out-of-hospital setting, if there is any doubt
can travel with the patient. It is equally as valid as as to whether a DNR order is valid or may have
a traditional DNR form and can be presented to been revoked, care should proceed as it would
(Continued )
54 | Emergency Medical Response
What Is a Do Not Resuscitate Order? continued
in the absence of a DNR order; this includes Do EMRs Fail to Provide the
activation of the EMS system and transport to a
hospital. Usually, the hospital is better equipped Standard of Care If They Follow
and has additional resources to determine the a DNR Order?
validity and applicability of a DNR order than
A professional responder who follows a valid
the resources that are available in the out-of-
DNR order is actually complying with the
hospital setting.
standard of care by respecting the patient’s
Professional and workplace providers should wishes, respecting the patient’s denial of consent
receive specific training from their employer, for CPR in the setting of either respiratory or
agency or medical director regarding cardiac arrest, and complying with the physician’s
DNR orders. order for DNR. Follow local protocols and medical
direction when presented with a DNR order.
Surrogate Decision Making emotional distress to the patient. If the patient feels
A surrogate decision maker is a third party who threatened with bodily harm and the other person
has been given the legal right to make decisions has the capability of inflicting harm, the act may be
regarding medical and health issues on another considered assault.
person’s behalf through a durable power of
attorney for healthcare. A person may be Battery
given this role for an older parent, an incapacitated
Battery is the legal term used to describe the
spouse or an ill child, for example. You must be able
unlawful touching of a person without that person’s
to see the legal document, and the writing should be
consent. The EMR must obtain consent before
understandable, leaving no room for interpretation.
providing care to a patient. Every patient has a
A healthcare proxy is the person named in a legal right to determine what happens to and who
durable power of attorney for healthcare to make touches that patient’s body.
medical decisions on the patient’s behalf. This
person may also be known as an attorney-in-fact, Abandonment
an agent or a patient advocate. The healthcare
Just as you must obtain the patient’s consent
proxy may be a friend, family member or other
before beginning care, you must also continue
person designated at an earlier time by the patient
to provide care once you have begun. Once you
or by the courts to be responsible for making
have started emergency care, you are legally
health and medical decisions for the patient.
obligated to continue that care until a person
Next of kin refers to the closest relatives, as with equal or higher training relieves you, you are
defined by state law, of a patient or deceased physically unable to continue or the patient refuses
person. Most states recognize the spouse care (Fig. 3-4). Usually, your obligation for care
and the nearest blood relatives as next of ends when more advanced medical professionals
kin, and these individuals may have certain take over. If you stop your care before that point
legal authority regarding medical decisions without a valid reason, such as leaving momentarily
for an incapacitated patient or the affairs of a to get the proper equipment, you could be
deceased person. legally responsible for the abandonment of a
patient in need.
OTHER LEGAL ISSUES Negligence
Assault Negligence refers to a failure to follow a
Assault is a threat or an attempt to inflict harm reasonable standard of care, thereby causing
on someone. Assault can be physical, sexual or or contributing to injury or damage to another.
both. It may result in injury, and often results in A person could be considered negligent by either
Chapter 3: Medical, Legal and Ethical Issues | 55
Fig. 3-4: Once you have started emergency care, you are legally obligated to continue that care until a person
with equal or higher training relieves you, you are physically unable to continue or the patient refuses care.
acting wrongly or failing to act at all. There are four CONFIDENTIALITY AND PRIVACY
elements of a negligence claim:
While providing care to a patient, you may
1. The EMR had a duty to act. When an EMR is on learn details about the patient that are private
duty, the duty to act is the obligation to respond and confidential. Information such as medical
to emergency calls and provide emergency care issues, physical and mental conditions, and any
according to the expected level of knowledge medications the patient is taking are personal to the
and skills. Once care has begun, the duty is patient and considered confidential. Respect the
to continue providing care until the patient patient’s privacy and obey the law by maintaining
can be handed over to someone of equal or confidentiality. Exceptions to this rule include
higher training. providing this information to the medical personnel
2. The EMR breached that duty. Breach of duty who will take over care of the patient from you and
refers to deviation from the standards of care any mandatory reporting requirements, public health
expected for the responder’s level of knowledge issues or legal requirements.
and skill.
3. The patient was injured because the EMR Health Insurance Portability
breached their duty. In legal terms, this is known and Accountability Act
as proximate cause. If injuries occurred to a
patient due to breach of duty or negligence Description
by the EMR, the patient must prove that these The Health Insurance Portability and Accountability
injuries were the direct result of the EMR’s Act (HIPAA) Privacy Rule was the first
action or non-action. comprehensive federal protection for the privacy
of protected health information (PHI). It makes
4. Harm or injury occurred.
CRITICAL Personal information, such as the patient’s medical issues, physical and mental
FACTS conditions, and medications they take, is considered confidential. You should treat
patient information with respect and not share it with unauthorized individuals.
56 | Emergency Medical Response
provisions for aspects such as patient control may be unable to communicate in an emergency
over health information, the use and release of (Fig. 3-5, A). The tag may be included on a
health records, appropriate disclosure of health bracelet, necklace or sports band. Others may
information, and civil and criminal penalties for carry this information on a wallet card. More
violation of patients’ privacy rights. Some states and more people are carrying their medical
have their own medical privacy laws. identification information on mobile phone apps
that responders can access even when the phone
Protected Health Information is locked by a password (Fig. 3-5, B). These
identifiers indicate special medical situations
Depending on the nature of your role as an EMR
(including whether you are providing EMR services
as part of your employment or affiliation with an
organization), you may have obligations under
HIPAA or state medical privacy laws. Regardless
of whether a privacy law applies, however, you
should treat patient information as confidential. You
must not share the patient’s health information with A
others, such as the media, employers, colleagues
or friends, unless the patient consents. You must
continue to maintain confidentiality even after your
role with the patient has finished. However, you
may release information if you have written consent
from the patient, or a parent or legal guardian if the
patient is a minor.
Permitted Disclosures of Health
Information Without Written Patient
Consent
In some circumstances, disclosure of health
information is appropriate without patient consent.
It is important to note that in most situations
you may share information with other healthcare
providers who are involved in caring for the patient,
and you may share a child’s information with their
parent or legal guardian. In addition, in some
situations, such as when a patient is transported to
a hospital or medical center, information must be
disclosed to facilitate payment for services. Your
employer or other organization with which you are
affiliated to provide emergency medical services
should give you guidance on documentation for
payment purposes.
Other situations where disclosure without consent
is permissible include cases of mandatory reporting
of abuse or neglect, situations involving public health
issues and some law enforcement situations. For
example, you must provide requested information if
you have received a subpoena.
SPECIAL SITUATIONS
B
Medical Identification
Medical identification tags are designed to provide Fig. 3-5, A–B: A medical identification tag (A) or an app on your
phone (B) can give responders important information about the
healthcare providers and EMS personnel with patient. You must look for them whenever you assess a patient.
pertinent health information about a patient who Photos: N-StyleID.com.
Chapter 3: Medical, Legal and Ethical Issues | 57
CRITICAL Medical identification tags alert you to the patient’s pertinent health information, such
FACTS as allergies, diabetes and epilepsy, when the patient cannot communicate. Look for
medical identification bracelets, necklaces, sports bands, wallet cards or mobile
phone apps whenever you examine a patient.
Although it is a physician’s job to declare a patient dead, death is obvious in
situations such as decapitation, rigor mortis, decomposition of the body, dependent
lividity, and transection or incineration of the body.
pertinent to a medical emergency. It is imperative
that you look for them whenever you examine a
patient. Examples of conditions you may be alerted
to include allergies, diabetes and epilepsy. Some
medical identification information lists a phone
number to call to obtain further information. Some
people also list their emergency contact(s) in their
mobile phone under the heading ICE, which stands
for in case of an emergency.
Obvious Death
Although it is ultimately a physician’s job to
declare a patient dead, you will often be faced
Fig. 3-6: Documentation about organ donation is often found
with situations in which death is obvious. In these on a patient’s driver’s license. Photo: courtesy of Donate Life
situations, resuscitative efforts may not be required. Pennsylvania.
These situations include:
other patient and provide the same lifesaving
Decapitation.
emergency care.
Rigor mortis.
Decomposition of the body.
Dependent lividity (discoloration in the skin Evidence Preservation
caused by the pooling of blood). Emergency medical care of the patient is the EMR’s
top priority. However, when faced with a crime
Transection of the body.
scene, there are some precautions you must take
Incineration of the body.
to ensure the integrity of the scene is not disturbed.
Do not disturb any item at the scene unless
Organ Donors emergency medical care requires it. Observe and
Organs may only be donated when there is a document anything unusual at the scene. Do not
signed, legal document that gives permission for cut through bullet or knife holes in clothing, as
the patient’s organs to be harvested in the case of they are part of the evidence collected during the
death. Often this documentation is an organ donor investigation. Work closely with appropriate law
card or a sticker on the patient’s driver’s license enforcement authorities and obtain permission
(Fig. 3-6). Treat these patients as you would any to do anything that may interfere with the
CRITICAL Most state laws require that EMRs report suspected child abuse, and some
FACTS states also require that they report other types of abuse and violence. In some
circumstances, an EMR may be mandated to report infectious diseases such as
hepatitis B or HIV/AIDS. Know your state’s requirements to ensure that you make the
necessary reports and do not make unauthorized disclosures.
58 | Emergency Medical Response
investigation, including using the phone at the PUTTING IT ALL TOGETHER
emergency scene.
In your role as an EMR, you are guided by certain
legal parameters, such as the duty to act and
Special Reporting Requirements professional standards of care. Injured or ill
Mandated reporting usually refers to the practice persons have a right to expect competent initial
of reporting situations in which a patient’s injuries care by an EMR. They also have a right to expect
may have been caused through battery, abuse that you have a thorough understanding of the
or other forms of violence. The requirements for ethical and legal issues involved.
reporting vary from state to state, and it is the
As a trained EMR, you have minimum standards
EMR’s responsibility to learn and follow specific
for your performance, but it is important that you
state requirements for reporting incidents in which
do not let your training stay at that minimum level.
abuse is suspected.
Practice your skills and increase your knowledge,
In most states, EMRs are required to report taking the opportunity to learn as much as you
suspected child abuse. Some states also require can within your scope of practice. Most areas
the reporting of abuse of older adults, patients require that EMRs participate in a minimum number
in domestic violence situations, injuries that may of continuing education or refresher courses to
be the result of a crime and suspected sexual remain certified.
assaults. Mandatory reporting can also apply to
As an EMR, you can provide the best service to
some infectious diseases such as tuberculosis,
your patients and adhere to the standard of care if
hepatitis B, HIV and AIDS.
you continually examine your role and skill level. You
You should check your state’s laws on mandatory should explain all of your actions, as appropriate,
reporting to learn what is covered, or check receive consent before performing any procedure
with your employer or the organization with and carry out those procedures to the best of
which you are affiliated when you provide your ability within your scope of practice. You
emergency medical services. You should fully must also be aware of the types of exceptional
document your observations when you deem it circumstances you may encounter, such as refusal
necessary to report a situation. You should act of care and providing care for patients who may
in good faith, report only what you know to be not be competent. Stay current on your state’s
factual, and avoid any speculation as to what laws that relate to EMR services to ensure that
you believe may have occurred or reporting how you are providing care in a high-quality and legally
you feel. compliant manner.
You Are the Emergency Medical Responder
You advised the cyclist to go home and rest. At home, the cyclist loses consciousness and his
roommate calls for an ambulance. Later, at the hospital, he is diagnosed as having a severe
head injury that could have been minimized if medical care had been provided earlier. Do you
believe there are any grounds for legal action against you? Why or why not?
Chapter 3: Medical, Legal and Ethical Issues | 59
4 THE HUMAN
BODY
You Are the Emergency Medical Responder
Your fire rescue unit responds to the scene of a motor-vehicle collision involving a car
with two people and a minivan driven by a woman who has two small children in car seats.
As you size up the scene, three of the five people appear to be injured. The first person,
a woman who was driving the car, is going in and out of consciousness. You suspect
her injuries may include possible fractured ribs. The second person, a passenger in the
same vehicle, has injuries on
the right side of the body.
The third person, the driver
of the minivan, appears to
have chest and abdominal
injuries, but she is awake
and alert and able to speak
with you. She is distraught
because her children are
in the back of the minivan
and she is concerned
about them. What would
you do? How would you
respond? How would you
describe the injuries and
the body systems involved
to more advanced medical
personnel?
KEY TERMS
Anatomy: The study of structures, including gross Integumentary system: A group of organs and
anatomy (structures that can be seen with the other structures that protects the body, retains
naked eye) and microscopic anatomy (structures fluids and helps to prevent infection.
seen under the microscope).
Musculoskeletal system: A group of tissues
Body system: A group of organs and other and other structures that supports the body,
structures that works together to carry out protects internal organs, allows movement,
specific functions. stores minerals, manufactures blood cells and
creates heat.
Cells: The basic units that combine to form all
living tissue. Nervous system: A group of organs and other
structures that regulates all body functions.
Circulatory system: A group of organs and
other structures that carries oxygen-rich blood Organ: A structure of similar tissues acting together
and other nutrients throughout the body and to perform specific body functions.
removes waste.
Physiology: How living organisms function
Digestive system: A group of organs and (e.g., movement and reproduction).
other structures that digests food and
eliminates wastes. Respiratory system: A group of organs and
other structures that brings air into the body
Endocrine system: A group of organs and other and removes wastes through a process called
structures that regulates and coordinates breathing, or respiration.
the activities of other systems by producing
chemicals (hormones) that influence Tissue: A collection of similar cells acting together
tissue activity. to perform specific body functions.
Genitourinary system: A group of organs and Vital organs: Those organs whose functions
other structures that eliminates waste and are essential to life, including the brain, heart
enables reproduction. and lungs.
LEARNING OBJECTIVES
After reading this chapter, and completing the class • Identify and describe the fundamental anatomy
activities, you will have the information needed to: and physiology of the major body systems.
• Identify various anatomical terms commonly used • Give examples of how body systems interrelate.
to refer to the body. • Describe the anatomical and physiological
• Describe various body positions. differences of children and infants and the
resulting considerations for emergency care.
• Describe the major body cavities.
• Understand the basics of medical terminology and
their application to emergency medical care.
Chapter 4: The Human Body | 61
INTRODUCTION means within; and the suffix “al,” which means
pertaining to. By understanding the parts of the
As an emergency medical responder (EMR), you word, we understand the term endotracheal
require a basic understanding of normal human to mean “pertaining to something within the
structure and function. Knowing what the body’s trachea.” This term might be used with the word
structures are and how they work will help you “tube,” to describe a type of tube used within
more easily recognize and understand injuries the trachea. The easiest way to learn medical
and illnesses. Body systems do not function combining forms (Table 4-1), their prefixes and
independently. Each system depends on other their suffixes is to memorize them. A few of the
systems to function properly. When your body is more common prefixes are: hypo- (below normal),
healthy, your body systems work well together. hyper- (above normal), a- (without, no), tachy- (fast)
But an injury or illness in one body part or system and brady- (slow) (Table 4-2). A few of the more
will often cause problems in others. Knowing the common suffixes are: -emic (pertaining to the
location and function of the major organs and blood), -emia (condition of the blood) and -a or
structures within each body system will help you to -ia (condition).
more accurately assess a patient’s condition and
provide the best care.
Table 4-1:
To remember the location of body structures, it is
important to visualize the structures that lie beneath Common Combining Forms
the skin. The structures you can see or feel are
reference points for locating the internal structures COMBINING WHAT DOES IT
you cannot see or feel. For example, to locate the FORM MEAN?
pulse on either side of the neck, you can use the Cardi/o- Heart, cardiac
middle of the throat as a reference point. Using
reference points will help you describe the location Neur/o- Nerve, neural
of injuries and other conditions you may find. This
Oro- Mouth
chapter provides you with an overview of important
reference points, terminology and the functions Arteri/o- Artery, arterial
of eight of the body systems. It also focuses on
body structure (anatomy) and body function Hem/o- Blood
(physiology). Therm/o- Heat
Vas/o- Duct, vessel, vascular
MEDICAL TERMINOLOGY
In order to have a common language with which
healthcare providers can accurately communicate Table 4-2:
about patients, it is important to have a basic Common Prefixes
understanding of medical terminology. One of the
key elements to understanding medical terminology
COMBINING WHAT DOES IT
is to break down the terms into their parts.
FORM MEAN?
Medical terms often are constructed using a Hyper- Excessive, above, over,
combining form (root word plus a combining vowel) beyond
that contains the meaning, plus a suffix (word
ending) that has its own meaning and/or a prefix Hypo- Less than normal, under
(word beginning).
Tachy- Fast, swift, rapid,
For example, the medical term “endotracheal” accelerated
is made up of the combining form “trache,”
Brady- Slow, dull
which means trachea; the prefix “endo,” which
CRITICAL Medical terms are often constructed from a root word and combining vowel, plus
FACTS a suffix and/or a prefix. The easiest way to learn these medical combining forms,
suffixes and prefixes is to memorize them.
62 | Emergency Medical Response
ANATOMICAL TERMS Frontal or coronal plane: That which divides
the body vertically into two planes, anterior
Directions and Locations (the patient’s front) and posterior (the
By knowing a few key locations of structures patient’s back).
and how to describe them, you can more Sagittal or lateral plane: That which divides the
accurately recognize a serious injury or illness body vertically into right and left planes.
and communicate with other emergency medical
services (EMS) personnel about a patient’s Transverse or axial plane: That which divides the
body horizontally, into the superior (above the
condition (Fig. 4-1, A–B). waist) and inferior (below the waist) planes.
Anterior/posterior: Any part toward the front of Medial/lateral: The terms medial and lateral refer
the body is anterior; any part toward the back to the midline, an imaginary line running down
is posterior. the middle of the body from the head to the
ground and creating right and left halves. Any
Superior/inferior: Superior describes any part
toward the patient’s head; inferior describes any part toward the midline is medial; any part away
part toward the patient’s feet. from the midline is lateral.
Midline
Superior
Proximal (Cephalic)
Anterior Posterior
Distal (Ventral) (Dorsal)
Inferior
(Caudal)
Right Left
A B
Fig. 4-1, A−B: (A) Any part of the body toward the midline is medial; any part away from the midline is lateral. Any part close to the trunk
is proximal; any part away from the trunk is distal. (B) Anterior refers to the front part of the body; posterior refers to the back of the body.
Superior refers to anything toward the head; inferior refers to anything toward the feet. Photos: courtesy of the Canadian Red Cross.
CRITICAL Knowing locations of anatomical structures and how to describe them will help you
FACTS recognize a serious injury or illness and help you better communicate with other EMS
personnel.
Chapter 4: The Human Body | 63
Proximal/distal: Proximal refers to any part close Positions
to the trunk (chest, abdomen and pelvis); distal
As a responder, you will often have to describe
refers to any part away from the trunk and nearer
a patient’s position to other EMS personnel and
to the extremities (arms and legs).
healthcare providers. Using correct terms will help
Superficial/deep: Superficial refers to any part you communicate the extent of a patient’s injury
near the surface of the body; deep refers to any quickly and accurately.
part far from the surface.
Internal/external: Internal refers to the inside and Terms used to describe body positions include:
external to the outside of the body.
Anatomical position. This position, where the
Right/left: Right and left always refer to the patient stands with body erect and arms down
patient’s right and left, not yours. at the sides, palms facing forward, is the basis
for all medical terms that refer to the body.
Movements Supine position. The patient is lying face-up on
Flexion is the term used to describe flexing or a their back (Fig. 4-3, A).
bending movement, such as bending at the knee or Prone position. The patient is lying face-down
making a fist. Extension is the opposite of flexion— on their stomach (Fig. 4-3, B).
that is, a straightening movement (Fig. 4-2). The Right and left lateral recumbent position.
prefix “hyper” used with either term describes The patient is lying on their left or right side
movement beyond the normal position. (Fig. 4-3, C).
Fowler’s position. The patient is lying on their
back, with the upper body elevated at a 45° to
60° angle (Fig. 4-3, D).
Body Cavities
The organs of the body are located within
hollow spaces in the body referred to as body
cavities (Fig. 4-4). The five major cavities
include the:
Flexion Cranial cavity. Located in the head and is
protected by the skull. It contains the brain.
Spinal cavity. Extends from the bottom of the
skull to the lower back, is protected by the
vertebral (spinal) column and contains the
spinal cord.
Extension Thoracic cavity (chest cavity). Located in
the trunk between the diaphragm and the
neck, and contains the lungs and heart. The
rib cage, sternum and the upper portion
of the spine protect it. The diaphragm
separates this cavity from the abdominal
cavity (Fig. 4-5).
Fig. 4-2: Flexion and extension.
CRITICAL Flexion is the term used to describe a bending movement. Extension describes a
FACTS straightening movement.
64 | Emergency Medical Response
A B
C D
Fig. 4-3, A–D: Body positions include (A) supine position; (B) prone position; (C) right and left lateral recumbent position;
(D) Fowler’s position.
Sternum
(breastbone)
Lung Ribs
Heart
Diaphragm
Fig. 4-5: The thoracic cavity is located in the trunk between the diaphragm
Fig. 4-4: The five major body cavities. and the neck.
Chapter 4: The Human Body | 65
Abdominal cavity. Located in the trunk below BODY SYSTEMS
the ribs, between the diaphragm and the pelvis.
The human body is a miraculous machine.
It is described using four quadrants created
It performs many complex functions, each
by imagining a line from the breastbone down
of which helps us live. The human body is
to the lowest point in the pelvis and another
made up of billions of different types of cells
one horizontally through the navel. This creates
that contribute in special ways to keep the
the right and left, upper and lower quadrants.
body functioning normally. Similar cells form
The abdominal cavity contains the organs of
together into tissues, and these in turn
digestion and excretion, including the liver,
form together into organs. Vital organs
gallbladder, spleen, pancreas, kidneys, stomach
such as the brain, heart and lungs are organs
and intestines (Fig. 4-6).
whose functions are essential for life. Each
Pelvic cavity. Located in the pelvis, and is the body system contains a group of organs and
lowest part of the trunk. Contains the bladder, other structures that are especially adapted
rectum and internal female reproductive organs. to perform specific body functions needed for
The pelvic bones and the lower portion of the life (Table 4-3).
spine protect it.
For example, the circulatory system consists
Further description of the major organs and their of the heart, blood and blood vessels. This
functions are in the next section of this chapter and system keeps all parts of the body supplied
in later chapters.
Front View Back View
Spine
Liver
Spleen
Stomach
Pancreas
Gallbladder
Abdominal Kidneys
cavity Large
intestine
Small
intestine
Fig. 4-6: The abdominal cavity contains the organs of digestion and excretion.
CRITICAL The organs of the body are located within hollow spaces in the body referred to as
FACTS body cavities. The five major cavities include the cranial, spinal, thoracic (chest),
abdominal and pelvic cavity.
66 | Emergency Medical Response
Table 4-3:
Body Systems
HOW THE SYSTEM WORKS
MAJOR
SYSTEMS PRIMARY FUNCTIONS WITH OTHER BODY
STRUCTURES
SYSTEMS
Musculoskeletal Bones, ligaments, Provides body’s framework; Provides protection to
system muscles and protects internal organs and organs and structures of
tendons other underlying structures; other body systems; muscle
allows movement; produces action is controlled by the
heat; manufactures blood nervous system
components
Respiratory Airway and lungs Supplies the body with oxygen Works with the circulatory
system and removes carbon dioxide system to provide oxygen to
and other impurities through the cells; is under the control of the
breathing process nervous system
Circulatory Heart, blood and Transports nutrients and oxygen Works with the respiratory
system blood vessels to body cells and removes system to provide oxygen to
waste products cells; works in conjunction
with the urinary and digestive
systems to remove waste
products; helps give skin color;
is under the control of the
nervous system
Nervous system Brain, spinal cord One of two primary regulatory Regulates all body systems
and nerves systems in the body; transmits through a network of nerve cells
messages to and from the brain and nerves
Integumentary Skin, hair and nails An important part of the body’s Helps protect the body from
system communication network; disease-producing organisms;
helps prevent infection and together with the circulatory
dehydration; assists with system, helps regulate body
temperature regulation; aids in temperature under control of the
production of certain vitamins nervous system; communicates
sensation to the brain by way of
the nerves
Endocrine Glands Secretes hormones and other Together with the nervous
system substances into the blood and system, coordinates the
onto the skin activities of other systems
Digestive Mouth, esophagus, Breaks down food into a usable Works with the circulatory
system stomach and form to supply the rest of the system to transport nutrients
intestines body with energy to the body and remove
waste products
Genitourinary Uterus, genitalia, Performs the processes of Assists in regulating blood
system kidneys and bladder reproduction; removes wastes pressure and fluid balance
from the circulatory system and
regulates water balance
Chapter 4: The Human Body | 67
with oxygen-rich blood. For the body to work
Bone
properly, all of the following systems must work
well together:
Muscle fiber
Musculoskeletal
Respiratory
Circulatory
Nervous Tendon
Integumentary
Endocrine
Digestive
Genitourinary
Fig. 4-7: Most of the body’s muscles are attached to bones by
tendons. Muscle cells, called fibers, are long and threadlike.
The Musculoskeletal System
There are three basic types of muscles, including:
The musculoskeletal system is a combination
of two body systems, the muscular and skeletal Skeletal. Skeletal, or voluntary, muscles are
systems, and consists of the bones, muscles, under the control of the brain and nervous
ligaments and tendons. This system performs the system. These muscles help give the body its
following functions: shape and make it possible to move when we
walk, smile, talk or move our eyes.
Supports the body
Smooth. Smooth muscles, also called
Protects internal organs involuntary muscles, are made of longer fibers
Allows movement and are found in the walls of tube-like organs,
Stores minerals ducts and blood vessels. They also form much
Produces blood cells of the intestinal wall.
Produces heat Cardiac. Cardiac muscles are only found in
the walls of the heart and share some of the
The adult body has 206 bones. Bone is hard, properties of the other two muscle types: they
dense tissue that forms the skeleton. The skeleton are smooth (like the involuntary muscles) and
forms the framework that supports the body. striated (string-like, like the voluntary muscles).
Where two or more bones join, they form a joint. They are a special type of involuntary muscle
Fibrous bands called ligaments usually hold bones that controls the heart. Cardiac muscles
together at joints. Bones vary in size and shape, have the unique property of being able to
allowing them to perform specific functions. generate their own impulse independent of the
Tendons connect muscles to bone. nervous system.
The Muscular System The Skeletal System
The muscular system allows the body to move. The skeleton is made up of six sections: the skull,
Muscles are soft tissues. The body has more spinal column, thorax, pelvis, and upper and lower
than 600 muscles, most of which are attached extremities (Fig. 4-8).
to bones by strong tissues called tendons
(Fig. 4-7). Muscle tissue has the ability to The skull: The skull is made up of two main
contract (become shorter and thicker) when parts: the cranium and the face. The cranium
stimulated by a tiny jolt of an electrical or nerve is made up of broad, flat bones that form the
impulse. Muscle cells, called fibers, are usually top, back and sides, as well as the front, which
long and threadlike and are packed closely house the brain. Thirteen smaller bones make
together in bundles, which are bound together by up the face, as well as the hinged lower jaw, or
connective tissue. mandible, which moves freely.
CRITICAL
The three types of muscles are skeletal (voluntary), smooth (involuntary) and cardiac.
FACTS
68 | Emergency Medical Response
Front View Back View
Cranium Skull
Face
Clavicle
Scapula
Thorax Ribs Thorax
Sternum
Spinal Spinal
column column
Humerus
Radius
Ulna
Pelvis
Coccyx
Femur
Patella
Tibia
Fibula
Fig. 4-8: The six parts of the skeleton are the skull, the spinal column, the thorax, the pelvis, and the upper
and lower extremities.
The spinal column: The spinal column, or spine, attached only to the thoracic vertebrae. Together,
houses and protects the spinal cord. It is the these structures protect the heart and lungs.
principal support system of the body. The The pelvis: The pelvis, also known as the hip
spinal column is made up of 33 small bones bones, is made up of several bones, including
called vertebrae, 24 of which are movable. the ilium, pubis and ischium. The pelvis supports
They are divided into five sections of the the intestines and contains the bladder and
spine: 7 cervical (neck), 12 thoracic (upper internal reproductive organs.
back), 5 lumbar (lower back), and 9 sacral
(lower spine with fused vertebrae) and coccyx
Upper extremities: The upper extremities, or
upper limbs, include the shoulders, upper
(tailbone) (Fig. 4-9). arms, forearms, wrists and hands. The
The thorax: The thorax, also known as the chest, upper arm bone is the humerus, and the two
is made up of 12 pairs of ribs, the sternum bones in the forearm are the radius and the
(breastbone) and the thoracic spine. Ten pairs ulna. The upper extremities are attached
of ribs are attached to the thoracic vertebrae to the trunk at the shoulder girdle, made
and sternum with cartilage, while the bottom up of the clavicle (collarbone) and scapula
two pairs of ribs, known as the floating ribs, are (shoulder blade).
Chapter 4: The Human Body | 69
Lower extremities: The lower extremities, or lower
limbs, consist of the hips, upper and lower legs,
ankles and feet. They are attached to the trunk
at the hip joints. The upper bone is the femur
or thigh bone, and the bones in the lower leg
are the tibia and fibula. The kneecap is a small
triangular-shaped bone, also called the patella.
Joints: Joints are the places where bones
connect to each other (Fig. 4-10). Strong, tough
bands called ligaments hold the bones at a joint
together. Most joints allow movement but some
are immovable, as in the skull, and others allow
only slight movement, as in the spine. All joints
have a normal range of motion—an area in which
they can move freely without too much stress
or strain.
The most common types of moveable joints are the
ball-and-socket joint, such as the hip and shoulder,
and the hinged joint, such as the elbow, knee and
finger joints. Different types of joints allow different
degrees of flexibility and movement. Some other
joint types include pivot joints (some vertebrae),
gliding joints (some bones in the feet and hands),
saddle joints (ankle) and condyloid joints (wrist)
(Fig. 4-11).
Pelvis
Hip
Femur
Fig. 4-9: The spinal column is divided into five sections: cervical, Fig. 4-10: Joints are the places where bones connect to
thoracic, lumbar, sacral and coccyx. each other.
CRITICAL The skeleton is made up of six sections: the skull, spinal column, thorax, pelvis, and
FACTS upper and lower extremities.
70 | Emergency Medical Response
Pivot joint
Gliding joint
Hinged joint
Saddle joint
Ball and Condyloid
socket joint joint
Fig. 4-11: Common types of moveable joints.
The Respiratory System Anatomy of the Respiratory System
The body can only store enough oxygen to last Upper Airway
for a few minutes. The simple acts of inhalation The upper airway includes the nose, mouth and
and exhalation in a healthy person are sufficient to teeth, tongue and jaw, pharynx (throat), larynx
supply normal oxygen needs. If for some reason (voicebox) and epiglottis (Fig. 4-12). During
the oxygen supply is cut off, brain cells will begin to inspiration (breathing in), air enters the body through
die in about 4 to 6 minutes, with certain permanent the nose and mouth, where it is warmed and
brain damage occurring after 10 minutes. The moistened. Air entering through the nose passes
respiratory system delivers oxygen to the body, through the nasopharynx (part of the throat posterior
and removes carbon dioxide from it, in a process to the nose), and air entering by the mouth travels
called respiration. through the oropharynx. The air then continues
Chapter 4: The Human Body | 71
Nose
Teeth Nasopharynx
Pharynx
Mouth Oropharynx
Tongue Epiglottis
Jaw Larynx
Lungs
Bronchi
Bronchioles
Fig. 4-12: The upper and lower airways.
down through the larynx, which houses the vocal Pediatric Considerations
cords. The epiglottis, a leaf-shaped structure, folds The structures involved in respiration
down over the top of the trachea during swallowing, in children and infants differ from those
to prevent foreign objects from entering the trachea. of adults (Table 4-4). They are usually
smaller or less developed in children and
Lower Airway infants. Some of these differences are
The lower airway consists of the trachea important when providing care. Because the
(windpipe), bronchi, lungs, bronchioles and alveoli structures, including the mouth and nose,
(Fig. 4-12). Once the air passes through the larynx, are smaller, they are obstructed more easily
it travels down the trachea, the passageway to the by small objects, blood, fluids or swelling.
lungs. The trachea is made up of rings of cartilage It is important to pay special attention to a
and is the part that can be felt at the front of the child or an infant to make sure the airway
neck. Once air travels down the trachea, it reaches stays open.
the two bronchi, which branch off, one to each
lung. These two bronchi continue to branch off into
smaller and smaller passages called bronchioles, Physiology of the Respiratory System
like the branches of a tree. External respiration, or ventilation, is the
mechanical process of moving air in and out of
At the ends of each bronchiole are tiny air the lungs to exchange oxygen and carbon dioxide
sacs called alveoli, each surrounded by between body tissues and the environment. It
capillaries (tiny blood vessels). These are the is primarily influenced by changes in pressure
site of carbon dioxide and oxygen exchange inside the chest that cause air to flow into or out of
in the blood. The lungs are the principal the lungs.
organs of respiration and house millions of tiny
alveolar sacs.
72 | Emergency Medical Response
CRITICAL Bones connect to each other at joints and are held together by ligaments. All
FACTS joints have a normal range of motion, but some are immovable or allow only slight
movement.
In a healthy person, respiration delivers oxygen the body needs. If that oxygen supply
is cut off, brain cells will begin to die in about 4 to 6 minutes.
External respiration, or ventilation, is the mechanical process of moving air in and out
of the lungs to exchange oxygen and carbon dioxide between body tissues and the
environment. It is primarily influenced by changes in pressure inside the chest that
cause air to flow into or out of the lungs.
Table 4-4:
Pediatric Considerations in the Respiratory System
ANATOMICAL DIFFERENCES IN CHILDREN PHYSIOLOGICAL DIFFERENCES AND IMPACT
AND INFANTS AS COMPARED WITH ADULTS ON CARE
Structures are smaller Mouth and nose are more easily obstructed by small
objects, blood or swelling
Primarily breathe through nose (especially infants) Airway is more easily blocked
Tongue takes up proportionately more space in the Tongue can block airway more easily
pharynx
Presence of “baby teeth” Teeth can be dislodged and enter airway
Face shape and nose are flatter Can make it difficult to obtain a good seal of airway
with resuscitation mask
Trachea is narrower, softer and more flexible Trachea can close off if the head is tipped back too
far or is allowed to fall forward
Have more secretions Secretions can block airway
Use abdominal muscles to breathe This makes it more difficult to assess breathing
Chest wall is softer Tend to rely more heavily on diaphragm for breathing
More flexible ribs Lungs are more susceptible to damage. Injuries may
not be as obvious
Breathe faster Can fatigue more quickly, leading to respiratory
distress
Chapter 4: The Human Body | 73
The body’s chemical controls of breathing are On each exhalation, carbon dioxide and other
dependent on the level of carbon dioxide in the blood. waste gases pass through the capillary walls into
If carbon dioxide levels increase, the respiration rate the alveoli to be exhaled.
increases automatically so that twice the amount of
air is taken in until the carbon dioxide is eliminated.
It is not the lack of oxygen but the excess carbon
The Circulatory System
dioxide that causes this increase in respiratory rate. The circulatory system consists of the heart, blood
Hyperventilation may result from this condition. vessels and blood. It is responsible for delivering
oxygen, nutrients and other essential chemical
Internal respiration, or cellular respiration, refers elements to the body’s tissue cells and removing
to respiration at the cellular level. These metabolic carbon dioxide and other waste products via the
processes at the cellular level, either within the bloodstream (Fig. 4-13).
cell or across the cell membrane, are carried out
to obtain energy. This occurs by reacting oxygen Anatomy of the Circulatory System
with glucose to produce water, carbon dioxide and
The heart is a highly efficient, muscular organ that
ATP (energy).
pumps blood through the body. It is about the size
of a closed fist and is found in the thoracic cavity,
Structures That Support Ventilation between the two lungs, behind the sternum and
During inspiration, the thoracic muscles contract, slightly to the left of the midline.
and this moves the ribs outward and upward. At the
same time, the diaphragm contracts and pushes The heart is divided into four chambers: right and
down, allowing the chest cavity to expand and the left upper chambers called atria, and right and left
lungs to fill with air. The intercostal muscles, the lower chambers called ventricles (Fig. 4-14). The
muscles between the ribs, then contract. During right atrium receives oxygen-depleted blood from
expiration (breathing out), the opposite occurs: the veins of the body and, through valves, delivers it
the chest wall muscles relax, the ribs move inward, to the right ventricle, which in turn pumps the blood
and the diaphragm relaxes and moves up. This to the lungs for oxygenation. The left atrium receives
compresses the lungs, causing the air to flow out. this oxygen-rich blood from the lungs and delivers
it to the left ventricle, to be pumped to the body
Accessory muscles are secondary muscles of through the arteries. There are arteries throughout
ventilation only used when breathing requires the body, including the blood vessels that supply
increased effort. Limited use can occur during the heart itself, which are the coronary arteries.
normal strenuous activity, such as exercising,
but pronounced use of accessory muscles There are four main components of blood: red
signals respiratory disease or distress. These blood cells, white blood cells, platelets and plasma.
muscles include the spinal and neck muscles. The red blood cells carry oxygen to the cells of the
The abdominal muscles may also be used for more body and take carbon dioxide away. This is carried
forceful exhalations. Use of abdominal muscles out by hemoglobin, on the surface of the cells. Red
represents abnormal or labored breathing and is a blood cells give blood its red color. White blood
sign of respiratory distress. cells are part of the body’s immune system and
help to defend the body against infection. There
Vascular Structures That Support are several types of white blood cells. Platelets are
Respiration a solid component of blood used by the body to
form blood clots when there is bleeding. Plasma
Oxygen and carbon dioxide are exchanged in is the straw-colored or clear liquid component of
the lungs through the walls of the alveoli and blood that carries the blood cells and nutrients to
capillaries. In this exchange, oxygen-rich air enters the tissues, as well as waste products away to the
the alveoli during each inspiration and passes organs involved in excretion.
through the capillary walls into the bloodstream.
CRITICAL The circulatory system consists of the heart, blood vessels and blood. It is
FACTS responsible for delivering oxygen, nutrients and other essential chemical elements
to the body’s tissue cells and removing carbon dioxide and other waste products via
the bloodstream.
74 | Emergency Medical Response
Superior
Aorta
vena cava
Pulmonary
veins Pulmonary
arteries
Veins
Heart
Arteries
Inferior
vena cava
Fig. 4-13: The circulatory system consists of the heart, blood vessels and blood.
Left Atrium
Right Atrium
Left Ventricle
Right Ventricle
Fig. 4-14: The heart’s four chambers.
Chapter 4: The Human Body | 75
CRITICAL There are three different types of blood vessels: arteries, veins and capillaries.
FACTS Arteries carry mostly oxygenated blood away from the heart. Veins carry
deoxygenated blood back to the heart. Capillaries are the tiny blood vessels that
connect the systems of arteries and veins.
There are different types of blood vessels that serve into the heart. Like arteries, veins also branch into
different purposes: arteries, veins and capillaries. smaller vessels the further away they are from the
Arteries carry blood away from the heart, mostly heart. Venules are the smallest branches and are
oxygenated blood. The exception is the arteries connected to capillaries. Unlike arterial blood,
that carry blood to the lungs for oxygenation, the which is moved through the arteries by pressure
pulmonary arteries. The aorta is the major artery from the pumping of the heart, veins have valves
that leaves the heart. It supplies all other arteries that prevent blood from flowing backward and help
with blood. As arteries travel further from the heart, move it through the blood vessels.
they branch into increasingly smaller vessels called
arterioles. These narrow vessels carry blood from Capillaries are the tiny blood vessels that connect
the arteries into capillaries (Fig. 4-15). the systems of arteries and veins. Capillary walls
allow for the exchange of gases, nutrients and
The venous system includes veins and venules. waste products between the two systems. In the
Veins carry deoxygenated blood back to the heart. lungs, there is exchange of carbon dioxide and
The one exception is the pulmonary veins, which oxygen in the pulmonary capillaries. Throughout the
carry oxygenated blood away from the lungs. The body, there is exchange of gases and nutrients and
superior and inferior vena cavae are the large waste at the cellular level.
veins that carry the oxygen-depleted blood back
Venule
Arteriole
Artery Vein
Capillaries
Fig. 4-15: As blood flows through the body, it moves through arteries, arterioles, capillaries,
venules and veins.
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Physiology of the Circulatory System
As the heart pumps blood from the left ventricle to Blood Clotting
the body, this causes a wave of pressure we refer
to as the pulse. We can feel this pulse at several One of blood’s characteristics is its ability to
points throughout the body. These “pulse points” clot. Normally, blood flows freely though the
occur where the arteries are close to the surface of blood vessels but if there is any trauma, blood
the skin, and over a bone (e.g., carotid pulse point must be capable of clotting so that bleeding
in the neck, brachial pulse point on the inside of the will stop.
upper arm).
The clotting mechanism is made up of
As the blood flows through the arteries, it exerts platelets and the thrombin system. Platelets
a certain force that we call blood pressure (BP). are small cell fragments made in the bone
BP is described using two measures, the systolic marrow that become sticky when bleeding
pressure (when the left ventricle contracts) and occurs. They adhere to the blood vessel wall
the diastolic pressure (when the left ventricle is at at the site of bleeding. The thrombin system
rest). Oxygen and nutrients are delivered to cells is made up of several proteins that use
throughout the body, and carbon dioxide and other chemical reactions to create fibrin. The fibrin
wastes are taken away, all through the delivery of clumps and, together with the platelets, forms
blood. This continuous process is called perfusion. the clot.
The primary gases exchanged in perfusion are
oxygen and carbon dioxide. All cells require oxygen
to function. Most of the oxygen is transported to
the cells attached to the hemoglobin, but a tiny
amount is also dissolved in the liquid component
of the blood, the plasma. The major waste product Brain
in the blood, carbon dioxide, is transported
mostly in the blood as bicarbonate and transported
by the hemoglobin molecule. A tiny amount of
carbon dioxide is dissolved in the plasma. Nerves to
and from the
spinal cord
The Nervous System Spinal cord
The nervous system is the most complex and
delicate of all the body systems. The center of the
nervous system, the brain, is the master organ of
the body and regulates all body functions. The
primary functions of the brain are the sensory
functions, motor functions and the integrated
functions of consciousness, memory, emotions and
use of language.
Anatomy of the Nervous System
The nervous system can be divided into two
main anatomical systems: the central nervous
system and the peripheral nervous system Central nervous
(Fig. 4-16). The central nervous system system
consists of the brain and spinal cord. Both Peripheral nervous
system
are encased in bone (the brain within the
cranium and the spinal cord within the spinal Fig. 4-16: The nervous system.
column), are covered in several protective
layers called meninges and are surrounded by
cerebrospinal fluid.
Chapter 4: The Human Body | 77
The brain itself can be further subdivided into the Physiology of the Nervous System
cerebrum, the largest and outermost structure; The nervous system can also be divided into
the cerebellum, also called “the small brain,” two functional systems, the voluntary and
which is responsible for coordinating movement; autonomic systems. The voluntary system controls
and the brainstem, which joins the rest of the movement of the muscles and sensation from the
brain with the spinal cord. The brainstem is the sensory organs.
control center for several vital functions including
respiration, cardiac function and vasomotor control The autonomic system is involuntary, and controls
(dilation and constriction of the blood vessels), the involuntary muscles of the organs and glands.
and is the place of origin for most of the cranial It can be divided into two systems: the sympathetic
nerves (Fig. 4-17). and parasympathetic systems. The sympathetic
system controls the body’s response to stressors
The peripheral nervous system is the portion such as pain, fear or a sudden loss of blood.
of the nervous system located outside These actions are sometimes referred to as the
the brain and spinal cord, which includes “fight-or-flight” response. The parasympathetic
the nerves to and from the spinal cord. These system works in balance with the sympathetic
nerves carry sensory information from the system, by controlling the body’s return to a
body to the spinal cord and brain, and motor normal state.
information from the spinal cord and brain to
the body.
The Integumentary System
The integumentary system consists of the skin,
hair, nails, sweat glands and oil glands. The skin
separates our tissues, organs and other systems
Cranium
from the outside world.
The skin is the body’s largest organ. It has three
Cerebrum major layers, each consisting of other layers
(Fig. 4-18). The epidermis, or outer layer, contains
the skin’s pigmentation, or melanin. The dermis,
or second layer, contains the blood vessels that
supply the skin, hair, glands and nerves, and
Cerebellum is what contributes to the skin’s elasticity and
Brainstem
strength. The deepest layer, the subcutaneous
layer, is made up of fatty tissue and may be of
Spinal cord varying thicknesses depending on its positioning
on the body.
Fig. 4-17: The brain.
CRITICAL The primary functions of the brain are the sensory functions, the motor functions and
FACTS the integrated functions of consciousness, memory, emotions and use of language.
The nervous system is divided into two functional systems. The voluntary system
controls movement of the muscles and sensation from the sensory organs. The
autonomic system controls the involuntary muscles of the organs and glands.
The skin is the largest organ in the human body. It protects against injury and
pathogens, regulates fluid balance and body temperature, produces vitamin D and
stores minerals.
78 | Emergency Medical Response
Hair
Skin
Epidermis
Dermis
Nerves
Subcutaneous
layer
Glands
Fatty tissue
Fig. 4-18: The skin’s major layers are the epidermis, the dermis and the subcutaneous layer.
The skin serves to protect the body from The Endocrine System
injury and from invasion by bacteria and other
The endocrine system is one of the body’s
disease-producing pathogens. It helps regulate
regulatory systems and is made up of ductless
fluid balance and body temperature. The skin
glands. These glands secrete hormones,
also produces vitamin D and stores minerals.
which are chemical substances that enter the
Blood supplies the skin with nutrients and helps
bloodstream and influence activity in different
provide its color. When blood vessels dilate
parts of the body (e.g., strength, stature, hair
(become wider), the blood circulates close to
growth and behavior).
the skin’s surface, making some people’s skin
appear flushed or red and making the skin feel
warm. Reddening or flushing may not appear in Anatomy of the Endocrine System
darker skin tones. When blood vessels constrict There are several important glands within the
(become narrower), not as much blood is close to body (Fig. 4-19). The hypothalamus and pituitary
the skin’s surface, causing the skin to appear pale glands are in the brain. The pituitary gland, also
or ashen, and feel cool. This pallor can be found referred to as the “master gland,” regulates growth
on the palms of the hands of people with darker as well as many other glands. The hypothalamus
skin tones. secretes hormones that act on the pituitary gland.
CRITICAL One of the critical functions controlled by the body’s endocrine system is the control
FACTS of blood glucose levels. The sympathetic nervous system is also regulated through
the endocrine system.
Chapter 4: The Human Body | 79
Pineal gland
Hypothalamus
Pituitary gland
Thyroid
Adrenal glands
Ovaries
Testes
Fig. 4-19: The endocrine system in females and males.
The thyroid gland is in the anterior neck and The sympathetic nervous system is also regulated
regulates metabolism, growth and development. It through the endocrine system. Adrenaline and
also regulates nervous system activity. The adrenal noradrenaline, produced by the adrenal glands,
glands are located on the top of the kidneys and cause multiple effects on the sympathetic
secrete several hormones, including epinephrine nervous system. Effects include vasoconstriction
(adrenalin) and norepinephrine (noradrenaline). (constricting of vessels), increased heart rate and
The gonads (ovaries and testes) produce dilation of smooth muscles, including those that
hormones that control reproduction and sex control respiration.
characteristics. The pineal gland is a tiny gland in
the brain that helps regulate wake/sleep patterns. The adrenal glands and pituitary gland are also
involved in kidney function and regulate water,
sodium chloride and potassium balance. The body
Physiology of the Endocrine System works to keep water and levels of electrolytes in the
One of the critical functions controlled by the body in balance.
body’s endocrine system is the control of blood
glucose levels. The Islets of Langerhans, located
in the pancreas, make and secrete insulin, The Digestive System
which controls the level of glucose in the blood The digestive system, or gastrointestinal system,
and permits cells to use glucose and glucagon consists of the organs that work together to
(a pancreatic hormone), which raises the level of break down food, absorb nutrients and eliminate
glucose in the blood. waste. It is composed of the alimentary tract
CRITICAL The digestive system, or gastrointestinal system, consists of the organs that work
FACTS together to break down food, absorb nutrients and eliminate waste.
80 | Emergency Medical Response
(food passageway) and the accessory organs The liver is the largest solid organ in the abdomen
that help prepare food for the digestive process and aids in the digestion of fat through the
(Fig. 4-20). production of bile, among other processes. The
gallbladder serves to store the bile. The pancreas
Food enters the digestive system through the secretes pancreatic juices that aid in the digestion
mouth and then the esophagus, the passageway of fats, starches and proteins. It is also the location
to the stomach. The stomach and other major of the Islets of Langerhans, where insulin and
organs involved in this system are contained in the glucagon are produced.
abdominal cavity. The stomach is the major organ
of the digestive system, and the location where Digestion occurs both mechanically and
the majority of digestion, or breaking down, takes chemically. Mechanical digestion refers to the
place. Food travels from the stomach into the small breaking down of food that begins with chewing,
intestine, where further digestion takes place and swallowing and moving the food through the
nutrients are absorbed. The hepatic portal system alimentary tract, and ends in defecation. Chemical
collects blood from the small intestine and transfers digestion refers to the chemical process involved
its nutrients and toxins to the liver for absorption when enzymes break foods down into components
and processing before continuing on to the heart. the body can absorb, such as fatty acids and
Waste products pass into the large intestine, or amino acids.
colon, where water is absorbed and the remaining
waste is passed through the rectum and anus.
Mouth
Esophagus
Liver
Stomach
Gallbladder
Pancreas
Large intestine
(colon) Small intestine
Rectum
Anus
Fig. 4-20: The digestive system.
Chapter 4: The Human Body | 81
CRITICAL The urinary system consists of organs involved in the elimination of waste products
FACTS that are filtered and excreted from the blood. It consists of the kidneys, ureters,
urethra and urinary bladder.
The Urinary System The Reproductive System
Part of the genitourinary system, the urinary Part of the genitourinary system, the reproductive
system consists of organs involved in the system of both men and women includes the
elimination of waste products that are filtered and organs for sexual reproduction.
excreted from the blood. It consists of the kidneys,
ureters, urethra and urinary bladder (Fig. 4-21). Male Reproductive System
The kidneys are located in the lumbar region The male reproductive organs are located
behind the abdominal cavity just beneath the outside of the pelvis and are more vulnerable
chest, one on each side. They filter wastes from to injury than those of the female. They include
the circulating blood to form urine. The ureters the testicles, a duct system and the penis
carry the urine from the kidneys to the bladder. (Fig. 4-22, A).
The bladder is a small, muscular sac that stores Puberty usually begins between the ages
the urine until it is ready to be excreted. The urethra of 10 and 14 and is controlled by hormones
carries the urine from the bladder and out of
secreted by the pituitary gland in the brain. The
the body.
testes produce sperm and testosterone, the
The urinary system removes wastes from the primary male sex hormone. The urethra is part
circulating blood, thereby filtering it. The system of the urinary system and transports urine from
helps the body maintain fluid and electrolyte the bladder; it is also part of the reproductive
balance. This is achieved through buffers, which system through which semen is ejaculated. The
control the pH (amount of acid or alkaline) in sperm contributes half the genetic material to
the urine. an offspring.
Female Reproductive System
The female reproductive system consists
of the ovaries, fallopian tubes, uterus and
vagina and is protected by the pelvic bones
(Fig. 4-22, B). Glands in the body, including
the hypothalamus and pituitary glands in the
brain, and the adrenal glands on the kidneys,
interact with the reproductive system by
releasing hormones that control and coordinate
the development and functioning of the
reproductive system.
Ureters
Kidneys The menstrual cycle is approximately 28 days
in length. Approximately midway through the
cycle, usually a single egg is released which, if
Urinary
bladder united with a sperm, will attach to the lining of
Urethra the uterus, beginning pregnancy. The female’s
ovum contributes half the genetic material to the
characteristics of a fetus.
Fig. 4-21: The urinary system.
82 | Emergency Medical Response
Fallopian tubes
Ovaries
Uterus
Duct system
Urethra
Penis Vagina
Testicles
A B
Fig. 4-22, A–B: (A) The male reproductive system. (B) The female reproductive system.
PUTTING IT ALL TOGETHER movement and feeling. Injuries to the ribs can make
breathing difficult. If the heart stops beating for any
By having a fundamental understanding of reason, breathing will also stop.
body systems and how they function and
interact, coupled with knowledge of basic In any significant injury or illness, body systems
medical terminology, you will be more likely may be seriously affected. This may result in a
to accurately identify and describe injuries progressive failure of body systems called shock.
and illnesses. Shock results from the inability of the circulatory
system to provide oxygenated blood to all parts of
Each body system plays a vital role in survival. the body, especially the vital organs.
All body systems work together, to help the body
maintain a constant healthy state. When the Generally, the more body systems involved in an
environment changes, body systems adapt to these emergency, the more serious the emergency. Body
new conditions. For example, the musculoskeletal systems depend on each other for survival. In
system works harder during exercise; the serious injury or illness, the body may not be able
respiratory and circulatory systems must also to keep functioning. In these cases, regardless of
work harder to meet the body’s increased oxygen your best efforts, the patient may die.
demands. Body systems also react to the stresses
caused by emotion, injury or illness. Fortunately, basic care is usually all you need to
provide support to injured body systems until more
Body systems do not work independently. The advanced care is available. By learning the basic
impact of an injury or a disease is rarely restricted principles of care described in later chapters, you
to one body system. For example, a broken may be able to make the difference between life
bone may result in nerve damage that will impair and death.
You Are the Emergency Medical Responder
As you get closer to the woman in the car, you see that she is clutching one side of her
abdomen, just below the rib cage. Her passenger is holding his right hip and looks dazed.
The woman in the minivan now exhibits shallow breathing and her pulse is weak. What do you
suspect is happening to the woman in the car?
Chapter 4: The Human Body | 83
5 LIFTING
AND MOVING
PATIENTS
You Are the Emergency Medical Responder
Your fire rescue unit is summoned to a recently remodeled building in response to a
9-1-1 call for a reported fire. You arrive to find smoke filling the area. Two people carry a
man through a doorway. Three others stagger through and collapse to the ground. Smoke
is blowing over them. Flames flicker inside the structure. You quickly size up the scene and
determine that the structure should be secure for the next few minutes. There is a large
grassy area that extends at least 200 feet in front of the building. Should you move victims
away from the vicinity of the burning building? Why or why not?
KEY TERMS
Ankle drag: A method of moving a patient by Position of comfort: The position a patient naturally
grasping the patient’s ankles; also known as the assumes when feeling ill or in pain; the position
foot drag. depends on the mechanism of injury or nature
of illness.
Backboard: A piece of equipment used to secure a
patient when extricating them from the scene and Power grip: A hand position for lifting that requires
moving them to a stretcher for transport. the full surface of the palms and fingers to come in
contact with the object being lifted.
Blanket drag: A method of moving a patient, using
a blanket, in an emergency situation where Power lift: A lift technique that provides a stable
equipment is limited and the patient is suspected move for the patient and protects the person lifting
of having a head, neck or spinal injury. from serious injury.
Body mechanics: The field of physiology that Reasonable force: The minimal force necessary
studies muscular actions and the function of the to keep a patient from harming themselves or
muscles in maintaining posture. others.
Clothes drag: A type of emergency move that uses Recovery position: A side-lying posture used to
the patient’s clothing; used for a patient suspected help maintain a clear airway in an unresponsive
of having a head, neck or spinal injury. patient who is uninjured and breathing normally.
Direct carry: A method of moving a patient from a Restraint: A method of limiting a patient’s
bed to a stretcher or vice versa; performed by two movements, usually by physical means such as
responders. a padded cloth strap; may also be achieved by
chemical means, such as medication.
Direct ground lift: A nonemergency method of
lifting a patient directly from the ground; performed Shoulder drag: A type of emergency move that is a
by several responders. variation of the clothes drag.
Draw sheet: A method of moving a patient from Squat lift: A lift technique that is useful when one
a bed to a stretcher or vice versa by using the of the lifter’s legs or ankles is weaker than the
stretcher’s bottom sheet. other.
Extremity lift: A two-responder, nonemergency lift Stair chair: Equipment used for patient transport in a
in which one responder supports the patient’s sitting position.
arms and the other the patient’s legs.
Stretcher: Equipment used for patient transport in a
Firefighter’s carry: A type of carry during which supine position.
the patient is supported over the responder’s
shoulders. Supine: The body position of lying flat on the back.
Firefighter’s drag: A method of moving a patient in Two-person seat carry: A nonemergency method
which the patient is bound to the responder’s neck of carrying a patient by creating a “seat” with the
and held underneath the responder; the responder arms of two responders.
moves the patient by crawling.
Walking assist: A method of assisting a patient to
Log roll: A method of moving a patient while keeping walk by supporting one of the patient’s arms over
the patient’s body aligned because of a suspected the responder’s shoulder (or each of the patient’s
head, neck or spinal injury. arms over the shoulder of one responder on
each side).
Pack-strap carry: A type of carry in which
the patient is supported upright, across the
responder’s back.
Chapter 5: Lifting and Moving Patients | 85
LEARNING OBJECTIVES
After reading this chapter, and completing the class • Describe the various devices associated with
activities, you will have the information needed to: moving a victim in the out-of-hospital setting.
• Define body mechanics. • Explain the guidelines for patient positioning and
packaging for transport.
• Explain the safety precautions to follow when
lifting and moving a patient. • Explain the indications for when to use restraints.
• Describe the conditions that require an emergency • Describe the types of restraints.
move. • Make appropriate decisions regarding the use
• Describe the indications for assisting in of equipment for moving a victim in the out-of-
nonemergency moves. hospital setting.
SKILL OBJECTIVES
After reading this chapter, and completing the class • Demonstrate an emergency move.
activities, you should be able to: • Demonstrate a nonemergency move.
INTRODUCTION Safety Precautions
At some point in many emergency situations, you Before you act, always size up the scene and
will need to lift and move a patient. Sometimes consider the factors affecting the situation:
this will be to provide easier access to administer
first aid. At other times, you will need to move the Any dangerous conditions at the scene
patient to a safer location. You may also need to The distance a patient must be moved
move a patient to transport them to the hospital. The size of the patient
This chapter will teach you how to quickly and Your physical ability
safely lift and move patients. Whether others can help you
The mechanism of injury (MOI) and patient’s
ROLE OF THE EMERGENCY possible condition
MEDICAL RESPONDER Any aids or equipment to facilitate patient
transport at the scene
When providing care, you will usually not face
hazards that require you to immediately move Failing to consider these factors could cause
patients. In most cases, you can provide care where injury. If you were to become injured, you
you find the patient. Moving a patient needlessly might be unable to move the patient and could
can lead to further injury. For example, moving a risk complicating the situation and making
patient who has a painful, swollen, deformed leg things worse.
without taking the time to immobilize it could result
in an open fracture if the end of the bone were to
tear the skin. Soft tissue damage, damage to the Know Your Own Physical Limitations
nerves, blood loss and infection could all result Lifting and moving a patient requires physical
unnecessarily. Needless movement of a patient with strength and a high level of fitness. If you
a head, neck or spinal injury could cause paralysis improperly lift a patient, you can permanently injure
or even death. However, there are some situations yourself. Adequate weight training, stretching
in which moving a patient would be appropriate, and cardiovascular exercises will help ensure
but only when you can do so safely. These that you are ready for the physical demands of
situations are when you need to protect a patient an emergency situation. You should only move
from immediate danger (e.g., a fire or flood), reach a patient by yourself if you can do so safely and
another patient who may have a more serious injury comfortably. Know your own physical limitations
or illness, and provide proper care (e.g., moving a and, when in doubt, ask for assistance from
patient who needs CPR onto a hard, flat surface). other responders.
86 | Emergency Medical Response
Body Mechanics clearly and frequently with your partner, the patient
and other emergency medical services (EMS)
Body mechanics refers to the field of physiology
personnel. If the patient is conscious, explain what
that studies muscular actions and the function of
you are doing or what you are about to do. Tell
the muscles in maintaining the posture of the body.
the patient what is expected of them, such as not
In other words, it is the study of using your body
reaching out to grab anything.
in the safest and most efficient way to achieve a
desired outcome.
Back in Locked-In Position
Make sure to employ the following principles of body
Always begin your lift facing the patient or object and
mechanics when lifting and moving a patient:
with your back in a locked-in position. Keep your legs
Keep your back straight. Lift with the legs, not shoulder-width apart, head up, back straight and
the back. Use the muscles in the legs, hips shoulders square (Fig. 5-1). Keep the weight of the
and buttocks and contract the muscles of patient or object as close to your body as possible.
your abdomen. Tighten the muscles in your back and abdomen and
keep your back straight while you lift. Keep your arms
Maintain a firm grip on the stretcher or the
locked and avoid twisting while carrying.
patient, as well as any other pieces of equipment
being used to move the patient, being sure
to never let go. Keep the patient’s weight as Power Grip
close to your body as possible and maintain a The power grip allows for maximum stability and
low center of gravity. Follow the manufacturer’s strength from your hands. To perform the power
operating instructions for the stretcher and grip, grab the object so that both palms and fingers
equipment you are using. come in complete contact with the object (Fig. 5-2).
Avoid twisting your body as you lift. All of your fingers should be bent at the same angle.
Maintain a firm footing, and walk in small
measured steps.
Power Lift
When possible, move forward rather than
The power lift technique provides a stable move
backward.
for the patient while protecting you from serious
Use good posture. Poor posture can fatigue your injury. To perform the power lift correctly, remember
back and abdominal muscles, making you more
prone to injuries. When standing, your ears,
shoulders and hips should be aligned vertically,
your knees should be bent slightly and your
pelvis tucked slightly forward. When sitting, your
weight should be distributed evenly and your
ears, shoulders and hips should be aligned.
PRINCIPLES OF MOVING
PATIENTS
There are a number of different ways to move
a patient to safety, and no one way is best. Any
of the following moves is acceptable, providing
that you can move a patient without injuring
yourself or causing further injury to the patient.
All team members should be trained in the proper
Fig. 5-1: When lifting patients, keep your back in a locked-in
techniques and have practiced them until the moves position, with your head up, back straight and shoulders square
become automatic. Communicate your next moves to the patient.
CRITICAL Before you act, always size up the scene and consider the factors affecting the
FACTS situation, including any dangerous conditions, your physical ability and the patient’s
possible condition.
Chapter 5: Lifting and Moving Patients | 87
Squat Lift
The squat lift is an alternative to the power lift and
is useful if one of your legs or ankles is weaker than
the other. Remember to avoid bending at the waist
when performing this lift.
Stand with your weaker leg slightly forward. The
foot on the weaker side should remain flat on the
ground throughout the lift sequence.
Squat down until you can grasp the object. Use
the power grip.
Push yourself up with your stronger leg (Fig. 5-4).
Fig. 5-2: In a power grip, both palms and fingers should be in Keep your back locked and lead with your head,
complete contact with the object being lifted. lifting your upper body before your hips.
Reverse the procedure to lower.
to keep your back locked and avoid bending at
the waist.
Reaching
Position your feet, making sure they are on a General Guidelines
flat surface and are a comfortable distance Emergency medical responders (EMRs) will often
apart (usually shoulder width), and turned have to reach for equipment or patients. To minimize
slightly outward to provide maximum comfort the risk of injury, try to reposition the object to avoid
and stability. reaching and lifting. If that is not possible, reach no
Bend your knees. You should not feel like you more than 20 inches in front of your body. When
are falling forward. reaching, keep your back in the locked position and
Tighten your back and abdominal muscles. do not twist. Support your upper body with your
Keep your back as straight as possible and do not free arm. When reaching overhead, do not lean
twist or turn. Make sure your feet are flat and your back from the waist (hyperextending).
weight is evenly distributed.
Position your hands. Use the power grip once Correct Reaching for Log Rolling
your hands are in position. Grip the object The log roll is usually performed when the patient
in the way that is most comfortable and is suspected of having a spinal injury. Ideally,
stable. For most people, that is approximately four people working in tandem perform it. One
10 inches apart. responder is located at the patient’s head, while
Lift, keeping your back locked, and make two or three others perform the actual move
sure your upper body lifts before your hips do (Fig. 5-5, A–E). The patient’s arms should be
(Fig. 5-3). at their side with the legs straight and together.
Reverse the process to lower. The responder at the patient’s head directs
the movement and maintains spinal motion
Fig. 5-3: Perform the power lift with your back locked to provide Fig. 5-4: The squat lift is a useful alternative to the power lift if
stability for the patient and to prevent injuring yourself. one of your ankles or legs is weaker than the other.
88 | Emergency Medical Response
A
B C
D E
Fig. 5-5, A–E: To perform a log roll: (A) Have one responder maintain spinal motion restriction of the head while (B) three responders
perform the actual move. (C) Roll the patient in tandem, (D) placing the backboard against the patient and (E) returning the patient in
tandem, always maintaining spinal motion restriction.
Chapter 5: Lifting and Moving Patients | 89
restriction (SMR), a technique used to restrict EMERGENCY MOVES
spinal motion, until the patient is secured on the
In any emergency move, take care to protect the head,
backboard. (For more information on SMR, see
neck and spine. If you suspect the patient of having
Chapter 23.) The other responders roll the patient
a head, neck or spinal injury, only the clothes drag or
onto the side, and onto the backboard.
blanket drag are safe ways to move the patient.
When performing a log roll, keep your back straight
and lean from the hips, not the waist. Use the Indications for Emergency Moves
shoulder muscles whenever possible.
In general, treat patients at the scene rather than
moving them to provide care. However, some
Pushing and Pulling situations require emergency moves. These include
There may be instances when you will need to push the following:
or pull an object. Push rather than pull whenever
possible. If pulling an object is necessary, keep Avoiding immediate danger: Danger to you
your back locked and bend your knees slightly. or the patient from fire, close proximity of
Keep the load between your shoulders and hips, explosives or other imminent hazards, lack of
and close to your body. This will keep the pull line oxygen, risk of drowning, possible explosion,
centered with your body. collapsing structure or other reasons such
as uncontrolled traffic hazards, civil unrest or
If you need to push an object, try to push from the extreme weather conditions.
area between your waist and shoulders whenever
possible. If the weight is below waist level, push
Gaining access to other patients: A person with
minor injuries may need to be moved quickly to
from a kneeling position, keeping your elbows bent allow you to reach other patients who may have
and your arms close to your body. This will increase life-threatening conditions.
the force you can apply. Avoid pushing or pulling
objects overhead, as there is an inherent risk and Providing proper care: A patient with a medical
emergency, such as cardiac arrest or heat
likelihood of injury.
stroke, may need to be moved to provide proper
care. For example, someone in cardiac arrest
Carrying needs CPR, which should be performed on a
To minimize injury both to yourself and to the firm, flat surface with the patient positioned on
patient, follow these guidelines when carrying the back. If the person collapses on a bed or in
a patient: a small bathroom, the surface or space may not
be adequate to provide appropriate care.
Before lifting or carrying, estimate the total
weight to be lifted or carried. Do not forget to Moves used by EMRs include assists, carries and
include the weight of any equipment used in drags. One or two people can do most of these
addition to the weight of the patient. moves and most of them do not require equipment
Know your own physical abilities and limitations. (the exception is the direct ground lift, which calls
Do not overestimate your abilities or those for three people). This is important because, with
of your team members. Call for additional most emergency moves, equipment is not often
assistance if required. Do not proceed with immediately available and time is critical.
a patient move until you can do so safely,
The greatest danger in moving a patient quickly is
regardless of your first instinct.
the possibility of aggravating a spinal injury. In an
Communicate clearly and frequently with your emergency, make every effort to pull the patient in
partner, the patient and other EMRs. the direction of the long axis of the body to provide
When you carry, keep the weight as close to as much protection to the head, neck and spine as
your body as possible, with your back in the possible. It is impossible to remove a patient from
locked-in position. a vehicle quickly with an emergency move and at
Bend and flex at your hips and knees rather than the same time provide much protection to the head,
at your waist. neck and spine.
CRITICAL In any emergency move, take care to protect the head, neck and spine. If you
FACTS suspect the patient of having a head, neck or spinal injury, only the clothes drag or
blanket drag are safe ways to move the patient.
90 | Emergency Medical Response
Clothes Drag
The clothes drag is an appropriate emergency
move for a person suspected of having a head,
neck or spinal injury (see Skill Sheet 5-1). This
move helps keep the head and neck stabilized.
To carry out a clothes drag, gather the patient’s
clothing behind the neck. Using the clothing, pull
the patient to safety. During the move, cradle the
patient’s head by both the clothing and your hands.
Move carefully, since you will be moving backward.
Keep your back as straight as possible and bend
your legs (Fig. 5-6). This type of emergency move
is exhausting and may result in back strain for the Fig. 5-6: Clothes drag.
responder, even when done properly.
Blanket Drag
The blanket drag is a good way to move a patient
in an emergency situation when stabilization
equipment is unavailable or the situation dictates that
there is not enough time or space to use stabilization
equipment (see Skill Sheet 5-2). The blanket drag is
appropriate for a patient suspected of having a head,
neck or spinal injury. Position a blanket (or tarp,
drape, bedspread or sheet) next to the patient. Keep
the patient between you and the blanket. Gather half
the blanket and place it against the patient’s side.
Being careful to keep about 2 feet of blanket above Fig. 5-7: Blanket drag.
the patient’s head, roll the patient toward your knees,
reach across and position the blanket directly next
to the patient. Gently roll the patient as a unit onto
the blanket, being careful not to twist the patient’s
spinal column. After smoothing out the blanket,
wrap it around the patient, gather up the excess at
the patient’s head, and drag, being sure to keep the
patient’s head as low as possible. Move carefully
because you are moving backward, and keep your
back as straight as possible (Fig. 5-7).
Shoulder Drag
The shoulder drag is a variation of the clothes
drag, in which you reach under the patient’s Fig. 5-8: Shoulder drag.
armpits (from the back), grasp the patient’s
forearms and drag the patient (Fig. 5-8). Keep
your back as straight as possible and do not twist pull on the long axis of the body and not bump
(see Skill Sheet 5-3). This move is exhausting and the patient’s head. Keep your back as straight as
should be done carefully, since you are moving possible and do not twist. Move carefully because
backward. The move may result in back strain. This you are moving backward, which may result in back
move is not safe for a patient suspected of having a strain (Fig. 5-9). This move is not safe for a patient
head, neck or spinal injury. suspected of having a head, neck or spinal injury.
Ankle Drag Firefighter’s Drag
For the ankle drag (also known as the foot For the firefighter’s drag, position the patient on
drag), firmly grasp the patient’s ankles and move the back. Bind the patient’s hands together gently
backward (see Skill Sheet 5-4). Be careful to at the wrists (see Skill Sheet 5-5). Alternatively,
Chapter 5: Lifting and Moving Patients | 91
you can strap a belt or other device behind the
patient’s scapulae, loop it through the straps on
your air pack and fasten. Straddle the patient on
your hands and knees, and slip your head through
the patient’s arms. Place the patient’s bound wrists
behind your head. Keeping your back as straight as
possible, and keeping the patient centered under
you, slowly crawl forward, carrying the patient with
you (Fig. 5-10). Be careful not to bump the patient’s
head. This move is not safe for a patient suspected
of having a head, neck or spinal injury.
Firefighter’s Carry Fig. 5-9: Ankle drag.
The firefighter’s carry is not appropriate for
patients with suspected head, neck, spinal or
abdominal injuries, since the patient’s body
is twisted, the head is not supported and the
patient’s abdomen bears the weight during the
movement. To perform the carry for a patient who
is lying face-up, grasp the patient’s wrists (see
Skill Sheet 5-6). While standing on the patient’s
toes, pull the patient over a shoulder. Finally,
pass an arm between the legs and grasp the arm
nearest you. Alternatively, you can kneel in front
of a seated patient, place one shoulder against
the patient’s abdomen and hoist the patient
across your shoulders. Pull the patient over a Fig. 5-10: Firefighter’s drag.
shoulder. The patient’s feet should be on one
side and the head on the other. Pass your arm
between the patient’s legs and grasp the patient’s
arm that is closest to you. Keep your back as
straight as possible, lift with your legs and stand
up (Fig. 5-11).
Pack-Strap Carry
The pack-strap carry can be used on both
conscious and unconscious patients. Using it
on an unconscious patient requires a second
responder to help position the patient on your
back. To perform the pack-strap carry, have the
patient stand, or have a second responder support
Fig. 5-11: Firefighter’s carry.
the patient (see Skill Sheet 5-7). Position yourself
with your back to the patient, back straight and
knees bent so that your shoulders fit into the
patient’s armpits. Cross the patient’s arms in front
NONEMERGENCY MOVES
of you and grasp the patient’s wrists (Fig. 5-12). Uses
Lean forward slightly and pull the patient up onto A nonemergency move requires no special
your back. Stand and walk to safety. Depending equipment and is generally performed with
on the size of the patient, you may be able to hold other responders. Do not use nonemergency
both the patient’s wrists with one hand. This leaves moves if there is a possibility of a spinal injury. A
your other hand free to help maintain balance, open nonemergency move is used to move a patient from
doors and remove obstructions. This move is not one location to another, such as from the incident
safe for a patient suspected of having a head, neck scene to an ambulance or other transport vehicle
or spinal injury. or to a stretcher, from a bed to a stretcher or from
92 | Emergency Medical Response
Fig. 5-12: Pack-strap carry.
the floor to a chair. It may also be used to move a
A
patient to a different position as part of the medical
treatment. The best way to move a patient in a
nonemergency situation is the easiest way that will
not cause injury or pain.
Nonemergency moves are used most frequently
with patients with altered mental status, patients
with inadequate breathing, patients who are
in shock or patients in other situations that are
potentially dangerous. Examples include a patient
who is on a beach with the tide coming in or one
who is lying on the ground in a busy traffic area.
Techniques
Walking Assist
The most basic move is the walking assist. It is
frequently used to help patients who simply need
assistance to walk to safety (see Skill Sheet 5-8).
Either one or two responders can use this method
with a conscious patient.
To carry out a walking assist, place the patient’s
arm across your shoulders and hold it in place
with one hand. Support the patient with your other
hand around the patient’s waist (Fig. 5-13, A). In
this way, your body acts as a crutch, supporting
the patient’s weight while you both walk. A second B
responder, if present, can support the patient in the Fig. 5-13, A–B: Walking assist with (A) one responder and
same way from the other side (Fig. 5-13, B). (B) two responders.
Chapter 5: Lifting and Moving Patients | 93
CRITICAL A nonemergency move is used to move a patient from one location to another. Do
FACTS not use nonemergency moves if there is a possibility of a spinal injury.
Two-Person Seat Carry arms over the chest. The responder kneeling
The two-person seat carry is a method of at the patient’s head places one arm under the
moving a patient that requires a second responder. patient’s shoulders, cradling the head, and places
To perform the two-person seat carry, put one arm the other arm under the patient’s upper back. The
under the patient’s thighs and the other across next responder places one arm under the patient’s
the patient’s back (see Skill Sheet 5-9). Interlock waist and the other under the buttocks. The third
your arms with those of a second responder, under responder cradles the patient’s hips and legs.
the patient’s legs and across the patient’s back. On a signal from the responder at the patient’s
The patient places their arms over the responders’ head, all three responders lift the patient to their
shoulders. The patient is then lifted in the “seat” knees and support the patient by rolling the patient
formed by the responders’ arms (Fig. 5-14). Keep against their chests (Fig. 5-15). On the next signal,
your back straight and lift with your legs. Do not all will rise to their feet and move the patient to the
use this move for a patient suspected of having a stretcher. Reverse the steps to lower the patient.
head, neck or spinal injury. Responders should keep their backs straight and
lift with their legs.
Direct Ground Lift
The direct ground lift requires at least three
Extremity Lift
responders. The three responders line up on one In the extremity lift, one responder kneels
side of the patient and kneel close to the patient behind the patient, keeping the back straight,
(see Skill Sheet 5-10). The patient should cross reaches under the patient’s arms and grasps
the patient’s opposite wrist (see Skill Sheet
5-11). The second responder kneels between
the patient’s legs and firmly grasps around the
patient’s knees and thighs. On a signal from the
responder at the patient’s head, both responders
move from a crouching position to a standing
position. The responders then move the patient
to a stretcher (Fig. 5-16).
Moving Patients from a Bed
to a Stretcher
There are two techniques designed for moving a
patient from a bed to a stretcher or vice versa: the
direct carry and the draw sheet.
Fig. 5-14: Two-person seat carry. Fig. 5-15: Direct ground lift.
94 | Emergency Medical Response
A
Fig. 5-16: Extremity lift.
Direct Carry
Position the stretcher at a right angle to the bed,
with the head of the stretcher at the foot of the
bed. Two responders position themselves beside
the bed on the same side as the stretcher. One
responder slides their arms around the patient’s
shoulders and back, and the second responder
cradles the patient’s waist and hips. On a signal
from the responder at the patient’s head, the
responders lift the patient simultaneously and B
curl the patient’s body in toward their chest.
With a minimum of steps, the responders can
then turn and place the patient on the stretcher
(Fig. 5-17, A–C). Responders should keep their
backs straight, lift with their legs and not twist
their bodies.
Draw Sheet
To transfer a patient from the stretcher to the
bed, the responders loosen the bottom sheet on
the stretcher and position the stretcher along the
side of the bed. Responders stand beside the C
stretcher and on the other side of the bed. The
Fig. 5-17, A–C: To perform a direct carry: On a signal from
responders on the bed side of the patient lean the responder at the patient’s head, (A) the responders lift the
over the bed and grasp the sheet firmly at the patient simultaneously, (B) the responders curl the patient’s body
patient’s head and hips. The responders on the in toward their chest and (C) place the patient on the stretcher.
stretcher side grasp the sheets in the same place.
They then slide the patient into the bed. If there
are more responders available, they should be
positioned to help support the patient’s legs by
grasping the sheet in the same manner as the initial
responders (Fig. 5-18).
EQUIPMENT
To best decide on the most suitable equipment for
patients under different conditions, it is important
to familiarize yourself with the different types
available and match the appropriate equipment for
the size and condition of each patient. Fig. 5-18: Draw sheet technique.
Chapter 5: Lifting and Moving Patients | 95
CRITICAL There are two techniques designed for moving a patient from a bed to a stretcher or
FACTS vice versa: the direct carry and the draw sheet.
Stretchers equipped with a collapsible undercarriage for
ease of loading. Some models are pneumatic
There are several types of stretchers designed to
or electronic and help reduce the amount of
deal with patient transport:
manual lifting involved in patient transport.
Wheeled stretchers are most commonly used They use a hydraulic lift system to raise and
when moving patients from a situation in which lower the frame.
transport by ambulance for more advanced Portable stretchers are lightweight and often
medical care is required (Fig. 5-19, A). They are are used as auxiliary stretchers in ambulances
A B
E F
Fig. 5-19, A–F: Types of stretchers include: (A) wheeled stretcher; (B) portable stretcher; (C) bariatric stretcher (photo: courtesy
of Stryker); (D) basket stretcher; (E) flexible stretcher; (F) scoop or orthopedic stretcher.
96 | Emergency Medical Response
(Fig. 5-19, B). They are designed for use with Backboards
additional patients, as well as for maneuvering in
Backboards are used to move a patient from
areas where space is limited.
the scene of the incident to a stretcher or other
The bariatric stretcher was designed to transport device. Backboards can also be used to
accommodate a weight of up to 1600 pounds provide spinal motion restriction of a patient’s head,
(Fig. 5-19, C). neck and spine and are considered a standard
Basket stretchers, also known as Stokes piece of EMS equipment (Fig. 5-21, A–B).
baskets, get their name because of their basket-
like shape (Fig. 5-19, D). They are capable A short backboard is an SMR device used for
of safely transporting and securing patients non-critical patients who are already in a sitting
requiring a backboard. There are two types: a position. The vest type and/or corset design is
welded metal frame with a chicken wire web and most commonly used to secure patients in this
a tubular aluminum frame that has been riveted situation, and allows the patient’s head, chest
to a molded polyethylene shell. and lower back to be strapped in. The Kendrick
Extrication Device (KED) is a vest-type device that
Flexible stretchers are made of canvas
is commonly used to stabilize patients in vehicle
or synthetic materials and are designed
to allow easy transport of patients from collisions who are in an upright position. It is used
confined spaces, narrow hallways and in together with a cervical collar (Fig. 5-22).
situations with multiple steps or rough terrain The full-body vacuum mattress can be used as
(Fig. 5-19, E). either a backboard or moving device once the
Scoop or orthopedic stretchers are designed patient is secured. This design allows the mattress
for patients weighing up to 300 pounds, and to conform to whatever shape is required to
are made to be assembled and disassembled accommodate the patient’s condition. It avoids the
around the patient (Fig. 5-19, F). need for additional padding and becomes rigid
once fully deflated.
Stair Chair
A stair chair is used when a wheeled stretcher
is deemed too long for the rescue or extrication
(Fig. 5-20). It is especially useful when there
PATIENT POSITIONING AND
is a small elevator or staircase in which a long PACKAGING FOR TRANSPORT
stretcher will not fit. It is recommended that three Make patients as comfortable as possible while
responders be present when using the stair chair awaiting transport. Unless a life-threatening
to ensure patient safety, two to act as carriers and emergency dictates the necessity, do not move an
one to serve as a spotter to watch for potential injured patient. A patient is usually moved by EMRs
difficulties. once the patient has been examined, evaluated
and stabilized. There are times when a patient’s
condition will dictate the position you place the
patient in.
Position of Comfort
Indications for Use
Patients with various injuries or illnesses may be
placed in a position of comfort, which is the
position that is most comfortable, unless the injury
or illness prevents it. This might include a patient
who is in pain, is experiencing breathing problems,
is nauseated or is vomiting.
Techniques
Someone with abdominal pain will be more
comfortable on the side with knees drawn up. If a
patient is experiencing breathing difficulties, the
Fig. 5-20: Stair chair. Photo: courtesy of the Canadian patient may be more comfortable sitting up rather
Red Cross. than lying down.
Chapter 5: Lifting and Moving Patients | 97
A B
Fig. 5-21, A–B: (A) Adult backboard and (B) pediatric backboard.
is unresponsive, or you cannot maintain an open
and clear airway because of fluids or vomit,
transport the patient on their side in a recovery
position.
Recovery Positions
Indications for Use
While recovery positions are not generally used
in an EMS or healthcare setting, it is important
to understand how and when to use them. For
patients who are unresponsive, but breathing
normally with no suspected head, neck, spinal,
Fig. 5-22: Kendrick Extrication Device. hip or pelvic injury, move the patient into a side-
lying recovery position after completing your
A patient who is nauseated or vomiting should assessment and gathering a patient history, based
be allowed to remain in whatever position on local protocols. Patients with a suspected
is most comfortable. However, you should head, neck, spinal, hip or pelvic injury should not
monitor the patient closely and position yourself be placed in a recovery position unless you are
to monitor and manage the patient’s airway. unable to manage the airway effectively or you
An alert but nauseated person should be are alone and need to leave the patient to call for
transported in a sitting-up position. If the patient additional resources.
98 | Emergency Medical Response
CRITICAL You should use a side-lying recovery position for patients who are unresponsive
FACTS but breathing normally. Patients with a suspected head, neck, spinal, hip or pelvic
injury should not be placed in a recovery position unless you are unable to manage
the airway effectively or you are alone and need to leave the patient to call for
additional resources.
Techniques To place an infant in a recovery position:
To place a supine adult or child in a recovery
position (Fig. 5-23):
Place the infant in a recovery position as would
be done for an older child.
Kneel at the patient’s side. You also can hold an infant in a recovery
position by:
Lift the patient’s arm that is closest to you up
next to their head. yyCarefully positioning the infant face-down
along your forearm.
Take the patient’s arm that is farthest from you
and place it next to their side. yySupporting the infant’s head and neck with
your other hand while keeping the infant’s
Grasp their leg that is closest to you and bend
mouth and nose clear (Fig. 5-24).
it up.
Place one of your hands on the patient’s
shoulder and your other hand on their hip that is Supine Position
farthest from you.
Indications for Use
Using a smooth motion, roll the patient toward
In a supine position, the patient is lying face-
you by pulling their shoulder and hip with your
up. The supine position should be used when
hands. Make sure the patient’s head remains in
assessing an unconscious patient, when a patient
contact with their extended arm.
needs CPR or assisted ventilation, or when
Stop all movement when the patient is on their side. a patient has suspected head, neck or spinal
Place their knee on top of the other knee so that injuries. In order to perform CPR effectively,
both knees are in a bent position. for example, a patient must be lying in a supine
Place the patient’s free hand under their chin to position. Transport a patient in shock in a
help support their head and airway. supine position.
Fig. 5-23: Use a side-lying recovery position for patients if they are unresponsive but breathing
normally and have no evidence of head, neck, spinal, hip or pelvic injury. Patients with a suspected
head, neck, spinal, hip or pelvic injury should not be placed in a recovery position unless you are
unable to manage the airway effectively or you are alone and need to leave the patient to call for
additional resources.
Chapter 5: Lifting and Moving Patients | 99
A
B
Fig. 5-24: An infant recovery position.
Techniques
A log roll is performed to transfer a patient to a
supine position. Ideally, four responders should
perform it. The most experienced member of
the team should be at the patient’s head. The
responder at the head will be the lead for the
move and will provide spinal motion restriction of
the head and neck during the move. To provide
SMR of the head, place your hands on either
side of the patient’s head at the jawline, with
your fingers behind the head at the base of
the skull. The second responder kneels at the
C
patient’s shoulders and upper back area. The third
responder kneels at the patient’s hips. The fourth Fig. 5-25, A–C: To perform a log roll: (A) One responder
provides spinal motion restriction to the head while three others
responder kneels on the opposite side to position perform the move. (B) One responder maintains spinal motion
the backboard or other extrication device. The restriction of the head while (C) the others reach across and roll
responder at the patient’s head leads the move. the patient onto their back.
On that responder’s count, the other responders
roll the patient as a team onto the patient’s side,
while the lead responder keeps the patient’s head MEDICAL RESTRAINT
stable. The responder on the opposite side of the If a patient is aggressive or violent and in need of
patient positions the backboard under the patient emergency care, they may need to be restrained.
(Fig. 5-25, A–C). However, an EMR should avoid restraining a patient
unless the patient presents a danger to themselves
100 | Emergency Medical Response
CRITICAL Restraint should be reserved only for situations where the patient presents a danger
FACTS to themselves or to others. If state laws prohibit you from using restraints, ensure
your safety and wait for proper authorities to arrive on the scene.
or to others. Also, be aware that some state laws The type of restraint to be used (e.g., humane
require EMRs to have police authorization before restraints that are padded and made of cloth,
they can use restraints. If you are not authorized leather or wide roller gauze versus metal
to use restraints, ensure your safety and wait handcuffs, which are not considered humane).
for someone with proper authority to arrive at
the scene. Using Restraints
If restraints must be used, be sure that you have
Even if you are authorized to use restraints, it is
adequate assistance. You will need at least four
still best to have police present, if possible. Seek
responders trained in the use of restraints, plus an
approval from medical direction. Be aware of and
additional EMR who can advise the patient what
follow local protocols involving the use of patient
is taking place. Plan out your actions before you
restraints. Restraining a patient without justification
take them. You must know ahead of time what each
can give rise to a claim of assault and battery.
responder will be doing so you can act quickly
and safely. Remember that both medical and law
Altered Mental Status enforcement personnel need to be consulted
Patients sometimes become aggressive or violent prior to the use of restraints. Always follow
as a result of illness or trauma. Any condition that local protocols.
reduces the amount of oxygen to the brain, such
Use only the force necessary to successfully apply
as head injuries, can cause a significant change in
the restraint. Estimate the range of motion of the
behavior. Too little oxygen could make a normally
patient’s arms and legs, and stay beyond range
calm patient suddenly become anxious or even
until ready. Once the decision has been made to
violent. Physical illness as a result of substance
restrain the patient, act quickly. Have one EMR talk
abuse, diabetic emergencies, heat or cold
to the patient throughout restraining. Approach
exposure, or problems with the nervous system
the patient with four responders simultaneously,
associated with aging can lead to alterations in
one preassigned to each limb. Use only restraints
behavior. Patients who are in an altered mental
that have been preapproved by medical direction.
state may need to be restrained.
Restraints should be humane—made of leather or
cloth. In addition, use only commercial wrist- and
Reasonable Force ankle-restraining straps.
When restraining a patient, an EMR should
Never secure a patient in a prone position. You
always use reasonable force—the minimum
must have access to the patient’s airways at all
force necessary to keep a patient from injuring
times. A patient in a prone position will not be
themselves or others. A force is considered
able to adequately breathe because the weight
reasonable if it is as great as or minimally greater
of the body will force the organs toward the
than the force the patient is exerting to resist. The
diaphragm, which could lead to hypoxia (lack
amount of force you should use depends on:
of oxygen) and other conditions. The lack of
The height and weight of the patient. oxygen may cause the patient to become more
aggressive. Be sure to monitor the patient’s
The mental state of the patient.
condition frequently.
The type of behavior the patient is manifesting.
CRITICAL When restraining a patient, use reasonable force. Force is considered reasonable if
FACTS it is as great as or minimally greater than the force the patient is exerting to resist.
Chapter 5: Lifting and Moving Patients | 101
Carefully and completely document, in detail, Avoid the common mistake of moving an injured
the events surrounding your use of force and the or ill person unnecessarily. If you recognize a
techniques that you used. potentially life-threatening situation that requires
the patient be moved immediately, use one of the
techniques described in this chapter. Use the
Types of Restraints
safest and easiest method to rapidly move the
In circumstances where you need to restrain a patient without causing injury to either yourself or
patient, you will be using physical restraints, such the patient. Practice the lifts, moves and carries
as soft leather or cloth straps. There are also ahead of time so that they will be automatic to you
medications that act as a chemical form of restraint, when you need to use them.
but these must only be administered under medical
authorization and by personnel trained to do so. It is important for you to familiarize yourself
Patients who are chemically restrained must be with some of the typical equipment used in
transported in an advanced life support (ALS) unit local EMS systems. Practice using the different
and should be monitored closely. Never leave any types of stretchers, backboards and extrication
restrained patient unattended. devices, as you could be called on to use them
at any time.
If it becomes necessary to restrain a patient,
PUTTING IT ALL TOGETHER follow the prescribed protocol carefully and
Take the time to size up the scene upon arrival ensure you have law enforcement and medical
and determine if moving the patient is necessary authorization before restraining a patient.
before attempting to do so. Remember that your Document the situation carefully to avoid future
safety and the safety of your team always come legal problems.
first. This is especially true in incidents involving
hazardous materials.
You Are the Emergency Medical Responder
You and two other firefighters get to the collapsed people. Two of them are unconscious. One
man indicates his lower left leg may have been fractured. You recognize the immediate danger
to the two unconscious patients and to the others who have escaped from the building. Time
is critical. You need to get everyone to a safer place. Additional fire rescue units and EMS
personnel have been called but have not arrived yet and the fire continues to build. How would
you move the unconscious patients? How would you move the man with the lower leg injury?
102 | Emergency Medical Response
Skill Sheet
Skill Sheet 5-1
Clothes Drag
NOTE: The clothes drag is an appropriate emergency move for a patient suspected of having a head,
neck or spinal injury.
STEP 1
Position the patient on their back.
STEP 2
Kneel behind the patient’s head.
STEP 3
Gather the patient’s clothing behind the neck.
STEP 4
Using the clothing, pull the patient to safety.
■■ During the move, cradle the patient’s
head by both the clothing and your
hands.
■■ Move carefully, since you will be moving
backward.
■■ Keep your back as straight as possible
and bend your legs.
Chapter 5: Lifting and Moving Patients | 103
Skill Sheet
Skill Sheet 5-2
Blanket Drag
NOTE: The blanket drag is appropriate for a patient suspected of having a head, neck or spinal injury.
STEP 1
Position a blanket (or tarp, drape, bedspread or sheet) next to the patient.
STEP 2
Keep the patient between you and the blanket.
STEP 3
Gather half the blanket and place it against the patient’s side.
■■ Keep about 2 feet of blanket above the patient’s head.
STEP 4
Roll the patient toward your knees, reach across and position the blanket directly next to
the patient.
STEP 5
Gently roll the patient as a unit onto the blanket, being careful not to twist the patient’s
spinal column.
(Continued)
104 | Emergency Medical Response
Skill Sheet
Skill Sheet 5-2
Blanket Drag Continued
STEP 6
After smoothing out the blanket, wrap it around
the patient.
STEP 7
Gather up the excess at the patient’s head and
drag the blanket.
■■ Be sure to keep the patient’s head as
low as possible.
■■ Move carefully backward, keeping your
back as straight as possible.
Chapter 5: Lifting and Moving Patients | 105
Skill Sheet
Skill Sheet 5-3
Shoulder Drag
NOTE: This move is not safe for a patient suspected of having a head, neck or spinal injury.
STEP 1
Reach under the patient’s armpits (from the
back), grasp the patient’s forearms and drag
the patient.
■■ Keep your back as straight as possible
and do not twist.
STEP 2
Carefully move backward.
106 | Emergency Medical Response
Skill Sheet
Skill Sheet 5-4
Ankle Drag
NOTE: This move is not safe for a patient suspected of having a head, neck or spinal injury.
STEP 1
Firmly grasp the patient’s ankles and move
backward.
■■ Be careful to pull on the long axis of the
body and not bump the patient’s head.
STEP 2
Carefully move backward.
■■ Keep your back as straight as possible
and do not twist.
Chapter 5: Lifting and Moving Patients | 107
Skill Sheet
Skill Sheet 5-5
Firefighter’s Drag
NOTE: This move is not safe for a patient suspected of having a head, neck or spinal injury.
STEP 1
Position the patient on the back. Bind the
patient’s hands together gently at the wrists.
STEP 2
Straddle the patient on your hands and knees, and slip your head through the patient’s arms.
STEP 3
Place the patient’s bound wrists behind
your head.
STEP 4
Slowly crawl forward, carrying the patient with
you.
■■ Keep your back as straight as possible.
■■ Keep the patient centered under you.
■■ Do not bump the patient’s head.
108 | Emergency Medical Response
Skill Sheet
Skill Sheet 5-6
Firefighter’s Carry
NOTE: The firefighter’s carry is not appropriate for patients with suspected head, neck, spinal or
abdominal injuries.
To perform the firefighter’s carry on a patient who is lying face-up:
STEP 1
Grasp the patient’s wrists.
STEP 2
While standing on the patient’s toes, pull the
patient over a shoulder.
STEP 3
Pass an arm between the legs and grasp the arm nearest you.
■■ Alternatively, kneel in front of a seated patient, place one shoulder against the
patient’s abdomen and hoist the patient across your shoulders.
(Continued)
Chapter 5: Lifting and Moving Patients | 109
Skill Sheet
Skill Sheet 5-6
Firefighter’s Carry Continued
STEP 4
Pull the patient over a shoulder.
STEP 5
The patient’s feet should be on one side and the head on the other.
STEP 6
Lift with your legs and stand up.
■■ Keep your back as straight as possible.
110 | Emergency Medical Response
Skill Sheet
Skill Sheet 5-7
Pack-Strap Carry
NOTE: This move is not safe for a patient suspected of having a head, neck or spinal injury.
The pack-strap carry can be used on both conscious and unconscious patients.
To perform the pack-strap carry on either a conscious or unconscious patient:
STEP 1
Have the patient stand, or have a second responder support the patient.
STEP 2
Position yourself with your back to the patient.
■■ Keep your back straight and knees bent so that your
shoulders fit into the patient’s armpits.
STEP 3
Cross the patient’s arms in front of you and grasp the patient’s
wrists.
(Continued)
Chapter 5: Lifting and Moving Patients | 111
Skill Sheet
Skill Sheet 5-7
Pack-Strap Carry Continued
STEP 4
Lean forward slightly and pull the patient up onto your back.
STEP 5
Stand and walk to safety.
112 | Emergency Medical Response
Skill Sheet
Skill Sheet 5-8
Walking Assist
NOTE: Either one or two responders can use this method with a conscious patient.
STEP 1
Place the patient’s arm across your shoulders
and hold it in place with one hand.
STEP 2
Support the patient with your other hand around
the patient’s waist.
NOTE: A second responder, if present, can
support the patient in the same way from the
other side.
Chapter 5: Lifting and Moving Patients | 113
Skill Sheet
Skill Sheet 5-9
Two-Person Seat Carry
NOTE: Do not use this move for a patient suspected of having a head, neck or spinal injury.
STEP 1
Put one arm under the patient’s thighs and the other across the patient’s back.
STEP 2
Interlock your arms with those of a second responder, under the patient’s legs and across
the patient’s back.
■■ The patient places their arms over the responders’ shoulders.
STEP 3
Lift the patient in the “seat” formed by the responders’ arms.
■■ Keep your back straight and lift with your legs.
114 | Emergency Medical Response
Skill Sheet
Skill Sheet 5-10
Direct Ground Lift
NOTE: The direct ground lift requires at least three responders.
STEP 1
All responders line up on one side of and kneel close to the patient.
■■ The patient should cross arms over the chest.
STEP 2
The responder kneeling at the patient’s head places one arm under the patient’s shoulders,
cradling the head, and places the other arm under the patient’s upper back.
STEP 3
The next responder places one arm under the patient’s waist and the other under the
buttocks.
STEP 4
The third responder cradles the patient’s hips
and legs.
(Continued)
Chapter 5: Lifting and Moving Patients | 115
Skill Sheet
Skill Sheet 5-10
Direct Ground Lift Continued
STEP 5
On a signal from the responder at the patient’s
head, all three responders lift the patient to
their knees.
■■ Provide support by rolling the patient
against the responders’ chests.
STEP 6
On the next signal, all carefully rise to a
standing position and then move the patient to
the stretcher.
■■ Reverse the steps to lower the patient.
■■ Keep backs straight and lift with the
legs.
116 | Emergency Medical Response
Skill Sheet
Skill Sheet 5-11
Extremity Lift
NOTE: The extremity lift requires two responders.
STEP 1
One responder kneels behind the patient,
keeping the back straight, reaches under
the patient’s arms and grasps the patient’s
opposite wrist.
STEP 2
The second responder kneels between the
patient’s legs, and firmly grasps around the
patient’s knees and thighs.
(Continued)
Chapter 5: Lifting and Moving Patients | 117
Skill Sheet
Skill Sheet 5-11
Extremity Lift Continued
STEP 3
On a signal from the responder at the patient’s
head, both responders move from a crouching
position to a standing position.
STEP 4
The responders then move the patient to the
stretcher.
118 | Emergency Medical Response
UNIT 2
Assessment
6 Scene Size-Up������������������������������������������������������������120
7 Primary Assessment ������������������������������������������������144
8 History Taking and Secondary Assessment ���� 172
9 Communication and Documentation ������������������ 211
6 SCENE
SIZE-UP
You Are the Emergency Medical Responder
You are summoned to a home where a 43-year-old mother and her two children were
apparently overcome by carbon monoxide from a gas oven. The power went out earlier
and has not been restored. The family members were found by a concerned neighbor.
When you arrive, you see the mother and one of the children who are conscious and
complaining of nausea and severe headaches. You also see a 6-year-old boy who
appears to be unresponsive and not breathing. What should you be concerned with prior
to conducting an assessment and providing care? Are there other services, such as fire
or police, you should summon to the scene?
KEY TERMS
Blast injury: An injury caused by an explosion; may Kinematics of trauma: The science of the forces
occur because of the energy released, the debris, involved in traumatic events and how they damage
or the impact of the person falling against an the body.
object or the ground.
Mechanism of injury (MOI): The force or energy
Blunt trauma: An injury in which a person is struck that causes a traumatic injury (e.g., a fall, explosion,
by or falls against a blunt object such as a steering crash or attack).
wheel or dashboard, resulting in an injury that
does not penetrate the body, may not be evident, Nature of illness: The medical condition or
and may be more widespread and serious than complaint for which the person needs care (e.g.,
suspected. shock, difficulty breathing), based on what the
patient or others report as well as clues in the
Chocking: The use of items such as wooden blocks environment.
placed against the wheels of a vehicle to help
stabilize it. Penetrating injury: An injury in which a person is
struck by or falls onto an object that penetrates or
Dispatcher: Personnel trained in taking critical cuts through the skin, resulting in an open wound
information from emergency callers and call or wounds, the severity of which is determined by
takers and relaying it to the appropriate rescue the path of the object (e.g., a bullet wound).
personnel.
Tripod position: A position of comfort that a
Hazardous materials (HAZMATs): Chemical person may assume automatically when breathing
substances or materials that can pose a threat becomes difficult; in a sitting position, the person
or risk to health, safety and property if not properly leans slightly forward with outstretched arms, and
handled or contained. hands resting on knees or an adjacent surface for
support to aid breathing.
Hematoma: A mass of usually clotted or partially
clotted blood that forms internally in soft tissue
space or an organ as a result of ruptured
blood vessels.
LEARNING OBJECTIVES
After reading this chapter, and completing the • Identify standard and specialized personal
class activities, you will have the information protective equipment (PPE).
needed to: • Describe common mechanisms of injury (MOIs)
• Explain the rationale for sizing up a scene. and natures of illness.
• Identify the elements of a scene size-up. • Recognize an unstable vehicle.
• Determine when a scene is safe to enter. • Explain the safety fundamentals of vehicle
stabilization.
• Describe common hazards found at the scene of a
trauma or medical emergency. • Know when to request and what types of
additional resources may be necessary at
• Have a basic understanding of scene and traffic the scene.
control and related safety issues.
• Describe other dangerous situations and
• Describe the principles of personal safety at an hazardous materials (HAZMATs).
emergency scene.
Chapter 6: Scene Size-Up | 121
INTRODUCTION which provide valuable information about the
emergency situation and will help ensure your own
It is natural when you arrive at the scene of an
well-being.
emergency to want to rush in and start helping
people who may be in obvious pain or distress. But, Use each of your senses to size up the scene. In
no matter what the situation, it is essential to take addition to seeing and feeling for hazards, listen
the time to carefully and systematically prepare for for unusual sounds, for example loud explosions
and size up the scene. By doing this, you may save or crackling sounds. Use your sense of smell to
time later, prevent further harm to yourself and the detect any unusual or unexpected odors, such as
patient, and reduce the risk of overlooked injuries. gasoline or other chemicals.
In this chapter, you will learn about the priority Always observe the scene thoroughly for dangers
of preparation, ensuring your personal safety, such as traffic, unstable structures, downed
determining the number of patients, identifying electrical lines, leaking fuels or fluids, smoke or
the mechanism of injury or nature of illness, and fire, broken glass, swift-moving water, violence,
assessing the possible need for additional resources. explosions or toxic gas exposure. Some emergency
scenes are immediately dangerous; others may
become dangerous while you are providing care.
DISPATCH INFORMATION Sometimes the dangers are obvious, such as
As an emergency medical responder (EMR), it at a fire or with the presence of hostile patients
is important that you come prepared with the or bystanders. Other dangers may be less
best available information before arriving at any obvious, such as the presence of hazardous
emergency scene. Therefore, paying close attention materials (HAZMATs) or unstable structures.
to the information the dispatcher has provided
to you is essential. This information gives you the Take safety measures that are appropriate to the
first clues as to what you may encounter, including situation. In some cases, this might mean leaving or
hazards you may need to take into consideration. It moving away from the scene if it is too dangerous,
will also affect the personal protective equipment and may require a call for specialized personnel or
(PPE) and other equipment you may need. other additional resources.
Keep in mind that the information provided by
Controlling the Scene
dispatch is likely to be incomplete and may not
be entirely accurate. The caller may have only Traffic Control
given a location and some indication that medical Once you have eliminated or removed the current
assistance was needed. Hazards may be present dangers, you need to prevent new hazards from
that were not relayed by the person who reported affecting the scene as you provide care for the
the emergency, or the person may deliberately lie or patient(s). This is frequently a concern when
exaggerate the severity of the condition in order to dealing with emergencies on or near a road, and
get medical attention. However, never undervalue traffic control may be needed. Always pay attention
the information dispatch can provide you as a to the road. Keep your eyes and ears open to avoid
foundation for your preparations. becoming a victim yourself.
Usually, the police will take responsibility for
SAFETY directing traffic at a scene. However, if the police
have not yet arrived, you may need to manage this
Scene Safety task. Always follow local protocols or guidelines,
Almost every emergency response carries a but, in general, one person should be designated
certain risk to the safety of the EMR. Upon to be in charge of traffic control. If possible, traffic
arrival at an emergency scene, safety should be should be directed onto an entirely different road. If
your first priority. Safety includes both personal another route is not possible, the blocked-off area
safety and the safety of others, including should be arranged so that any moving traffic is at
patients and bystanders. Begin with assessment least 50 feet from the scene.
of the scene and the surroundings, both of
CRITICAL Safety includes both personal safety and the safety of others, including patients and
FACTS bystanders.
122 | Emergency Medical Response
The redirection of the vehicles needs to start Ambulances or other transport and emergency
well back from the scene. Traffic may be moving vehicles should be positioned to help control
quickly, and you need to provide plenty of the scene. If there are other emergency vehicles
time for vehicles to slow down and move over. present, ambulances should be parked in front of
Flares, reflective cones, signs and other warning the scene with the tires angled away from where
devices should be put in position, about 10 to care is being provided and with the loading doors
15 feet apart in a slanting line (Fig. 6-1, A–C). facing away from traffic. Ambulances and fire
Avoid placing a flare near puddles of fluid that apparatus should be blocking the road as much
may have spilled or leaked out of the involved as possible but allow other emergency vehicles to
vehicles, as the fluid may be flammable. On a access the scene. If other emergency vehicles are
curve, start the line of flares at the beginning of present, they should park down from the scene with
the curve; on a hill, start at the top of the hill. If their tires angled away from where care is being
the crash happened on a two-way road, put up provided. If there is a fire, park at least 100 feet
flares or warning devices in both directions. Any away; in a HAZMAT situation, aim for a distance
responders setting out the flares or waving traffic of 2000 feet or park where directed by on-scene
away should be wearing reflective clothing based personnel or the dispatcher. Also look for a location
on local, state and national guidelines and always that is uphill and upwind if there are HAZMATs or
be walking toward traffic. Do not turn your eyes fire. Leave emergency lights on to provide another
away from oncoming traffic. warning to drivers approaching the scene, and turn
headlights to a lower setting.
50 Feet
50 Feet
B
50 Feet
Fig. 6-1, A–C: (A) Proper position of flares on a straight road; (B) proper position
of flares on a curved road; (C) proper position of flares on a hill.
Chapter 6: Scene Size-Up | 123
Crowd Control on overall scene safety. If resources allow, this
You can help keep the situation calm at the scene responder should have no other task than ensuring
by staying calm yourself. For example, walk quickly scene safety.
to patients rather than run. Walking is not only
safer but also sends a message to the crowd that Personal Safety
you are in control and confident. In very chaotic Of your primary responsibilities, safety should
situations, it may help to set up a barrier around the always be foremost. You should always ensure
scene and designate one person to ensure people your own safety. When you arrive on the scene,
stay behind the barrier. your first priority is to determine your own personal
safety needs. The only safe scene is one that does
Re-Evaluating the Scene not represent a threat to you or to the response
Continually reassess the situation for new team. A cornerstone of personal safety is the use
dangers that may arise. For example, a building of appropriate PPE.
or structure that seemed stable when you arrived Approach all emergency scenes cautiously until you
may begin to crumble or become unstable. True can size up the situation. If you arrive at the scene
scene safety and control is a continuous, not an by vehicle, park a safe distance away. If the scene
initial, process. Ensure a responder has been appears safe, continue to evaluate the situation as
assigned to serve as a safety officer to focus you approach (Fig. 6-2).
Fig. 6-2: Continue to evaluate the scene as you approach for the extent of the emergency, apparent danger, and
number and behavior of patients and bystanders.
124 | Emergency Medical Response
CRITICAL Once you determine the scene is safe, approach and continue to evaluate the scene.
FACTS Evaluation should include location and extent of the emergency, scene dangers,
number of patients, and behavior of patients and bystanders.
To ensure the safety of all involved, always evaluate the scene, wear PPE, call for
additional personnel if needed and only treat within the scope of your training.
Pay particular attention to the: Personal Protective Equipment
Location of the emergency. Standard Precautions Overview
PPE is an important component of standard
Extent of the emergency.
precautions, which are based on the principle that
Apparent scene dangers.
all blood and OPIM such as body fluids, secretions,
Apparent number of injured or ill people. excretions (except sweat), nonintact skin and
Behavior of the patient(s) and any bystanders. mucous membranes may contain transmissible
infectious agents. Standard precautions include
If at any time the scene appears unsafe, move to a
a group of infection prevention practices that
safe distance. Notify additional personnel and wait
apply to all patients, regardless of suspected
for their arrival. Never enter a dangerous scene
or confirmed infection status, in any healthcare
unless you have the training and equipment to do
delivery setting. They are based on universal
so safely. Well-meaning responders have been
precautions, which were developed for protection
injured or killed because they forgot to watch for
of healthcare personnel. Standard precautions
hazards. If your training has not prepared you
focus on protection of responders and patients.
for a specific emergency, such as a fire or an
incident involving HAZMAT, notify appropriate
personnel. Implementation of Standard
Precautions
When arriving at an emergency scene, always The extent of standard precautions used is
follow these four guidelines to ensure your personal determined by the anticipated blood and OPIM
safety and that of bystanders: exposure, and includes the use of:
1. Take time to evaluate the scene. Doing so
will enable you to recognize existing and
Hand washing. Keeping hands clean is one of
the best ways to keep from getting sick and
potential dangers. spreading illnesses.
2. Wear appropriate PPE for the situation. Be a
constant advocate for the use of appropriate
Gloves. Disposable latex-free gloves should
be worn whenever you touch or are in contact
protective equipment. with a patient. Gloves are essential for any
3. Do not attempt to do anything you are not rescue situation.
trained to do. Know what resources are
available to help.
Gowns. A gown may provide further protection
from blood and OPIM that could otherwise be
4. Get the help you need by notifying additional splashed onto your clothing or skin.
personnel. Be prepared to describe the scene
and the type of additional help you require.
Masks. Masks block blood and OPIM, including
airborne droplets, from reaching your face; most
Another important aspect of personal safety is germs and viruses can enter the body easily
protecting yourself from exposure to infectious through the mouth or nose.
diseases. This is especially important if you are Protective eyewear. In hazardous situations,
providing care for a patient when blood and other these protect your eyes from debris and heat as
potentially infectious materials (OPIM) may be well as blood and OPIM.
present. Since it is impossible to know if a patient CPR breathing barriers (e.g., resuscitation
may be infected or not, you should always take masks and bag-valve-mask [BVM] resuscitators).
protective measures. These protective measures Use when providing ventilations to the patient
are discussed in detail in Chapter 2. is necessary.
Chapter 6: Scene Size-Up | 125
Personal Protective Equipment Safety of Others
PPE includes clothing or specialized equipment You have a responsibility for the safety of others at
that provide some protection to the wearer from the scene, as well as for your own personal safety.
substances that may pose a health or safety Discourage bystanders, family members or other
risk. Use the appropriate PPE, such as steel- responders from entering an area that appears
toe boots, helmets, heat-resistant outerwear, unsafe. You can ask well-intentioned individuals
self-contained breathing apparatus and leather to help you keep unauthorized people away from
gloves, that is specific to the potential hazard unsafe areas and summon more appropriate help.
(Fig. 6-3). Some dangers may require you to take special
measures, such as placing physical barriers to
Specialized protective equipment and gear
prevent onlookers from getting too close. Other
are designed to protect appropriately trained
situations may require you to act quickly to free
responders, and include items such as:
someone who is trapped or to move a patient in
Chemical and biological suits. immediate danger.
Specialized rescue equipment for difficult or
complicated extrications. Patient Safety
Ascent or descent gear for specialized Once you are confident of your own safety
rescue situations. and the safety of the general scene, turn to
the safety of the patient. As you approach the
In addition to using appropriate PPE, do not forget patient, continue to scan the area for possible
the role that frequent hand washing or use of hand dangers. Do not move a patient unless there is an
sanitizers play to keep you—and those around immediate danger.
you—safe, by reducing the spread of germs.
Ideally, you should move patients only after you
have assessed and properly cared for them. If the
patient does not seem to be seriously injured, and
the area is dangerous, you can ask the patient
to move to safety where you can provide care. If,
however, immediate dangers threaten a patient’s
life, you must decide whether to move the person.
If the area is dangerous and the patient is not
able to move, move the patient as quickly and
safely as possible without making the injuries or
illness worse. If the situation is so dangerous that
you cannot reach or move the patient, move to
safety yourself and call for additional assistance.
If there is no immediate danger, tell the patient
not to move.
Situations that may require an emergency move
include:
The presence of explosives or other HAZMATs
that present an immediate danger (such as a
natural gas or gasoline/fuel leak or fire).
The inability to make the scene safe (such as a
structure about to collapse).
The need to get to other patients who have a more
serious problem to provide the appropriate care.
When it is necessary to provide appropriate
care (such as moving a patient to the top or
bottom of a flight of stairs to perform CPR).
Fig. 6-3: Protect yourself from substances that may be harmful Chapter 5 provides more detailed information on
or contaminated by using appropriate PPE specific to the how to safely move injured or ill patients.
potential hazard.
126 | Emergency Medical Response
Bystander Safety mechanism of injury or nature of illness. As you
Look for bystanders who are in potential danger at gain experience, you will be able to arrive at a
the scene. You may be able to take steps to reduce scene and quickly scan the area to make a rough
the danger, but if not, tell them to move to safety. determination of the injuries or illnesses you can
expect to be dealing with.
If the scene is safe and you need help, look for
bystanders who may be able to assist you. They
Mechanism of Injury
may be able to tell you what happened or how
many people were involved, or they may help in Mechanism of injury (MOI) refers to the physical
other ways. A bystander who knows a patient may events that caused the injury. It is important to
know whether there are any medical conditions or determine MOI because it can alert responders
allergies you should be aware of. Bystanders can to possible hidden or more serious injuries that
meet and direct an ambulance to your location, may not be immediately visible. Some of the most
help keep the area free of unnecessary traffic and common MOIs an EMR will encounter are vehicle
even help you provide care if it is appropriate. crashes, blunt trauma, falls and penetrating trauma.
Vehicle Crashes
Number of Patients The science of the energy of motion (kinetics), and
Another important aspect when you are sizing up the the resulting damage to the human body (trauma),
scene is the number of patients at the scene. Often is called the kinematics of trauma. Nowhere
this is quick and easy to determine. But in some is the kinematics of trauma more apparent than
cases—for example, a multiple-vehicle crash or a in motor-vehicle crashes, which demonstrate all
significant explosion—it can be quite challenging. too vividly the effects of speed and rapid changes
Patients may be trapped inside motor vehicles or in speed (acceleration and deceleration) on the
may have been forcefully ejected from their vehicles human body. When a car crashes into another
and away from the immediate scene. An open door vehicle or an object such as a tree, the people
provides a clue that a patient has left the vehicle inside will continue moving at the same speed
or was thrown from it. If one patient is bleeding or the car was traveling until something stops them.
screaming loudly, you may overlook another patient That “something” may be a seat belt, a car seat
who is unconscious. It is also easy in any emergency harness, the steering wheel, dashboard or air bag.
situation to overlook a small child or an infant if they Even when the person’s body collides with the
are not crying. Accounting for the number of patients steering wheel, the person’s internal organs
who require care is also important for determining continue to move until they are stopped by the
the number of ambulances needed. body’s framework—such as the ribs or skull. In a
If it appears that there are more patients than sense, there are three separate events, or collisions:
you and the others with you can care for, call for first, the car hits another vehicle or an object and
additional help immediately. If you start helping the its forward motion is stopped; second, the person
patients right away, you are likely to forget to make hits the interior of the car and stops; and finally the
the call. Once you have called for additional help, person’s internal organs hit the skeleton or muscular
you can quickly assess the patients to determine framework of the body and stop (Fig. 6-4, A–C).
which ones you will begin caring for first. Just as the first collision can cause both obvious
damage to the car—the crumpled fender—and
hidden damage—the leaking radiator—so the last
MECHANISM OF INJURY AND two collisions can cause both visible and invisible
NATURE OF ILLNESS damage to the people in the vehicle. The extent of
Once you are able to work safely with the patient, the damage will depend in part on the speed and
observe the scene and the patient to gather weight of the vehicles and the kinetic energy of
information about what has happened and the motion that is absorbed.
CRITICAL Common MOIs include motor-vehicle crashes, falls, and blunt or penetrating trauma.
FACTS
Motor-vehicle collisions clearly demonstrate the impact that the energy of motion has
to cause damage to the human body. This is referred to as the kinematics of trauma.
Chapter 6: Scene Size-Up | 127
A
B C
Fig. 6-4, A–C: The kinematics of trauma are apparent in motor-vehicle crashes. (A) The car hits another vehicle or an object and its
forward motion is stopped. (B) The person hits the interior of the car and is stopped. (C) The person’s internal organs hit the skeleton or
muscular framework of the body and stop.
The wreckage of cars, aircraft or machinery may or completely through the windshield. If you
contain hazards such as sharp pieces of metal or see damage to the dashboard and windshield,
glass, fuel and moving parts. Therefore, do not try you should anticipate that the driver may have
to rescue someone from wreckage unless you have abdominal, chest and head injuries. These can
the proper training and equipment, such as turnout include abdominal injuries to the liver and spleen;
(or “bunker”) gear, safety glasses, gloves and a serious chest injuries, such as fractured ribs,
helmet. Specialized rescue teams can be called in ruptured lungs and torn arteries; and head injuries
for extensive or heavy rescue. Care for the patient including facial injuries. Keep in mind that the
is provided only after the wreckage has been person’s neck and brain may also be injured, and
stabilized. Gather as much information as you can, this sometimes happens without any bleeding or
and make sure more advanced medical personnel bruising on the face (Fig. 6-5).
have been called.
Rear-End Crash
There are five types of motor-vehicle crashes, and
In a rear-end collision, the rear vehicle pushes
each yields a different possible pattern of injuries:
the vehicle in the front forward. The driver and
head-on, rear-end, side impact, rotational impact
any passengers will feel their heads and necks
and rollover.
whipped back at first, and then they will be jolted
forward as the car stops. The backward motion of
Head-On Crash the head and neck often leads to a strained neck,
In a head-on crash, the driver will keep moving or what is often called a whiplash injury. After this
when the vehicle stops, and either will be thrown sudden acceleration, the car will usually come
upward against the steering wheel and windshield, to an abrupt stop because of the damage to the
or downward under the steering wheel. In some vehicle. This sudden stopping may cause injuries
cases, the driver may actually be thrown partially
128 | Emergency Medical Response
Fig. 6-5: A head-on car crash. Photo: courtesy of Captain Phil Kleinberg, EMT-P.
similar to those in a head-on crash. Typically, these the person is thrown in a new direction, possibly
crashes cause the brain to move backward, hitting colliding with the door, the steering wheel, the roof
the rear of the skull, and then forward, striking the of the car and any passengers. Injuries to many
front of the skull as the vehicle comes to a stop. parts of the body are possible. If the person was
A well-positioned headrest in a vehicle can often not wearing a seat belt, the person may be ejected
prevent these types of injuries. from the car through an open or broken window or
door. This puts the person at greater risk, because
Side Impact the car may roll onto them. If the crash takes place
If a vehicle hits the side of another car, the door on a road, the person may be ejected in front of
and frame of the car can be pushed into the bodies oncoming traffic. Responders should check around
of the driver and passengers. There may be injuries the scene in case there are other people who have
to any parts of the person’s body, especially if the been ejected. Sometimes these individuals can
crash was forceful enough to crush the side of land at some distance from the car. They may also
the car. If the person was not wearing a seat belt, be under the car.
the person may have been thrown against other
passengers or against the far side of the car, so Unstable Vehicles
injuries can be found on both sides of the body. Any movement of the vehicle during patient care
or extrication can prove dangerous or even deadly
Rotational Impact to patients with severe injuries, or could result in
Rotational impact occurs when the vehicle is injury to rescue personnel. Local fire department
thrown off center. It is the result of the vehicle and rescue squad personnel specially trained in
striking an object and rotating around it. This can vehicle stabilization and extrication will respond to
cause a variety of injury patterns, usually due to the the scene when notified.
person being struck by stationary objects inside To make the rescue setting as safe as possible, it
the vehicle, such as the steering wheel, doorposts, is important to ensure the vehicle is stable. You can
windows or dashboard. assume a vehicle is unstable if it is:
Rollover Positioned on a tilted surface.
When a car rolls over, the driver and/or Stacked on top of another vehicle, even partly.
passenger(s) inside experiences a series of Positioned on a slippery surface.
impacts (Fig. 6-6). Each time the car starts to turn, Overturned or on its side.
Chapter 6: Scene Size-Up | 129
Fig. 6-6: A rollover crash. Photo: courtesy of Captain Phil Kleinberg, EMT-P.
Vehicles must be stabilized in order to attempt to prevents these injuries but can cause injuries to the
remove a patient. Placing blocks or wedges against shoulder, chest and abdomen.
the wheels of the vehicle will greatly reduce the
chance of the vehicle moving. This process is called Air bags may be in the front of the car only, or may
chocking. You can use items such as rocks, logs, be in the door panels, roof rails and the side of seat
wooden blocks and spare tires. If a strong rope or backs. They are designed to inflate very rapidly just
chain is available, it can be attached to the frame before the initial impact and then deflate again just
of the vehicle and then secured to strong anchor as quickly. Because they deflate so quickly, they
points, such as large trees, guardrails or another may not stop all forward motion of the driver’s head
vehicle. Letting the air out of the vehicle’s tires also and chest, so it is important to check to see if the
reduces the possibility of movement. For further driver also hit the steering wheel. If the steering
details on how to stabilize a vehicle, see Chapter 28. wheel is damaged, the driver may have serious
abdominal or chest injuries, even if the air bag was
activated. Be sure to lift the air bag to examine the
Seat Belts and Air Bags
steering wheel for evidence of damage. Air bags
In all types of motor-vehicle crashes, the benefits of can also cause injuries to the head, face, eyes,
seat belts and air bags far outweigh the risks, but spine and arms, especially if the person is less than
there are also possible injuries associated with them. 5'2" tall. These injuries can prove fatal.
If the lap belt is fastened too low on the person’s In some collisions, the air bag is not deployed
body, across the base of the pelvis, it can dislocate and may present a hazard during extrication. If the
the hips. If it is fastened too high, it can cause patient is pinned directly behind an undeployed
injury to the abdomen. Worn without a shoulder air bag, both of the vehicle’s battery cables should
strap, a lap belt will keep the person from being be disconnected following established safety
ejected from the car but still allows a person’s head protocols. Ideally, the system should be deactivated
to strike the dashboard; a back-seat passenger before any attempts are made to extricate the
can also strike the back of the front seat as a patient. Do not mechanically cut through or
result of lap belt-only usage. A shoulder strap
CRITICAL A vehicle is unstable when it is on a tilted or slippery surface, atop another vehicle,
FACTS overturned or on its side.
130 | Emergency Medical Response
displace the steering column until the system has seen in motorcycle crashes. The rider is often
been deactivated. The air bag module should not ejected from the vehicle and the ATV may roll over
be cut or drilled into. Also, heat should not be onto the rider.
applied to the area of the steering wheel hub; an
undeployed air bag inflates in a normal manner if Snowmobile riders involved in a crash often
the chemicals sealed inside reach a temperature experience serious head and neck injuries, and the
above 350º F or 177º C. For further details on an snowmobile may roll over onto the rider. Winter
undeployed air bag, see Chapter 28. weather may make it difficult for the rider to see
protruding objects or wires and this can lead to
Additional Hazards collisions and injuries.
Other hazards at a motor-vehicle crash include
Blunt Injuries
fire, leaking fluids, downed power lines and special
considerations for alternative-fueled vehicles, such When someone is struck by or falls against a blunt
as hybrid and electric vehicles. For further details object—one with no sharp edges or points—the
on alternative-fueled vehicles, see Chapter 28. resulting injuries are often closed wounds. This type
of wound is known as a blunt injury or blunt trauma.
This means that although the soft tissues of skin,
Motorcycle Crashes
muscle, nerves and blood vessels may be damaged,
Motorcycle riders do not have the protection of a the skin is not broken and there is no visible bleeding.
vehicle body around them, so in a crash situation The patient may look unharmed, but there may be
they are at particular risk for severe injuries. serious, even fatal, injuries to the internal organs as
Motorcycle crashes may result in head-on impact, well as significant internal bleeding. The extent of the
angular impact, ejection from the motorcycle or injuries may not be immediately visible and may only
injury from “laying the bike down” (sliding down on appear after a period of time. The injuries may also
one side of the bike). be more extensive than they appear.
If a crash is head-on, the sudden deceleration The responder should look for:
causes the rider to be thrown into or over the
handlebars. Hitting the handlebars may cause Contusions or bruises—Swelling, discoloration
injuries to the chest, abdomen or legs, depending and pain where the person was hit.
on the rider’s position. If the person is completely
ejected from the bike, there may be internal injuries
Hematoma—A large, bluish lump formed by
blood collecting under the skin (Fig. 6-7).
and head, neck, back and extremity injuries.
Without a helmet, the rider is more likely to have Small- or medium-sized contusions need to only have
serious or fatal head injuries. cold packs applied. Larger contusions and bruising
or hematomas may indicate that there are more
Often when motorcycles crash, it is because the serious hidden injuries. It is also important to check
bike and rider come in contact with a protruding
object, such as a tree branch, road sign or fence
post, or another vehicle and often at high speeds.
The rider may be injured by the object and then
suffer further injuries as the bike falls or slides.
When a motorcycle rider realizes that a crash is
likely, the rider may try to slow down the bike and
reduce the risk by deliberately laying the bike down
on its side, placing a leg between the bike and the
road. This leads to injuries to the soft tissues of the
leg, which can go quite deep, depending partly on
what protective clothing the rider is wearing. If the
lower leg is trapped against the exhaust pipe or
engine, the patient can also have serious burns.
Recreational Vehicle Crashes
Since all-terrain vehicles (ATVs) are frequently
ridden off-road or on uneven ground and are not
very stable, they are prone to tipping over. In an
ATV crash, expect to see injuries similar to those Fig. 6-7: A hematoma may indicate more serious hidden injuries.
Chapter 6: Scene Size-Up | 131
for possible bone fractures, especially if there is a lot In addition to the path of the object, the speed
of swelling or pain or if the body part is deformed. with which the projectile travels through the body
is also a determining factor: the faster the object
Falls is moving, the more widespread the damage
Falls are another common cause of injury. done. If the patient falls onto something sharp, or
The severity of the injuries caused by a fall is is stabbed with a knife or another object, this is
determined by: termed a low-velocity penetrating trauma. If the
weapon or object used is available at the scene,
The distance the patient fell (the speed of the it can provide some hints as to the extent of the
fall increases when the person falls from a injuries. A knife, for example, only harms the tissues
greater height). it actually contacts, so knowing how long the
The surface the patient landed on (a soft, knife is will indicate how deep the injuries may be.
yielding surface will reduce the injuries). Knowing the angle of penetration will also give you
Any objects in the way that might have slowed clues about possible injuries.
the fall or, on the other hand, injured the patient
during the fall. Because it hits the body at greater speed, a bullet
or pellet fired from a handgun, rifle or shotgun will
The position of the patient’s body on landing.
cause damage to the body well beyond its actual
If the patient falls from a height of more than 15 feet pathway through the body. This is because it carries
onto a hard surface, injuries may be severe, even if with it a wave of pressure that compresses tissues
the patient looks unharmed at first glance. You may around it as it speeds through the body (Fig. 6-8,
discover fractured bones in the feet, ankles, legs, A–B). Always check for a possible exit wound, which
pelvis and spine. In falls from a greater height, the may be larger than the entrance wound, because
patient may also have damage to internal organs. this helps to determine the bullet’s pathway through
the body. The most serious, and most often fatal,
It is a natural reflex to throw out your hands when gunshots are to the head, chest and abdomen. While
you are falling. When a fall involves the hands bullets that hit the arms and legs are less likely to be
hitting the ground, the person’s wrists may be quickly fatal, they can cause severe bleeding and
fractured and, if the person falls from a great permanent damage to the limbs. Keep in mind that a
enough height, there also might be a fracture or small entrance hole, which may not bleed very much,
injury to the elbow and shoulder. may hide dramatic and serious internal injuries.
A person falling headfirst usually throws out the
arms, so injuries or fractures in the arms and Blast Injuries
shoulders are typical. The head may be pushed Another type of injury is a blast injury, which is
forward or backward on landing, or may be caused by an explosion. There are three phases to
pressed down by the person’s body, and any of an explosion and, therefore, three possible MOIs
these can cause serious injury to the head and from it (Fig. 6-9, A–C):
spine. The rest of the body will then hit the ground,
and injuries to the chest and pelvis can happen In the primary phase, the energy released
during this phase of the fall. during the explosion sends a wave of pressure
expanding outward from the center of the blast.
Individuals hit by this pressure can experience
Penetrating Injuries injury to any body part that is air-filled, especially
A penetrating injury occurs when the patient is the lungs, stomach, intestines and inner ears. In
hit by or falls onto something that can penetrate some cases, this can be fatal, even though the
or cut through the skin. This will cause an open person may show no external injuries.
wound (or wounds, as there may be both an
entrance and exit wound) and bleeding.
In the secondary phase, the debris around the
center of the blast is blown outward and can
The path of the projectile through the body usually cause injury when it strikes the person—often
determines the severity of the injury. For example, with considerable speed and force. These blunt
if a knife or bullet does not damage any internal or penetrating injuries will generally be visible
organs or major blood vessels, the resulting injuries and easily recognized. If some of the debris is
may be fairly minor, but a stabbing or shotgun blast on fire, the person may be burned.
that hits the heart or lungs or severs an artery can In the tertiary phase, the person is knocked to
quickly lead to a fatality. the ground or against a wall or other objects by
the force of the explosion. Depending on how far
132 | Emergency Medical Response
A
C
Fig. 6-9, A–C: There are three phases of a blast injury.
(A) Primary phase: Energy sends a wave of pressure expanding
outward from the center of the blast. (B) Secondary phase:
B Debris around the center of the blast blows outward, causing
blunt or penetrating injuries and sometimes burns. (C) Tertiary
Fig. 6-8, A–B: For a penetrating injury, always check for phase: Force of the explosion knocks a person to the ground,
(A) an entrance wound and (B) a possible exit wound. against a wall or into other objects.
away the person is, and how large the explosion, medical condition. Recognizing the nature of
the injuries may be similar to those sustained by illness helps you to plan the steps to provide
someone ejected during a car crash. immediate care.
Nature of Illness A conscious patient may be able to describe the
symptoms, or there may be obvious signs (e.g.,
In some situations, you may be called to a scene
labored breathing, vomiting). If the patient is unable
because a person is ill. Or, if you are called
to speak, ask any bystanders or family what they
to an emergency and there is no evidence of
have observed about the patient, and about any
trauma, but the patient has signs and symptoms
pre-existing conditions.
of a problem, you may suspect an illness or a
Chapter 6: Scene Size-Up | 133
Fig. 6-11: Patients with abdominal pain might pull the knees in
toward the chest.
is called the tripod position (Fig. 6-10). Patients
with abdominal pain often pull their knees up
toward their chest, either lying down or sitting with
their back against a hard surface (Fig. 6-11). Loss
of bladder or bowel control can indicate that the
patient has had a stroke or a seizure.
Any observations should be recorded, as they not
only help you evaluate the situation, but may help
the healthcare provider who will see the patient in
an entirely different environment.
Fig. 6-10: The tripod position.
ADDITIONAL RESOURCES
Determining the nature of illness can be made more Once you have sized up the scene and determined
difficult if the patient or others do not tell the truth. the mechanism of injury or nature of illness, you will
If a person overdosed on drugs, for example, the be able to decide what additional resources are
family may deny knowing what caused the problem needed to keep you and the patient safe or to provide
and may lie about drug use if you ask about it care. The number of resources will depend on any
directly. It is important to scan the scene for items hazards at the scene, the number of injured or ill
that may provide clues about the problem. Look persons, as well as the nature of injuries or illnesses.
for prescription and nonprescription medications,
evidence of alcohol or recreational drug use, and Chemical and biological suits can provide
medical equipment in regular use. protection against HAZMATs and biological threats
of varying degrees. Specialized rescue equipment
Consider the patient’s location and environment may be necessary for difficult or complicated
as well. For example, has the patient been in the extrications.
woods or long grass? Then you might need to
examine the patient for snake or spider bites. Is the
weather extremely hot and humid? Heat stroke or
Calling for Additional Resources
other heat-related illnesses are a possibility. You may need to call for:
Simply observing the patient can also tell you a Advanced life support (ALS), to provide a higher
great deal. Patients with chest pain or breathing level of care for patients with a severe illness or
problems often lean forward while sitting in what trauma.
CRITICAL You may be called to a scene because a person is ill and there is no evidence of
FACTS trauma. Recognizing the nature of illness helps you to plan the steps to provide
immediate care.
134 | Emergency Medical Response
Air medical transport (e.g., helicopter), to Notify dispatch so that the appropriate
provide the fastest transport to the appropriate personnel may be brought to the scene.
hospital or trauma center. Do not approach the scene.
Utilities (e.g., power/gas company), to assess, Remain uphill and upwind a safe distance from
turn off or isolate dangerous downed power the scene (Table 6-1).
lines or leaking pipes.
Await specialized resources.
Fire department, to contain or extinguish fires
from any source. For more information on HAZMAT emergencies,
including training and guides that are available,
Law enforcement, to direct or reroute traffic, or
refer to Chapter 29.
to maintain control with any potentially violent
bystanders, patients or perpetrators.
Violence
Hazardous Materials Violence can take place in a wide variety of settings,
HAZMATs are any chemical substances or materials but certain factors make it much more likely to occur.
that can pose a threat to the health, safety and These include scenes of domestic violence, fights
property of an individual. Any HAZMAT poses a in bars, gang fights, street fights, potential suicide,
special risk for responding personnel. When you or any situation where angry bystanders or family
approach an emergency scene, look for clues that members are present. At scenes where there has
indicate the presence of HAZMATs. These include: been arguing, fighting or threats, the potential for
violence is increased. Look for anything that indicates
Signs (placards) on vehicles, storage facilities violence has taken place, such as broken glass,
or railroad cars identifying the presence of overturned furniture, weapons, or alcohol or drug use.
hazardous materials. The risk of violence may be increased in situations
Clouds of vapor. where there is yelling, swearing, threatening, pacing,
or when a person is using clenched fists or throwing
Spilled liquids or solids.
objects. There may be other signs of tension, for
Unusual odors.
example an awkward silence in a situation where
Leaking containers, bottles or gas cylinders. you expect a lot of activity and noise. You may
Chemical transport tanks or containers. also discover a history of aggressive behavior, which
increases the risk of violence.
Those who transport or store HAZMATS in specific
quantities are required by the U.S. Department There are times when restraining a patient may
of Transportation to post placards identifying the be necessary, to ensure the safety of the patient,
specific hazardous material, by name or number, yourself and bystanders. Restraint should be used
and its specific dangers. as a last resort, however, and must be carried
out only after consultation with law enforcement
In order to identify the material, it is helpful to have
and medical direction. Use only as much force as
binoculars on hand. Binoculars allow you to view
is necessary to restrain the patient, and always
the scene from a safe distance. If you do not see
follow local protocols. Always keep your personal
a placard but suspect a HAZMAT is present, try
safety in mind when restraining patients. For
to get information before you approach the scene.
further information on the use of restraint, refer to
Do not approach a HAZMAT scene unless you are
Chapter 5.
trained to do so and have appropriate PPE such as
a self-contained breathing apparatus (SCBA) and If you arrive at the scene of violence or a crime,
chemical protective suit. do not try to reach any patient until you are sure
the scene is safe. Someone who has been shot,
If you find clues that there may be HAZMATs on
stabbed or sustained other injuries from violence
the scene:
may have severe injuries but, until the scene is safe,
CRITICAL Once you have sized up the scene and determined the mechanism of injury or nature
FACTS of illness, you will be able to decide what additional resources are needed to keep
you and the patient safe or to provide care. The number of resources will depend on
any hazards at the scene, the number of injured or ill persons, as well as the nature
of injuries or illnesses.
Chapter 6: Scene Size-Up | 135
there is nothing you can do to provide care. For Table 6-1:
the scene to be safe, law enforcement personnel Responding to Specific
must make it secure. Wait for law enforcement to
arrive and secure the scene before attempting to Emergency Situations
provide care unless you are part of a team working
under specific protocols with responding law SITUATION APPROPRIATE BEHAVIOR
enforcement agencies.
Hazardous If you suspect hazardous materials,
Police usually gather evidence at a crime scene, materials stay a safe distance away, upwind
so do not touch anything except what you must and uphill. Do not create sparks.
to provide care. Once law enforcement secures Notify dispatch immediately.
the crime scene and allows you to enter to
Motor- Do not attempt a rescue until
provide care, make sure that they are aware of
vehicle wreckage has been stabilized.
your presence and actions. Always have and use
crashes
appropriate PPE.
Domestic Violence
Domestic violence situations are among the most may be a clue that should lead you to suspect
potentially dangerous scenes you may encounter potential danger and heighten your awareness
as an emergency medical responder (EMR). when responding to the scene.
Domestic violence crosses all boundaries, affecting
people of all ages, races, education, socioeconomic If law enforcement has not been called, call them
classes and sexual orientations. However, there right away and do not approach until the police
are certain circumstances that may indicate that arrive and secure the scene. Your personal safety
domestic violence may be a factor. Any of the always outweighs the need to respond.
following conditions should lead you to suspect Once inside, your awareness must continue.
domestic violence and respond accordingly: While the police may have already secured the
• The injured person will not admit to being abused. scene, it is appropriate for you to do so also;
• The injuries sustained do not fit the history, visually check everyone for weapons. Determine
and the patient seems to be ashamed or who is in the residence and where they are.
embarrassed about the injuries. Once identified, any bystanders should be asked
• You observe injuries that involve contusions to leave. Do not allow residents to get between
and lacerations of the face, head, neck, you and an exit route, and do not let yourself be
breasts and abdomen. backed into a corner. Know where your team
• The suspected perpetrator of the violence is members are at all times and ensure that they
unwilling to allow the injured person to give a are equally aware of what else is going on. Look
history or be alone with emergency medical at body cues such as clenched fists, flared
services (EMS) personnel. nostrils and flushed cheeks. If there are weapons
• There are excessive delays between the injury present, ask law enforcement to intervene.
and seeking treatment. Remember that while you were originally called
• The patient repeatedly uses EMS services. to help, your presence, along with that of law
• The injuries occur during pregnancy. enforcement, may change the dynamics of
• Substance abuse is involved. the scene.
• There are frequent suicide gestures.
Stay calm. Take your time and take nothing
Law enforcement agencies generally send two for granted. Assume control of the situation
officers to answer domestic disturbances, to slowly. Introduce yourself, speaking directly to
reduce the potential of danger. EMRs should take the patient. Explain what you are doing. Ask
a similar approach to domestic disturbances, open-ended questions, allowing the patient to
with heightened awareness to all possible clues. talk. Restore control to the patient. Do not be
For example, the calling party denies calling judgmental. If you can, separate yourself and the
EMS personnel when you arrive at the door. This patient from the suspected perpetrator.
136 | Emergency Medical Response
PUTTING IT ALL TOGETHER intruding on the scene. In some cases, it may mean
moving the patient. A safe scene may change to a
Use the information you received from the dangerous one quickly. As you care for the patient,
dispatcher to begin your planning, but remember be aware of your surroundings and be prepared to
that it may be inaccurate or outdated. Make sure take any necessary steps to ensure your safety.
you have whatever protective equipment you will
need available. Your first priority is your own safety, Analyze the scene to determine the number and
so look first for any hazards that might put you locations of patients and also the MOI or nature of
at risk. illness. Then create a plan to provide appropriate
care. If your assessment tells you that you will
After your own safety, your next priority is to keep need help, call the appropriate personnel before
patients and bystanders safe. This may mean beginning to provide care for the patient.
redirecting traffic or preventing people from
You Are the Emergency Medical Responder
You have taken the proper precautions to make it safe for you to enter the scene and begin
assessing and providing care for carbon monoxide poisoning. What if the mother and children
lived in a place other than a single-family home? What additional considerations or actions
might there be?
Chapter 6: Scene Size-Up | 137
ENRICHMENT
Dealing with Hazards at the Scene
In addition to the specific emergency situations already discussed, other hazardous scenes require special
consideration (Table 6-2). Remember to always expect the unexpected and make sure the scene is safe before
entering. If it is not, notify the necessary agencies to do what is necessary to provide you with a safe working
environment.
Traffic
Traffic is often the most common danger you and other emergency personnel will encounter. If you drive to a
collision scene, always try to park where your vehicle will not block other emergency vehicle traffic, such as an
ambulance that needs to reach the scene. The only time you should park in a roadway or block traffic is:
To protect an injured person.
To protect any responders, including yourself.
To warn oncoming traffic, if the situation is not clearly visible.
Others can help you put reflectors, traffic cones, flares or lights along the road. These items should be placed
well back from the scene to enable oncoming motorists to stop or slow down in time (Fig. 6-12).
Table 6-2:
Additional Emergency Situations
SITUATION APPROPRIATE BEHAVIOR
Traffic Leave a path for arriving emergency vehicles. Put up reflectors, traffic cones, flares or lights to
direct dangerous traffic away from the scene.
Fire Never approach a burning vehicle or enter a burning building without proper equipment and
training. If in a burning building, do not open hot doors or use elevators, and stay close to the floor.
Electricity Assume all downed wires are dangerous. Do not attempt to move them. Do not touch any
metal fence, metal structure or body of water in contact with a wire. Notify the fire department
and power company immediately.
Water and Follow the rule of reach, throw, row then go. Never enter water or go on ice unless you are
ice trained to do so and have proper rescue equipment.
Unsafe Do not enter structures that you suspect are unsafe. Call for trained and equipped personnel.
structures Gather as much information as possible about the victim(s).
Natural Report to the incident commander in charge (incident commanders are covered in Chapter
disasters 30). Follow the rescue plan and standard operating procedures. Avoid obvious hazards and be
cautious when using equipment.
Multiple Report to the incident commander in charge. Care for patients with the most life-threatening
patients conditions first.
Hostile If the victim or bystanders threaten you, retreat to safety. Never try to restrain, argue with or
situations force care on a victim. Summon law enforcement personnel.
Suicide Do not enter until summoned by law enforcement personnel. Do not touch anything except
what you must to provide care.
Hostage Do not enter until summoned and cleared by law enforcement personnel. Gather as much
situations information as possible about the victims.
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Dealing with Hazards at the Scene continued
Fig. 6-12: You may have to control traffic to maintain a safe scene if the emergency occurs on or near a roadway.
Emergency personnel are sometimes injured or killed by traffic at emergency scenes. In fact, hazards on the
roadway are the number-one cause of death among EMS workers. If you are not a law enforcement officer, and
dangerous traffic makes the scene unsafe, wait for more help to arrive before providing care.
There are several important reasons to control traffic at the scene: to protect the crash scene from further
potential collisions, prevent injury to the rescue team, ensure minimal disruption and allow emergency vehicles to
reach the scene. On arrival, request the assistance of additional law enforcement and fire services to help control
the scene.
Fire
Any fire can be dangerous. Make sure the local fire department has been summoned. Only firefighters, who are
highly trained and properly equipped against fire and smoke, should approach a fire. Do not let others approach.
Gather information to help the responding fire and EMS units. Find out the possible number of people trapped,
their location, the fire’s cause, and whether any explosives or chemicals are present. Give this information to
emergency personnel when they arrive. If you are not trained to fight fires or lack the necessary equipment, follow
these basic guidelines:
Do not approach a burning vehicle.
Never enter a burning or smoke-filled building.
CRITICAL
Hazards on the roadway are the number-one cause of death among EMS workers.
FACTS
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Dealing with Hazards at the Scene continued
If you are in a building that is on fire, always check doors before opening them with the back of your hand. If a
door is hot to the touch, do not open it.
Avoid smoke and fumes by staying close to the floor.
Never use an elevator in a building that may be burning.
Downed Electrical Lines
Downed electrical lines also present a major hazard to responders. Always look for downed wires at a scene, and
always treat them as dangerous. If you find downed wires, follow these guidelines:
Move the crowd back from the danger zone. The safe area should be established at a point twice the length of
the span of the wire (i.e., the distance between the poles).
Never attempt to move downed wires.
Notify the fire department and the power company immediately. Always assume that downed wires are
energized, or live. Even if they are not energized at first, they may become energized later.
If downed wires are in contact with a vehicle, do not touch the vehicle and do not let others touch it. Tell
anyone in the vehicle to stay still and stay inside the vehicle. Never attempt to remove people from a vehicle
with downed wires across it, no matter how seriously injured they may seem.
Do not touch any metal fence, metal structure or body of water in contact with a downed wire. Wait for the
power company to shut off the power source.
Water and Ice
Water and ice also can be serious hazards. To help a conscious person in the water, always follow the basic rule of
“reach, throw, row then go.” You may reach out to someone in trouble with a branch, a pole or even your hand, being
careful not to be pulled into the water. When the person grasps the object, lean back and pull the person to safety.
If you cannot reach the person, try to throw the person something nearby that floats. If you have a rope
available, attach an object that floats to one end, such as a life jacket, plastic jug, ice chest or empty gas can.
Never enter a body of water to rescue someone unless you have been trained in water rescue, and then only as a
last resort. If possible, you can use a boat to get closer (row), but not close enough that the patient can grab the
side of the boat and tip it. The “go” part of this technique is only for those who can perform deep-water rescue.
Fast-moving water is extremely dangerous and often occurs with floods, hurricanes and low head dams. Ice is
also treacherous. It can break under your weight, and the cold water beneath can quickly overcome even the best
swimmers. Never enter fast-moving water or venture out on ice unless you are trained in this type of rescue. Such
rescues require careful planning and proper equipment. Wait until trained personnel arrive.
Unsafe Structures
Buildings and other structures, such as mines, wells and unreinforced trenches, can become unsafe because of
fire, explosions, natural disasters, deterioration or other causes. An unsafe building or structure is one in which:
The air may contain debris or hazardous gases.
There is a possibility of being trapped or injured by collapsed walls, weakened floors and other debris.
Try to establish the exact or probable location of anyone in the structure. Gather as much information as you can,
call for appropriate help and wait for the arrival of personnel who are properly trained and equipped.
Natural Disasters
Natural disasters include tornadoes, hurricanes, earthquakes, forest fires and floods. Rescue efforts after a
natural disaster are usually coordinated by local resources until they become overwhelmed. Then the rescue
efforts are coordinated by a government agency such as the local, regional or state emergency management
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Dealing with Hazards at the Scene continued
Fig. 6-13: When responding to a natural disaster, be sure to carefully size up the scene and avoid obvious hazards. Photo:
courtesy of Captain Phil Kleinberg, EMT-P.
agency. If the disaster is large enough or a federal disaster is declared, it may be coordinated with the assistance
of the Federal Emergency Management Agency (FEMA). Typically, you first would report to the incident
commander or the individual they designate to be in charge at the scene, then work with the disaster response
team and follow the rescue plan.
Natural disasters pose more risks than you might realize. Often, more injuries and deaths result from electricity,
HAZMATs, rising water and other dangers than from the disaster itself. When responding to a natural disaster, be sure
to carefully size up the scene, avoid obvious hazards and use caution when operating rescue equipment (Fig. 6-13).
Never use gasoline-powered equipment, such as chain saws, generators and pumps, in confined spaces.
Multiple Patients
Scenes that involve more than one patient are referred to as multiple-casualty incidents (MCIs). Such scenes
make your task more complex, since you must determine who needs immediate care and who can wait for more
help to arrive. MCIs are covered in more detail in Chapter 30.
Hostile Situations
Environmental factors, such as HAZMATs, electricity and unsafe structures, are not the only dangers you may
encounter. You may sometimes encounter a hostile patient or family member. Any unusual or hostile behavior,
including rage, may be a result of the emergency, injury, illness or fear. Many patients are afraid of losing control
and may show this as anger. Hostile behavior also may result from the use of alcohol or other drugs, lack of
oxygen or an underlying medical condition.
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Chapter 6: Scene Size-Up | 141
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Dealing with Hazards at the Scene continued
Fig. 6-14: If a patient or person with the patient becomes hostile, remain calm and remember that you cannot provide care
without consent.
If a patient needing care is hostile toward you, try to calmly explain who you are and that you are there to help.
Remember that you cannot provide care without the patient’s consent (Fig. 6-14). If the person accepts your offer
to help, keep talking as you assess the patient’s condition. When the patient realizes you are not a threat, the
hostility usually goes away.
If the patient refuses your care or threatens you, withdraw from the scene. Never try to restrain, argue with or
force care on a patient. If the patient does not let you provide care, wait for more advanced medical personnel to
arrive. Sometimes a close friend or a family member will be able to reassure a hostile patient and convince the
patient to accept your care.
However, family members or friends who are angry or hysterical can make your job more difficult. Sometimes
they may not allow you to provide care. At other times, they may try to move the patient before they have been
stabilized. A terrified parent may cling to a child and refuse to let you help. When family members act this way,
they often feel confused, guilty and frightened. Be understanding and explain the care you are providing. By
remaining calm and professional, you will help calm them.
Hostile crowds are a threat that can develop when you least expect it. As a rule, you cannot reason with a
hostile crowd. If you decide the crowd at a scene is hostile, wait at a safe distance until law enforcement and
additional EMS personnel arrive. Approach the scene only when police officers declare it safe and ask you to
help. Never approach a hostile crowd unless you are trained in crowd management and supported by other
trained personnel.
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Dealing with Hazards at the Scene continued
Suicide
Never enter a suicide scene unless police have made it secure. If the person is obviously dead, be careful not to
touch anything at the scene such as a weapon, medicine bottle, suicide note or other evidence. If the scene is
safe and the person is still alive, provide emergency care as needed. Concentrate on your care for the patient and
leave the rest to law enforcement personnel.
Never approach an armed suicidal person unless you are a law enforcement officer trained in crisis
intervention. Approach only if you have been summoned to provide care once the scene has been secured.
If you happen to be on the scene when an unarmed individual threatens suicide, try to reassure and calm the
person. Make sure that appropriate personnel have been notified. You cannot physically restrain a suicidal person
without medical or legal authorization. Listen to the person and try to keep the person talking until help arrives. Try
to be understanding. Do not dare the person to act, or trivialize the person’s feelings. Unless your personal safety
is threatened, never leave a suicidal person alone.
Hostage Situation
If you encounter a hostage situation, your first priority is to not become a hostage yourself. Do not approach the
scene unless you are specially trained to handle these situations. Assess the scene from a safe distance and call
for law enforcement personnel. A police officer trained in hostage negotiations should take charge.
Try to get any information from bystanders that may help law enforcement personnel. Ask about the number
of hostages, any weapons seen and other possible hazards. Report any information to the first law enforcement
official on the scene. Remain at a safe distance until law enforcement personnel summon you.
Chapter 6: Scene Size-Up | 143
7 PRIMARY
ASSESSMENT
You Are the Emergency Medical Responder
Your rescue unit arrives at a scene to find a distraught mother who says, “I can’t wake
my baby up.” The infant appears to be unconscious and is turning blue. How would you
respond? What are your immediate priorities? What should you do first?
KEY TERMS
Agonal breaths: Isolated or infrequent gasping in Level of consciousness (LOC): A person’s
the absence of normal breathing in an unconscious state of awareness, ranging from being fully
person; can occur after the heart has stopped alert to unconscious; also referred to as
beating. Agonal breaths are not normal breathing mental status.
and are considered a sign of cardiac arrest.
Minute volume: The amount of air breathed in a
Airway: The pathway for air from the mouth and nose minute; calculated by multiplying the volume of
through the pharynx, larynx and trachea and into air inhaled at each breath (in mL) by the number
the lungs. of breaths per minute.
AVPU: Mnemonic describing the four levels of patient Perfusion: The circulation of blood through the
response: Alert, Verbal, Painful and Unresponsive. body or through a particular body part for the
purpose of exchanging oxygen and nutrients
Brachial artery: The main artery of the upper arm; with carbon dioxide and other wastes.
runs from the shoulder down to the bend of
the elbow. Primary (initial) assessment: A check for
conditions that are an immediate threat to a
Breathing rate: Term used to describe the number patient’s life.
of breaths per minute.
Pulse: The beat felt from each rhythmic contraction
Capillary refill: A technique for estimating how of the heart.
the body is reacting to injury or illness by
checking the ability of the capillaries to refill Respiratory arrest: A condition in which there is
with blood. an absence of normal breathing.
Carotid artery: The major artery located on either Respiratory distress: A condition in which a
side of the neck that supplies blood to the brain. person is having difficulty breathing or requires
extra effort to breathe.
CPR breathing barrier: Device that allows for
ventilations without direct mouth-to-mouth contact Signs: Term used to describe any observable
between the responder and the patient; includes evidence of injury or illness, such as bleeding or
resuscitation masks, face shields and bag-valve- unusual skin color.
mask (BVM) resuscitators.
Signs of life: A term sometimes used to
Cyanotic: Showing bluish discoloration of the describe normal breathing and a pulse in an
skin, nailbeds and mucous membranes due to unresponsive patient.
insufficient levels of oxygen in the blood.
Stoma: A surgical opening in the body; a stoma may
Glasgow Coma Scale (GCS): A measure of level be created in the neck following surgery on the
of consciousness (LOC) based on eye opening, trachea to allow the patient to breathe.
verbal response and motor response.
Symptoms: What the patient reports experiencing,
Head-tilt/chin-lift maneuver: A common method such as pain, nausea, headache or shortness
for opening the airway unless the patient is of breath.
suspected of having an injury to the head, neck
or spine. Vital signs: Important information about the patient’s
condition obtained by checking respiratory rate,
Hypoxic: Having below-normal concentrations of pulse and blood pressure.
oxygen in the organs and tissues of the body.
Jaw-thrust (without head extension) maneuver:
A maneuver for opening the airway in a patient
suspected of having an injury to the head, neck
or spine.
Chapter 7: Primary Assessment | 145
LEARNING OBJECTIVES
After reading this chapter, and completing the class • Describe the methods used to assess
activities, you will have the information needed to: circulatory status.
• Summarize the reasons for forming a general • Explain the differences in obtaining a pulse in an
impression of the patient. adult, a child and an infant.
• Explain the purpose of the primary • Explain the need to assess a patient for
(initial) assessment. external bleeding.
• Describe methods for assessing a patient’s level of • Describe how to assess a patient for
consciousness (LOC). severe bleeding.
• Explain the differences in assessing the LOC of an • Describe how to assess breathing rate and quality,
adult, a child and an infant. pulse rate and quality, and skin appearance.
• Describe methods of assessing whether a patient • Describe how to establish priorities for care
is breathing. including recognition and management of shock.
• Distinguish a patient with adequate breathing from
a patient with inadequate breathing.
SKILL OBJECTIVES
After reading this chapter, and completing the class • Demonstrate how to open the airway using the
activities, you should be able to: head-tilt/chin-lift maneuver and the jaw-thrust
(without head extension) maneuver.
• Perform a primary assessment.
• Demonstrate how to use a resuscitation mask.
• Demonstrate how to assess LOC.
INTRODUCTION THE IMPORTANCE
In previous chapters, you learned how to prepare OF THE SCENE SIZE-UP
for an emergency, the precautions to take when Once you recognize that an emergency has
approaching the scene and how to recognize occurred and decide to act, always remember the
a dangerous situation. You also learned about importance of sizing up the scene first. A primary
your roles and responsibilities. As an emergency assessment should never occur until after the
medical responder (EMR), you can make a scene size-up. The four main components to
difference in an emergency—you may even save a consider during a scene size-up include:
life. But to do this, you must learn how to provide
care for an injured or ill person, and set priorities 1. Scene safety.
for that care. 2. The mechanism of injury (MOI) or nature
of illness.
When an emergency occurs, one of the most
3. The number of patients involved.
essential aspects of your job is the primary
(initial) assessment. The primary assessment 4. The resources needed.
is the process used to quickly identify those
conditions that represent an immediate threat Ensuring Scene Safety
to the patient’s life, so that you may properly Always begin by making sure the scene is safe
treat them as they are found. An effective for you, other responders, the patient(s) and
primary assessment includes creating a any bystanders, as discussed in Chapter 6.
general impression of the patient, checking for Take the necessary precautions when working
responsiveness and checking airway, breathing in a dangerous environment. If you do not have
and circulatory status.
146 | Emergency Medical Response
the necessary training and equipment, do not or nature of illness may be the only way you can
approach the patient—summon the appropriate identify what occurred.
personnel. Keep assessing the situation, and,
if conditions change, you then may be able to Recognizing Patients
approach the patient. Remember, nothing is gained
by risking your safety. An emergency that begins When you size up the scene, look carefully for
with one injured or ill person could end up with two more than one patient. You may not see everyone
if you are hurt. at first. For example, in a motor-vehicle collision,
an open door may be a clue that someone has left
the vehicle or was thrown from it. If one patient is
Determining Mechanism of Injury bleeding or screaming loudly, you may overlook
or Nature of Illness another patient who is unconscious. It is also easy
When attempting to determine the MOI or nature in an emergency situation to overlook small children
of illness, you must look around the scene for clues or infants if they are not crying.
to what caused the emergency and the extent of
the damage (Fig. 7-1). Consider the force that may
have been involved in creating an injury. These Summoning More Advanced
considerations will help you to think about the Medical Personnel
possible types and extent of the patient’s injuries. At times, you may be unsure if more advanced
Take in the whole picture. How a motor vehicle medical personnel are needed. For example, the
is damaged or the presence of nearby objects, patient may ask you not to call an ambulance or
such as shattered glass, a fallen ladder or a spilled transport vehicle to avoid embarrassment about
medicine container, may suggest what happened. creating a scene. Your training as an EMR will help
If the patient is unconscious, determining the MOI you make the decision. As a general rule, summon
Fig. 7-1: Search the scene for clues to determine what caused the emergency or injury and the
extent of the damage.
CRITICAL Primary assessment is essential to the job of an EMR to ensure proper care.
FACTS However, a scene size-up to evaluate safety, MOI or nature of illness, number of
patients and resources needed should always be done first.
To determine the MOI or nature of illness, check the scene for clues and consider
the force that may have been involved.
Chapter 7: Primary Assessment | 147
more advanced medical personnel for any of the patients. Bystanders may also be able to tell you
following conditions: what happened or help in other ways. A bystander
who knows the patients may know whether
Unconsciousness, an altered level of they have any medical conditions or allergies.
consciousness (LOC) or a brief loss Bystanders can also meet and direct an ambulance
of consciousness to your location.
Breathing problems (difficulty breathing or
no breathing)
Chest pain, discomfort or pressure lasting more GENERAL IMPRESSION
than a few minutes, that goes away and comes OF THE PATIENT
back or that radiates to the shoulder, arm, neck,
Once you have conducted a scene size-up and
jaw, stomach or back
assessed that the scene is safe for you and
Persistent abdominal pain or pressure your colleagues, your first step in the primary
No pulse assessment is to determine what has occurred
Severe, life-threatening bleeding (bleeding that and what is happening with the patient—a general
spurts or gushes steadily from a wound) impression. This general impression will determine
your immediate course of action.
Vomiting blood or passing blood
Severe (critical) burns Questions to ask yourself include:
Suspected poisoning
Does the patient look sick or injured?
Seizures
Is there a noticeable MOI?
Stroke (sudden weakness on one side of
Is the patient awake or alert?
the face/facial droop, sudden weakness on
one side of the body, sudden slurred speech Does the patient appear to be breathing?
or trouble getting words out, or a sudden Is the patient bleeding?
severe headache) What is the patient’s approximate age?
Suspected or obvious injuries to the head, neck
Your general impression may alert you to a serious
or spine
problem that requires additional resources or
Painful, swollen, deformed areas (suspected to a minor problem you can care for easily. You
broken bone) or an open fracture will discover these problems by looking for
It is impossible to provide a complete or definitive any signs and symptoms the patient may have.
list—there are always exceptions. Trust your Signs are evidence of injury or illness that you
instincts and follow local protocols. It is better to can observe, such as bleeding or unusual skin
have more advanced medical personnel respond to appearance. Symptoms are what the patient
a nonemergency than arrive at an emergency too reports experiencing, such as pain, nausea,
late to help. headache or shortness of breath. If you see
severe, life-threatening bleeding as you are forming
your general impression, immediately control
The Role of Bystanders the bleeding with any available resources if it is
Do not underestimate the role of bystanders in safe to do so, or delegate the responsibility to
an emergency situation. Scene safety is always another responder so you can begin your primary
first and foremost, so look for bystanders who are assessment. You may even ask the patient, if they
in potential danger and instruct them to move to are conscious and alert, to apply pressure to their
safety. Ask anyone present how many people may wound while you prepare to provide care. For
be involved in the emergency; bystanders may step-by-step instructions on performing a primary
provide essential information to help you identify assessment, see Skill Sheet 7-1.
CRITICAL Many conditions warrant summoning advanced medical personnel. These include
FACTS severe, life-threatening bleeding, breathing problems, prolonged chest pain,
seizures, and suspected head, neck or spinal injuries—to name a few.
148 | Emergency Medical Response
Age Delineation
As part of gaining a general impression,
attempt to determine the patient’s age. For
the purpose of this text, an adult is considered
anyone approximately 12 years old or older.
A child is considered 1 to about 12 years of
age, and an infant is under 1 year of age. The
approximate age of the patient will have an
effect on the care you provide.
For use of automated external defibrillators
(AEDs)—based on Food and Drug
Administration (FDA) approval of these
devices—a child is considered to be
between the ages of 1 and 8 or weighing
less than 55 pounds. If precise age or
weight is not known, the responder should
use their best judgment and not delay care
in determining age.
As you perform the primary assessment, check for
immediate life-threatening conditions. This means
assessing whether the patient: Fig. 7-2: When approaching a patient, approach from the front
so the patient can see you without needing to turn their head.
Is conscious.
Has an open and clear airway. First, speak to the patient. This may be to warn
Is breathing. the patient to remain still if there is a situation that
could cause damage to the head, neck or spine.
Has a pulse.
For example, in a motor-vehicle collision or a fall
As you assess the patient, determine if spinal off a ladder, the patient would need to remain still.
precautions are necessary based on your general Identify yourself as a responder and state that you
impression and the suspected MOI. If the scene are there to help. Obtain consent from the patient
suggests an MOI in which the patient may have a before beginning the primary assessment and
head, neck or spinal injury, you must ensure that providing care.
the patient’s head and neck do not move by using
manual stabilization and the jaw-thrust (without When approaching a patient, you should try to
head extension) maneuver. approach from the front so that the patient can see
you without needing to turn their head (Fig. 7-2).
This is especially important in the case of a
RESPONSIVENESS suspected head, neck or spinal injury.
Establishing Responsiveness Ask questions such as:
When approaching a patient, check for
responsiveness and assess their level of What happened?
consciousness (LOC). This can range from What is your name?
being fully alert to being unconscious and Where are you?
unresponsive to any stimuli such as voice or pain. What day of the week is it?
CRITICAL Always check for life-threatening conditions: unconsciousness; severe, life-
FACTS threatening bleeding; a blocked airway; abnormal or absent breathing; and no pulse.
Chapter 7: Primary Assessment | 149
The answers to these questions will give you an Patient Response—AVPU
idea of the patient’s LOC and orientation. Keep
In describing a patient’s LOC, a four-level, mnemonic
in mind that certain pre-existing conditions and
scale is traditionally used, referred to as AVPU.
diseases may be responsible for a patient’s
The letters A, V, P and U each refer to a stage of
orientation. If possible, speak with family members
awareness (Table 7-1).
to establish if this is usual behavior for the patient
or if it represents a change. Alert: Patients who are alert are conscious
and aware of their surroundings, able to
Pediatric Considerations acknowledge your presence and able to
Be aware that children and infants may be respond to your questions.
fully aware of you but unable to answer your Verbal: Sometimes the patient is only able
questions. This response can be for a variety to react to sounds, such as your voice. The
of reasons. Children may not be able to speak patient’s eyes may be closed but they open
or understand your questions, they may not when hearing your voice or when the patient is
speak or understand English, they may be told to open them. The patient may appear to
too frightened of the situation or of you as a be lapsing into unconsciousness. A patient who
stranger, or they may be crying too hard and has to be stimulated by sound to respond is
be unable to stop. If possible, try to assess described as responding to verbal stimuli.
a young child or an infant in a parent’s or Painful: A patient who does not respond to
caregiver’s arms or lap. Approach slowly and verbal stimuli or commands, but does respond
gently, and give the child or infant some time when someone inflicts pain, is described as
to get used to you, if possible. Use the child’s responding to painful stimuli. Pinching the
name, if you know it. earlobe or the skin above the collarbone are
examples of painful stimuli used to try to get
Considerations for Older Adults a response (Fig. 7-3). Be cautious however
In older patients, certain conditions and about pinching the earlobe in patients who may
diseases may be responsible for changes in have neck trauma, as they may try to move their
LOC. For example, a patient with dementia head away from an irritating stimulus. Instead,
may be confused by your questions. The forcefully pinch or squeeze the fleshy section of
patient also may not speak or understand skin between the patient’s thumb and forefinger.
English. When you think this might be the Unresponsive: Patients who do not respond to
case, speak with family members if possible any stimuli are described as being unconscious
to establish if this is usual behavior for the or unresponsive to stimuli.
patient or if it represents a change. Also,
do not assume that difficulty responding Table 7-1:
to questions about time and current events
necessarily means the patient is disoriented.
Levels of Consciousness
It is not unusual for people who live alone
LEVEL CHARACTERISTIC BEHAVIOR
to lose track of time, and some may not
follow current events. In this case, alter your Alert Able to respond appropriately
questions so that they address information to questions
related to the patient’s immediate environment
and the circumstances surrounding why Verbal Responds appropriately to verbal
you were called in order to truly gauge the stimuli
patient’s orientation.
Painful Only responds to painful stimuli
Unresponsive Does not respond
CRITICAL To assess LOC, ask simple questions such as, “What is your name?” LOC can
FACTS range from being fully alert to unconsciousness. Always approach a patient from the
front to avoid head turning.
In describing a patient’s LOC, a four-level, mnemonic scale is traditionally used,
referred to as AVPU. The letters A, V, P and U each refer to a stage of awareness.
150 | Emergency Medical Response
objects or debris? Will an oral (or nasal) airway be
necessary to prevent the tongue from falling back
in the throat and blocking the airway? Refer to
Chapter 11 for information on suctioning and the
use of airways.
If the patient is wearing dentures, leave
them in place unless they become loose and
block the airway. Dentures help support the
patient’s mouth and cheeks, making it easier
to seal the resuscitation mask if you need to
provide ventilations.
Fig. 7-3: A patient may respond only to painful stimuli, such as a
pinch or pull of the skin above the collarbone. Opening the Mouth
If you need to open the mouth to clear the airway of
fluids or debris and the patient is unresponsive, use
Once you have assessed the patient’s LOC, the the cross-finger technique to open the patient’s
next thing you must do is to check the patient’s mouth with a gloved hand:
airway, breathing and circulation (pulse and
skin characteristics). Kneel beside the patient near their head.
Ensure that the patient is unresponsive.
Cross the thumb and forefinger of one hand.
AIRWAY STATUS Put your thumb on the patient’s lower teeth
The pathway for air passage between the mouth and your forefinger on the patient’s upper
and nose to the lungs is called the airway. Without teeth (Fig. 7-4).
an open airway, the patient cannot breathe. A Use a scissors motion to open the mouth.
patient who can speak or cry is conscious, has
an open airway, is breathing and has a pulse. Assessing Airway and Breathing
However, the patient may still be at risk of a in the Responsive Patient
compromised airway.
If the patient speaks, you know that the airway
Assess the airway with the unconscious patient is functional, but the patient may still be at risk.
face-up. First, verify if the airway is patent (open If a patient’s breathing is noisy, the sounds
and clear). If the patient is breathing (chest is can indicate the type of problem. For example,
rising and falling with air moving in and out) or stridor (high-pitched whistling sound) can
the patient is speaking to you and aware of the indicate that the airway is narrowing through
surroundings, then you need to ensure that the swelling, a foreign body or trauma. Continually
airway remains open and clear. Continue to reassess and monitor the patient’s breathing
assess the patient’s respiratory status throughout because breathing status, rate and quality can
the period that you provide care. The airway can change suddenly.
become blocked by fluids, solid objects, the
tongue or swollen tissue caused by trauma or Assessing Airway and Breathing
severe allergic reaction.
in the Unresponsive Patient
Determine whether there is a need for any It is more difficult to tell if an unconscious patient
interventions to establish or maintain patency. For has an open airway. To open the airway for a
example, does the patient require suctioning to patient who has not suffered an injury to the head,
remove fluids or a finger sweep to remove solid neck or spine, open and maintain the airway using
CRITICAL Without an open airway, the patient cannot breathe. A patient who can speak or cry
FACTS is conscious, has an open airway, is breathing and has a pulse. However, the patient
may still be at risk of a compromised airway.
Chapter 7: Primary Assessment | 151
Fig. 7-4: The cross-finger technique uses a scissoring motion of the thumb and forefinger to open
an unresponsive patient’s mouth.
the head-tilt/chin-lift maneuver. For patients of
all ages, tilt the head back and lift the chin to open
the airway. Do not tilt a child’s or an infant’s head
back as far as an adult’s. Tilting the head back
too far can close off a child’s airway. Tilt a child’s
head so the airway is slightly past the neutral
position and tilt an infant’s head so the airway is in
a neutral position.
Opening the Airway—Head-Tilt/ A
Chin-Lift Maneuver
To open the airway with the head-tilt/chin-
lift maneuver:
1. Kneel beside the patient’s head and neck.
2. Place one hand on the patient’s forehead.
3. Place the fingertips of two or three fingers
of your other hand under the bony part of
the patient’s lower jaw near the chin. If the
patient is a child or an infant, use only one or
two fingers. B
4. Use firm backward pressure from the palm
of your hand to tilt the head back while lifting
the jaw up with the fingertips to extend the
chin forward (Fig. 7-5, A). If the patient is a
child, tilt the head so the airway is only slightly
past neutral (Fig. 7-5, B). For an infant, tilt
the head so the airway is in a neutral position
(Fig. 7-5, C).
5. Keep pressure on the patient’s forehead to help
maintain the airway in an open position. C
Fig. 7-5, A–C: (A) Correct angling of head-tilt/chin-lift
maneuver in an adult; (B) correct angling of head-tilt/chin-lift
maneuver in a child; (C) correct angling of head-tilt/chin-lift
maneuver in an infant.
152 | Emergency Medical Response
Fig. 7-6: Jaw-thrust (without head extension) maneuver.
Opening the Airway—Jaw-Thrust rise and fall. Look, listen and feel for breathing for at
(Without Head Extension) Maneuver least 5 seconds, but no more than 10 seconds. You
To open the airway for someone who has a will simultaneously check for breathing and a pulse.
suspected head, neck or spinal injury, use the jaw- Pulse checks will be discussed later in this chapter.
thrust (without head extension) maneuver Check the patient’s neck to see if they breathe
to keep the head and neck in a neutral position through a stoma. A stoma is an opening in the
(Fig. 7-6). This maneuver moves the tongue away neck to allow a person to breathe after surgery to
from the back of the throat, allowing air to enter remove part or all of the larynx (voice box) or other
the lungs without moving the head and neck. After structures of the airway (Fig. 7-7). The person
opening the airway, look, listen and feel for breathing.
Do not move the head to the side, forward or back.
You can perform this maneuver with or without
a resuscitation mask. Note that if you cannot
establish an open airway using the jaw-thrust
(without head extension) maneuver, use the head-
tilt/chin-lift maneuver instead. For step-by-step
instructions on performing the jaw-thrust (without
head extension) maneuver, see Skill Sheet 7-2.
BREATHING STATUS
If the patient is breathing, the chest will rise and
fall. However, you must also listen and feel for signs
of breathing. Position your ear over the patient’s
Fig. 7-7: A stoma is an opening in the neck that allows a person
mouth and nose so you can hear and feel air as it to breathe. Photo: courtesy of the International Association of
escapes. At the same time, look for the chest to Laryngectomees.
CRITICAL For an unconscious and unresponsive patient, look, listen and feel for breathing and
FACTS check for a pulse for at least 5 seconds, but no more than 10 seconds.
Chapter 7: Primary Assessment | 153
may breathe partially through this opening, or may Pediatric Considerations
breathe entirely through the stoma instead of Children and infants breathe more quickly
through the nose and mouth. Use a round, pediatric than adults. Children can breathe up to
mask if you need to provide ventilations. 30 breaths per minute, while infants can
have a respiratory rate up to 50 breaths per
Isolated or infrequent gasping in the absence of minute. While counting the breaths, assess
normal breathing in an unconscious person may whether breathing is shallow, deep or normal,
be agonal breaths, which can occur after the and whether the child or infant appears
heart has stopped beating. Agonal breaths are not to be having difficulty breathing. Normal
breathing and are considered a sign of cardiac (effective) breathing appears effortless. Keep
arrest. Do not confuse this with normal breathing. in mind that infants have periodic breathing,
If there are only agonal breaths, care for the patient so changes in the pattern of breathing are
as if they are not breathing at all. normal. Also, agonal breaths do not occur
If the patient is breathing, assess the rate and frequently in children.
depth of the breathing. A healthy adult breathes As with adults, if a child or an infant is
regularly, quietly and effortlessly. The normal breathing spontaneously, you must still
breathing rate for an adult is between 12 and 20 reassess regularly to ensure that the
breaths per minute. However, some people breathe breathing status does not change.
slightly slower or faster (Table 7-2). You can usually
observe the chest rising and falling.
Breathing rate may be abnormal for the patient’s
To determine the breathing rate, listen for the age, meaning either too slow or too fast.
sounds as the patient inhales and exhales. Count Respirations may be too slow: less than 8 per
the number of times the patient breathes (inhaling minute for adults, less than 10 per minute for
and exhaling is one breath) for either 15 seconds children and less than 20 per minute for infants;
and multiply that number by 4, or 30 seconds and or they may be too fast: greater than 20 per
multiply that number by 2. If the patient is awake minute for adults, greater than 30 per minute
and alert, do not to let the patient know or disclose for children and greater than 60 per minute
when you are observing breathing, as the patient for infants.
may become self-conscious. This can cause a
change in breathing pattern and not provide an Depth of breathing may also be abnormal, with
accurate assessment. Simultaneously checking shallow movement of the chest as it rises and falls.
breathing and the pulse is a good way to not alert Abnormal breathing may be noisy. There may be a
the conscious patient that you are observing their gurgling noise without secretions in the mouth or
breathing. If the patient is breathing, continue to wheezing. Other abnormal breath sounds include
maintain an open airway. whistling sounds, crowing sounds or snoring.
Table 7-2:
Normal Breathing Rates
NUMBER OF
AGE BREATHS ADDITIONAL NOTES
PER MINUTE
Adults (12 years old 12 to 20 ••Normal chest rise and fall
or older) ••Quiet breathing (no abnormal breathing sounds)
••No great effort of breathing
••Rates may alter due to emotional and physical conditions
Children (1 to about 15 to 30 ••Sometimes breathe irregularly, so may need to assess for
12 years old) 1 minute and repeat frequently
••Rates may alter due to emotional and physical conditions
Infants (under 25 to 50 ••Have periodic breathing (periods of rapid, shallow breathing
1 year of age) that occur during sleep; normal for infants)
154 | Emergency Medical Response
The amount of effort a conscious patient puts into Breathing very shallow respirations. The patient
breathing can be observed by watching to see if is likely not receiving an adequate supply
the patient is using the accessory muscles—the of oxygen.
muscles in the neck, between the ribs and/or the Breathing increasingly slow. Oxygen intake
abdomen—to breathe. Nasal flaring is another will be dropping and the patient is likely not
indication of difficulty breathing, as is the tripod receiving an adequate supply of oxygen.
position, where the patient sits and leans forward,
bracing both arms on knees or an adjacent surface
Tolerant of assisted ventilation. For those who
are not tolerant of assisted ventilation, you can
for support to aid breathing. use a “blow-by” technique. Refer to Chapter 12
Administer supplemental oxygen or provide for more information.
ventilations as appropriate, based on local It is important to remember that the respiratory
protocols, if the patient is having trouble breathing. status of a patient can change suddenly
This would be necessary if the patient is: (Table 7-3).
Unresponsive. Monitor the patient’s airway If the patient is not breathing normally and
to ensure that respirations are continuing and has no pulse and the cause is the result of a
are effective. drowning, give 2 ventilations prior to beginning
Hypoxic. Pale, cool, clammy, moist skin is an CPR. Provide ventilations using a resuscitation
early sign of inadequate oxygenation. mask or BVM. These CPR breathing barriers
Cyanotic. The patient is not receiving can help protect against disease transmission
adequate oxygen. This is a clear but late sign when performing CPR or giving ventilations to
of inadequate oxygenation. The mouth, lips and a patient.
nailbeds would appear blue in color.
Table 7-3:
Respiratory Status and Providing Care
SIGNS RESPIRATORY STATUS PROVIDING CARE
••Normal rate and depth of breathing ••Breathing is adequate ••Monitor breathing for any changes
••Absence of abnormal breath sounds ••Administer supplemental oxygen, if
••Air moves freely in and out of the chest available, based on local protocols
••Normal skin color
••Rate and/or depth of breathing is ••Breathing is inadequate ••Assist ventilations
slower or faster than normal range ••Breathing is either slow ••Administer supplemental oxygen, if
••Breathing is shallow or shallow available, based on local protocols
••There are no breath sounds or breath ••Patient is moving some
sounds are diminished air in and out of the chest
••Breathing is noisy: crowing, stridor, ••Breathing is not enough
snoring, gurgling or gasping to sustain life
••Cyanosis (blue or gray skin color)
••Decreased minute volume
••The chest does not rise ••Patient is not breathing ••Provide ventilation
••No evidence of air moving in through ••Administer supplemental oxygen, if
mouth or nose available, based on local protocols
••There are no breath sounds
CRITICAL It is important to remember that the respiratory status of a patient can change
FACTS suddenly.
Chapter 7: Primary Assessment | 155
Resuscitation Mask breathing. Have the patient assume a position of
To use a resuscitation mask, select the proper size comfort. After the patient inhales, have them slowly
of mask for the patient (adult, child or infant), kneel exhale through the lips, pursed as though blowing
to the side of or above the patient’s head and then: out candles. This creates back pressure, which
can help open airways slightly until more advanced
Assemble the mask and valve, attaching the medical personnel arrive.
one-way valve to the mask, if necessary.
Open the airway past a neutral position for an Table 7-4:
adult and slightly past neutral for a child. For
an infant, tilt the head so that the airway is in a Artificial-Ventilation Rates
neutral position.
NUMBER OF
Place the mask over their mouth and nose, starting
AGE VENTILATIONS PER
from the bridge of the nose. Place the bottom of
the mask below the mouth but not past the chin. MINUTE*
Seal the mask. Adult (12 years old About 12 (1 ventilation
Blow into the mask (Fig. 7-8). Give 2 ventilations. and older) about every 5–6 seconds)
Each ventilation should last about 1 second
Child (1 year to About 20 (1 ventilation
and make the chest begin to rise. Pause briefly
about 12 years old) about every 3 seconds)
between ventilations to let the exhaled air escape.
Infant (under 1 year About 20 (1 ventilation
For step-by-step instructions on using a resuscitation
of age) about every 3 seconds)
mask, see Skill Sheets 7-3 and 7-4. See Table 7-4
and Chapter 10 for more information about the use Newborn 30 to 60 (1 ventilation
of breathing devices and artificial ventilations. about every 1–2 seconds)
If breathing is too slow for the age of the patient, *Each ventilation should be approximately 1 second in duration.
speak to the patient; response to verbal stimuli may
increase breathing. If the patient is unresponsive,
painful stimuli may increase breathing. If these work
in regulating the respirations, monitor the patient Bag-Valve-Mask
to ensure the respiratory rate does not drop again.
If the patient is not breathing, the patient will likely
Resuscitators
need assistance. Assist breathing by either giving Bag-valve-mask (BVM) resuscitators are
ventilations or administering supplemental oxygen, difficult to use by a single responder. Two
if available, based on local protocols. emergency medical responders (EMRs)
should provide ventilations with a BVM: one to
Someone with asthma or emphysema who is in
establish and maintain the airway and seal of
respiratory distress may try to do pursed-lip
the mask, and the other to deliver ventilations
by squeezing the bag. EMRs should not use
the BVM during one-responder CPR. Instead,
they should use a technique, such as mouth-
to-mask, that minimizes the need for changes
in position and minimizes interruptions of
chest compressions during CPR.
Only responders who are well trained in—and
have frequent opportunities to perform—
one-responder BVM should consider using
this technique. These responders need to
continuously monitor their efforts to ensure
adequate ventilations, and change to an
alternate method if necessary.
When providing BVM ventilations, one
responder maintains the airway and seals the
Fig. 7-8: Seal the properly positioned mask over the patient’s
mouth and nose, use the head-tilt/chin-lift maneuver to open the
mask while the other delivers ventilations.
airway and blow into the mask.
156 | Emergency Medical Response
If the patient is not breathing normally (respiratory When the heart is healthy, it beats with a steady
arrest) but has a pulse, provide ventilations with rhythm. This beat creates a regular pulse. A normal
a resuscitation mask and administer supplemental pulse for an adult ranges from 60 to 100 beats
oxygen, if available, based on local protocols. If per minute (Table 7-5). A well-conditioned athlete
additional EMRs and equipment are available, use may have a pulse of 50 beats per minute or lower.
a BVM. Once you have begun giving ventilations, A pulse of greater than 100 beats per minute is too
continue until the patient begins to breathe
spontaneously and adequately or until more
advanced medical personnel take over.
CIRCULATORY STATUS
While assessing the patient’s airway and breathing,
you should simultaneously assess blood circulation
by feeling for a pulse. If the heart has stopped,
blood will not circulate throughout the body. If
blood does not circulate, the patient will suffer
severe brain damage or die because of a lack of
oxygen (Fig. 7-9).
Pulse
The most commonly used method of checking for
adequate circulation is to check for a pulse. With
every heartbeat, a wave of blood moves through
the blood vessels. This creates a beat called the
pulse. You can feel it with your fingertips in the
arteries near the skin.
Fig. 7-9: Time is critical in life-threatening emergencies.
Table 7-5:
Normal Pulse Rates
AGE NUMBER OF BEATS PER MINUTE ADDITIONAL NOTES
Adults (12 years old 60 to 100 ••A well-conditioned athlete may have a
or older) pulse of 50 beats per minute or lower.
••An adolescent (11–14 years old) may
have a pulse rate of 60 to 105.
Children (1 to about Toddler (1–3 years): 80 to 130 ••Normal pulse rates vary based on the
12 years old) Preschool-age (3–5 years): 80 to 120 child’s age.
School-age (6–10 years): 70 to 110 ••An adolescent (11–14 years old) may
have a pulse rate of 60 to 105.
Infants (under Newborn: 120 to 160 ••Normal pulse rates vary based on the
1 year old) Infant (1–5 months): 90 to 140 infant’s age.
Infant (6 months to 1 year): 80 to 140
CRITICAL A “normal” pulse is relative. Ask about any known congenital disorders or other
FACTS natural explanations for an irregular pulse as part of your patient history.
Chapter 7: Primary Assessment | 157
fast for an adult at rest. Certain medications, such
as beta-blockers, can cause the heart to beat at
slower rates, which would be considered normal
for that person.
Pediatric Considerations
A normal pulse in a child varies according to
age, from 80 to 130 for children ages 1–3,
to 60 to 105 in adolescents ages 11–14.
An infant can have a normal pulse ranging
from 80 to 140 beats per minute. A slow
or fast pulse for a child and an infant varies A
according to age.
If the heartbeat changes, so does the pulse.
An abnormal pulse may be a sign of a potential
problem. Signs of an abnormal pulse include:
Irregular pulse.
Weak and hard-to-find pulse.
Excessively fast or slow pulse.
When someone is severely injured or ill, the heart
may beat unevenly, producing an irregular pulse.
The rate at which the heart beats can also change. B
The pulse speeds up when a person is excited,
anxious, in pain, losing blood or under stress. It
slows down when a person is relaxed. Some heart
conditions or medications can also speed up or
slow down the pulse rate. Sometimes changes
may be very subtle and difficult for you to detect.
The most important change to note is a pulse that
changes from being present to no pulse at all. It is
important to remember that the definition of what is
a “normal” pulse may be different for some. Be sure
to ask if there are known congenital disorders or
other natural explanations for a seemingly slow or
C
irregular heartbeat as part of the patient history.
Fig. 7-10, A–C: A pulse can be checked in arteries located close
Checking a pulse involves placing two fingers on top to the skin’s surface and over a bony structure. These include the
(A) carotid, (B) radial and (C) brachial arteries.
of a major artery located close to the skin’s surface
and over a bony structure. Pulse sites that are easy causing a loss of pulse. If you cannot find the pulse
to locate are the carotid arteries in the neck, the in one place of a responsive patient, try another
radial arteries in the wrists and the brachial arteries location, such as in the other wrist.
in the upper arms (Fig. 7-10, A–C). There are also
other pulse sites you may use. To check the pulse If the patient is conscious and breathing, check the
rate, count the number of beats in either 15 seconds pulse to determine the rate and quality of the pulse.
and multiply that number by 4 or in 30 seconds and For conscious adults and children, you usually
multiply that number by 2. The number you get is the check the radial pulse on the thumb side of the
number of heartbeats per minute. patient’s wrist. For infants, you should check the
brachial artery located on the inside of the upper
An injured or ill patient’s pulse may be hard to find. arm, midway between the shoulder and elbow.
If you have trouble finding a pulse, keep checking
for one periodically. If a patient is breathing If the patient is unconscious, remember to
normally, the heart is also beating. There may be simultaneously find out whether the patient has
a loss in circulation to the injured area, however, an open and clear airway, is breathing and has a
158 | Emergency Medical Response
pulse. If the patient is not breathing normally, you If the patient does not have a pulse, you need
should only be concerned whether the pulse is to keep blood containing oxygen circulating.
present or absent and not with the rate and quality. This involves performing chest compressions to
Check the pulse for an adult or a child at either circulate the oxygen to the brain and providing
of the carotid arteries located in the neck. Check ventilations to get oxygen into the patient’s lungs.
the brachial pulse of an infant in the middle of the This procedure is called CPR and is described in
upper arm. Check for breathing and a pulse for Chapter 13.
at least 5 seconds, but no more than 10 seconds.
To find the carotid pulse, place two fingers on the Perfusion
front of the neck, then slide your fingers toward The next step is to establish whether the patient
you and down into the groove at the side of the is maintaining adequate blood flow. Perfusion
neck. Feel for at least 5 seconds, but no more than describes the circulation of blood through the
10 seconds. Sometimes the pulse may be difficult body or through a particular body part. The
to find, since it may be slow or weak. However, if appearance of the skin and its temperature
you do not find a definite pulse within 10 seconds, can be helpful in providing information about
do not waste any more time attempting to the patient’s circulation. Checking the skin
find one. Assume there is no pulse and begin characteristics requires you to look at and feel the
resuscitation immediately. skin. There are four aspects of skin conditions to
note, including:
In some cases, the person may be unresponsive
but breathing normally. Generally that person Color. Is it pale and ashen, or flushed and pink?
should be placed in a side-lying recovery position, Temperature. Is it hot or cold?
if there is no suspected head, neck, spinal, hip or
pelvic injury. However, there are a few situations
Moisture. Is it moist or dry?
when you should move a person into a recovery Capillary refill. Is it normal or slow?
position even if there is a suspected head, neck,
spinal, hip or pelvic injury. Examples of these Skin Color
situations include if you are alone and have to leave In some people, the skin looks red when the body
the person (e.g., to call for additional resources), is forced to work harder. The heart pumps faster to
or you cannot maintain an open and clear airway get more blood to the tissues, and this increased
because of fluids or vomit. Placing a person in a blood flow causes reddened skin or a flushed
recovery position will help keep the airway open appearance. Reddening or flushing may not appear
and clear (Fig. 7-11). in darker skin tones. In contrast, the skin may look
Fig. 7-11: Use a side-lying recovery position for an unresponsive patient with no suspected head,
neck, spinal, hip or pelvic injury.
Chapter 7: Primary Assessment | 159
pale or bluish if blood flow is inadequate. Pale reliable in children and infants up to the age of 6
skin may indicate low body temperature, blood than it is in adults.
loss, shock or poor blood flow to a body part. For
individuals with darker skin tones, this pallor can be Capillary refill is an estimate of the amount of blood
found on the palms of the hands. flowing through the capillary beds, such as those
in the fingertips. The capillary beds in the fingertips
are normally rich with blood, which causes the pink
Skin Temperature color under the fingernails. When a serious injury
Skin temperature is also a sign of blood circulation. or illness occurs, the body attempts to conserve
Increased blood flow makes the skin feel warm. blood in the vital organs. As a result, capillaries in
Cool skin may indicate low body temperature or the fingertips are among the first blood vessels to
shock (Fig. 7-12). constrict, thereby limiting their blood supply.
Skin Moisture Environmental temperature can play a role in the
effectiveness of capillary refill. If the patient is
You can also gain information from the degree of
exposed to cold temperatures, the capillary refill
moisture on the skin. Normal skin is dry or slightly
will normally be slow. Refill slows because blood
moist. Wet or sweaty skin may indicate physical
is directed away from the peripheral areas of the
exertion, stress, severe pain or shock.
body, like the limbs, in an effort to maintain core
body temperature.
Capillary Refill
One technique for estimating how the body
Pediatric Considerations
is reacting to injury or illness is to check the
In children, check capillary refill in fingernails
ability of the capillaries to refill with blood. This
or toenails. In infants, check capillary refill in
technique, known as capillary refill, is more
the forearm or over the kneecap.
To check capillary refill, squeeze the body part
(tip of a finger or thumb) for about 2 seconds
and then release. In a healthy child, the normal
response is for the area to turn pale as you press
it and immediately turn pink again as you release
(Fig. 7-13). If the area does not return to pink
within 2 seconds (the time it takes to say “capillary
refill”), this indicates insufficient circulation and
a potentially serious injury or illness. Remember
that environmental temperature can play a role in
the effectiveness of this technique. If the child is
exposed to cold temperatures, the capillary refill
Fig. 7-12: Assess a person’s skin temperature by partially normally will be slow as the body is attempting to
removing your glove and feeling the skin. maintain core body temperature.
Fig. 7-13: To check capillary refill, squeeze the tip of a finger or thumb for about 2 seconds and then release.
160 | Emergency Medical Response
CRITICAL Check vital signs, such as pulse and respiratory rate, often while you wait for more
FACTS advanced medical personnel to take over.
IDENTIFYING LIFE THREATS Other signs that indicate a person may be going
into shock include restlessness or irritability;
Consciousness, breathing and circulation, altered LOC; nausea or vomiting; pale, ashen,
including pulse and skin characteristics, are cool, moist skin; rapid breathing and pulse; and
called vital signs. They are sometimes referred excessive thirst. In particular, restlessness and
to as “signs of life.” Check the vital signs often irritability are often the first signs of shock.
as you monitor a patient while you wait for more
advanced medical personnel to take over. Assess If the patient is in shock, control any external bleeding
the patient to determine if it is a life-threatening as soon as possible to minimize blood loss and
condition. If the patient is unstable, care for the life- administer supplemental oxygen, if available, based
threatening condition as soon as it is discovered. on local protocols. Lay the patient flat (supine). Keep
For stable patients (vital signs within normal range), the patient from getting chilled or overheated.
assess the patient’s condition and provide care as
necessary. Patients who are unstable should be
reassessed at least every 5 minutes, or more often PUTTING IT ALL TOGETHER
if indicated by the patient’s condition. Reassess The primary assessment helps to identify any life-
stable patients every 15 minutes, or as deemed threatening conditions so they can be cared for
appropriate by the patient’s condition. rapidly. Problems that are not an immediate threat
can become serious if you do not recognize them
Newborn Considerations and provide care. By following the proper steps
The APGAR scoring system is the universally when conducting the primary assessment, you
accepted method of assessing a newborn at will give the patient with a serious injury or illness
1 minute after birth, at 5 minutes after birth the best chance for survival. Before you proceed
and again at 10 minutes after birth. APGAR with a primary assessment, be certain to size up
stands for Appearance, Pulse, Grimace, the scene to make sure there are no dangers to
Activity and Respiration. The term APGAR you, the patient and bystanders, and to consider
also stands for the person who developed it, the MOI, nature of illness, the number of patients
Virginia Apgar, MD. For more information on involved and additional resources you may need.
assessing a newborn, refer to Chapter 24.
The essential aspects to the primary assessment
are making a general impression of the patient and
SHOCK checking responsiveness, airway, breathing and
circulation. Determine if there are any immediate
If the patient shows signs of shock, you will need
threats to life, such as the presence of severe,
to provide care for shock during the primary
life-threatening bleeding, or an absence of
assessment. In order to determine whether shock
breathing or pulse.
should be treated immediately, watch for:
Although this plan of action can help you decide
Decreased responsiveness.
what care to provide in any emergency, providing
Unresponsiveness to verbal commands. care is not an exact science. Because each
A heart rate that is too fast or too slow. emergency and each patient is unique, an emergency
Skin signs of shock. may not occur exactly as it did in a classroom setting.
A weak or no radial pulse (brachial pulse Even within a single emergency, the care needed
for infants). may change from one moment to the next.
You Are the Emergency Medical Responder
As you begin a primary assessment, you verify that the infant is unconscious. What are your
next steps in the primary assessment? Should you call for more advanced medical personnel?
Why or why not?
Chapter 7: Primary Assessment | 161
Skill Sheet
Skill Sheet 7-1
Primary Assessment
NOTE: Always follow standard precautions when providing care.
Size up the scene for safety, form a general impression and then:
STEP 1
Check for responsiveness:
■■ Shout, “Are you OK?” and then tap the shoulder
and shout again, “Are you OK?”
■■ For an infant, tap the underside of the foot.
STEP 2
If no response:
■■ Summon more advanced medical personnel if you have not already done so.
■■ If the patient is face-down, roll the patient onto their back while supporting the head,
neck and back.
▼ (Continued)
162 | Emergency Medical Response
Skill Sheet
Skill Sheet 7-1
Primary Assessment Continued
STEP 3
Open the patient’s airway and simultaneously check for
breathing and a pulse for at least 5 seconds, but no more
than 10 seconds.
■■ To open the airway from the side, use the
head-tilt/chin-lift maneuver. To open the airway
from above the patient’s head, use the jaw-thrust
(with head extension) maneuver. If a head, neck
or spinal injury is suspected, use the jaw-thrust
(without head extension) maneuver.
■■ For an adult or a child, feel for a carotid pulse by
placing two fingers in the middle of the patient’s
throat and then sliding them into the groove at the
side of the neck closest to you. Press in lightly;
pressing too hard can compress the artery.
■■ For an infant, feel for the brachial pulse on the
inside of the upper arm between the infant’s elbow
and shoulder. Press in lightly; pressing too hard can
compress the artery.
NOTE: For a drowning victim, give 2 ventilations prior
to Step 4.
▼ (Continued)
Chapter 7: Primary Assessment | 163
Skill Sheet
Skill Sheet 7-1
Primary Assessment Continued
STEP 4
Provide care based on the conditions found.
NOTE: If a patient is unresponsive, but breathing normally with no suspected head, neck, spinal,
hip or pelvic injury, move the patient into a side-lying recovery position. Patients with a suspected
head, neck, spinal, hip or pelvic injury should not be placed in a recovery position unless you are
unable to manage the airway effectively or you are alone and need to leave the patient to call for
additional resources.
164 | Emergency Medical Response
Skill Sheet
Skill Sheet 7-2
Jaw-Thrust (Without Head Extension)
Maneuver
NOTE: Always follow standard precautions when providing care.
After sizing up the scene and establishing that the patient is unresponsive, lying face-up and a head,
neck or spinal injury is suspected:
STEP 1
Kneel above the patient’s head.
STEP 2
Put one hand on each side of the patient’s head, with
your thumbs near the corners of the mouth pointed
toward the chin.
STEP 3
Use your elbows for support if needed.
STEP 4
Slide your fingers into position under the angles of the patient’s jawbone.
■■ For a child or an infant, only use two or three fingers of each hand.
STEP 5
Without moving the patient’s head, apply downward pressure with your thumbs and lift the jaw.
NOTE: If the patient’s lips close, pull back the lower lip with your thumbs.
Chapter 7: Primary Assessment | 165
Skill Sheet
Skill Sheet 7-3
Using a Resuscitation Mask—Adult,
Child and Infant
NOTE: Always follow standard precautions when providing care. Size up the scene for safety.
Always select a properly sized mask for the patient.
STEP 1
Assemble the mask and valve.
■■ Attach the one-way valve to the resuscitation mask,
if necessary.
STEP 2
Open the airway.
■■ Using the head-tilt/chin-lift maneuver, open the airway
so it is:
zz Past a neutral position for an adult.
zz Slightly past a neutral position for a child.
zz In a neutral position for an infant.
STEP 3
Position the mask.
■■ Kneel to the side of or above the patient’s head and place
the mask over their mouth and nose, starting from the
bridge of the nose.
■■ Place the bottom of the mask below the mouth but not
past the chin.
▼ (Continued)
166 | Emergency Medical Response
Skill Sheet
Skill Sheet 7-3
Using a Resuscitation Mask—Adult, Child
and Infant Continued
STEP 4
Seal the mask.
■■ From the side of the patient’s head:
zz With your top hand, place your thumb and fingers
around the top of the resuscitation mask to
create a “C.”
zz With your other hand, slide your first two fingers into
position on the bony part of the patient’s chin.
zz Apply even, downward pressure with your top hand
and the thumb of your lower hand to seal the top
and bottom of the mask.
■■ From above the patient’s head:
zz Place your thumbs and index fingers along each side of the resuscitation mask
to create a “C” on both sides of the mask.
zz Slide your other fingers into position behind the angles of the patient’s jawbone
to create an “E” on both sides of the patient’s jawbone.
zz Apply even, upward pressure with your fingers to “lift” the jaw into the mask.
STEP 5
Blow into the mask.
■■ Give 2 ventilations to the patient.
■■ Each ventilation should last about 1 second and make the
chest begin to rise. Pause briefly between ventilations to
let the exhaled air escape.
Chapter 7: Primary Assessment | 167
Skill Sheet
Skill Sheet 7-4
Using a Resuscitation Mask—Head, Neck or
Spinal Injury Suspected: Jaw-Thrust (Without
Head Extension) Maneuver—Adult or Child
NOTE: Always follow standard precautions when providing care. Size up the scene for safety. Always
select a properly sized mask for the patient.
If a head, neck or spinal injury is suspected:
STEP 1
Assemble the resuscitation mask.
■■ Attach the one-way valve to the resuscitation mask,
if necessary.
STEP 2
Position the mask.
■■ Kneel above the patient’s head.
■■ Place the mask over the patient’s mouth and nose, starting
from the bridge of the nose.
■■ Place the bottom of the mask below the mouth but not past
the chin.
▼ (Continued)
168 | Emergency Medical Response
Skill Sheet
Skill Sheet 7-4
Using a Resuscitation Mask—Head, Neck or Spinal
Injury Suspected: Jaw-Thrust (Without Head Extension)
Maneuver—Adult or Child Continued
STEP 3
Seal the mask.
■■ Slide your fingers into position under the angles of the
patient’s jawbone.
■■ Without moving the patient’s head, apply even, downward
pressure to seal the mask.
STEP 4
Open the airway.
■■ Without tilting the head back, open the airway by pushing
or thrusting the lower jaw up with your fingers along
the jawbone.
STEP 5
Blow into the mask.
■■ Give 2 ventilations to the patient.
■■ Each ventilation should last about 1 second and make the
chest begin to rise. Pause briefly between ventilations to let
the exhaled air escape.
Chapter 7: Primary Assessment | 169
ENRICHMENT
Glasgow Coma Scale
The Glasgow Coma Scale (GCS) is a tool used to assess a patient’s LOC (Table 7-6). Originally intended to
assess LOC following a head injury, it is now considered valuable for primary and ongoing assessments of any
medical or trauma patient.
A GCS score is based on three parameters: eye opening (E), verbal response (V) and motor response (M).
The total score will range from 3 to 15 (E+V+M = 3–15), with 3 representing coma or death and 15 representing
a fully awake and alert patient. A GCS score of 8 or less indicates severe brain injury, 9–12 indicates moderate
brain injury and 13–14 indicates mild brain injury.
For patients more than 5 years of age, use the standard scale. For children under the age of 5, the verbal
responses must be adjusted using the Pediatric Glasgow Coma Scale (PGCS) (Table 7-7).
Table 7-6:
Glasgow Coma Scale
RESPONSE STATUS SCORE
Eye Opening (E) Spontaneous 4 points
Opens to verbal command 3 points
Opens to pain 2 points
No response 1 point
Verbal Response (V) Oriented and speaks 5 points
Confused conversation, but able to answer questions 4 points
Inappropriate responses, words discernible 3 points
Incomprehensible speech or sounds 2 points
No response 1 point
Motor Response (M) Obeys verbal commands 6 points
Purposeful movement to painful stimulus 5 points
Withdraws from pain (flexion) 4 points
Abnormal flexion from pain 3 points
Extension in response to pain 2 points
No response 1 point
170 | Emergency Medical Response
ENRICHMENT
Glasgow Coma Scale continued
Table 7-7:
Pediatric Glasgow Coma Scale1
AREA ASSESSED CHILDREN INFANTS SCORE
Eye Opening (E) Opens spontaneously Opens spontaneously 4 points
Opens in response to verbal Opens in response to verbal 3 points
stimuli stimuli
Opens in response to pain only Opens in response to pain only 2 points
No response No response 1 point
Verbal Response (V) Oriented, appropriate Coos and babbles 5 points
Confused Irritable cries 4 points
Inappropriate words Cries in response to pain 3 points
Incomprehensible words or Moans in response to pain 2 points
nonspecific sounds
No response No response 1 point
Motor Response (M) Obeys commands Moves spontaneously and 6 points
purposefully
Localizes painful stimulus Withdraws to touch 5 points
Withdraws in response to pain Withdraws in response to pain 4 points
Responds to pain with Responds to pain with 3 points
decorticate posturing decorticate posturing
(abnormal flexion) (abnormal flexion)
Responds to pain with Responds to pain with 2 points
decerebrate posturing decerebrate posturing
(abnormal extension) (abnormal extension)
No response No response 1 point
1
Adapted from Davis RJ et al: Head and spinal cord injury. In Textbook of pediatric intensive care, edited by MC Rogers. Baltimore, Williams & Wilkins,
1987; James H, Anas N, Perkin RM: Brain insults in infants and children. New York, Grune & Stratton, 1985; and Morray JP et al: Coma scale for use in
brain-injured children. Critical Care Medicine 12:1018, 1984.
Chapter 7: Primary Assessment | 171
8
HISTORY
TAKING AND
SECONDARY
ASSESSMENT
You Are the Emergency Medical Responder
You arrive at the scene of a motor-vehicle collision, a fender bender, in which a woman
who was driving her husband to the hospital because he was complaining of chest
pain, struck the car in front of her. A police unit is on the scene assisting the husband,
who collapsed and apparently is unconscious. Your partner proceeds to help the
police officer with the unconscious patient. You notice that the woman is clutching one
of her arms. As a responding firefighter, how would you respond to and assess the
injured woman?
KEY TERMS
Auscultation: Listening to sounds within the body, Physical exam: Exam performed after the primary
typically through a stethoscope. assessment; used to gather additional information
and identify signs and symptoms of injury
Blood pressure (BP): The force exerted by blood and illness.
against the blood vessel walls as it travels
throughout the body. Pulse oximetry: A test to measure the percentage
of oxygen saturation in the blood using a
Chief complaint: A brief description, usually in pulse oximeter.
the patient’s own words, of why emergency
medical services (EMS) personnel were called Rapid medical assessment: A term describing a
to the scene. rapid head-to-toe exam of a medical patient.
DCAP-BTLS: A mnemonic to help remember the Rapid trauma assessment: A term describing a
signs to look for during a physical exam, which rapid head-to-toe exam of a trauma patient.
is often done during the secondary assessment;
the initials stand for deformities, contusions, Respiratory rate: The number of breaths per minute;
abrasions, punctures/penetrations, burns, normal rates vary by age and other factors.
tenderness, lacerations and swelling.
SAMPLE history: A way to gather important
Detailed physical exam: An in-depth head-to-toe information about the patient, using the
physical exam; takes more time than the rapid mnemonic SAMPLE; the initials stand for signs
assessment, and is only done when time and the and symptoms, allergies, medications, pertinent
patient’s condition allow. medical history, last oral intake and events leading
up to the incident.
Diastolic blood pressure: The force exerted
against the arteries when the heart is between Secondary assessment: A head-to-toe
contractions, or at rest. physical exam as well as the focused history;
completed following the primary assessment and
DOTS: A mnemonic to help remember what to management of any life-threatening conditions.
look for during the physical exam; the initials
stand for deformities, open injuries, tenderness Sphygmomanometer: A device for measuring BP;
and swelling. also called a BP cuff.
Focused trauma assessment: A physical exam Stethoscope: A device for listening, especially to the
on a trauma patient, focused only on an isolated lungs, heart and abdomen; may be used together
area with a known injury such as a hand with an with a BP cuff to measure BP.
obvious laceration.
Systolic blood pressure: The force exerted against
Ongoing assessment: The process of repeating the arteries when the heart is contracting.
the primary assessment and physical exam while
Vial of Life: A community service program that
continually monitoring the patient; performed
provides emergency medical services (EMS)
while awaiting the arrival of more highly trained
personnel and other responders with vital health
personnel or while transporting the patient.
and medical information (including any advance
OPQRST: Mnemonic to help remember the questions directives) when a person who suffers a medical
used to gain information about pain; the initials emergency at home is unable to speak; consists
stand for onset, provoke, quality, region/radiate, of a label affixed to the outside of the refrigerator
severity and time. to alert responders and a labeled vial or container
that has pertinent medical information, a list of
Palpation: Examination performed by feeling part of medications, health conditions and other pertinent
the body, especially feeling for a pulse. medical information regarding the occupant(s).
Chapter 8: History Taking and Secondary Assessment | 173
LEARNING OBJECTIVES
After reading this chapter, and completing the class • State the areas of the body that are evaluated
activities, you will have the information needed to: during the physical exam.
• Explain the purpose of the patient history. • Identify further questions that may be asked during
the physical exam.
• Explain the components of the SAMPLE history.
• Identify the components of the ongoing
• Explain the purpose of the secondary assessment. assessment.
• Explain the importance of properly assessing a • Explain the importance of properly assessing a
patient’s vital signs. patient’s blood pressure (BP).
• Explain the components of a physical exam. • Describe the techniques used to measure BP.
SKILL OBJECTIVES
After reading this chapter, and completing the class • Demonstrate how to obtain BP by auscultation
activities, you should be able to: and palpation.
• Demonstrate how to obtain a SAMPLE history. • Demonstrate how to perform a secondary
assessment.
• Demonstrate how to obtain baseline vital signs.
INTRODUCTION OBTAINING THE FOCUSED/
In Chapter 7, you learned how to conduct a MEDICAL HISTORY
primary assessment, which helps you to determine A crucial aspect of your job is to find out as much as
if the patient has any life-threatening conditions possible about the emergency situation, so that you
through checking level of consciousness (LOC), can communicate this information to more advanced
airway, breathing and circulatory status. However, medical personnel. In addition to your close
as you will learn in this chapter, you can obtain observation of the scene and patient, interviews
more information about the patient through history with those involved are generally your best sources
taking and the secondary assessment, which of information. Remember never to enter a scene
includes interviewing the patient and bystanders, unless you are sure you can do so safely.
monitoring vital signs and conducting a physical
exam. As with the primary assessment in the Asking the patient about the incident and any
case of serious injury or illness, performing and existing medical conditions is called obtaining a
documenting a thorough history and secondary history. Obtaining a history should not take much
assessment can increase the patient’s chance time and may be done before or during the physical
of survival. exam. Keep in mind that, for a critical trauma
CRITICAL A crucial aspect of your job is to find out as much as possible about the emergency
FACTS situation so that you can communicate this information to more advanced medical
personnel.
Asking the patient about the incident and any existing medical conditions is called
obtaining a history. Obtaining a history should not take much time and may be done
before or during the physical exam.
174 | Emergency Medical Response
patient or an unconscious medical patient, the Considerations for Older Adults
history will likely be performed after the physical Keep in mind that older people usually prefer
exam. For a medical patient who is responsive, the to be addressed more formally, as in
history will likely be performed first. “Mr. Smith” or “Mrs. Smith.” Position yourself
at eye level with the patient and speak slowly.
Under ideal circumstances, patients will be able Older patients may sometimes appear
to tell you themselves all you need to know about confused. This can be caused by conditions
what happened and any related medical issues. such as dementia or Alzheimer’s disease. It
Help relieve the patient’s anxiety by explaining who can also be the result of an acute medical
you are and that you are there to help. Also ask the condition and may not be typical behavior for
patient’s name and use it. Always obtain consent that person. Make sure the patient can see
before touching or providing care to a patient. and hear you, as an older patient may have
vision or hearing problems. Allow time for
Pediatric Considerations the older patient to respond. Always treat the
If a child or an infant does not respond to patient with dignity and respect (Fig. 8-1).
your questions, it does not always mean the
child or infant is unable to respond. Children Sources of information may also be all around
and infants may be frightened of you or the you. Be sure to check the patient for a medical
situation, may not understand the question or identification tag or bracelet, or other medical
may not be able to speak. Position yourself information sources, such as wallet cards or mobile
at or below eye level with the child to avoid phone apps. Other hints include the presence of
being intimidating. Do not separate the medication containers, medical equipment or a
child from a parent or legal guardian, unless service animal. If you are in the patient’s home,
absolutely necessary. you should also look for a Vial of Life label on
the outside of the refrigerator door—it signifies
Necessary information cannot always be obtained that a vial or container, such as a sealable plastic
from the patient. The patient may be unconscious, bag, contains vital medical information and has
disoriented, agitated or otherwise uncooperative, been placed on the top shelf of the refrigerator
or the patient may not understand and/or speak door. Some people keep their medications in the
English. In these cases, interviews with family, refrigerator, so it also is a good idea to look for
friends, caregivers, bystanders or public safety these items.
personnel may be helpful.
Fig. 8-1: Always treat older patients with dignity and respect.
Chapter 8: History Taking and Secondary Assessment | 175
CRITICAL Necessary information cannot always be obtained from the patient. The patient may
FACTS be unconscious, disoriented, agitated or otherwise uncooperative, or the patient
may not understand and/or speak English. In these cases, interviews with family,
friends, caregivers, bystanders or public safety personnel may be helpful.
The most important component of a patient history is the chief complaint. This is the
reason why EMS personnel were called to the scene.
COMPONENTS OF A PATIENT Keep in mind that the most obvious problem is not
always the most serious problem. For instance, if
HISTORY a patient’s arm is mangled in a car crash, it may
Obtaining a full patient history involves several appear to be the chief complaint, until you find
components. Key among them is the chief out the patient is having chest pain and crashed
complaint, which will allow you to make the the car after blacking out. When interviewing the
important distinction of whether you are dealing patient about the chief complaint, remember to
with a trauma or medical emergency. Other ask the “who, what, when, where and how” of
components to consider are the mechanism of the incident.
injury (MOI) or nature of illness, the presence and
assessment of pain, as well as an evaluation of any Understanding the chief complaint generally
relevant medical information. makes it clear whether you are dealing with a
trauma patient—someone who is injured—
or a medical patient—someone who is ill—or
Chief Complaint a combination. This primary division will guide
The most important component of a patient how you manage the patient.
history is the chief complaint. This is the
reason why emergency medical services (EMS)
personnel were called to the scene. The best Mechanism of Injury or
way to determine the chief complaint is to ask the Nature of Illness
patient, “Why did you call for EMS personnel?” The next piece of information to determine is the
Record the chief complaint in the patient’s own MOI for a trauma patient or the nature of illness for
words (Fig. 8-2). a medical patient.
Fig. 8-2: Understanding the chief complaint will help you determine if you are dealing with someone who is
injured or someone who is ill. Photo: courtesy of Terry Georgia.
176 | Emergency Medical Response
Fig. 8-3: If no one is available to interview, look for clues on the scene to determine what might have
happened. Photo: courtesy of the Canadian Red Cross.
Mechanism of Injury Nature of Illness
In the case of an injury, it is important to find out In the case of a medical patient, ask the patient,
how the injury occurred and determine what the family, friends or any bystanders why EMS
forces were that caused the injury. This may help personnel were called. If no one is available to
predict the specific type of injuries the patient interview, observe the scene. Look for clues such
may have. as a very hot or very cold environment or the
presence of drugs or poisons (Fig. 8-3).
It will also help you determine whether there is any
risk of a spinal injury. If the MOI suggests there The steps involved in conducting a secondary
is, tell the patient not to move and provide manual assessment on a medical patient depend on
stabilization by restricting motion and supporting whether the patient is responsive or unresponsive.
the head and neck in the position in which you
found it. Once you have dealt with the risk of spinal If the medical patient is responsive, obtain the
injury, follow the steps for trauma patients. These history first and then perform your exam. In this
steps depend on whether there is a significant MOI situation, the history is your first priority because
or not. it may be the most valuable information you
obtain and also because it is prudent to speak
Examples of a significant MOI include: immediately with a responsive patient, since this
status might change.
Being ejected from a vehicle or thrown from
a motorcycle.
A fall from greater than 15 feet or three times the
SAMPLE HISTORY
patient’s height.
Using the mnemonic SAMPLE, determine the
A vehicle rollover.
following six items for the patient history:
A vehicle collision.
A pedestrian struck by a vehicle. Signs and symptoms
An injury that causes a change in mental status, Allergies
respiratory distress or signs of shock. Medications
A penetrating injury to the head, neck, chest Pertinent medical history
or abdomen.
Last oral intake
A blast injury or significant burn.
Events leading up to the incident
Chapter 8: History Taking and Secondary Assessment | 177
Fig. 8-4: Family members or friends may be able to provide information about children.
For step-by-step instructions on obtaining a a child or with an adult who momentarily lost
SAMPLE history, see Skill Sheet 8-1. consciousness and may not be able to recall what
happened or is disoriented. Ask family members,
In addition to the SAMPLE history, ask the friends or bystanders what happened (Fig. 8-4).
patient to explain what happened. Ask questions They may be able to give you helpful information,
such as: such as telling you if a patient has a medical
condition you should be aware of. They may also be
What happened?
able to help calm the patient, if necessary.
Are you having any pain?
How would you describe the pain? You can Obtain consent before approaching or touching
expect to hear descriptions such as burning, the patient. Patients may be frightened; offer
throbbing, aching or sharp pain. reassurance. Be calm and patient and, if possible,
Is the pain spreading or radiating? ensure you are in a comfortable and private
location where you will not be interrupted. Use
On a scale of 1 to 10, with 1 being lowest and
open-ended questions, and encourage the patient
10 being highest, how bad is the pain?
to talk using verbal and nonverbal cues. Show you
When did the pain start? (See OPQRST.)
are listening by repeating and paraphrasing the
Sometimes the patient will be unable to give patient’s replies. Maintain eye contact and speak
you the information. This is often the case with slowly, deliberately and in simple terms.
CRITICAL Assessing the MOI may help predict the specific type of injuries the patient may
FACTS have. Significant MOIs include being ejected or thrown from a vehicle; falling from
greater than 15 feet or three times the patient’s height; receiving a penetrating injury
to the head, neck, chest or abdomen; or any injury that causes an altered mental
status, respiratory distress or signs of shock.
In the case of a medical patient, ask the patient, family, friends or any bystanders
why EMS personnel were called.
The mnemonic SAMPLE refers to what essential information to obtain when taking
a history. It refers to signs and symptoms, allergies, medications, pertinent medical
history, last oral intake and event leading up to the incident.
178 | Emergency Medical Response
Signs and Symptoms THE SECONDARY ASSESSMENT
Signs include any medical or trauma assessment The purpose of the secondary assessment is to
findings you can see, feel, hear or smell. For locate and further assess the signs and symptoms
example, this would include measuring blood of an injury or illness. The secondary assessment
pressure (BP), seeing an open wound or feeling consists of a head-to-toe physical exam. It may
skin temperature. Symptoms refer to what the only consist of a rapid assessment (rapid trauma
patient reports, for example, “I’m having trouble assessment or rapid medical assessment) or it
breathing,” “I have a headache” or “My chest hurts.” may also include a detailed physical exam at a
For further symptoms, ask the patient to describe later stage.
the current problem. Ask questions such as:
If you find life-threatening injuries or medical
Where do you have pain? conditions during the primary assessment, such as
Are you feeling nauseated? unconsciousness; severe, life-threatening bleeding;
Do you have a headache? no breathing or no pulse, do not waste time with
the detailed physical exam. Instead, focus your
Are you having any difficulty breathing?
attention on providing care for the life-threatening
conditions. Complete a secondary assessment
Allergies following the primary assessment, once all life-
Ask the patient whether they are allergic to any threatening conditions are addressed and have
medications, food or environmental elements, such been stabilized, if time and resources permit.
as dust, pollen or bees.
For patients with a significant MOI or other
critical finding such as altered mental
Medications status, take the following steps during the
Ask the patient questions to determine whether secondary assessment:
they are currently using any medications, both
prescription and over-the-counter (OTC). Ask 1. Continue to maintain spinal motion restriction
additional questions such as: and an open airway.
2. Consider the need for additional resources,
Do you take any vitamins or herbal remedies? including basic life support or advanced life
Have you taken someone else’s medications? support, and the need for transport (e.g., for
Did you take any recreational drugs? life-threatening conditions, such as airway
Are you using any medication patches? trauma).
3. Reassess the patient’s mental status, as this
may change at any time.
Pertinent Medical History
4. Perform a rapid trauma assessment, which
Determine whether the patient is under a is a rapid head-to-toe physical exam.
healthcare provider’s care for any condition, if the
patient has had a similar problem in the past, or if A rapid trauma assessment involves checking
the head, neck, chest, abdomen, pelvic
the patient has been recently hospitalized or had
region, legs, arms and then the back for
recent surgeries. If the patient is female, ask if she
signs of trauma.
is or could be pregnant.
5. Assess baseline vital signs.
6. Obtain a SAMPLE history. If the patient
Last Oral Intake is responsive, ask some history questions
Determine when the patient last had something simultaneously with the physical exam.
to eat or drink and what it was. Also, ask if the 7. Prepare the patient for transport
patient has recently taken any medication, and if (simultaneously as assessment is being
so, what. conducted).
8. Provide emergency care.
Events Leading Up to the Incident 9. Obtain trauma score (e.g., Glasgow Coma
Determine what the patient was doing before and Scale [GCS]), if trained.
at the time of the incident. The events leading up to
Your major concern during the rapid trauma
the incident could help identify the MOI or nature
assessment is any potentially life-threatening
of illness.
injuries that you must manage immediately.
Chapter 8: History Taking and Secondary Assessment | 179
CRITICAL Complete a secondary assessment following the primary assessment, once all
FACTS life-threatening conditions are addressed and have been stabilized, if time and
resources permit.
For the trauma patient who does not have a 3. Assess baseline vital signs.
significant MOI such as those outlined above, 4. Position a patient who is unresponsive, but
follow these steps: breathing normally, with no suspected head, neck,
spinal, hip or pelvic injury, in a side-lying recovery
1. Perform a focused trauma assessment
position and ensure protection of their airway.
(e.g., for a laceration to the leg).
5. Obtain a SAMPLE history from the family or
2. Obtain a SAMPLE history and baseline vital signs.
any bystanders, if available.
3. Perform components of a detailed physical
6. Provide emergency care.
exam, as needed.
4. Provide emergency care.
Physical Exam
For a responsive trauma patient, follow these steps Many patients view a physical exam with
for the secondary assessment (Skill Sheet 8-2): apprehension and anxiety—they feel vulnerable
1. Obtain the SAMPLE history. and exposed. Maintain professionalism throughout
the physical exam and display compassion toward
2. Assess the patient’s complaints (OPQRST—
the patient. Explain what areas you are going to
onset, provoke, quality, region/radiate, severity
assess. If you have questions about an area and
and time).
the patient is responsive, ask questions prior to
3. Perform a focused trauma assessment unless examining the area. Maintain the patient’s privacy
signs and symptoms make the focus unclear, in during the physical exam, such as by conducting
which case you would perform a rapid trauma the exam in an area that cannot be seen by
assessment (head to toe). bystanders. When you need to remove the patient’s
4. Assess baseline vital signs. clothing, cut it away rather than manipulating the
5. Perform components of the detailed physical patient to remove it. Cover each area after you have
exam, as needed. examined it. Try to keep the patient calm, and keep
6. Provide emergency care. the patient from moving the head, neck and spine
7. Consider the need for additional resources, and any body part that hurts to move.
including basic life support or advanced life
support, and the need for transport (e.g., for life- Pediatric Considerations
threatening conditions, such as anaphylaxis). You may find it helpful to use distracting
measures, such as a teddy bear or doll, to
If a medical or trauma patient is unresponsive, gain the trust of a child. Keeping the child
consider the patient as critical, requiring that you with the parent or legal guardian can also help
begin with a rapid patient assessment, to gain as ease the child’s fear. If the child becomes
much information as possible on the nature of illness. extremely agitated or upset, conduct a toe-
For an unresponsive patient who is breathing to-head assessment of the child, unless there
normally, take the following steps for the secondary is a suspected life-threatening injury or illness.
assessment (Skill Sheet 8-3):
Considerations for Older Adults
1. Consider the need for additional resources, When assessing older patients, consider that
including advanced life support, and the need they may have glasses and/or hearing aids
for transport (e.g., for life-threatening conditions, and will be better able to participate in the
such as a heart attack). assessment process if they are wearing them.
2. Perform a rapid medical or trauma assessment Expect the assessment to take a little longer
(head to toe). with older adult patients than with a younger
A rapid patient assessment involves adult. Keep in mind that it might take older
checking the head, neck, chest, abdomen, adult patients a little longer to respond. For
pelvic region, legs, arms and then the back other considerations for older adults, refer to
for signs of medical problems. Chapter 26.
180 | Emergency Medical Response
Your exam may focus on a specific area, based on Open injuries. Open injuries may include
the patient’s chief complaint, or be specific to a anywhere there is bleeding, including the scalp.
particular injury or illness. As you discover certain These may be serious, such as open injuries
signs and symptoms, there may be specific relevant to the chest, or less serious, as in cuts and
questions you should ask. scrapes. Open injuries also include penetrating
wounds, such as knife or gunshot wounds.
For the rapid assessment, be sure to examine the
patient systematically from head to toe, placing Tenderness. Tenderness may be experienced
special emphasis on areas suggested by the chief even when there are no obvious signs of injury.
complaint, but remembering to examine the whole When there is tenderness of the abdomen, it
body. The patient may focus on a bothersome is important to determine in which quadrant
complaint or a painful one, and fail to identify a the patient feels pain. Begin in the quadrant
more serious problem. where the patient feels the least pain so this
does not influence the remaining assessment of
The physical exam for trauma and medical patients the abdomen.
is similar, in that the purpose is to gather additional
information. However, the type of information
Swelling. Swelling may indicate an accumulation
of blood, air or other fluid in the tissues below
you are assessing for may be different in the two the skin. In an extremity, it may indicate that the
different types of patients. With the trauma patient, bone is broken.
you are looking for evidence of injury; with the
medical patient, you are trying to determine the
severity of the condition. For example, if you are OPQRST
examining a limb in the trauma patient, you may be As part of the physical exam, if the patient is
most interested in tenderness, pain, swelling and responsive, ask questions to gain information
deformities, as well as pulse and motor/sensory about pain. One method of questioning can be
function, as an indication of injury. For the medical remembered using the mnemonic OPQRST, which
patient, you may be looking for signs of inadequate stands for onset, provoke, quality, region/radiate,
circulation, discoloration or swelling, as well as severity and time. It can be used for both patients
motor/sensory function, as a sign of the status of who have been injured and those who have a
the brain or heart. medical condition.
When you perform the physical exam, gather Onset: What were you doing when the pain
additional information on the patient’s condition. started? Was the onset abrupt or gradual?
As you examine the patient, compare each body
part on one side of the body to the other. You can
Provoke or palliation: What makes it worse?
What makes it better?
gain information by inspecting visually as well as
palpating (feeling) areas of the body. Quality: Is the pain blunt, sharp, burning,
crushing or tearing?
Region/Radiate: Where is the pain and does
DOTS it radiate (spread)? Do you have pain or
The mnemonic DOTS may be helpful during the discomfort somewhere else?
physical exam for patients who have been injured. Severity: On a scale of 1 to 10, how intense is
It stands for: the pain?
Time: When did it start? How long has it been
Deformities. Deformities may include present? How has it changed since it started?
depressions or indentations, parts that have
shifted away from their usual position, parts that For trauma patients, the mnemonic DCAP-BTLS
are more rigid or less rigid than normal (e.g., will remind you of the most common signs you
abdomen) or obvious signs of broken bones. may find.
CRITICAL As part of the physical exam of a responsive patient, ask questions using the
FACTS OPQRST mnemonic.
Chapter 8: History Taking and Secondary Assessment | 181
DCAP-BTLS
During the detailed physical exam, the mnemonic gurgling or stridor in the upper airway. Auscultate
DCAP-BTLS may help you remember the signs (listen) to the lungs with a stethoscope for
you are looking for as you conduct your head-to- breath sounds. You can also listen for the sound
toe assessment. The letters stand for: of broken bones rubbing against each other,
which is called crepitus. Use your sense of smell.
• Deformities. This is one way you can detect any unusual
• Contusions. or unexpected odors such as the presence of
• Abrasions. alcohol or a fruity-smelling breath, as well as the
• Punctures/Penetrations. possible presence of urine or feces.
• Burns.
• Tenderness. As with any physical exam, try to keep the patient
• Lacerations. calm and comfortable. Rather than focusing
• Swelling. on your findings, explain what you are doing to
minimize any distress about the injuries. Do not
Keep these types of injuries in mind as you move the patient unnecessarily if you suspect a
check each major area. Remember to use each neck or spinal injury.
of your senses. Many of these types of injuries
If there is a serious MOI, it is crucial to completely
can be seen upon examination. By palpating
expose the patient to look for additional injuries.
(feeling) for injuries, you can determine if there
Protect the patient’s privacy by covering all
are any deformities or swelling and if the patient
patients, male or female of any age, with a sheet
is experiencing any pain or tenderness. Even
and only expose the area you are examining.
if the patient cannot tell you, you can observe
any grimacing on the patient’s face. In addition When you need to remove clothing, cut it away
to seeing and feeling for signs of injury, listen rather than manipulating the patient to remove it.
for abnormal breathing sounds, for example Cover each area after you have examined it.
DETAILED PHYSICAL EXAM The physical exam process involves looking
(inspection), listening (auscultation) and feeling
Once the focused history and physical exam (palpation). You may even smell something
have been completed and any life-threatening you can gather as information, such as the smell
conditions have been managed, a detailed of bleach on the breath, which may indicate
physical exam may be conducted. This exam poisoning. After telling the patient exactly what you
is not carried out on every patient. It requires are going to do and asking the patient to hold still,
much more time than a rapid assessment to inspect and palpate each part of the body, starting
conduct, as it is more detailed, and so can with the head, before you move on to the next area
only be performed when time and the patient’s (see Skill Sheet 8-4).
condition allow. Often, it is conducted in the
ambulance or other transport vehicle, en route Ask the patient to tell you if any areas hurt. Avoid
to the hospital. touching any painful areas or having the patient
move any area that causes discomfort. Watch
The detailed physical exam is a systematic head- facial expressions and listen for a tone of voice that
to-toe exam that helps you gather additional may reveal pain. Look for a medical identification
information about injuries or conditions that may tag or bracelet or a medical identification app on
need care. These injuries or conditions are not the patient’s mobile phone (Fig. 8-5, A–B). This
immediately life threatening but could become information may help you determine what is wrong,
so if not cared for. For example, you might find whom to call for help and what care to provide.
minor bleeding or possible broken bones as you
conduct your exam of the patient. As you conduct As you do the head-to-toe exam, think about how
the physical exam, tell the patient what you are the body normally looks and feels. Be alert for
going to do. any sign of injuries—anything that looks or feels
182 | Emergency Medical Response
unusual. If you are uncertain whether your finding
is unusual, check the other side of the body for
symmetry. Once the detailed physical exam is
complete, reassess the vital signs and continue
A emergency care.
Head
To check the head, gently feel for any deformities.
If you feel a depression or soft area, do not place
any pressure over the area. Look for blood or clear
fluid in or around the ears, nose and mouth. Blood
or clear fluid can indicate a serious head injury. Is
there presence of vomit around the mouth? Look at
the teeth (Fig. 8-6).
Check the LOC again and note any change. Look
at facial symmetry. Check the pupils. If they are
unequal, this is an abnormal finding. Do they
react to light by constricting and to darkness by
dilating? This reaction is normal. If they remain
constricted or dilated, this is an abnormal finding.
Does the shape of the eyes look unusual? Look
for bruising on the face, especially around
the eyes.
Neck
To check the neck, look and feel for any
abnormalities (Fig. 8-7, A–C). Does the patient
breathe through a stoma? A stoma is an opening
in the neck to allow a person to breathe after
surgery to remove part, or all, of the larynx (voice
box) or other structures of the airway. The person
may breathe partially through this opening, or may
B
breathe entirely through the stoma instead of
through the nose and mouth.
Fig. 8-5, A–B: A medical identification tag (A) or mobile phone
app (B) may help determine what is wrong, what care to provide
and whom to call. Photos: N-StyleID.com.
Fig. 8-6: Blood or clear fluid in the ears, mouth or nose can indicate a serious head injury.
Chapter 8: History Taking and Secondary Assessment | 183
A
Fig. 8-8: A distended jugular vein.
Are there any open wounds? Is the patient using
the accessory muscles for breathing (a sign of
difficulty)? Is the jugular vein distended (enlarged
and protruding) (Fig. 8-8)?
If the patient has not suffered an injury involving
the head or trunk and does not have any pain or
discomfort in the head, neck or back, then there is
little likelihood of spinal injury. You should proceed
to check other body parts. If, however, you suspect
a possible head or spine injury because of the
MOI, such as a motor-vehicle collision or a fall
B from a height, minimize movement to the patient’s
head and spine. You will learn about spinal motion
restriction (SMR), techniques for stabilizing and
immobilizing the head and spine, in Chapter 23.
Chest
Check the collarbones and shoulders by feeling for
deformity (Fig. 8-9). Check the chest by asking the
patient to take a deep breath and then blow the air
out. Ask the patient if there is any pain. Auscultate
for lung sounds if you are trained to do so. Look
and listen for more subtle signs of breathing
difficulty, such as wheezing or diminished lung
sounds. Feel the ribs for deformity. Examine the
chest. Does it rise and fall without effort or is there
C evidence of an effort to breathe? Are there any
Fig. 8-7, A–C: (A) A stoma without a prosthesis. (B) A open wounds? Is the chest symmetrical?
stoma with tracheoesophageal prosthesis. Prosthesis should
not be removed by an EMR. (C) A stoma with a heat and
moisture exchange filter. The filter should be removed in an Abdomen
emergency. Photos: courtesy of the International Association of
Laryngectomees. Next, ask if the patient has any pain in the
abdomen. Expose the abdomen and look for
discoloration, open wounds or distension
(swelling). Are there any scars or protruding
organs? Does the patient look pregnant? Look
at the abdomen for any pulsating. If there is no
pulsating, apply slight pressure to each of the
abdominal quadrants (Fig. 8-10), avoiding any
areas where the patient had indicated pain.
184 | Emergency Medical Response
Pelvis
Check the hips, asking the patient if there is any
pain. Place your hands on both sides of the pelvis,
push in on the sides and then push down on the
hips. Check for instability and any reaction to pain.
Extremities
Check only one extremity at a time. Look at and feel
each leg for any deformity. If there is no apparent
sign of injury, ask the patient to move the toes, foot
and leg. Repeat this procedure on the other leg.
Finally, determine if the patient has any pain in the
arms or hands. Feel the arms for any deformity.
Check limbs for symmetry and check the pulse.
Look at color. If there is no apparent sign of injury,
ask the patient to move the fingers, hand and arm.
Repeat this procedure on the other arm. Check for
distal circulation and sensation in both arms and
legs. Check capillary refill.
Back
Examine the back for any injuries by palpating
equally along the spine from the neck downward,
Fig. 8-9: Examine the chest, looking for deformities or signs that with your fingertips. Check for any reaction to pain.
the patient is having difficulty breathing.
Look for discoloration, open wounds and any signs
of bleeding. Your exam should be methodical and
purposeful so that you do not overlook any details
(Fig. 8-11).
Fig. 8-10: Examine the abdomen for tenderness, rigidity, Fig. 8-11: Examine the back methodically, looking for
discoloration, open wounds, swelling or pulsating masses. discoloration, open wounds, bleeding or reactions to pain.
Chapter 8: History Taking and Secondary Assessment | 185
If the patient can move all body parts without pain adult is between 12 and 20 breaths per minute.
or discomfort and there are no other apparent However, some people breathe slightly slower
signs or symptoms of injury, have the patient or faster.
attempt to rest for a few minutes in a sitting
position. If more advanced help is not needed, Excitement, fear and exercise cause breathing to
continue to check the signs and symptoms and increase and become deeper. Certain injuries or
monitor the patient’s condition. illnesses can also cause both the rate and quality
of breathing to change.
Take note of the information you find during the
physical exam. Sometimes you may need to have As you assess the patient, watch and listen for
a partner fill out the form with the information you any changes in breathing. Abnormal breathing
gather. This will help you when it is time to give may indicate a potential problem. The signs and
a verbal report to the next level of care as you symptoms of abnormal breathing include:
transfer the patient. Immediately treat any life-
threatening problems found in the detailed physical
Gasping for air.
exam by delegating care to another responder if Noisy breathing, including whistling sounds,
wheezing, crowing, gurgling or snoring.
one is available. It is important to complete the
entire exam so that nothing is missed. Excessively fast or slow breathing.
Painful breathing.
OBTAINING BASELINE Pediatric Considerations
VITAL SIGNS Respiratory rates in children and infants
The initial set of vital signs provides a starting point vary by age. The following are the normal
for establishing a baseline to determine the status respiratory rates by age category:
of your patient. The vital signs can tell you how the Newborns: 30 to 50 breaths per minute
body is responding to injury or illness. Look for Infants (0 to 5 months): 25 to 40 breaths
changes in vital signs as you provide care and note per minute
anything unusual (see Skill Sheet 8-5). Infants (6 to 12 months): 20 to 30 breaths
per minute
Vital signs are taken after managing life-
threatening problems found during the primary Toddlers (1 to 3 years): 20 to 30 breaths
assessment. They are normally taken after the per minute
rapid assessment is complete; however, if several Preschoolers (3 to 5 years): 20 to 30
responders are on scene, they may be taken breaths per minute
simultaneously. Note that absolute values are not School age (6 to 10 years): 15 to 30
as important as trends. breaths per minute
There are three major vital sign measures to Adolescents (11 to 14 years): 12 to 20
be taken: breaths per minute
Respiratory rate In the primary assessment, the goal is to determine
Pulse whether a patient is breathing at all, whereas in the
BP secondary assessment, you are concerned with
the rate, rhythm and quality of breathing. Look,
You may also measure skin characteristics (color, listen and feel again for breathing (Fig. 8-12).
temperature and moisture) and pupils at this stage. Look for the rise and fall of the patient’s chest
or abdomen. Listen for sounds as the patient
Respiratory Rate inhales and exhales. Count the number of times
a patient breathes (inhales and exhales) in
A healthy person breathes regularly, quietly and
30 seconds and multiply that number by 2, or
effortlessly. The normal respiratory rate for an
CRITICAL When obtaining baseline vital signs, the respiratory rate, pulse and BP are essential.
FACTS Skin characteristics and pupils can be assessed as well.
186 | Emergency Medical Response
Fig. 8-12: Take note of rate, rhythm and quality when evaluating breathing in the secondary assessment.
Photo: courtesy of Terry Georgia.
in 15 seconds and multiply that number by 4. of problems with breathing, for example, because
This is the number of breaths per minute. As you of air or fluid around the lungs or reduced air flow
check for the rate and quality of breathing, try to part of the lungs.
to do it without the patient’s knowledge. If the
patient realizes you are checking breathing, this Pulse
may cause a change in breathing pattern without
the patient being aware of it. Maintain the same With every heartbeat, a wave of blood moves
position you would when you are checking the through the blood vessels. This creates a beat
pulse for a responsive patient. called the pulse. You can feel it with your fingertips
in arteries near the surface of the skin. In the
Refer to Chapter 7 for more information on primary assessment, the goal is to determine
breathing rate and quality. whether a pulse is present. To determine this,
you check the carotid arteries. In the secondary
Lung sounds, or breath sounds, are the noises assessment, you are trying to determine pulse
produced by the lungs during breathing. Some rate, rhythm and quality. This is most often done
are normal and others are abnormal. The most by checking the radial pulse located on the thumb
common abnormal breath sounds are crackles, side of the patient’s wrist.
rhonchi, stridor and wheezing. Crackles, also
called rales, are small popping, rattling or bubbly When the heart is healthy, it beats with a steady
sounds that are produced when closed spaces rhythm. This beat creates a regular pulse. A normal
pop open. They can be described as fine or pulse for an adult is between 60 and 100 beats
coarse. Rhonchi are low-pitched snoring sounds per minute. A well-conditioned athlete may have
caused by the narrowing of the airway and the a pulse of 50 beats per minute or lower. Refer to
presence of secretions in the airway. Stridor is a Chapter 7, Table 7-5 for average pulse rates by
harsh, high-pitched sound due to constriction in age. If the heartbeat changes, so does the pulse.
the upper airways. Wheezing is a high-pitched An abnormal pulse may be a sign of a potential
whistling sound created by air flowing through problem. These signs include:
narrow airways; it can be heard on exhalation
and inhalation. An irregular pulse.
A weak and hard-to-find pulse.
Absent or decreased normal sounds on one or
both sides of the chest can also be an indication
An excessively fast or slow pulse.
Chapter 8: History Taking and Secondary Assessment | 187
When severely injured or unhealthy, the heart may An injured or ill patient’s pulse may be hard to
beat unevenly, producing an irregular pulse. The find. Remember, if a patient is breathing normally,
rate at which the heart beats can also change. The the heart is also beating. However, there may be
pulse speeds up when a patient is excited, anxious, a loss in circulation to the injured area, causing a
in pain, losing blood or under stress. It slows down loss of pulse. If you cannot find the pulse in one
when a patient is relaxed. Some heart conditions place, check it in another location, such as in the
can also speed up or slow down the pulse rate. other wrist.
Sometimes changes may be subtle and difficult
to detect. The most important change to note is a Pediatric Considerations
pulse that changes from being present to no pulse When measuring the pulse in an infant, use
at all. the brachial artery rather than the radial artery,
Checking a pulse is a simple procedure. Place as in adults. Pulse measurement in children
two fingers on top of a major artery where it is and infants varies by age:
located close to the skin’s surface and over a bony
structure. Pulse points that are easy to locate
Newborns: 120 to 160 beats per
minute (bpm)
include the carotid arteries in the neck, the radial
artery in the wrist, the femoral arteries in the groin Infants (0 to 5 months): 90 to 140 bpm
and, for infants, the brachial artery in the inside Infants (6 to 12 months): 80 to 140 bpm
of the upper arm (Fig. 8-13). To check the pulse Toddlers (1 to 3 years): 80 to 130 bpm
rate, count the number of beats in 30 seconds and Preschoolers (3 to 5 years): 80 to 120 bpm
multiply that number by 2, or the number of beats School age (6 to 10 years): 70 to 110 bpm
in 15 seconds and multiply that number by 4. The
result is the number of heartbeats per minute. If you
Adolescents (11 to 14 years): 60 to 105 bpm
find the pulse is irregular, you may need to check it
for more than 30 seconds. Blood Pressure
Another vital sign used to assess a patient’s
condition is blood pressure (BP). BP measures
the force of blood against the walls of the artery as
it travels through the body. It is a good indicator of
how the circulatory system is functioning.
Neck Because a patient’s BP can vary greatly, it is only
(Carotid) one of several factors that give you an overall
picture of a patient’s condition. Stress, excitement,
Arm injury and illness can affect BP.
(Brachial)
When a person is injured or ill, a single BP
measurement is often of little value. A more
accurate picture of a patient’s condition
Wrist
(Radial)
immediately after an injury or the onset of an illness
is whether BP changes over time while you provide
Leg care. For example, a patient’s initial BP reading
(Femoral)
could be uncommonly high as a result of the
stress of the emergency. It can also be temporarily
elevated just because the patient is in the presence
of a medical professional, a phenomenon called
“white coat hypertension.” Providing care, however,
usually relieves some of the fear, and BP may return
to within a normal range. At other times, BP will
remain unusually high or low. For example, an injury
Foot resulting in a severe loss of blood may cause BP
(Posterior tibial)
(Dorsalis pedis)
to remain unusually low. You should be concerned
about unusually high or low BP or a large change
in BP whenever signs and symptoms of injury or
Fig. 8-13: Easily located pulse sites. illness are present.
188 | Emergency Medical Response
A B
Fig. 8-14, A–B: Equipment needed to measure blood pressure includes (A) a blood pressure cuff and (B) a stethoscope.
Equipment for Measuring Blood At this point, you do not hear anything through
Pressure the stethoscope. As you turn the valve to slowly
To measure BP, you need two pieces of equipment: release pressure on the brachial artery, the cuff
a sphygmomanometer (BP cuff) and a pressure eventually matches and then drops
stethoscope (Fig. 8-14, A−B). below the systolic blood pressure. When the cuff
pressure reaches this point, you begin to hear
A sphygmomanometer is made up of two main the pulse sounds. As the cuff pressure drops to
parts: an inflatable cuff that is wrapped around the equal the diastolic blood pressure in the artery, the
patient’s arm (or leg) and a manometer. The cuff is sounds change or fade away.
made of fabric and comes in several sizes. It has a
rubber bladder inside, which is connected at the The second part to the sphygmomanometer is the
end to a hose with a rubber ball, called a bulb. A manometer, a gauge that measures systolic and
valve in the bulb opens and closes to control the diastolic pressure. The numbers on the gauge show
flow of air into the bladder. The valve is controlled the pressure in millimeters; the higher the number,
by a screw. If you turn the screw to the left, it opens the greater the pressure. There are three types of
the valve and lets the air escape from the bladder. manometers: mercury, aneroid and electronic.
If you turn the screw to the right, it closes the valve
The aneroid manometer shows the pressure
so that when you pump air into the bladder with
readings on a round dial with an arrow that points
the bulb, the valve keeps the air inside the bladder,
making the cuff tight. to the numbers (Fig. 8-15, A). Although there is no
mercury column, the numbers on the dial are equal
When you pump air into the cuff, the bladder to millimeters of mercury (mmHg). The arrow moves
pressure increases until it is strong enough to from zero to the higher numbers as you inflate
stop the blood flow through the brachial artery. the cuff.
CRITICAL To measure BP, you need two pieces of equipment: a sphygmomanometer (BP cuff)
FACTS and a stethoscope.
Chapter 8: History Taking and Secondary Assessment | 189
The electronic manometer (Fig. 8-15, B) eliminates called a diaphragm. The earpieces, which are
the need for using a stethoscope and listening connected to the other end of the tubing, fit into
for the pulse sounds, because it takes the BP your ears and allow you to hear sounds. Some
readings for you and displays them on a digital stethoscopes have a bell-shaped end in addition
screen like the one on an electronic thermometer. to the diaphragm. Before taking a person’s BP,
check the tubing and diaphragm for cracks and
The stethoscope is used together with the holes that could make it difficult to hear and could
sphygmomanometer to allow you to hear the cause you to make an error in the BP reading.
BP sounds. It consists of two pieces of tubing To prevent the spread of infection, use alcohol
that are connected at one end to a flat disk to clean the diaphragm after each contact with a
person. If you use a stethoscope that is used by
other caregivers and is used on a regular basis,
clean the earpieces with alcohol before putting
them in your ears.
Measuring Blood Pressure
BP is measured in millimeters of mercury, or
mmHg. It is reported as two numbers, systolic BP
over diastolic blood pressure (Table 8-1). Systolic
blood pressure is the force exerted against the
arteries when the heart is contracting. An average
adult systolic blood pressure is 120 mmHg.
Diastolic blood pressure is the force exerted
A against the arteries when the heart is between
contractions, with an average adult reading of
80 mmHg.
An accurate reading can be acquired through
auscultation (listening) or by palpation (feeling);
see Skill Sheets 8-6 and 8-7.
To measure BP by auscultation, use the BP cuff
together with the stethoscope as follows:
Have the patient sit or lie down in a comfortable
position. Make sure the forearm is on a
supported surface in front or to the side of the
patient and not hanging down or raised above
the level of the heart.
Select an appropriately sized cuff for the patient.
The cuff should cover approximately two-thirds
of the patient’s upper arm. Place the cuff so that
the bladder is centered over the brachial artery
B
and the bottom edge of the cuff is about 1 inch
above the crease of the elbow.
Fig. 8-15, A–B: (A) An aneroid manometer. (B) An electronic
manometer.
CRITICAL BP is measured in millimeters of mercury, or mmHg. It is reported as two numbers,
FACTS systolic blood pressure over diastolic blood pressure. Systolic blood pressure
is the force exerted against the arteries when the heart is contracting. Diastolic
blood pressure is the force exerted against the arteries when the heart is between
contractions.
190 | Emergency Medical Response
Table 8-1:
Categories for Blood Pressure Levels in Adults in Millimeters
of Mercury (mmHg)1
CATEGORY SYSTOLIC (Top number) DIASTOLIC (Bottom number)
Normal Less than 120 Less than 80
Prehypertensive 120–139 80–89
High blood pressure
Stage 1 140–159 90–99
Stage 2 160 or higher 100 or higher
1
For adults 18 and older who are not on medication for high blood pressure, are not having a short-term serious illness and do not have other
conditions, such as diabetes or kidney disease. When systolic and diastolic blood pressures fall into different categories, the higher category should
be used to classify blood pressure level. For example, 160/80 mmHg would be stage 2 high blood pressure. Source: www.nhlbi.nih.gov/health/dci/
Diseases/Hbp/HBP_WhatIs.html.
Fig. 8-16: When measuring blood pressure by auscultation,
center the diaphragm of the stethoscope firmly over the brachial Fig. 8-17: Estimating a systolic blood pressure requires you to
artery. feel for the radial pulse.
Place the stethoscope earpieces in your ears, Continue to release the air from the bulb and
with the earpieces facing forward. Center the watch the manometer. Once you hear the
diaphragm of the stethoscope firmly over the last sound, record the reading on the gauge.
brachial artery, about 1 inch above the crease This is the diastolic pressure, or the pressure
of the elbow (Fig. 8-16). between heartbeats.
Close the thumb valve by rotating the knob
Palpation can prove particularly helpful and
clockwise and then squeeze the rubber bulb to
recommended in noisy environments where
inflate the cuff. This compresses the brachial
auscultation may prove difficult or potentially
artery, momentarily stopping the blood flow.
inaccurate. Measuring BP by palpation requires
Stop inflating when you can no longer hear
you to feel the radial artery as you inflate the BP
the pulse.
cuff (Fig. 8-17).
Next, slowly release the air in the cuff at
approximately 2 to 4 mmHg per second by Have the patient sit or lie down in a comfortable
turning the valve counterclockwise and listen position. Make sure the forearm is on a
with the stethoscope. Watch the pressure supported surface in front or to the side of the
gauge and note the number, recorded in even patient and not hanging down or raised above
numbers, when you first hear the pulse again. the level of the heart.
This is the systolic pressure, or the pressure of
the blood when the heart beats.
Chapter 8: History Taking and Secondary Assessment | 191
Fig. 8-18: Blood pressure cuffs come in sizes for small, average and large arms.
Select an appropriately sized cuff for the patient Pediatric Considerations
(Fig. 8-18). The cuff should cover approximately It is difficult to obtain an accurate BP reading
two-thirds of the patient’s upper arm. Place the on a child. First, the cuff must fit correctly,
cuff so that the bladder is centered over the and it is difficult to have the correct size for a
brachial artery and the bottom edge of the cuff wide range of children. However, determining
is about an inch above the crease of the elbow. BP in children is not as important as it is with
Locate the patient’s radial pulse, then close the adults. In general, children under 3 years of
thumb valve by rotating the knob clockwise and age do not have their BP taken. What is more
then squeeze the rubber bulb to inflate the cuff. important in assessing children is adequate
This compresses the brachial artery which in airway management. Children’s BP may not
turn compresses the radial artery, momentarily drop until there has been a significant loss of
stopping the blood flow. Stop inflating when you blood. Therefore, provide care for shock if the
can no longer feel the radial pulse. Record the MOI calls for it, regardless of BP.
reading on the manometer.
BP may be estimated in children. The formula
Continue to inflate the cuff for another 20 mmHg for the average BP for a child is 90 + (2 × the
beyond this point. Release the pressure slowly age of the child in years). This formula can be
by turning the regulating valve counterclockwise, used for children up to the age of 12.
and allow it to deflate at about 2 to 4 mmHg
per second. Continue to feel for the radial pulse BP numbers in children and infants vary by
as the cuff deflates. The point at which the age (see Table 8-3).
pulse returns is the approximate systolic blood
pressure. This BP reading should be shown Infants (1 to 12 months): systolic 70 mmHg
with an even number followed by the letter P (lower limit of normal); diastolic 2/3 of
to indicate palpation, for example, 130/P. It is systolic pressure. Ranges for newborns
important to note whether the patient was lying vary depending on birth weight and whether
or sitting when the reading was taken. the newborn is full term or premature.
Children (1 to 12 years):
When the proper equipment is not available, you can
approximate the systolic blood pressure in certain
yyLower limit of normal: systolic 70 mmHg
+ (2 × age in years); diastolic 2/3 of
pulse locations. For example, the radial artery, systolic pressure
located at the wrist, indicates a systolic pressure
of about 80 mmHg. The femoral artery indicates a yyUpper limit of normal: systolic 90 mmHg
+ (2 × age in years); diastolic 2/3 of
systolic pressure of about 70 mmHg. The carotid
systolic pressure
artery in the neck indicates a systolic pressure of
about 60 mmHg. Two options for approximating the Adolescents: systolic 90 mmHg (lower limit
systolic blood pressure include asking the patient of normal); diastolic 2/3 of systolic pressure
what their normal BP is or inflating the cuff to 160 For other pediatric considerations, see
mmHg. For precautions to be aware of when taking Chapter 25.
blood pressure, see Table 8-2.
192 | Emergency Medical Response
Table 8-2:
Precautions for Taking a Patient’s Blood Pressure
PRECAUTION REASON
Place the cuff on the patient’s bare arm or lightly Heavy clothing may give an incorrect reading.
clothed arm. When the diaphragm is placed on heavy clothing,
it creates noises that make it difficult to hear
pulse sounds.
Select the correct cuff size: adult-size for most Using the correct size results in an accurate reading.
adults, extra-large for some adults and child-size
for small people.
Wrap the cuff smoothly and snugly. A smooth wrap gives an accurate reading.
Position the cuff correctly, with the center of the Correct positioning gives an accurate reading.
bladder over the brachial artery.
Do not place the cuff on a cast. The cuff cannot compress the cast, which results in
no reading.
Do not place the cuff on an arm with an IV in place. The pressure from the cuff could stop the flow of fluid
and possibly cause the needle to clog or dislodge
from the vein.
Do not place the cuff on the weak arm of a patient Circulation in these conditions is impaired, resulting
who has had a stroke or on a patient’s paralyzed arm. in an inaccurate reading. Also, an inflated cuff
For a woman who has had a mastectomy, do not decreases circulation in the arm and may cause
place the cuff on the arm that is on the same side as some damage.
the mastectomy.
Do not place the cuff on an arm that has an AV fistula Placing and inflating the blood pressure cuff over this
that is used for hemodialysis. site can cause low blood flow, blood clot formation
within the fistula as well as collapse of the fistula,
making the site unusable. This could lead to surgical
intervention for the patient.
Table 8-3:
Normal Blood Pressure Ranges in Children and Infants
AGE SYSTOLIC DIASTOLIC
Children (1 to 12 years old) 90 + (2 × age in years) mmHg 2/3 of systolic pressure
Infants (1 to 12 months) 70 + (2 × age in years) mmHg 2/3 of systolic pressure
Newborns (ages 1 to 28 days) > 60 mmHg (varies depending on birth > 14 mmHg (varies depending on
weight and gestation) birth weight and gestation)
Chapter 8: History Taking and Secondary Assessment | 193
ONGOING ASSESSMENT Reassess Vital Signs
Once you have completed the secondary Repeat vital signs as necessary each time you
assessment and provided care for any injuries and reassess the patient. Repeat BP, pulse and
illnesses, provide ongoing assessment and care respiration (see Table 8-4).
while you wait for more advanced medical care to
arrive. The purpose of the ongoing assessment is Reassess Chief Complaint
to identify and treat any changes in the patient’s
Constantly reassess the patient’s chief complaint
condition in a timely manner and to monitor the
or major injury. Determine if the pain or discomfort
effectiveness of interventions or care provided.
is remaining the same, getting worse or getting
Record additional findings and turn this information
better. Ask the patient whether there are any new
over to the next level of care.
or previously undisclosed complaints.
The patient’s condition can gradually worsen, or
a life-threatening condition, such as respiratory
or cardiac arrest, can occur suddenly. Do not
assume that the patient is out of danger just Table 8-4:
because there were no serious problems at first. Vital Signs by Age
Reassess the patient at regular intervals. Patients
who are unstable should be reassessed at least ADULTS (About 12 years and older)
every 5 minutes or more often if indicated by the
patient’s condition. Reassess stable patients every Pulse 60 to 100 beats per minute
15 minutes, or as deemed appropriate by the
patient’s condition. Blood pressure 90−140 mmHg systolic
60−90 mmHg diastolic
The physical exam and history do not need to be
repeated unless there is a specific reason to do Respirations 12 to 20 breaths per minute
so. If any life-threatening conditions develop, stop
whatever you are doing and provide appropriate CHILDREN (Age 1 to about 12 years)
care immediately.
Pulse 80 to 100 beats per minute
Reassessment includes the:
Blood pressure 80−110 mmHg systolic
Primary assessment.
Respirations 15 to 30 breaths per minute
Vital signs.
Chief complaint. INFANTS (Age 1 to 12 months)
Interventions, or care provided.
Pulse 100 to 140 beats per minute
Reassess Primary Assessment
Blood pressure 70−95 mmHg systolic
Reassess each aspect of the primary assessment
and compare to the patient’s baseline status. For Respirations 25 to 50 breaths per minute
LOC, is the patient maintaining the same level of
responsiveness or becoming more or less alert? NEONATAL/NEWBORN (Full term to
Recheck the airway to ensure it is open and clear. 28 days)
Reassess the adequacy of breathing by monitoring
breathing rate, depth and effort. Auscultate breath Pulse 120 to 160 beats per minute
sounds to determine if there has been a change.
Reassess the adequacy of circulation by checking Blood pressure > 60 mmHg systolic
both carotid and radial pulses. Recheck skin Respirations 40 to 60 breaths per minute
characteristics (color, temperature and moisture).
CRITICAL Ongoing assessment should be done after the secondary assessment. Its purpose
FACTS is to identify and care for any changes in the patient’s condition and to monitor the
effectiveness of care provided.
194 | Emergency Medical Response
Reassess Interventions illness and whether the patient is responsive or
unresponsive. Use the mnemonic SAMPLE to
Reassess the effectiveness of each intervention
gather all of the necessary information. For some
performed. Consider the need for new
patients, if there is time and the patient’s condition
interventions or modifications to care already
warrants it, you will go back and complete a
being provided.
detailed physical exam.
Once the assessment is complete, perform
THE NEED FOR MORE ongoing assessments until more advanced
ADVANCED MEDICAL personnel take over. Reassess at least every
PERSONNEL 5 minutes for unstable patients and every
15 minutes for stable ones, or as dictated by the
While waiting for more advanced medical care
patient’s condition.
(Table 8-5), help the injured or ill patient stay calm
and as comfortable as possible. These conditions Although this plan of action can help you decide
are by no means a complete list. It is impossible what care to provide in any emergency, providing
to describe every possible condition since there care is not an exact science. Because each
are always exceptions. Trust your instincts. If you emergency and each patient are unique, an
think there is an emergency, there probably is. It is emergency may not occur exactly as it did in a
better to call for more advanced medical care than classroom setting. The care needed may change
to wait. from one moment to the next. For example, the
primary assessment may indicate the patient is
conscious, has no severe, life-threatening bleeding,
PUTTING IT ALL TOGETHER is breathing and has a pulse. However, during your
Once you have sized up the scene and performed physical exam, you may notice that the patient
a primary assessment, you are ready to move on begins to experience difficulty breathing. At this
to the secondary assessment. This requires you to point, there is a need to summon more advanced
perform a physical exam to find and care for any medical personnel, if this has not already been
other problems that are not an immediate threat done, and provide appropriate care. Provide
to life but might become serious if you do not necessary information about the patient’s condition
recognize them and provide care. This head- once more advanced medical personnel arrive.
to-toe physical exam involves looking at and
Many variables exist when dealing with
feeling the body for abnormalities. Use the
emergencies. You do not need to “diagnose” what
mnemonic DOTS as you perform the physical
is wrong with the patient to provide appropriate
exam. For many patients, this will be a rapid
care. Treat the conditions you find, always caring
medical or trauma assessment.
for life-threatening conditions first. Perform the
Obtain pertinent history from the patient. This is primary and secondary assessments as a guideline
especially important if the patient is suffering from to help you assess the patient’s condition.
an illness that has already been diagnosed and is
As you read the remaining chapters, remember the
being cared for by a healthcare provider. Whether
steps of the assessments. They form the basis for
you obtain the history before, after or during the
providing care in any emergency.
physical exam depends on the MOI or nature of
You Are the Emergency Medical Responder
The injured woman accompanies you to a separate area so you can assess her for injuries.
She is still clutching her arm. What steps would you take to identify any injuries or conditions
that may need medical care? After assessing this patient, you find no life-threatening
conditions. How often would you reassess her and why?
Chapter 8: History Taking and Secondary Assessment | 195
Table 8-5:
When to Call for More Advanced Medical Personnel
CONDITION SIGNS AND SYMPTOMS
Unconscious or • Patient does not respond to tapping, loud voices or other attempts to awaken.
decreased level of
consciousness
Trouble breathing • Breathing is noisy (sounds such as wheezing or gasping).
• Patient feels short of breath.
• Skin has a flushed, pale or bluish appearance.
No breathing • You cannot see the patient’s chest rise and fall.
• You cannot hear and feel air escaping from the nose and/or mouth.
No pulse • You cannot feel the carotid pulse in the neck or the pulses in other pulse points.
Severe bleeding • Patient has bleeding that spurts or gushes steadily from the wound.
Persistent pain or • There is chest pain, discomfort or pressure lasting more than a few minutes;
pressure in the chest that goes away and comes back; or that radiates to the shoulder, arm, neck, jaw,
stomach or back.
Persistent pain or • Patient has persistent pain or pressure in the abdomen that is not relieved by
pressure in the abdomen resting or changing positions.
Vomiting blood or • You can see blood in vomit, urine or feces.
passing blood
Severe (critical) burns • Patient has burns that cover a large surface area; cover more than one body part;
involve the head, neck, mouth or nose; or affect the airway.
• Patient has burns other than localized superficial burns to a small child or older
adult patient; those affecting the hands, feet or genitals; or those resulting from
chemicals, explosions or electricity.
Suspected poisoning • Patient shows evidence of swallowed, inhaled, absorbed or injected poison,
such as presence of drugs, medications, cleaning agents, or hypodermic needles
and syringes.
• Mouth or lips may be burned.
Sudden illness requiring • Patient has seizures, severe headaches, slurred speech or changes in the level of
assistance consciousness; unusually high or low blood pressure; or a known diabetic condition.
Stroke • Patient has sudden weakness on one side of the face/facial droop, sudden
weakness on one side of the body, sudden slurred speech or trouble getting
words out or a sudden severe headache.
Head, neck or back • Consider how the injury happened: for example, a fall, severe blow or collision
(spinal) injuries suggests a head injury.
• Patient complains of severe headaches or neck or back pain.
• Patient is unconscious.
• Blood or clear fluid is detected in the ears, mouth or nose.
• There is bleeding or deformity of the scalp, face or neck.
Possible broken bones • Consider how the injury happened: for example, a fall, severe blow or collision
suggests a fracture.
• There is evidence of damage to blood vessels or nerves: for example, slow
capillary refill, no pulse below the injury or loss of sensation in the affected part.
• Patient is unable to move the body part without pain or discomfort.
• There is a swollen or deformed limb.
• Fractures are associated with open wounds.
196 | Emergency Medical Response
Skill Sheet
Skill Sheet 8-1
How to Obtain a SAMPLE History
NOTE: Always follow standard precautions when providing care.
STEP 1
Using the mnemonic SAMPLE, determine the following six items for the patient history:
1. Signs and symptoms: Signs include seeing bleeding; hearing breathing distress; and
feeling cool, moist skin. Symptoms include pain, nausea, headache and difficulty
breathing.
2. Allergies: Determine if the patient is allergic to any medications, food, or environmental
elements, such as pollen or bees.
3. Medications: Determine if the patient is presently using any medications, prescription
or nonprescription.
4. Pertinent medical history: Determine if the patient is under a healthcare provider’s
care for any condition or if the patient has had a similar problem in the past or been
recently hospitalized.
5. Last oral intake: This intake includes solids or liquids and can include food, fluid and
medication.
6. Events leading up to the incident: Determine what the patient was doing before and at
the time of the incident.
Chapter 8: History Taking and Secondary Assessment | 197
Skill Sheet
Skill Sheet 8-2
How to Perform a Secondary Assessment
for a Responsive Trauma Patient
NOTE: Always follow standard precautions when providing care.
STEP 1
Obtain a SAMPLE history (see Skill Sheet 8-1).
STEP 2
Assess the patient’s complaints (use the mnemonic OPQRST—onset, provoke, quality, region/
radiate, severity and time).
STEP 3
Perform a focused trauma assessment unless signs and symptoms make the focus unclear, in
which case you would perform a rapid trauma assessment (head to toe).
STEP 4
Assess baseline vital signs.
STEP 5
Perform components of the detailed physical exam, as needed.
STEP 6
Provide emergency care.
▼
NOTE: Consider the need for additional resources, including basic life support or advanced life
support, and the need for transport (e.g., for life-threatening conditions, such as anaphylaxis).
If the trauma patient is unresponsive, consider the patient as critical, requiring that you begin with
a rapid trauma assessment, to gain as much information as possible on the nature of illness.
198 | Emergency Medical Response
Skill Sheet
Skill Sheet 8-3
How to Perform a Secondary Assessment
for an Unresponsive Patient Who Is Breathing
Normally
NOTE: Always follow standard precautions when providing care.
STEP 1
Consider the need for additional resources, including advanced life support, and the need for
transport (e.g., for life-threatening conditions, such as a heart attack).
STEP 2
Perform a rapid medical or trauma assessment (head to toe).
STEP 3
Assess baseline vital signs.
STEP 4
Position a patient who is unresponsive but breathing normally with no suspected head, neck,
spinal or hip injuries, in a side-lying recovery position and ensure protection of their airway.
STEP 5
Obtain a SAMPLE history (see Skill Sheet 8-1) from the family or any bystanders, if available.
STEP 6
Provide emergency care.
Chapter 8: History Taking and Secondary Assessment | 199
Skill Sheet
Skill Sheet 8-4
Physical Exam
NOTE: Always follow standard precautions when providing care.
STEP 1
Perform physical exam beginning with the head and
neck.
STEP 2
Check the shoulders and chest.
STEP 3
Check the abdomen.
▼ (Continued)
200 | Emergency Medical Response
Skill Sheet
Skill Sheet 8-4
Physical Exam Continued
STEP 4
Check the pelvis.
STEP 5
Check the legs and feet.
STEP 6
Check the arms and hands, including capillary refill.
STEP 7
Check the patient’s back.
Chapter 8: History Taking and Secondary Assessment | 201
Skill Sheet
Skill Sheet 8-5
How to Obtain Baseline Vital Signs
NOTE: Always follow standard precautions when providing care. When assessing breathing, look
for a stoma or other signs of a neck breather.
STEP 1
Check respirations for rate, rhythm and quality of
breathing.
■■ Look, listen and feel for breathing.
zz Look for the rise and fall of the patient’s
chest or abdomen.
zz Listen for sounds as the patient inhales
and exhales.
■■ Count the number of times a patient
breathes in 30 seconds.
zz Multiply that number by 2 (or in 15 seconds by 4). This is the number of breaths
per minute.
■■ Record your findings.
NOTE: As you check for the rate and quality of breathing, try to do it without the patient’s
knowledge. If the patient realizes you are checking breathing, this may cause a change in
breathing pattern without the patient being aware of it. Maintain the same position you would
when you are checking the pulse for a responsive patient.
STEP 2
Check for a pulse.
■■ Place two fingers on top of a major artery
near the skin’s surface and over a bony
structure.
zz Pulse points include the carotid arteries
in the neck, the radial artery in the wrist
and, for infants, the brachial artery in the
inside of the upper arm.
zz To check the pulse rate, count the
number of beats in 30 seconds and multiply
that number by 2 (or in 15 seconds by 4).
■■ Record your findings.
NOTE: An injured or ill patient’s pulse may be hard to find. If a patient is breathing, the heart is
also beating. There may be a loss in circulation to the injured area, causing a loss of pulse. If
you cannot find the pulse in one place, check it in another, such as in the other wrist.
▼ (Continued)
202 | Emergency Medical Response
Skill Sheet
Skill Sheet 8-5
How to Obtain Baseline Vital Signs Continued
STEP 3
Check skin characteristics and pupils.
NOTE: Checking the skin characteristics requires you
to look at and feel the skin. You may need to partially
remove a disposable glove in order to determine skin
moisture and temperature. Be careful not to come in
contact with any blood or open wounds.
■■ To check skin characteristics look or feel
for:
zz Color. Is it pale and ashen, or flushed
and pink?
zz Temperature. Is it hot or cold?
zz Moisture. Is it moist or dry?
zz Capillary refill. Is it normal or slow?
■■ Record your findings.
Chapter 8: History Taking and Secondary Assessment | 203
Skill Sheet
Skill Sheet 8-6
Taking and Recording a Patient’s Blood
Pressure (by Auscultation)
NOTE: Always follow standard precautions when providing care.
STEP 1
Approximate systolic blood pressure.
■■ Either ask the patient what their BP is or use 160 mmHg as an alternative.
NOTE: The radial artery, located at the wrist, indicates a systolic pressure of about 80 mmHg.
The femoral artery in the leg indicates a systolic pressure of about 70 mmHg. The carotid artery
in the neck indicates a systolic pressure of about 60 mmHg.
STEP 2
Select an appropriately sized cuff for the patient.
STEP 3
Position the cuff.
STEP 4
Locate brachial pulse.
▼ (Continued)
204 | Emergency Medical Response
Skill Sheet
Skill Sheet 8-6
Taking and Recording a Patient’s Blood
Pressure (by Auscultation) Continued
STEP 5
Position the diaphragm of the stethoscope over the
pulse point.
NOTE: Hold the diaphragm in place with your
fingers, not your thumb, because you may hear
the pulse in your thumb instead of the patient’s
brachial pulse.
STEP 6
Inflate cuff. Stop inflating when you can no longer
hear the pulse.
STEP 7
Deflate cuff slowly until pulse is heard.
▼ (Continued)
Chapter 8: History Taking and Secondary Assessment | 205
Skill Sheet
Skill Sheet 8-6
Taking and Recording a Patient’s Blood
Pressure (by Auscultation) Continued
STEP 8
Continue deflating cuff until the pulse is no longer heard.
STEP 9
Quickly deflate cuff by opening the valve.
STEP 10
Record findings.
■■ Watch the pressure gauge and note the number, recorded in even numbers, when you
first hear the pulse again (systolic pressure).
■■ Continue to release the air from the bulb and watch the manometer. Once you hear
the last sound, record the reading on the gauge (diastolic pressure).
206 | Emergency Medical Response
Skill Sheet
Skill Sheet 8-7
Taking and Recording a Patient’s Blood
Pressure (by Palpation)
NOTE: Always follow standard precautions when providing care.
STEP 1
Select an appropriately sized cuff for the patient’s
arm and position the cuff.
STEP 2
Locate the radial pulse.
STEP 3
Inflate the cuff beyond where pulse disappears.
▼ (Continued)
Chapter 8: History Taking and Secondary Assessment | 207
Skill Sheet
Skill Sheet 8-7
Taking and Recording a Patient’s Blood
Pressure (by Palpation) Continued
STEP 4
Deflate the cuff slowly until pulse returns; the point
where the pulse returns is the approximate systolic
blood pressure.
STEP 5
Quickly deflate the cuff by opening the valve.
STEP 6
Record the approximate systolic blood pressure with a “P” for palpation method (e.g., 130/P).
208 | Emergency Medical Response
ENRICHMENT
Pulse Oximetry
Purpose
Pulse oximetry is used to measure the percentage of oxygen saturation in the blood. The reading is taken by a
pulse oximeter (Fig. 8-19) and appears as a percentage of hemoglobin saturated with oxygen. Normal saturation
is approximately 95 to 99 percent. The reading is recorded as 95 to 99 percent SpO2 (Table 8-6).
Pulse oximetry also is used to assess the adequacy of oxygen delivery during positive pressure ventilation and
the impact of other medical care provided.
When monitoring a conscious patient’s oxygen saturation levels using a pulse oximeter, you may reduce the
flow of oxygen and change to a lower-flowing delivery device if the oxygen level of the patient reaches over
94 percent.
The percent of oxygen saturation always should be documented whenever vital signs are recorded and in
response to therapy to correct hypoxia. A reading below 94 percent may indicate hypoxia. Pulse oximetry should
be used as an added tool for patient evaluation, as it is possible for patients to show a normal reading but have
trouble breathing, or have a low reading but appear to be breathing. When treating the patient, all symptoms
should be assessed, along with the data provided by the device. The pulse oximeter reading never should be used
to withhold oxygen from a patient who appears to be in respiratory distress or when it is the standard of care to
apply oxygen despite good pulse oximetry readings, such as in a patient with chest pain.
Indications
Pulse oximetry should be applied whenever a patient’s oxygenation is a concern and for the following situations:
All patients with neurologic, respiratory or cardiovascular complaints
All patients with abnormal vital signs
All patients who receive respiratory depressants (morphine, diazepam, midazolam)
Critical trauma patients
Pulse oximetry should be taken and recorded with vital signs for stable patients every 15 minutes, and reassessed
and recorded at least every 5 minutes for unstable patients.
Fig. 8-19: A pulse oximeter measures the oxygen saturation level in a patient’s blood.
Continued on next page
Chapter 8: History Taking and Secondary Assessment | 209
ENRICHMENT
Pulse Oximetry continued
Table 8-6:
Pulse Oximetry
RANGE VALUE TREATMENT
Normal 95 to 100 percent None
Mild hypoxia 91 to 94 percent Administer supplemental oxygen using a nasal cannula or
resuscitation mask, based on local protocols.
Moderate hypoxia 86 to 90 percent Administer supplemental oxygen using a non-rebreather mask or
bag-valve-mask resuscitator, based on local protocols.
Severe hypoxia ≤ 85 percent Administer supplemental oxygen using a non-rebreather mask
or bag-valve-mask resuscitator with positive pressure, based on
local protocols.
Procedure
When using a pulse oximeter, refer to the manufacturer’s directions to ensure proper use. In general, the
procedure for measuring pulse oximetry is the same.
Once the machine is turned on, allow for self-tests. If the patient is wearing nail polish, remove it using
an acetone wipe, as it can interfere with the reading. Then apply the probe to the patient’s finger. The
manufacturer also may recommend alternative measuring sites, such as the finger and then the earlobe on the
next measurement.
Pediatric Considerations
The manufacturer may recommend alternative measuring sites for pulse oximetry in infants, such as the foot.
The machine will register the oxygen saturation level. Once it begins to register, record the time and the initial
saturation percent, if possible, on the prehospital care report. Verify the patient’s pulse rate on the oximeter with
the actual pulse of the patient. Be sure to monitor critical patients continuously until more advanced medical
personnel are available. If you are recording a one-time reading, be sure to monitor the patient for a few minutes,
as oxygen saturation can vary. As mentioned above, document the percent of oxygen saturation whenever vital
signs are recorded and in response to therapy to correct hypoxia.
Limitations
Some factors may reduce the reliability of the pulse oximetry reading, including:
Hypoperfusion, poor perfusion (shock).
Cardiac arrest (absent perfusion to fingers).
Excessive motion of the patient during the reading.
Fingernail polish.
Carbon monoxide poisoning (carbon monoxide saturates hemoglobin).
Hypothermia or other cold-related illness.
Sickle cell disease or anemia.
Cigarette smokers (due to carbon monoxide).
Edema (swelling).
Time lag in detection of respiratory insufficiency. (The pulse oximeter could warn too late of a decrease in
respiratory function based on the amount of oxygen in circulation.)
210 | Emergency Medical Response
9 COMMUNICATION
AND
DOCUMENTATION
You Are the Emergency Medical Responder
As the closest responders in the area, your police unit is called to the scene where an older
woman has collapsed in front of her home. When you arrive, a neighbor tells you that the
woman suddenly collapsed and tripped on the concrete step in the walkway in front of her
home. She is now conscious but a little dazed, and you find that she is also very frightened
and apprehensive. What can you do to try to ease the woman’s fears and reduce her
anxiety as you assess her for injuries?
KEY TERMS
Closed-loop communication: A communication Minimum data set: A standardized set of data
technique in which the listener repeats orders points about the response and care for patients;
word for word to ensure the message was heard this information is included in the prehospital care
and understood accurately. report (PCR).
Communications center (dispatch): The point Patient narrative: A section on the prehospital care
of contact between the public and responders report where the assessment and care provided to
(also known as a public safety answering point, or the patient are described.
PSAP); responsible for taking basic information
from callers and dispatching the appropriate Prehospital care report (PCR): A document
personnel; in some communities may also provide filled out for all emergency calls; used to keep
prearrival instructions to the 9-1-1 caller. medical personnel informed so they can provide
appropriate continuity of care; also serves as
Medical control: Direction given to emergency a record for legal and billing purposes; may
medical responders (EMRs) by a physician be written or electronic; if electronic, it is then
when EMRs are providing care at the scene of an E-PCR.
an emergency or are en route to the receiving
facility; may be provided either directly via radio Run data: A section on the PCR where information
or indirectly by pre-established local medical about the incident is documented.
treatment protocols; also called standing orders.
LEARNING OBJECTIVES
After reading this chapter, and completing the class • Identify the components of the prehospital care
activities, you will have the information needed to: report (PCR).
• Recognize the importance of effective • Describe the fundamental components of
communication within the emergency medical documentation and related issues.
services (EMS) system. • Explain the importance of maintaining
• Recognize the need for compassion and confidentiality about the condition, circumstances
empathy when caring for a patient’s physical and care of the patient.
and mental needs. • Describe the elements of a verbal report given
• Communicate willingly and with sensitivity in the during the transfer of care.
care of all patients.
INTRODUCTION bystanders is of utmost importance to understand
what took place. By using various techniques to
When you arrive on the scene to assist injured or gain the trust and confidence of the public, an
ill persons, what you think you see and what has EMR can discover details of the injury or illness
actually happened may not be the same thing. It that may otherwise go undiscovered.
is easy to make judgments that may turn out to be
incorrect. Communication may be difficult in times Communication among response team members
of stress, particularly if there are other factors is also a major part of responding to a medical
involved, such as language barriers or fear. For or trauma emergency. Communication is
this reason, the emergency medical responder important for EMRs, as they may need to call
(EMR) must be able to assess the situation and for additional resources to transfer patient care
work out the best methods of obtaining the needed to other responders or to the receiving facility.
information. Other factors such as background Communication is also important as it facilitates
noise may also inhibit communication between the interaction within the team structure. By using
EMR and other members of the team or patient. the appropriate communication techniques, and
Effective communication with the patient and understanding the equipment used and the type
212 | Emergency Medical Response
of information that needs to be relayed, the EMR and licensed by the Federal Communications
improves the quality of care provided to the patient. Commission (FCC).
The final element of emergency care is The base station is the hub of communications and
documentation. Records of all that has occurred, should be situated in the best possible location for
from the beginning of the call for help to the point sending and receiving signals. It must have access to
at which the patient has been transported to power and an antenna for maximum quality reception.
the receiving facility or to a higher level of care,
are extremely important. Proper and thorough Mobile radios are mounted in emergency vehicles.
documentation will assist more advanced medical Their ability to send and receive messages varies
personnel in continuing care and can help in any and is affected by terrain and objects, such as tall
associated legal proceedings. buildings, which may be in the vicinity.
Portable radios are handheld radios that are
particularly useful when you must be out of your
COMMUNICATING WITHIN THE vehicle. Their range is limited but can be boosted
EMERGENCY COMMUNICATIONS by use of a repeater, a device that receives a low-
SYSTEM powered radio signal and rebroadcasts it at a higher
power. Repeaters increase the amount of territory
For an emergency medical services (EMS) system you can access through radio communication.
to run properly, constant communication must be a
priority among its key components, which include: Digital equipment uses an encoder and a decoder,
which allow emergency personnel to communicate
The communications center (dispatch), which more easily, without overutilizing bandwidth. A mobile
is responsible for taking basic information data terminal uses data rather than voice instructions.
from callers and dispatching the appropriate The terminal is situated in the emergency vehicle, and
personnel. In some communities, the information is relayed from the base to the terminal
communications center may also provide (Fig. 9-1). The information is then displayed in text,
prearrival instructions to the 9-1-1 caller. to be read off the screen. To respond, emergency
The medical director and receiving facility, often personnel can transmit in the same manner or push a
a hospital. button to switch to voice mode.
The EMS personnel in the field.
Rules for Radio Communication
To work efficiently, the EMS system must have The FCC regulates the use of radio communication
a communications system geared toward its systems. Therefore, those who use these systems
particular needs. Often, this involves a radio must follow FCC rules. Ground rules for use of an
communication system and/or a mobile phone EMS radio communication system help ensure that
system for communication among members of information is communicated as completely and
its network. accurately as possible. (The FCC website can be
found at fcc.gov.)
Radio Communication
Here are some important FCC rules to follow when
System Components using an EMS radio communication system:
Radio communication for an EMS system is
composed of four key components, including the Use assigned or licensed EMS frequencies only
base station, mobile radios, portable radios and for EMS-related communication.
repeaters. All radios in the United States, including Before speaking, listen to make sure the channel
those used by EMS personnel, are regulated you are using is clear.
CRITICAL For an EMS system to run properly, constant communication among the
FACTS communication center, the medical director, the receiving facility and EMS
personnel must be a priority.
Radio communication for an EMS system is composed of four key components,
including the base station, mobile radios, portable radios and repeaters.
Chapter 9: Communication and Documentation | 213
Fig. 9-1: A mobile data terminal is situated in the emergency vehicle and displays information in text that has
been relayed from the base.
Close your vehicle windows to avoid distortions. individual digits (e.g., to avoid confusing 15 with
To communicate, press the push-to-talk (PTT) 50, say “fifteen,” then “one-five”).
button and wait 1 second before speaking. Give only objective, verifiable information
Speak slowly, with your lips about 2–3 inches and remember that others can listen in on
from the microphone. radio communications. Do not use patients’
names or other identifying information in your
Address the unit you are calling by its name and
communications.
number, and then identify yourself by your unit
name and number. Use “affirmative” and “negative” rather than
“yes” and “no.”
Wait for the unit to let you know they are ready
to receive your communication.
Use concise, clear and plain language in your Communicating with Dispatch
communications. Because of a lack of uniformity The communications center (dispatch)
across jurisdictions and the need for rapid and is also known as a public safety answering
clear communications from different responding point (PSAP). The role of dispatch is to receive
agencies in a major crisis, the 10 code system emergency calls and send the appropriate team
(operational/brevity codes) is being phased out to respond. Dispatch is the point of contact
in favor of plain language as required by the between the public and responders (Fig. 9-2). In
Department of Homeland Security (DHS) and the 9-1-1 system, emergency medical dispatchers
in support of the National Incident Management (EMDs) must decide which emergency service
System (NIMS). resources are required. Most EMS dispatch
Keep transmissions brief, organized and to the centers use a validated system to determine
point. Omit courtesy terms like “please” and the appropriate response based on information
“thank you.” received from the caller. These systems can be
When saying numbers that might be confused computer based but they are often a physical flip
with other numbers, say the number, then the card-type system.
CRITICAL Ground rules for use of a radio communication system, as set forth by the FCC,
FACTS help ensure that information is communicated completely and accurately throughout
the EMS system.
214 | Emergency Medical Response
Fig. 9-2: Dispatch serves as a liaison between the public and emergency response personnel.
EMDs (and the call takers who assist them) must if you have been relieved by more advanced
gather as much information as possible regarding medical personnel. When relaying information
the emergency. They also may advise callers about transport, you must inform dispatch of
about what the callers may be able to do while how many patients you have, the name of the
awaiting your arrival. Dispatchers note the time the receiving facility and your ETA.
call was received and the time they dispatched On arrival, notifying dispatch that you have
emergency services. Also, they usually record all arrived at the hospital or other designated
conversations and radio dispatches, in order to location such as a helicopter landing zone.
have an indisputable record of the events. (For
more information on EMDs, refer to Chapter 27.)
When the patient transfer is complete and you
are able to leave the hospital, letting dispatch
As an EMR and depending on the work setting, you know you are once again available for service.
are responsible for: You may have to contact dispatch again once
you return to your station or home base.
Receiving instructions from dispatch and
acknowledging receipt. Communicating with Medical Control
Providing an estimated time of arrival (ETA) to
Depending on your EMS system, medical control
dispatch, if requested, and reporting any delays
may or may not be located at the receiving facility.
along the route that may change the ETA.
There may be times when you must speak to
Announcing your arrival at the scene to dispatch, medical control while you are on scene. This would
and providing your assessment of whether most likely be in a situation in which standing
additional resources should be sent or if orders or protocols would not be sufficient and
assigned resources can be released. you have questions about the care provided to the
Informing dispatch when you leave for transport patient. Communications with medical control must
to the hospital or when your role is finished, be thorough but brief.
CRITICAL When communicating with medical control, always identify yourself and give all
FACTS relevant information on the patient and the care provided.
Successful interpersonal communication with patients and their families means
being empathetic, having awareness of cultural differences, showing sensitivity to
an individual’s emotions and listening effectively.
Chapter 9: Communication and Documentation | 215
When communicating with medical control, provide Communicating with the
the following information: Receiving Facility
Who you are (unit, level of service and your role) As soon as possible, the transport crew should
notify the receiving facility about the patient, any
Patient characteristics (age, gender, chief
special alerts concerning the patient’s condition
complaint)
and the ETA. The receiving facility (medical control)
The patient’s mental status
or operator is informed if there are any changes in
SAMPLE (signs and symptoms, allergies, the patient and the ETA, and communicates any
medications, pertinent medical history, last oral changes in the patient’s condition.
intake, events leading up to the incident) history
Relevant information about past illnesses When communicating with the receiving facility,
give the following information:
Vital signs and results of your physical
assessment
Who you are (unit and role)
Any care you provided and the patient’s
How many patients will be arriving
response to the care
Patient characteristics (age, gender, chief
Your questions complaint)
Ask whether you should perform any further Immediate history (events leading to the injury or
actions, and estimate when you will arrive at the illness)
receiving facility. Whenever you receive medical Any care you provided and the patient’s
direction, repeat the order word for word. This response to the care
is called closed-loop communication. Write Any vital information, such as the need for
down important or lengthy medical instructions. isolation or specialized services (e.g., a trauma
team)
Communicating with Medical ETA
Personnel At the receiving facility, crew members will
When other EMS personnel arrive on the scene, provide additional information about the scene
identify yourself and give a verbal report. Interact and the patient(s). They will also complete
within the team structure, communicating any whatever documentation is necessary to
information concerning the patient and the scene to meet local or state standards and their
law enforcement and other responders (Fig. 9-3). organization’s protocols.
Fig. 9-3: Communicate any information regarding the patient and the scene to other EMS personnel who
arrive, working within the team structure. Photo: courtesy of Terry Georgia.
216 | Emergency Medical Response
Mobile Phone Communication Communicate with patients in a way that achieves
a positive relationship. Before doing anything,
Mobile phones are becoming more popular in some
unless it is a life-threatening situation, introduce
EMS districts. They can be useful for covering
yourself to the patient and family members, if
longer distances than radio communication,
present. Tell the patient what your role is and what
and their sound clarity in communication is
you will do. Introducing the other members of your
usually superior. Since mobile phones are fairly
team is also important.
maintenance-free and provide the ability for direct
communication between parties, they are also Medical and trauma emergencies can be
often used as backup sources of communication frightening to those involved. When speaking to an
should the radio system fail. However, there are injured or ill person and family members, be sure
drawbacks to mobile phones. For example, in to speak slowly and clearly (Fig. 9-4). Avoid using
cases of emergencies that involve multiple people, medical terms and abbreviations, and speak in
mobile phone service can be compromised due to words that are easily understandable.
system overload and it often cannot be recorded
to assist in creating a record of events and orders If possible, try to adapt the physical environment
received. Mobile phones are also impractical for to facilitate communication by making sure there
multiunit coordination. is adequate lighting and that you have minimized
distractions such as noises, interference from
others and noisy equipment nearby. Get down
INTERPERSONAL to the patient’s eye level to avoid appearing
COMMUNICATION threatening. Make eye contact and use body
Every person deserves equal care, dignity and language that shows you are open and interested
respect for their differences including age, in what people have to say, for example, standing
language, ethnicity, culture or socioeconomic with arms at your sides instead of crossed, and
status. To be empathetic means to understand, with hands open rather than in closed fists.
to be sensitive to cultural differences and to the
thoughts, feelings and experiences of another One way to put people at ease is to address
person. In order to listen effectively to what is being them by name, whenever possible. Note, however,
said to you, it is important that you have empathy that if the patients are older adults, as a matter
for the people involved. of showing respect, you should not call them by
Fig. 9-4: Medical or trauma emergencies can be frightening. Speak clearly and slowly. Photo: courtesy
of Ted Crites.
Chapter 9: Communication and Documentation | 217
their first names unless invited to do so. A general may lead you to another related one. Asking more
rule of thumb is to address individuals in the than one question at a time may provide confused
way that they introduce themselves to you. For responses. Avoid interruptions as much as
example, if the patient and family member introduce possible. Allow the patient to finish a thought. If you
themselves as Mr. and Mrs. Smith, you should need clarification, ask questions at the end of the
address them as such. patient’s statement.
If possible, have the patient tell you their name and Depending on the type of information you are
what problems they are having. It may be instinctive trying to find out, you may want to ask closed
for family members or friends to do so, but it is or direct questions, to which patients should
best if you can have the patient speak, so you can be able to give you a “Yes” or “No” answer or
observe the patient’s ability to communicate, level a short answer. For example, you might ask,
of consciousness (LOC) and mental status. You “Did you have something to eat?” or “What time
can also learn a lot about physical problems just by was it when you last ate?” For more detailed
observing people while they are talking. If someone information, you may need to ask more open-
can only speak a few words before needing to ended questions, which allow for more detailed
take a breath, for example, that may mean there is answers. This type of question may be a little
a respiratory emergency. Someone clutching the more difficult for patients to answer but can
stomach or chest may be doing so without being provide answers with greater depth. A typical
aware of it, and this can give you information. open-ended question might be, “How are you
Someone who winces with pain should be asked feeling right now?”
about the pain. If the patient cannot speak or is
From the patient’s perspective, not being listened
unable to give you information, then ask bystanders
to can be frustrating. Consider the last time you
for the information.
had to repeat information to someone several
Listen carefully to what the injured or ill person times; it is not a pleasant experience. Listening
is telling or trying to tell you. Observe the patient lets people know you believe they are important.
as you listen (Fig. 9-5). Provide reassurance if If you ask a question, listen for the answer. Make
there seems to be some reluctance to speak notes, if necessary, so you do not forget what was
about a topic. Mention that any information you said. If you forget too often, the patient may stop
are told about the problem may be important and answering your questions.
will remain confidential, even if it is upsetting to As you interview the patient or bystanders, be
talk about. Attempt to gather patient information careful to avoid the pitfalls of interviewing. For
in a private setting that is away from bystanders. example, be sure to word questions so that you
Individuals may feel uncomfortable giving do not provide false assurance or reassurance.
information about the situation in front of others. Avoid giving advice or asking leading or biased
Because of the stressful nature of the situation, it questions. Try to let the person you are interviewing
is always best to ask one question at a time so the do most of the talking, and do not interrupt. Avoid
person answering can concentrate while giving asking “Why” questions, which can be perceived
the answers. Also, the answer to one question as judgmental; in most circumstances you do
not need to know why something happened, only
what happened.
Listen to what bystanders tell you; they may
have seen or heard something that will help you
determine how to care for the patient. But, after
they have provided the information you require,
you must consider the patient’s privacy while you
continue to assess the situation and provide care.
Often, bystanders want to stay and watch. Be
firm but reasonable with bystanders. Ask them to
move away for the safety and comfort of everyone.
If a crowd appears that could become hostile,
explaining your role may set the crowd at ease. If,
Fig. 9-5: Making eye contact with a patient helps them feel more however, the crowd appears to be threatening, call
comfortable. for backup from the appropriate service.
218 | Emergency Medical Response
It is important not to make judgments about a Documentation of injuries and illnesses is also
patient on the basis of cultural or other differences, useful when analyzing current response practices
such as the patient’s physical appearance. Instead, and protocols and planning preventative action
be more mindful of your own physical appearance. for the future. Records are also used for quality
By being neat and well groomed, you help give assurance (QA) and quality improvement (QI)
both patients and their family members a sense of practices within a department.
confidence in you.
If you are providing care for someone who speaks a PREHOSPITAL CARE REPORT
language you do not understand, call for someone
who can translate. A family member or neighbor, for Description and Uses of the
example, may be able to speak both your language Prehospital Care Report
and that of the patient. Some dispatch centers and A prehospital care report (PCR), also
hospitals also offer language line services, which called a run report or trip sheet, is the essential
may be useful. documentation for each emergency call (Fig. 9-6).
The primary function of this report is to ensure
Watch the patient’s body language, whether your high-quality patient care. Hospital and other more
language is spoken or not. Nonverbal clues can help advanced medical personnel need to know what
determine what is wrong. Be sensitive to cultural transpired during a call in order to provide the
differences; in some cultures, it may be inappropriate patient with appropriate continuity of care. This
to make eye contact or for someone of the opposite information allows medical personnel to determine
gender to help the patient. There are also cultural what treatment the patient needs and which
differences that relate to the appropriate distance complaints must be addressed first. The PCR can
to stand apart from another person. Respect these also be used to evaluate care provided and identify
differences and do what you can to help. areas where quality of care requires improvement
in future scenarios. Keeping good records allows
EMRs to learn from both successes and failures.
THE IMPORTANCE OF
DOCUMENTATION The PCR has multiple functions. As mentioned
before, the PCR also serves as a legal document,
Documentation procedures are established by
particularly if the responder was present at the
state regulations or local policy and may vary from
scene of a crime or if the incident leads to legal
state to state and one EMS system to another.
proceedings. It is not uncommon to be called to
Documenting your care is as important as the care
testify in court years after the response. In addition,
provided. Your record will help more advanced
the PCR is a valuable educational and research
medical personnel to assess the patient and
tool. The information may be used in research
continue care. It is important to write the record as
projects on a variety of issues, including studies on
soon as possible after the emergency, while the
the safety and efficacy of certain interventions, the
information is fresh. Because a patient’s condition
cost-effective implementation of patient care or the
may change before arriving at the receiving facility,
typical presentation of certain injuries or illnesses.
a record of the condition immediately after the
The PCR also has an administrative function—
emergency will provide useful information for
serving as an important part of the patient’s
responders and emergency department staff. They
medical record. It may be used for billing, insurance
can compare the current condition with what you
reimbursement or maintaining statistics on hospital
recorded earlier.
emergency services.
Your record is a legal document and is important Given the importance and multiple functions of
if legal action occurs. Should you be called to the PCR, it is crucial that the PCR is filled out
court for any reason, your record will support what accurately, completely and correctly. Some PCRs
you saw, heard and did at the emergency scene.
CRITICAL A PCR is the essential document of every emergency call. Not only does it serve
FACTS as a patient’s medical record, it also fulfills important legal, educational and
administrative functions. Documentation procedures and regulations are set forth
locally or through the state.
Chapter 9: Communication and Documentation | 219
PREHOSPITAL CARE REPORT PCR# ________________
Call Date Provider Number Unit Number Incident Number Interfacility Transfer Number Call Disposition
___/___/___
Response Transport Time of Time Time First ALS Time Arrived Time Left Scn / Time Arrived Contact Made with: Time of Contact
Call Enroute on Scene on Scene Call Canceled at Destination Base Hospital
1 Code 1 Receiving Facility
2 2 : Control Facility
:
3 3 : : : : : None
Patient Name (Last, First, Mi) Patient Address Incident Location
____________________________________________ ____________________________________________
Patient Age Patient DOB Patient Gender Est. Patient Weight County Map Zone No. Pts. At Scene
Mos Male
Yrs ___/___/___ Female kg
Chief Complaint ___________________________________________ Pain Level: __ Allergies ____________________________
Medical History _____________________________________________________ Medications __________________________
_______________________________________________________________ _________________________________
_______________________________________________________________ _________________________________
_______________________________________________________________ _________________________________
Initial Physical Examination GCS Mechanism
of Injury
Unremarkable Eye Verbal Motor
4 spont 5 oriented 6 obeys
Head 3 voice 4 confused 5 localizes
2 pain 3 inapprop 4 withdrwl
Neck 1 none 2 incompr 3 flexion Types of
1 none 2 extensn Illness/Injury
Chest 1 none
Abdomen
Time E V M Total
Back : ___+___+___ =
Pelvis : ___+___+___ =
Limbs
: ___+___+___ =
Neuro
Skin Signs
Field Clinical Impression:
Care Giver Time Procedure / Medication (with dose, route) Response / Comments / ECG Resp Blood Pulse Pain
FD/PD/BS/PH CODE DESCRIPTION (MD Signature: Base Order) Rate Pressure Rate Level
: /
: /
: /
: /
: /
: /
: /
: /
: /
: /
: /
: /
Medication Wasted: Time: Signature: Witness Signature:
Special Scene Conditions: Safety Eq Used: MVA Conditions: Destination Decision Reason Receiving Hosp
ALS w/o base contact MCI Lap Restraint Bent steering wheel Nearest Rec. Facility Triage to trauma center
Complicated extrication Multiple EMS providers Lap/Shoulder restraint Death in same vehicle MCI/DCF Triage to other specialty center
DNR Possible provider exposure Child Safety seat Ejection Physician request Other
Drug use suspected Unsafe scene Airbag Passenger comptmnt intrusn Pt/Family request ________________ Base Hospital
ETOH use suspected Other: Helmet Rollover
Hazardous materials Protective Clothing
Tier I Trauma Triage: Tier II Trauma Triage Pediatric Trauma Triage Base
GCS Motor Score < 5 Flail Chest Open/depress, skull fx Glasgow Coma Score Motor Component < 5 AND MD
Systolic BP < 85 Combo Burn/Trauma Paralysis BP < 80 if patient over age 6; < 70 if under 6 ___________
Penetrating Trauma: Head, Neck, Chest, Torso 2 or more long bone fx. Amput. Prox. wrist/ankle Advanced airway or continuous support of airway
Paramedic Judgement Pelvic fracture Fall > 20 ft. Penetrating trauma: head, neck, chest, torso or proximal to
MICN
pedestrian thrown/run over Pregnancy elbow/knee with vascular compromise
Judgement of the paramedic or flight nurse Flail Chest Pelvis Fracture
Amput. Prox. wrist/ankle Traumatic paralysis __________
Care Transferred To Cert. Number Name (print) Signature
A)
Agency Time
: B)
Name
C)
Continuation form used
Fig. 9-6: The PCR is essential for proper documentation of an emergency.
220 | Emergency Medical Response
Fig. 9-7: PCRs should be filled out accurately, completely and correctly, regardless of whether they are
written or electronic. Photo: courtesy of Captain Phil Kleinberg, EMT-P.
are completed with pen and paper, while many and respiration rate. In an E-PCR, these often
others are filled out electronically and called an appear as drop-down menus.
E-PCR (Fig. 9-7). 4. Patient narrative. The patient narrative section
is an open-ended portion of the PCR in which
Sections of the PCR a description of the assessment and care is
provided. The goal is to provide a complete
Typically, the four sections of a PCR include:
and thorough picture of what went on and
1. Run data. The run data section contains what the patient’s condition is. This section
administrative information, including the time must include the SAMPLE history, the patient’s
the incident was reported, when the unit was chief complaint (in the patient’s own words,
notified, when the unit arrived and left the if possible), how the chief complaint began
scene, when the unit arrived at its destination and how it progressed, and the mechanism
and when the transfer of care was made. It of the injury or nature of illness. It should also
also includes such information as the EMS unit include relevant details of the patient’s medical
number, names of the EMS crew members, and history. It is important to remain objective in this
their levels of certification and the address to section: that is, describe what happened but
which the unit was dispatched. do not draw any conclusions about the situation.
2. Patient data. The patient data section contains
all the background information on the patient, Minimum Data Set
including legal name, age, gender, birth date, The minimum data set refers to all the
home address, Social Security Number (where information that must be included in the PCR.
required), and billing and insurance information. It consists of the following:
It also contains the time the incident occurred,
address where the patient was picked up and Patient information gathered by the EMR
any care the patient received before EMS yyTime of events
personnel arrived. yyAssessment findings, including the following:
3. Check boxes. The check boxes section, as the Chief complaint
name implies, contains a series of boxes that LOC
are checked in accordance with the patient’s Systolic and diastolic blood pressure
condition. The check boxes refer to information Skin perfusion (capillary refill)
about the patient, including vital signs (often Skin color and temperature
more than one set must be taken), chief Pulse rate
complaint, level of consciousness, appearance Respiratory rate and effort
Chapter 9: Communication and Documentation | 221
yyEmergency medical care provided care you recommended providing to the patient,
yyPatient demographics, such as age and gender and make one last effort to convince the patient to
yyChanges in the patient after care and who the accept this care before leaving the scene. Be sure
patient was turned over to to include in the PCR that the patient received a
yyObservations at the scene complete explanation of the possible consequences
yyDisposition (e.g., whether the patient refused of refusing care, including the risk of death if this is
care or was transported to a hospital) appropriate. Offer the patient alternative methods
Administrative information of obtaining care, such as visiting the patient’s
yyTime the incident was reported family healthcare provider. Tell patients that you or
yyTime the unit was notified another EMS team is willing to return to the scene
yyTime unit en route to the call should they change their decision. Make sure this
yyTime the unit arrived at the scene is all documented in the PCR and is signed by the
yyTime the unit left the scene patient and a witness, if available. Always follow
yyTime of arrival at the receiving facility local protocols for refusal of care as they may differ
yyTime of transfer of care from state to state. (For more information on refusal
yyTime unit available for next call of treatment, see Chapter 3.)
Note that it is important to use accurate and
synchronous clocks to allow all involved to gather Falsification
accurate medical information. For example, it The PCR must be a thorough and accurate
is important to know details such as how long record of what occurred during a call. Any error
the patient was in cardiac arrest. The National of omission or commission in care must be
EMS Information System (NEMSIS), which is a highlighted in the PCR, along with any steps that
system to gather data on the local and state level were made to correct the situation. Only document
of EMS systems and prehospital care, can be a the facts on the PCR. Do not leave anything out
helpful tool for tracking data in the local area and and do not add anything that was not done.
benchmarking services, regions and states for
Be aware that falsification of a PCR is a serious
system and patient care improvement opportunities.
offense. It can lead to revocation of your
certification or license and even to criminal
Confidentiality charges. More seriously, it can significantly
Control of the contents of a PCR falls within the compromise patient care.
Health Insurance Portability and Accountability Act
(HIPAA). HIPAA has strict rules about how patient Parts of the PCR that are most frequently falsified
information is used and distributed. Violation are vital signs and treatment. EMRs who forget to
of HIPAA rules can have severe penalties. The measure vital signs have been known to make them
contents of the PCR must be kept confidential, up, or those who forget certain crucial treatments,
as it contains personal and potentially sensitive such as administering supplemental oxygen to a
information about the patient. While in your care, it patient with chest pain, may fail to mention this
is your responsibility to ensure that the PCR is in error. Be honest; it is far better for you and the
appropriate hands. (For more information on HIPAA patient if you own up to your mistakes up front.
and confidentiality, refer to Chapter 3.)
TRANSFER OF CARE
Refusal of Treatment When more advanced medical personnel arrive on
While any competent adult has the right to refuse the scene, you will need to give a verbal report on
treatment, questions may come up later as to the number of patients involved, their conditions
whether the patient was truly competent at the time and the emergency situation. If a multipart PCR
of refusing treatment. Therefore, it is important to is available, the copy should be transferred with
perform as complete an assessment of the patient the patient. This relieves the transferring provider
as is possible, given the situation. For a patient who from having to collect redundant information, thus
refuses treatment, record on the PCR exactly what saving time.
CRITICAL Control of the contents of a PCR falls within HIPAA.
FACTS
222 | Emergency Medical Response
Specifically, you will need to provide the following PUTTING IT ALL TOGETHER
information about the patient(s):
Communication and documentation are a major
Current condition part of providing emergency care. It is important
for everyone on the team to understand what is
Age and gender
going on and what happened before they arrived
Chief complaint
on the scene. This is only possible through
Brief, pertinent history of what happened good communication with patients, bystanders
How you found the patient(s) and colleagues.
Major past injuries or illnesses
Although emergency situations may make
Vital signs
it difficult for some patients to effectively
Pertinent findings of the physical exam(s) communicate, the EMS team, by showing
Emergency care provided and the response confidence and encouragement, can
to care successfully elicit the required information.
Effective communication within the response
team is based on understanding the modes
SPECIAL SITUATIONS of communication (radios, phones), factors for
Documentation of the emergency situation and effective communication (speaking clearly, using
the care you provided is not only important for correct terminology) and speed of communication.
the patient, but also may prove essential for local By following the rules and protocols of your region,
authorities when legal matters are involved. It is miscommunication should be kept to a minimum.
particularly important to report any abuse, exposure
to dangerous situations or injuries. Documentation is the final step in providing
emergency care. State laws and regulations
Once your report is complete, it should be require that documentation be done as accurately
submitted to the proper authorities in the proper and as soon as possible following the emergency
time frame and should include the names of all situation. In the midst of the emergency, it is
agencies, people and facilities involved in the possible to forget instructions or answers to
emergency response. questions, so it is best to take notes when asking
questions of patients and bystanders, and also
As always when writing these legal documents, when receiving instructions from medical control.
be objective. Write only the facts and your
observations; do not write your own subjective Always remember to be objective in your reports as
comments or opinions and do not draw any of your these documents may be used for legal purposes
own conclusions. The only subjective comments or or for evaluating procedures. Finally, keep a copy
opinions should be those of the patient. Be sure to of all records for yourself based on local protocols;
sign and date the document. Always keep a copy for this will allow you to have access to the information
your own records while making copies to distribute should it be needed.
to the proper authorities based on local protocols.
Your region or location will have its own standards
and procedures, which will indicate which authorities
are authorized to receive this documentation.
You Are the Emergency Medical Responder
As you assess the older adult patient, you learn that her chief complaint is that she “blacked
out” momentarily and fell. The patient is afraid that she has broken her hip. She has pain in her
pelvis and is unable to move her left leg. You give a verbal update to the EMS personnel who
have just arrived to take over medical care and transport the patient.
Why is it important for communications to be brief and concise? What are some examples of
effective interpersonal communication? Why is it important to thoroughly document your call,
observations and actions?
Chapter 9: Communication and Documentation | 223
UNIT 3
Airway
10 Airway and Ventilation�����������������������������������������������225
11 Airway Management�������������������������������������������������� 258
12 Supplemental Oxygen������������������������������������������������281
10 AIRWAY AND
VENTILATION
You Are the Emergency Medical Responder
Your medical emergency response team has been called to the fitness center by building
security, on a report of an employee who complained of having difficulty breathing. You
and your partner arrive and find the employee conscious with a chief complaint of difficulty
breathing. The patient says he just “overdid it” on the treadmill. He appears to be out of
breath and is having trouble speaking in full sentences. You begin a primary assessment
and determine that the patient is in respiratory distress. What should you do? What can
you do to assist the patient with his breathing?
KEY TERMS
Apnea: A condition that causes breathing to stop Finger sweep: A method of clearing the mouth of
periodically or be significantly reduced. foreign material that presents a risk of blocking
the airway or being aspirated into the lungs.
Artificial ventilation: A mechanical means
used to assist breathing, such as with a Foreign body airway obstruction (FBAO): The
bag-valve-mask (BVM) resuscitator or presence of foreign matter, such as food, that
resuscitation mask. obstructs the airway.
Aspiration: To take, suck or inhale blood, vomit, Hyperventilation: Rapid, deep or shallow breathing;
saliva or other foreign material into the lungs. usually caused by panic or anxiety.
Asthma: An ongoing condition in which the Hypoxia: A condition in which insufficient oxygen is
airways swell; the air passages can become delivered to the body’s cells.
constricted or blocked when affected by
various triggers. Midaxillary line: An imaginary line that passes
vertically down the body starting at the axilla
Asthma attack: The sudden worsening of asthma (armpit); used to locate one of the areas for
signs and symptoms, caused by inflammation of listening to breath sounds.
the airways and the tightening of muscles around
the airways of a person with asthma, making Midclavicular line: An imaginary line that passes
breathing difficult. through the midpoint of the clavicle (collarbone)
on the ventral surface of the body; used to locate
Asthma trigger: Anything that sets off an asthma one of the areas for listening to breath sounds.
attack, such as animal dander, dust, smoke,
exercise, stress or medications. Midscapular line: An imaginary line that passes
through the midpoint of the scapula (shoulder
Bag-valve-mask (BVM) resuscitator: A handheld blade) on the dorsal surface of the body;
breathing device consisting of a self-inflating bag, used to locate one of the areas for listening
a one-way valve and a face mask; can be used to breath sounds.
with or without supplemental oxygen.
Overventilation: Blowing too much air into
Breathing emergency: An emergency in which the patient, which can enter the stomach,
breathing is impaired; can become life threatening; causing gastric distention and likely vomiting.
also called a respiratory emergency. Overventilation can also increase the amount
Chronic obstructive pulmonary disease (COPD): of pressure in the chest, which compresses the
A progressive lung disease in which the patient blood vessels returning to the heart, thus limiting
has difficulty breathing because of damage to the effective circulation.
lungs; airways become obstructed and the alveolar
Oxygenation: The addition of oxygen to the body;
sacs lose their ability to fill with air.
also, the treatment of a patient with oxygen.
Crackles: An abnormal fine, crackling breath sound
Paradoxical breathing: An abnormal type
on inhalation that may be a sign of fluid in the
of breathing that can occur with a chest
lungs; also known as rales.
injury (e.g., flail chest); one area of the chest
Cricoid: A solid ring of cartilage just below and moves in the opposite direction to the rest of
behind the thyroid cartilage. the chest.
Cyanosis: A condition in which the patient’s skin, Pathophysiology: The study of the abnormal
nail beds and mucous membranes appear a bluish changes in mechanical, physical and biochemical
or greyish color because of insufficient levels of functions caused by an injury or illness.
oxygen in the blood.
Pneumonia: A lung infection caused by a virus
Deadspace: The areas within the respiratory or bacterium that results in a cough, fever and
system between the pharynx and the alveoli difficulty breathing.
that contain a small amount of air that does not
reach the alveoli. Positive pressure ventilation: An artificial
means of forcing air or oxygen into the lungs
Emphysema: A chronic, degenerative lung disease of a person who has stopped breathing or
in which there is damage to the alveoli. has inadequate breathing.
(Continued)
226 | Emergency Medical Response
KEY TERMS continued
Pulmonary embolism: Sudden blockage of an Stridor: An abnormal, high-pitched breath sound
artery in the lung; can be fatal. caused by a blockage in the throat or larynx;
usually heard on inhalation.
Rales: An abnormal breath sound; a popping,
clicking, bubbling or rattling sound, also known Suctioning: The process of removing foreign
as crackles. matter, such as blood, other liquids or food
particles, by means of a mechanical or manual
Respiratory failure: Condition in which the suctioning device.
respiratory system fails in oxygenation and/or
carbon dioxide elimination; the respiratory Tidal volume: The normal amount of air breathed
system is beginning to shut down; the person at rest.
may alternate between being agitated and sleepy.
Ventilation: The exchange of air between the lungs
Resuscitation mask: A pliable, dome-shaped and the atmosphere; allows for an exchange of
breathing device that fits over the mouth and oxygen and carbon dioxide in the lungs.
nose; used to provide artificial ventilations and
administer supplemental oxygen. Wheezing: A high-pitched whistling sound
heard during inhalation but heard most
Rhonchi: An abnormal breath sound when breathing loudly on exhalation; an abnormal breath
that can often be heard without a stethoscope; sound that can often be heard without
a snoring or coarse, dry rale sound. a stethoscope.
LEARNING OBJECTIVES
After reading this chapter, and completing the class • Relate the maneuver used to open the airway to
activities, you will have the information needed to: the mechanism of injury.
• Describe the structure and function of the • Explain why basic airway management and
respiratory system. ventilation skills take priority over many other
basic life-support skills.
• List the signs of inadequate breathing.
• Describe how to perform mouth-to-mouth,
• Describe how to care for a patient experiencing mouth-to-nose and mouth-to-stoma ventilations.
respiratory distress.
SKILL OBJECTIVES
After reading this chapter, and completing the class • Demonstrate how to give ventilations if a head,
activities, you should be able to: neck or spinal injury is suspected.
• Demonstrate how to give ventilations using a • Demonstrate how to assist a patient with an
resuscitation mask. asthma inhaler (Enrichment skill).
• Demonstrate how to give ventilations using a
bag-valve-mask (BVM) resuscitator.
INTRODUCTION The airway is the pathway from the mouth and
nose to the lungs. A person who can speak or cry
Because oxygen is vital to life, always ensure that is conscious, has an open airway, is breathing and
the patient has an open airway and is breathing. has a pulse. It is more difficult to tell if an unconscious
Ensuring an open airway is one of the most important person has an open airway. You will have to take into
steps you can take for any patient. Without an consideration possible injury or illness.
open airway, a person cannot breathe and will die.
Chapter 10: Airway and Ventilation | 227
Once you have an open airway, you may need to the trachea during swallowing, so that food
to clear any obstructions and then assess cannot enter. This airway protection does not occur
breathing. If the person is experiencing a if a person is unconscious.
breathing emergency, you may need to provide
artificial ventilations. Once air has traveled through the pharynx, it passes
through the larynx. At the top of this structure,
A breathing emergency is often detected during made mostly of cartilage, muscle and membranes,
the primary assessment. In a breathing emergency, is the hyoid bone—a horseshoe-shaped bone that
a person’s breathing can become so impaired that supports the structures of the larynx below and
life is threatened. There are two types of respiratory attaches to the tongue and other oral structures
emergencies: respiratory distress, a condition in above. Below the hyoid bone are the thyroid and
which breathing becomes difficult; and respiratory cricoid cartilages, which form the larynx. Within
arrest, a condition in which breathing stops. the larynx lie the vocal cords, narrow muscles that
stretch horizontally across from anterior to posterior.
This chapter will address the causes, signs and
symptoms of respiratory emergencies. Some The lower airway tract begins below the level of the
of these emergencies are caused by chronic vocal cords, and consists of the trachea, bronchi
conditions such as chronic obstructive pulmonary and lungs. The trachea, or windpipe, is a hollow
disease (COPD), and others are caused tube, supported by rings of cartilage. It extends
by acute emergencies such as asthma and downward until it divides into two branches called
pulmonary embolism. bronchi, one of which travels into each lung. The
two bronchi are hollow tubes, also supported by
THE RESPIRATORY SYSTEM cartilage, that further divide into lower airways
called bronchioles.
Anatomy
The respiratory system is divided into the upper and Bronchioles are thin hollow tubes that lead to
lower airway tracts. The upper airway tract begins the alveoli, and that remain open through smooth
where air enters the respiratory system, through muscle tone. The millions of alveoli are small
the mouth and nose. Air that is inhaled through the sacs that form the end of the airway. Each one
nose is warmed and humidified. Air may also be has a thin walled sac that shares a wall with the
inhaled through the mouth and over the tongue, capillary blood vessels in contact with it. It is at
within the oral cavity. The mouth provides an airway, this site, where the one-celled walls of the alveoli
especially during an emergency. and capillaries come into contact, where external
respiration—the exchange of oxygen and carbon
Once air is inhaled, it passes through the throat, dioxide between the respiratory and circulatory
or pharynx. The pharynx is divided into three parts, system—takes place.
from superior to inferior: the nasopharynx, the
oropharynx and the laryngopharynx. The nasopharynx The circulatory system then transports the
lies behind the nasal cavity. The oropharynx lies oxygen-rich blood to the brain, organs, muscles
behind the oral cavity and is the shared passageway and other parts of the body. Some body tissues,
for both food and air. such as those in the brain, are very sensitive to
oxygen deprivation. Other vital organs can be
Below the oropharynx is the laryngopharynx, the adversely affected unless oxygen supplies are
lowest part of the throat, which divides into two restored quickly. The brain is the control center for
passageways. In the posterior (back) portion is the breathing. It adjusts the rate and depth of breaths
entrance to the esophagus, the passageway for according to the oxygen and carbon dioxide levels
food. In the anterior (front) is the larynx, which is in the body. Breathing requires that the respiratory,
the continuation of the respiratory system. Above circulatory, nervous and musculoskeletal systems
the larynx is the epiglottis, a flap of cartilage that work together. Injuries or illnesses that affect any of
folds down over the larynx to close off the entrance these systems may cause breathing emergencies.
CRITICAL Ensuring an open airway is one of the most important steps you can take in caring for
FACTS a patient, because a person cannot breathe without an open airway. A patient who
can speak or cry is conscious, has an open airway, is breathing and has a pulse.
228 | Emergency Medical Response
Pathophysiology at the cellular level between the capillaries and
the cells. If an insufficient amount of oxygen
Normal breathing occurs in ambient (surrounding)
is delivered to the cells, this is referred to as
air, which contains all the necessary gases for
hypoxia, and may result from an obstructed
normal respiration. Patients may suffer breathing
airway, shock, inadequate breathing, drowning,
difficulties because of an inadequate amount of
strangulation, choking, suffocation, cardiac arrest,
oxygen breathed in during respiration. Breathing
chest or head trauma, carbon monoxide poisoning
difficulties may also occur as a result of breathing
or complications of general anesthesia.
in a low-oxygen environment or when poisonous
gases are in the air. Other causes of breathing
difficulties include infection of the lungs; illnesses RESPIRATORY EMERGENCIES
such as asthma, which narrows the airway and
A respiratory emergency occurs when air cannot
causes wheezing; excess fluid in the lungs or
travel freely and easily into the lungs, and can be
excess fluid between the lungs and blood vessels;
life threatening because it greatly cuts down on
traumatic injuries to the lungs that cause bruising
the oxygen the body receives or because it cuts
(lung contusion); and poor circulation.
off the oxygen entirely. This can stop the heart
Breathing difficulties may also develop due to and prevent blood from reaching other vital
upper airway problems caused by swelling, organs. Unless the brain receives oxygen within
obstruction or trauma. Swelling of the upper airway 4 to 6 minutes, brain damage is possible. Within
can occur due to anaphylaxis (severe allergic 6 to 10 minutes, brain damage is likely, and after
reaction) or asthma. Choking, caused by airway 10 minutes, brain damage is certain (Fig. 10-1).
obstruction, is one of the most common causes
of breathing emergencies, and can occur due to
anatomical or mechanical obstruction. Trauma can
occur due to a blow to the upper chest, a puncture
or a crush injury.
Breathing problems may develop because of
ineffective circulation. This can be the result
of shock—an acute condition in which the
circulatory system fails to adequately circulate
oxygen-rich blood to all cells of the body—or
cardiac arrest, when the heart stops functioning
as a pump.
Sometimes the rate or depth of breathing is
inadequate, leading to an insufficient volume of
air moving into and out of the lungs. Respiration
may be ineffective due to unconsciousness,
altered level of consciousness, injury to the chest,
poisoning, overdose, or diseases such as COPD
or emphysema.
Oxygenation refers to the amount of oxygen in
the bloodstream. Oxygen is exchanged between
the alveoli of the lungs and the capillaries, and Fig. 10-1: Time is critical in respiratory emergencies.
CRITICAL There are many reasons why a person may have difficulty breathing. Reasons
FACTS include an inadequate amount of oxygen being taken in, a low-oxygen environment,
the presence of poisonous gases, infection, trauma, poor circulation or other
health-related issues.
Oxygenation refers to the amount of oxygen in the bloodstream. Hypoxia is the term
used to describe an insufficient amount of oxygen delivered to the cells.
Chapter 10: Airway and Ventilation | 229
There are two types of respiratory emergencies: become partly obstructed and the alveolar sacs
respiratory distress, a condition in which breathing lose their ability to fill with air, making it difficult
becomes difficult, and respiratory arrest, a for air to be inhaled and exhaled.
condition in which breathing stops.
The most common cause of COPD is cigarette
Respiratory distress can be caused by: smoking, but it may also be caused by inhaling
other types of lung irritants, pollution, dust or
A partially obstructed airway. chemicals over a long period of time. It is usually
Illness. diagnosed when patients are middle aged or older.
Chronic conditions such as asthma. Combined with asthma, COPD is the third-ranking
Electrocution, including lightning strikes. cause of death in the United States and a major
cause of illness.
Heart attack.
Injury to the head, chest, lungs or abdomen. Signs and symptoms include the following:
Allergic reactions.
Drugs. Coughing up a great deal of mucus
Poisoning. A tendency to tire easily
Emotional distress. Loss of appetite
Bent posture with shoulders elevated and
Trouble breathing can be the first sign of a more lips pursed to make breathing easier
serious emergency such as a heart problem. A fast pulse
Recognizing the signs of breathing problems and
providing care are often the keys to preventing
Round, barrel-shaped chest
these problems from becoming emergencies that Confusion (caused by lack of oxygen to
the brain)
are more serious.
Patients with COPD require help focusing on
If you encounter someone with a breathing problem,
breathing, as deep breaths help fill the lungs with
the patient will most likely be conscious. Breathing
air and maintain flexibility in the chest wall. Patients
problems can be identified by watching and
can learn special breathing exercises to help them
listening to the patient’s breathing and by asking
relax and breathe slowly, which increases the flow
how the patient feels. Although breathing problems
of oxygen to the lungs.
have many causes, you do not have to know the
exact cause of a breathing emergency to care for it.
Asthma
Signs and symptoms of respiratory emergencies
Asthma is an ongoing illness in which the
include:
airways swell. An asthma attack happens when
Slow or rapid breathing. an asthma trigger, such as exercise, cold air,
allergens or other irritants, affects the airways,
Unusually deep or shallow breathing.
causing them to suddenly swell and narrow.
Gasping for breath.
This makes breathing difficult, which can be
Wheezing, gurgling or high-pitched noises. very frightening.
Unusually moist or cool skin.
The Centers for Disease Control and Prevention
Flushed, pale, ashen or bluish skin color.
(CDC) estimates that approximately 24 million
Shortness of breath.
Americans are diagnosed with asthma in their
Dizziness or light-headedness. lifetimes. Asthma is more common in children
Pain in the chest or tingling in the hands, feet and young adults than in older adults, but its
or lips. frequency and severity are increasing in all age
Apprehensive or fearful feelings. groups (Fig. 10-2). Asthma results in about
1.6 million visits to emergency departments
Chronic Obstructive annually in the United States.
Pulmonary Disease You can often tell when a person is having an
Chronic obstructive pulmonary disease asthma attack by the hoarse whistling sound the
(COPD) is a progressive lung disease in which the person makes while inhaling and/or exhaling. This
patient has difficulty breathing because of damage sound, known as wheezing, occurs because
to the lungs. In a patient with COPD, the airways air becomes trapped in the lungs. Coughing that
230 | Emergency Medical Response
The medications stop the muscle spasms and
open the airway, which makes breathing easier.
Controlling the environmental variables, whenever
possible, helps reduce the triggers that can lead to
the start of an asthma attack.
A trigger is anything that sets off or starts an asthma
attack. A trigger for one person is not necessarily a
trigger for another. Some asthma triggers are:
Dust, smoke and air pollution.
Exercise.
Plants and molds.
Fig. 10-2: Asthma is more common in children than in adults.
Perfume.
Medications, such as aspirin.
occurs after exercise, crying or laughing is another
sign that an asthma attack is taking place.
Animal dander.
Temperature extremes and changes in the
Signs and symptoms of an asthma attack include: weather.
Strong emotions, such as anger, fear or anxiety.
Coughing or wheezing noises.
Infections, such as colds or other respiratory
Difficulty breathing. infections.
Shortness of breath.
Some anti-inflammatory medications prescribed
Rapid, shallow breathing.
for the long-term control of asthma are taken daily.
Sweating.
Other medications are prescribed for quick relief
Tightness in the chest. and are taken only when a person is experiencing
Inability to speak in complete sentences. the signs and symptoms of an asthma attack
Bent posture with shoulders elevated and lips (Fig. 10-3). These medications help relieve the
pursed to make breathing easier. sudden swelling and are called bronchodilators.
Feelings of fear or confusion.
Usually, people diagnosed with asthma control their Pneumonia
attacks by controlling environmental variables and Pneumonia is an infection that causes inflammation
through medication and other forms of treatment. of the lungs. Because of the inflammation, the air sacs
Fig. 10-3: Medications used to treat asthma attacks stop the muscle spasms and open the airway,
which makes breathing easier.
Chapter 10: Airway and Ventilation | 231
in the lungs begin to fill with fluid, and oxygen has Fear or anxiety is often the cause of
trouble reaching the bloodstream. Pneumonia can hyperventilation but it can also result from a head
be a serious illness in older adults because of injury, severe bleeding or conditions such as
normal age-related changes such as a weakened infection, heart failure and lung disease. Asthma
cough reflex and impaired mobility, and can even and stress can also trigger hyperventilation.
result in death.
Note that anxiety is only one cause of rapid
Pneumonia can be caused by viruses (often a breathing, and most patients experiencing this
complication of the flu), bacteria, fungi or other symptom are not hyperventilating. If you are certain
organisms. Symptoms include high fever, chills, the patient is not experiencing life-threatening
chest pain and shortness of breath. In addition symptoms, the most effective response is to calm
to these symptoms, older patients commonly the patient. Listen to the patient’s concerns and try
exhibit other symptoms including increased to reassure and encourage the patient to breathe
respiration rate, breathing difficulty and congestion. slower or breathe through pursed lips. If the patient
Altered mental status may also present in older does not respond to this, administer supplemental
patients. Older adults may also develop aspiration oxygen, if it is available, based on local protocols.
pneumonia. Residents who are in a coma or using
feeding tubes are especially at risk for developing Pulmonary Embolism
pneumonia. Bacterial pneumonia is treated with
A pulmonary embolism is a blockage in the
antibiotics. Administering supplemental oxygen may
arteries of the lungs. Symptoms include a sudden
help relieve some of the symptoms of pneumonia.
onset of dyspnea (difficulty breathing; shortness
of breath), chest pain that is localized and does
Acute Pulmonary Edema not radiate, coughing, coughing up blood and
Pulmonary edema is an abnormal build-up of fluid fainting. The embolism usually has traveled from a
in the lungs that can result in death if not properly blood clot in another part of the circulatory system
treated. It is usually caused by inadequate heart (typically the legs), and then lodges somewhere in
pumping when the left ventricle starts to eject less an artery in the lung.
blood than the right. This places excessive pressure
With a pulmonary embolism, there is poor oxygen
on the lungs and allows fluid to leak into the alveoli
and carbon dioxide gas exchange in the alveoli,
and capillaries. Acute pulmonary edema causes
as the clot prevents blood from flowing through
severe respiratory distress, altered mental status
the capillaries; this inadequate exchange results
and coughing, with some bloody sputum. Signs and
in respiratory distress. The degree of distress
symptoms of pulmonary edema include shortness
depends on the size of the clot. Pulmonary embolism
of breath; difficulty breathing, including wheezing or
is more common in smokers, cancer patients,
gasping for breath; cyanosis (a bluish color of the
fracture patients, surgery patients, patients with
skin and mucous membranes); frothy (foamy) pink
cardiovascular disease, and those who have been
sputum; pale skin; excessive sweating; restlessness,
on prolonged bed rest or suffered a trauma. It is also
anxiety and a feeling of apprehension; a feeling of
more common in older adults. Larger clots can cause
suffocating or drowning; and chest pain when the
death very quickly. Therefore, rapid recognition, care
condition is caused by coronary artery disease.
and transport of the patient to a hospital is crucial.
Gradual symptoms include difficulty breathing
when lying flat, awakening at night with a feeling of
breathlessness, unusual shortness of breath during Emphysema
physical activity and significant weight gain when Emphysema is a chronic disease caused by
the condition develops because of congestive heart damage to the air sacs in the lungs. It is also
failure. Administering supplemental oxygen is a degenerative, in that it worsens over time. When
primary step in the care of pulmonary edema. the alveoli lose elasticity, they become distended
(swollen and expanded) with trapped air and stop
Hyperventilation working properly. As the number of affected alveoli
increases, breathing becomes increasingly difficult.
Hyperventilation occurs when a person breathes
The most common symptom of emphysema is
faster and shallower or deeper than normal. When
shortness of breath. Exhaling is also extremely
a patient is hyperventilating, carbon dioxide levels
difficult. Other signs include cyanosis, barrel-
in the blood decrease, reducing blood flow to the
shaped chest, fatigue, loss of appetite and weight
brain. This causes fear, anxiety and confusion, as
loss, mild cough and breathing through pursed lips.
well as dizziness and a numb and tingly feeling in
The patient may feel restless, confused and weak.
the fingers and toes.
232 | Emergency Medical Response
In advanced cases of emphysema, the patient may AIRWAY
even go into respiratory or cardiac arrest.
Opening the Airway
As you learned in Chapter 7, there are two common
Pediatric Considerations methods used to open a patient’s airway: the head-
Respiratory Emergencies
tilt/chin-lift maneuver and the jaw-thrust (without
It is very important to recognize breathing
head extension) maneuver. The first is generally
emergencies in children and infants and to
the preferred method except in cases where spinal
act before the heart stops beating. When
injury is suspected. Both maneuvers lift the tongue
adult hearts stop beating, it is frequently due
from the back of the throat and allow air to move
to disease. Children’s and infants’ hearts,
into and out of the lungs. Once the airway is open,
however, are usually healthy. When a child’s
it is important to maintain an open airway as you
or an infant’s heart stops, it is usually the
continue to provide care.
result of a breathing emergency.
When attending to a child with respiratory Signs of an Open Airway
problems, keep in mind that lower airway If the airway is open and clear (patent), you will
disease may be caused by birth problems be able to see the rise and fall of the patient’s
or infections such as bronchiolitis, chest, hear air coming out of the patient’s mouth
bronchospasms, pneumonia or croup. and nose, and feel air as the patient exhales. If the
Several of the illnesses and diseases that patient is able to speak in full sentences without
affect the respiratory system in children distress, the airway is open and adequate. The
are preventable through vaccines. These ability to speak is a sign that air is moving past the
include diphtheria; Haemophilus influenzae vocal cords. The sound of the patient’s voice is
type b (Hib); measles, mumps and rubella another indication of airway status. A patient who is
(MMR); meningococcal; pertussis (whooping speaking in normal tones has an adequate airway
cough); pneumococcal disease; mycoplasma and is breathing effectively.
pneumonia (pneumonia-like illnesses); and
varicella (chickenpox). Other diseases may Signs of an Inadequate Airway
not have respiratory symptoms but may be Patients with an inadequate airway need close
spread through respiratory transmission, such attention and monitoring. They may be visibly
as mumps and rotavirus (severe diarrhea). unable to catch their breath or they may gasp for
air and make grunting sounds. Some signs are
Considerations for Older Adults subtle, but if you are not sure, play it safe and
Respiratory Emergencies take steps to maintain an open airway at all times.
It is sometimes less obvious that older Not every sign is present in every patient who has
adult patients are suffering symptoms of an inadequate airway.
a respiratory emergency, as they may be If you observe any unusual sounds with breathing,
less sensitive to pain. You are more likely to take prompt action to open the airway, as they
encounter older patients who suffer from may be signs of an airway obstruction. Stridor is
pneumonia or chronic, age-related breathing a harsh, high-pitched sound the person may make
problems such as emphysema and pulmonary when inhaling possibly due to the larynx being
edema. Remember that older patients may swollen and blocking the upper airway. If the patient
present with different symptoms from those is snoring, the tongue or other tissues in the mouth
experienced by younger patients. may be relaxed and blocking the upper airway.
CRITICAL A patient who is awake and alert but unable to speak, can only speak a few
FACTS words or has a hoarse-sounding voice may be having severe difficulty breathing.
Inadequate breathing may also be caused by swelling due to trauma, infection or an
allergic reaction.
Foreign body airway obstruction (FBAO) is an emergency situation that needs immediate
attention. The most common cause of an FBAO is a solid object, such as food.
Chapter 10: Airway and Ventilation | 233
A patient who is awake and alert but unable Clearing the Airway
to speak, can only speak a few words or has a
hoarse-sounding voice may be having severe
Techniques to Clear an
difficulty breathing. Inadequate breathing may also Airway Obstruction
be caused by swelling due to trauma, infection or More than one method exists to clear the airway
an allergic reaction. in conscious patients. Protocols may vary but
abdominal thrusts, back blows and chest thrusts
If there is no air movement, the patient is each have been proven to effectively clear
experiencing apnea, which is the complete an obstructed airway in conscious patients.
absence of breathing. In this situation, the chest Frequently, a combination of more than one
will not rise and fall and you will not be able to technique may be needed to expel an object
hear or feel any air coming out of the patient’s and clear the airway. See Chapter 11 for more
mouth and nose. The patient needs artificial information on airway obstruction.
ventilation, and if apnea is not corrected in a timely
manner, there will be significant consequences. Techniques to Remove Foreign
Sometimes there may be no detectable air movement Matter from the Upper Airway
because of an airway obstruction. In an unconscious Two techniques can be used to remove visible
patient, if efforts to open the airway are unsuccessful foreign matter and fluids from the upper airway
and ventilations do not make the chest begin to of an unconscious patient: finger sweeps and
rise, immediately provide CPR, starting with suctioning. The particular technique you choose will
compressions. Before attempting ventilations, check depend on the patient’s condition and the foreign
the airway for an obstruction. Look inside the mouth matter, and may require the use of both skills.
for liquid, food, teeth, dentures, blood, vomit or other
foreign objects that may be blocking the airway, such Finger sweeps. Finger sweeps involve
removing an object or other foreign matter from
as a small toy. If you see the obstruction, remove it
a patient’s mouth with a finger. They are only
and continue CPR until there is an obvious sign of
performed on an unconscious patient and only
life. CPR is discussed in detail in Chapter 13.
when you can see foreign matter in the patient’s
mouth. Always wear disposable latex-free gloves
Causes of Airway Obstruction when performing a finger sweep.
There are two types of airway obstruction: Suctioning. The purpose of suctioning is
mechanical and anatomical. Any foreign body to remove blood, fluids or food particles from
lodged in the airway is a mechanical obstruction the airway. Some suctioning devices cannot
and an emergency situation that needs immediate remove solid objects such as teeth, foreign
attention. The most common cause of foreign bodies or food.
body airway obstruction (FBAO) in adults
is a solid object, such as food. Fluids such as See Chapter 11 for more information on how
saliva, blood or vomit can also block the airway. to perform a finger sweep and how to use a
Other causes of airway obstruction include loose suctioning device.
or broken dentures. In the case of small children
under age 4, large chunks of food and small Recovery Positions
objects such as toy parts and balloons commonly In some cases, the person may be unresponsive
cause airway obstruction. but breathing normally. For patients who are
In an unconscious patient, the most common cause unresponsive, but breathing normally with no
of airway obstruction is the tongue. This is known suspected head, neck, spinal, hip or pelvic
as an anatomical obstruction. An unconscious injury, move the patient into a side-lying recovery
patient loses muscle tone, which may cause the position after completing your assessment
tongue to fall back and block the airway. As the and gathering a patient history, based on local
patient tries to breathe, the tongue moves further protocols. Patients with a suspected head,
into the throat. neck, spinal, hip or pelvic injury should not be
placed in a recovery position unless you are
Other conditions that can block the airway unable to manage the airway effectively or you
anatomically include swelling due to trauma, are alone and need to leave the patient to call
infection, asthma, emphysema or anaphylaxis. for additional resources. Placing a person in a
An obstruction may also be caused by trauma recovery position will help keep the airway open
to the neck. See Chapter 11 for more information and clear (Fig. 10-4). Refer to Chapter 5 for the
on airway obstruction. steps for a recovery position.
234 | Emergency Medical Response
The depth of respiration is as important as the rate.
Breathing must be deep enough to bring oxygen
into the lungs and from there to the bloodstream.
The normal rise and fall of the patient’s chest
indicates adequate depth.
A healthy adult should breathe regularly, quietly and
effortlessly. No muscles in the neck or shoulders
are involved, and there is not excessive use of the
abdominal muscles. There are no unusual sounds,
such as wheezing or whistling.
Oxygenation
Oxygenation happens naturally with ventilation,
the mechanical process of moving air in and out
of the lungs. A healthy person with adequate
oxygenation is clear thinking and calm and has
normal skin color.
Signs of Inadequate Breathing
Fig. 10-4: Place an unresponsive patient who is breathing
normally with no suspected head, neck, spinal, hip or pelvic injury Inadequate breathing needs careful monitoring.
into a side-lying recovery position. You may not notice all of the signs and symptoms
at once, and some can be hard to spot. If you
see any of them, be prepared to give assisted
ASSESSING BREATHING ventilation.
Determining the Presence
of Breathing Ventilation
To determine whether or not the patient is Any of the following signs suggests that the patient
breathing, look for the rise and fall of the chest, is expending too much effort to breathe and that
listen for the sounds of breathing, and feel for breathing is inadequate:
movement as air escapes from the patient’s mouth
and nose as you simultaneously check for a pulse. Muscles between the ribs pull in on inhalation:
Adequate breathing requires both sufficient rate As the patient breathes in, you may notice the
and depth. muscles pulling inward between the ribs, above
the collarbone, around the muscles of the neck
Signs of Adequate Breathing, and below the rib cage.
Oxygenation and Ventilation Pursed lips breathing: The patient exhales
through pursed lips (much like a whistling);
Breathing is considered adequate when respiratory
this maneuver helps control the patient’s
rate, depth and effort are normal. The following
breathing pattern.
are normal rates, although some people naturally
breathe at slightly slower or faster rates: Nasal flaring: Flaring out of the nostrils on
inhalation is a sign of inadequate breathing in
Adults—12 to 20 breaths per minute children and infants.
Children—15 to 30 breaths per minute Fatigue: Apparent signs of fatigue are also an
Infants—25 to 50 breaths per minute indication of the work of breathing.
CRITICAL The normal rate of breathing for adults is 12 to 20 breaths per minute. For children,
FACTS it is 15 to 30 breaths per minute, and for infants, it is 25 to 50 per minute. Adequate
breathing means that respiratory rate, depth and effort are normal.
Any of the following signs suggests that breathing is inadequate: muscles between
the ribs pull in on inhalation, pursed lips breathing, nasal flaring, fatigue, excessive
use of abdominal muscles to breathe, sweating and deviated trachea.
Chapter 10: Airway and Ventilation | 235
Excessive use of abdominal muscles to breathe: This is often seen when the patient has flail chest.
This means the patient is using the abdominal A patient with an injury to the chest wall or ribs will
muscles to force air out of the lungs. often place an arm over the area to protect and
Sweating: A patient who is sweating and “splint” it. (For further information on chest wall
anxious may be in severe respiratory distress. movement, see Chapter 21.)
Sitting upright and learning forward (tripod A penetrating wound to the chest can cause
position): A patient who is sitting upright rapid deterioration in breathing as well. An
and leaning forward with hands on knees is injury to one side of the chest wall will cause
struggling to breathe. unequal movement; one side will remain hyper-
Deviated trachea: If you observe pendulum inflated and not move with the other side
motions of the trachea while the patient is during breathing.
breathing in, this may be the result of chest
trauma resulting in a lung injury. The trachea Irregular respiratory patterns may also be a sign of
will move to the side of the uninjured lung. inadequate breathing, particularly when associated
This is typically a very late sign of a with a slow or rapid heart rate. These signs
life-threatening situation. typically occur together in children.
Abnormal breath sounds are also a sign of
inadequate breathing. Listen for abnormal sounds Inadequate Oxygenation
such as stridor, wheezing or crackles/rales. Problems with inadequate oxygenation may
Wheezing or whistling sounds indicate restricted occur for a variety of reasons and can cause
air flow and are common with conditions such headaches, increased breathing rate, nausea and
as asthma, allergic reactions or emphysema. vomiting, altered mental status and, ultimately,
Crackles/rales have a fine cracking sound death. The ambient air may be abnormal, for
on inhalation (much like the sound of Velcro® example in an enclosed space or at a high
being pulled apart) and may indicate fluid in altitude, or there may be poisonous gas or
the lungs. carbon monoxide present. Breathing in poison
has an almost immediate impact, destroying
Inadequate depth of breathing may also indicate lung tissue and causing respiratory distress
problems with ventilation. Shallow breathing, or respiratory failure. Carbon monoxide is
even if it is rapid, often means that the patient is a colorless, odorless and tasteless gas with a
not getting enough oxygen. Markedly increased severe impact because the gas blocks the ability
breathing that is unusually deep is also a sign of of the red blood cells to carry oxygen throughout
inadequate respiration. If the person is struggling the body.
to breathe, the depth is not adequate.
A reduction of oxygen in the body causes
Rate provides additional information about the headaches, increased breathing rate, nausea
adequacy of breathing. A very slow breathing and vomiting, altered mental status and,
rate—less than 8 breaths per minute for adults, ultimately, death.
less than 10 breaths per minute for children and
less than 20 breaths per minute for infants—is a One of the signs of inadequate oxygenation
sign of inadequate breathing. Breathing that is too may be cyanosis, an abnormal blue or grey
fast is often shallow and inadequate. discoloration of the skin, mucous membranes
or nail beds of the fingers and toes. Cyanosis
Unusual or irregular movement of the chest wall is a serious sign that the body is not receiving
may indicate inadequate breathing. A chest injury enough oxygen. Pale, cool, clammy skin is an
needs immediate attention because it can cause early and frequent sign of severe breathing
rapid and severe deterioration of the person’s difficulties resulting in falling oxygen levels.
breathing. Chest wall trauma may cause a few Mottling, another sign of inadequate oxygenation,
different problems. In paradoxical breathing, is a blotchy pattern of skin discoloration, often
an area of the chest moves in the opposite caused by shock (Fig. 10-5). Without enough
direction to the rest of the chest, i.e., moving in oxygen, patients also experience an altered
while the patient is breathing in (inspiration), and mental state, becoming restless, agitated,
out while the patient is breathing out (expiration). confused or anxious.
236 | Emergency Medical Response
ARTIFICIAL VENTILATION
Artificial ventilation refers to the various
mechanical ways that can be used to help a patient
“breathe.” When assisting a patient with artificial
ventilations, make sure the force of air is consistent
and just strong enough to cause the chest to begin
to rise during each breath.
Mouth-to-Mask Ventilation
Resuscitation Mask
Using a resuscitation mask allows you to
breathe expired air (with or without supplemental
oxygen) into a patient without making mouth-
Fig. 10-5: Cyanosis and mottling are some of the visible signs of
to-mouth contact (Fig. 10-6). Use of the mask
inadequate oxygenation. reduces the risk of disease transmission while
providing enough oxygen (about 16 percent
oxygen in your exhaled breath) to sustain life.
Minute Volume Flexible and shaped to fit over the patient’s mouth
and nose, resuscitation masks:
A patient may appear to be breathing
adequately but not be getting enough air Help get air quickly to the patient through both
to sustain life. One way of determining the the mouth and nose.
adequacy of breathing is by measuring the Create a seal over the patient’s mouth and nose.
minute volume. Minute volume is the amount Can be connected to supplemental oxygen,
of air breathed in per minute, and it depends if equipped with an oxygen inlet.
on both the rate and depth of breathing. (Both
rate and depth must be sufficient for breathing
Protect against disease transmission.
to be considered adequate.) Minute volume Are more effective for delivering ventilations
when only one responder is present.
is calculated by multiplying these two factors:
rate × volume per breath = minute volume. Resuscitation masks should be easy to assemble
The amount of air breathed in at each breath, the and use, and made of a transparent, pliable
depth, is also referred to as the tidal volume. material that allows you to make a tight seal over
Normally, a single breath contains approximately the patient’s mouth and nose. They have a one-
500 milliliters (mL) of air. Tidal volume is best way valve for releasing exhaled air and a standard
assessed by watching for adequate chest 15-mm or 22-mm coupling assembly (the size of
movement (rise and fall), and listening and the opening for the one-way valve). Resuscitation
feeling for air movement from the mouth and masks work well under different environmental
nose during inhalation and exhalation. conditions, such as extreme heat or cold.
For example, a patient who is breathing
12 times per minute and taking in 500 mL of air
per breath has a minute volume of 6000 mL
(500 × 12 = 6000 mL of air per minute). While
most of that 6000 mL of air reaches the alveoli,
a small amount, approximately 150 mL, remains
in the area between the pharynx and the alveoli.
This area is referred to as the deadspace.
This amount must be taken into consideration,
as it reduces the volume of each breath. In
this example, 150 × 12 breaths = 1800 mL
that never reaches the alveoli within a minute.
For a patient who is breathing quickly, it may
seem that breathing is adequate when it is
not. Remember to reduce the calculated minute
volume taking deadspace into consideration. Fig. 10-6: Use of a resuscitation mask reduces the risk of
disease transmission.
Chapter 10: Airway and Ventilation | 237
Mouth-to-Mouth
Ventilation
As an emergency medical responder (EMR),
you should follow standard precautions
whenever providing ventilations. However, there
may be circumstances when you do not have
immediate access to a resuscitation mask or
BVM. The risk of contracting a disease from
mouth-to-mouth ventilations is low. Although
protocols may vary, you may decide to give
mouth-to-mouth ventilations without a barrier.
To provide ventilations to a patient without
a mask:
1. Use the head-tilt/chin-lift maneuver to open
the airway, provided you do not suspect an
injury to the head, neck or spine. Fig. 10-7: Infant and child resuscitation masks are available and
2. Gently pinch the patient’s nose shut with should be used to care for children and infants.
the thumb and index finger of your hand
that is on the patient’s forehead. Pediatric Considerations
3. Make a tight seal around the patient’s Resuscitation Masks
mouth with your mouth. For an infant, Infant and child resuscitation masks are
seal your mouth over the mouth and nose, available and should be used to care for infants
instead of pinching the nose shut. and children (Fig. 10-7). Adult resuscitation
4. Blow into the patient’s mouth until you masks should not be used in an emergency
see the chest begin to rise. situation unless a pediatric resuscitation mask
is not available and medical control advises
Each breath should last about 1 second, with
you to do so. Always use the appropriate
a brief pause between breaths to let the air
equipment matched to the size of the patient.
flow back out. Watch that the patient’s chest
rises each time you blow in, to ensure that
your breaths are effective. minute (LPM). For more information on administration
of oxygen, see Chapter 12. For step-by-step
instructions on giving ventilations to adults, children
and infants, see Skill Sheets 10-1 and 10-2.
A limitation of the resuscitation mask is that, without
use of a BVM or supplemental oxygen, it only
delivers 16 percent oxygen through the responder’s Special Considerations
exhaled breath (50 percent with supplemental Air in the Stomach
oxygen), which is considerably less than what is When providing ventilations, blow slowly, with
delivered using a BVM with supplemental oxygen. just enough air to make the patient’s chest begin
When serious injury or sudden illness occurs, the to rise. If you blow too much air into the patient
body does not function properly, and supplemental (overventilation), it may enter the stomach,
oxygen can help meet the increased demand for causing gastric distention. The patient will then
oxygen for all body tissues. If the patient requires likely vomit, which can obstruct the airway and
a higher concentration of oxygen than normal and complicate resuscitation efforts.
the resuscitation mask has an oxygen inlet,
connect it to supplemental oxygen. Normal Vomiting
concentration of oxygen in the air is 21 percent. When you provide ventilations, the patient may
Your exhaled breath (expired air) contains about vomit. If this occurs, quickly turn the patient onto
16 percent. A resuscitation mask can deliver the side to keep the vomit from blocking the
approximately 35 to 55 percent oxygen to a person airway and entering the lungs. Support the head
when the oxygen is delivered at 6 to 15 liters per and neck and turn the body as a unit toward you.
238 | Emergency Medical Response
After vomiting stops, clear the patient’s airway by
wiping the patient’s mouth out using a finger sweep
and suction if necessary, turn the patient onto the
back and continue with ventilations.
Mask-to-Nose Breathing
If the patient’s mouth is injured, you may need to
provide ventilations through the nose. To perform
mask-to-nose breathing using a resuscitation mask:
Open the airway using the head-tilt/chin-lift
maneuver.
Place the resuscitation mask over the patient’s
mouth and nose. Fig. 10-8: If the patient has a stoma, provide ventilations through
a round pediatric resuscitation mask placed over the stoma.
Use both hands to keep the patient’s mouth
closed.
Patients with Suspected Head,
Seal the resuscitation mask with both hands.
Neck or Spinal injuries
Provide ventilations.
If you suspect a patient has sustained an injury
to the head, neck or spine, there are special
Mask-to-Stoma Breathing considerations you must keep in mind. You may
On rare occasions, you may see an opening in a not always know if a patient has sustained this
patient’s neck as you tilt the head back to check kind of injury and may have to rely on bystander
for breathing. If the patient has a stoma and needs information or mechanism of injury (MOI). Suspect
artificial ventilation, follow the same steps for an injury to the head, neck or spine if the patient:
mouth-to-mask breathing, except:
Was involved in a motor-vehicle, motorcycle
Look, listen and feel for breathing with your ear or bicycle crash as an occupant, rider or
over the stoma. pedestrian.
Maintain the airway in a neutral position. (This Was injured as a result of a fall from greater than
ensures the patient’s airway is neither flexed nor standing height.
extended, as the stoma provides access to the
lower airway.)
Complains of neck or back pain, tingling in the
extremities or weakness.
Use a pediatric resuscitation mask over the
Is not fully alert.
patient’s stoma.
Appears to be intoxicated.
If possible, pinch the nose and close the mouth,
Appears frail or over 65 years of age.
as some patients with a stoma may still have a
passage for air that reaches the mouth and nose Has an obvious head or neck injury.
in addition to the stoma. Check for the following signs and symptoms of
Provide ventilations (Fig. 10-8). a possible head, neck or spinal injury before you
attempt to provide care:
Patients with Dentures
Leave dentures in place unless they become loose
Changes in the level of consciousness (LOC)
and block the airway. Dentures help support the Severe pain or pressure in the head, neck
or back
patient’s mouth and cheeks, making it easier to
seal the resuscitation mask during ventilation. Loss of balance
CRITICAL Suspect an injury to the head, neck or spine if the patient was involved in a motor-
FACTS vehicle, motorcycle or bicycle crash as an occupant, rider or pedestrian; was injured
as a result of a fall from greater than standing height; complains of neck or back pain,
tingling in the extremities or weakness; is not fully alert; appears to be intoxicated;
appears frail or over 65 years of age; or has an obvious head or neck injury.
Chapter 10: Airway and Ventilation | 239
Partial or complete loss of movement of any release the bag, the valve closes and air from the
body part surrounding environment refills the bag. BVMs
Tingling or loss of sensation in the hands, have several advantages. They:
fingers, feet or toes
Increase oxygen levels in the blood by using the
Persistent headache air in the surrounding environment instead of the
Unusual bumps, bruises or depressions on the air exhaled by the responder.
head, neck or back
Can be connected to supplemental oxygen.
Seizures
Are more effective for delivering ventilations
Blood or other fluids in the ears or nose than using a resuscitation mask, when used
External bleeding of the head, neck or back correctly.
Impaired breathing or vision as a result of injury Protect against disease transmission and
Nausea or vomiting inhalation hazards if the patient has been
exposed to a hazardous gas.
Bruising of the head, especially around the eyes
and behind the ears May be utilized with advanced airway adjuncts.
If you suspect an unconscious patient may have an Pediatric Considerations
injury to the head, neck or spine, remember to first Pediatric BVMs
take care of severe, life-threatening bleeding, the Infant and child BVMs are available and
airway and breathing. Try to open the airway using should be used for infants and children
the jaw-thrust (without head extension) maneuver (Fig. 10-9, B). Using an adult BVM on an infant
first (see Skill Sheet 10-3). If the jaw-thrust (without has the potential to cause harm and should
head extension) maneuver does not open the not be used unless a pediatric BVM is not
airway, use the head-tilt/chin-lift maneuver. available and medical control advises you to
do so. Always use the appropriate equipment
Bag-Valve-Mask Resuscitator matched to the size of the patient.
Ventilations To use a BVM with one responder:
Bag-Valve-Mask Resuscitator
A bag-valve-mask (BVM) resuscitator is a 1. Assemble the BVM as needed.
handheld device used to ventilate patients and 2. Open the airway past a neutral position (for an
administer higher concentrations of oxygen than adult) while positioned at the top of the patient’s
a pocket mask (Fig. 10-9, A). BVMs are used by head (cephalic position).
either one responder responsible for managing 3. Use an E-C hand position:
the airway and delivering ventilations or two ●● Place one hand around the mask, forming an
responders in a multiple-responder situation. E with the last three fingers and a C with the
A BVM has three parts: a bag, a valve and a mask. thumb and index finger around the mask.
By placing the mask on the patient’s face and ●● Seal the mask completely around the patient’s
squeezing the bag, you open the one-way valve, mouth and nose by lifting the jaw into the mask
forcing air into the patient’s lungs. When you while maintaining an open airway.
A B
Fig. 10-9, A–B: BVMs come in a variety of sizes for use with (A) adults, (B) children and infants.
240 | Emergency Medical Response
4. Provide ventilations: Ventilation rates vary with the age of the patient.
●● With the other hand, depress the bag about Adequate ventilation rates are:
halfway to deliver between 400 to 700 milliliters
of volume to make the chest begin to rise. 30–60 ventilations per minute at about
1 second each for a newborn (0 to 1 month).
●● Give smooth and effortless ventilations that
last about 1 second. 20 ventilations per minute at 1 second each for
a child or an infant.
While a BVM is often used by a single responder 10–12 ventilations per minute at 1 second each
(see Skill Sheet 10-4), evidence shows that two for an adult.
responders are needed to most effectively operate
a BVM. One responder opens and maintains the You can determine whether ventilation is adequate
airway and ensures the BVM mask seal, while by watching the chest rise and fall. Ventilating a
the second responder delivers ventilations by patient at rates that are too fast or with too much
squeezing the bag slowly with both hands at the volume can be dangerous.
correct intervals to the point of creating chest rise
(see Skill Sheet 10-5). Overventilation and Hyperventilation
To use a BVM with two responders: In any resuscitation situation, it is essential not
to overventilate or hyperventilate the patient.
1. Assemble the BVM as needed. With each ventilation provided, intrathoracic
2. Open the airway past a neutral position (for an pressure (i.e., pressure in the chest cavity)
adult) while positioned at the top of the patient’s increases, causing the blood vessels returning
head (cephalic position). to the heart to be compressed. This decreases
the amount of blood filling the heart and the
3. Use an E-C hand position (first responder):
coronary blood flow.
●● Place both hands around the mask, forming an
E with the last three fingers on each hand and Overventilation and hyperventilation further
a C with the thumb and index finger around increase the intrathoracic pressure, which in turn
both sides of the mask. further decreases the amount of blood filling the
●● Seal the mask completely around the heart and the coronary blood flow. The reduction
patient’s mouth and nose by lifting the of blood flowing back into the heart significantly
jaw into the mask while maintaining an limits effective circulation to the brain and other
open airway. vital organs. Overventilation and hyperventilation
4. Provide ventilations (second responder): should be avoided to improve patient outcomes.
●● Depress the bag about halfway to deliver
Responders should hyperventilate a patient only
if directed by a specific protocol.
between 400 to 700 milliliters of volume to
make the chest begin to rise.
●● Give smooth and effortless ventilations Science Note: Hyperventilation most
that last about 1 second. commonly occurs when patients are being
ventilated when they are in respiratory arrest
or when an advanced airway is placed during
Providing Controlled Ventilation cardiac arrest. It is critical to avoid
Knowing the recommended ventilation rates hyperventilation of the patient because it
for use with a BVM will ensure that you leads to increased intrathoracic pressure
provide patients with adequate oxygen without and a subsequent decrease in coronary
causing harm. For example, too many breaths filling and coronary perfusion pressures by
(hyperventilation) or too much volume of air putting pressure on the vena cava.
(overventilation) can result in air going into the
stomach, which can cause vomiting.
CRITICAL BVMs can hold more than 1000 milliliters of volume and should never
FACTS be completely deflated when providing ventilations. Doing so could lead to
overventilation and hyperventilation. Also, pay close attention to any increasing
difficulty when providing BVM ventilation. This difficulty may indicate an increase in
intrathoracic pressure, inadequate airway opening or other complications. Be sure
to share this information with the team for corrective actions.
Chapter 10: Airway and Ventilation | 241
Assisted Ventilation During
Normal Ventilation Respiratory Distress
Assisted ventilation improves both oxygenation
Versus Positive and ventilation. A patient in respiratory distress
Pressure Ventilation cannot breathe easily. Without adequate breathing,
not enough oxygen reaches the cells, resulting
There are several differences between in hypoxia. The patient becomes agitated and
normal ventilation and positive pressure aggressive.
ventilation. First, in normal ventilation,
the movement of the diaphragm dropping Assisted ventilation is given when the patient
creates negative pressure inside the chest, shows signs and symptoms of inadequate
which causes air to be sucked into the lungs. breathing, including:
During positive pressure ventilation using a
resuscitation mask or BVM, the movement of
Breathing and heart rates that are too fast or
too slow.
air is created by the responder pushing the
air artificially into the lungs. Cyanosis.
Inadequate chest wall motion.
A second difference is in how the blood Changes in consciousness.
moves within the body during normal
versus positive pressure ventilation. In
Restlessness.
normal ventilation, the blood returns to Chest pain.
the heart from the body and is pulled back Procedure
to the heart as a part of breathing. During When providing assisted ventilation to a patient
positive pressure ventilation, there is a during respiratory distress:
decreased volume of blood returning to the
heart when the lungs are inflated. Also, the Explain the procedure if the patient is conscious.
amount of blood pumped out of the heart A patient who is not breathing properly can
is reduced. become anxious or panic. Calming the patient may
make them more receptive to your assistance.
Esophageal opening pressure is also different
in the two kinds of ventilation. During normal Place the mask over the patient’s mouth and nose.
ventilation, the esophagus remains closed, Initially assist at the rate at which the patient has
and no air enters the stomach. During positive been breathing. Squeeze the bag each time the
pressure ventilation, air is pushed into the patient begins or tries to inhale.
stomach during ventilation. If there is excess Adjust the rate as the patient’s breathing begins
air in the stomach, this may lead to vomiting to return to normal.
and aspiration.
If breathing is slower than usual, provide extra
Finally, positive pressure ventilation has the ventilations in between the patient’s own breaths.
added risk of harming the patient due to If breathing is rapid and shallow, provide ventilations
excess rate or depth of ventilation. Ventilating when the patient inhales. If the patient has adequate
the patient too quickly or too deeply may cause breathing, administer oxygen at 15 LPM based
low blood pressure, vomiting or a decrease on local protocols. Keep checking for signs of
in blood flow when the chest is compressed inadequate breathing.
during CPR.
Limitations
Patients who are hypoxic may become combative.
A patient with this kind of altered mental status may
CRITICAL Assisted ventilation is given when the patient shows signs and symptoms of
FACTS inadequate breathing, including breathing and heart rates that are too fast or
too slow, cyanosis, inadequate chest wall motion, changes in consciousness,
restlessness and chest pain.
242 | Emergency Medical Response
deteriorate quickly and become unable to breathe airway is blocked for any reason may die unless
adequately. Maintain the airway and monitor the immediate steps are taken to open the airway.
patient closely.
Once the patient’s airway is clear, you can begin
Make sure the mask fits tightly around the to assess breathing. Inadequate breathing
patient’s mouth and nose. If there is not a causes problems with inadequate ventilation
good seal, an insufficient volume of air will be and oxygenation. Breathing abnormalities can be
delivered to the patient. assessed by observing physical signs and breath
sounds, and by measuring the rate and depth
of breathing.
Ventilation of an Apneic Patient
with a Pulse A breathing emergency can become life
Absence of breathing (apnea) is a life-threatening threatening and should be detected during the
condition that requires urgent care. Begin primary assessment. Knowing the signs and
artificial ventilation at once using a resuscitation symptoms of respiratory distress and respiratory
mask or BVM. Ventilation is provided for an arrest will help you determine the appropriate care
apneic (nonbreathing) patient if the chest wall is for each condition.
not moving and there is no air moving in and out of
For a patient with a pulse who is not breathing,
the mouth and nose, or if occasional gasping
provide artificial ventilation by using a resuscitation
breathing is noted. Continue to monitor the
mask or BVM. Under specific circumstances,
patient’s condition. Ensure you have the proper
artificial ventilation can be provided mask-to-nose
size equipment for the apneic patient when
or mask-to-stoma. When using a resuscitation
providing artificial ventilation.
mask, be careful not to breathe too much air
into the patient, as this may cause air to enter
PUTTING IT ALL TOGETHER the stomach and cause vomiting. Also, special
considerations must be made for children, patients
Ensuring that a patient’s airway is open and clear is with dentures and patients suspected of having a
an important step in providing care. A patient whose head, neck or spinal injury.
You Are the Emergency Medical Responder
While waiting for emergency medical services (EMS) personnel to arrive, you complete a
SAMPLE history and secondary assessment. You have helped the patient into a position
of comfort for breathing when he loses consciousness and stops breathing. He has a pulse.
What care should you provide now?
Chapter 10: Airway and Ventilation | 243
Skill Sheet
Skill Sheet 10-1
Giving Ventilations—Adult and Child
NOTE: Always follow standard precautions when providing care. Size up the scene for safety and then
perform a primary assessment. Always select the properly sized mask for the patient.
If there is a pulse but no breathing:
STEP 1
Assemble the resuscitation mask as necessary, and position
the mask.
STEP 2
Seal the mask.
STEP 3
Open the airway by tilting the head back and lifting the chin.
▼ (Continued)
244 | Emergency Medical Response
Skill Sheet
Skill Sheet 10-1
Giving Ventilations—Adult and Child Continued
STEP 4
Blow into the mask.
■■ For an adult, give 1 ventilation about every 5–6 seconds.
■■ For a child, give 1 ventilation about every 3 seconds.
■■ Each ventilation should last about 1 second and make
the chest begin to rise. The chest should fall before the
next ventilation is given.
NOTE: For a child, tilt the head slightly past a neutral position.
Do not tilt the head as far back as for an adult. For a patient with
a suspected head, neck or spinal injury, use the jaw-thrust (without
head extension) maneuver to open the airway to give ventilations.
STEP 5
Recheck for breathing and a pulse about every 2 minutes:
■■ Remove the mask and simultaneously check for breathing and a pulse for at least
5 seconds, but no more than 10 seconds.
If the chest does not begin to rise:
■■ Retilt the head, and then give another ventilation.
■■ Provide care based on the conditions found.
Chapter 10: Airway and Ventilation | 245
Skill Sheet
Skill Sheet 10-2
Giving Ventilations—Infant
NOTE: Always follow standard precautions when providing care. Size up the scene for safety and then
perform a primary assessment. Always select the properly sized mask for the patient.
If there is a pulse but no breathing:
STEP 1
Assemble the resuscitation mask as necessary, and position the resuscitation mask.
STEP 2
Seal the mask.
STEP 3
Open the airway by tilting the head to a neutral position and
lifting the chin.
▼ (Continued)
246 | Emergency Medical Response
Skill Sheet
Skill Sheet 10-2
Giving Ventilations—Infant Continued
STEP 4
Blow into the mask.
■■ Give 1 ventilation about every 3 seconds.
■■ Each ventilation should last about 1 second and make the
chest begin to rise. The chest should fall before the next
ventilation is given.
STEP 5
Recheck for breathing and a pulse about every 2 minutes:
■■ Remove the mask and simultaneously check for breathing and a pulse for at least
5 seconds, but no more than 10 seconds.
If the chest does not begin to rise:
■■ Retilt the head, and then give another ventilation.
■■ Provide care based on the conditions found.
Chapter 10: Airway and Ventilation | 247
Skill Sheet
Skill Sheet 10-3
Giving Ventilations—Head, Neck or Spinal
Injury Suspected: Jaw-Thrust (Without Head
Extension) Maneuver—Adult and Child
NOTE: Always follow standard precautions when providing care. Size up the scene for safety and then
perform a primary assessment. Always select the properly sized mask for the patient.
If there is a pulse, but no breathing and a head, neck or spinal injury is suspected:
STEP 1
Assemble the resuscitation mask.
STEP 2
Position the mask.
■■ Kneel above the patient’s head.
■■ Place the mask over their mouth and nose, starting
from the bridge of the nose.
■■ Place the bottom of the mask below the mouth but
not past the chin.
STEP 3
Seal the mask.
■■ Slide the fingers into position under the angles of the
patient’s jawbone without moving the head or neck.
▼ (Continued)
248 | Emergency Medical Response
Skill Sheet
Skill Sheet 10-3
Giving Ventilations—Head, Neck or Spinal Injury
Suspected: Jaw-Thrust (Without Head Extension)
Maneuver—Adult and Child Continued
STEP 4
Open the airway.
■■ Thrust the jaw upward without moving the head or neck to lift the jaw and
open the airway.
STEP 5
Blow into the mask.
■■ For an adult, give 1 ventilation about every 5–6 seconds
■■ For a child, give 1 ventilation about every 3 seconds.
■■ Each ventilation should last about 1 second and make
the chest begin to rise. The chest should fall before the
next ventilation is given.
STEP 6
Reassess for breathing and a pulse about every 2 minutes:
■■ Remove the mask and simultaneously check for breathing and a pulse for at least
5 seconds, but no more than 10 seconds.
Chapter 10: Airway and Ventilation | 249
Skill Sheet
Skill Sheet 10-4
Giving Ventilations Using a Bag-Valve-Mask
Resuscitator—One Responder
NOTE: Always follow standard precautions when providing care. Size up the scene for safety and then
perform a primary assessment. Always select the properly sized mask for the patient. Assemble the
BVM if necessary.
STEP 1
Assemble the BVM as needed.
STEP 2
Open the airway past a neutral position (for an adult) while positioned at the top of the
patient’s head (cephalic position).
STEP 3
Use an E-C hand position:
■■ Place one hand around the mask, forming an E with the last three fingers and a C with
the thumb and index finger around the mask.
■■ Seal the mask completely around the patient’s mouth and nose by lifting the jaw into
the mask while maintaining an open airway.
STEP 4
Provide ventilations:
■■ With the other hand, depress the bag about halfway to deliver between 400 to
700 milliliters of volume to make the chest begin to rise.
■■ Give smooth and effortless ventilations that last about 1 second.
NOTE: For a child, tilt the head slightly past a neutral position. Do not tilt the head as far back
as for an adult. For an infant, position the head in a neutral position.
250 | Emergency Medical Response
Skill Sheet
Skill Sheet 10-5
Giving Ventilations Using a Bag-Valve-Mask
Resuscitator—Two Responders
NOTE: Always follow standard precautions when providing care. Size up the scene for safety and then
perform a primary assessment. Always select the properly sized mask for the patient. Assemble the
BVM if necessary.
STEP 1
Assemble the BVM as needed.
STEP 2
Open the airway past a neutral position (for an adult) while positioned at the top of the
patient’s head (cephalic position).
STEP 3
Use an E-C hand position (first responder):
■■ Place both hands around the mask, forming an E with the last three fingers on each
hand and a C with the thumb and index finger around both sides of the mask.
■■ Seal the mask completely around the patient’s mouth and nose by lifting the jaw into
the mask while maintaining an open airway.
STEP 4
Provide ventilations (second responder):
■■ Depress the bag about halfway to deliver between 400 to 700 milliliters of volume to
make the chest begin to rise.
■■ Give smooth and effortless ventilations that last about 1 second.
NOTE: For a child, tilt the head slightly past a neutral position. Do not tilt the head as far back
as for an adult. For an infant, position head in a neutral position.
Chapter 10: Airway and Ventilation | 251
ENRICHMENT
Assessing Breath Sounds
Unobstructed airways are easy to identify with a stethoscope. You should hear air moving on inspiration (breathing
in) and expiration (breathing out). If there are decreased lung sounds in a particular area of the lungs, you will hear
no sound or a reduced sound compared with the other areas in the lungs.
To listen to the lungs in the front, you must identify the midclavicular lines and move down the chest. Place
your stethoscope at the second intercostal space, usually just above the sternum line (Fig. 10-10, A). Do this on
both the left and right sides to compare sounds.
To listen on the side, identify the midaxillary lines and place your stethoscope between the fourth and fifth
intercostal space, approximately in line with the nipple (Fig. 10-10, B). Again, do this on both sides to be able to
compare sounds.
Finally, listen in the back by identifying the midscapular lines and moving down the back (Fig. 10-10, C).
Do this again on both sides.
When the airway becomes obstructed due to accumulation of fluid in the lungs or a blockage in the airway,
you may hear other sounds, such as:
Wheezing—a high-pitched whistling sound heard during inspiration but heard most loudly on expiration.
Wheezing can often be heard without a stethoscope.
Rales—a popping, clicking, bubbling or rattling sound.
Rhonchi—described as a snoring or coarse, dry rale sound.
Stridor—a wheeze-like sound heard on inhalation and exhalation.
A B
C
Fig. 10-10, A–C: To assess breath sounds: (A) Identify midclavicular lines and place your stethoscope at the second intercostal space;
(B) identify the midaxillary lines and place your stethoscope between the fourth and fifth intercostal space; (C) identify the midscapular
lines and move down below the scapula. Be sure to listen to and compare both sides for each step.
252 | Emergency Medical Response
ENRICHMENT
Assisting the Patient with Asthma
As an EMR, you may find yourself in the position of needing to assist a patient with asthma in using an inhaler
(see Skill Sheet 10-6). Having a basic knowledge of inhalers is of benefit to an EMR and to the patient with
asthma to whom you may provide care.
Asthma Medication: Types, Indications and Contraindications
There are three types of medications used in the management of asthma, each with a different purpose:
Long-term-control medications are used regularly to control chronic symptoms and prevent attacks.
Quick-relief medications, also called rescue medications, are used as needed for relief of symptoms during an
asthma attack.
Medications for allergy-induced asthma are used to decrease sensitivity to a particular allergen and prevent
the immune system from reacting to allergens.
Indications for asthma medication include recurrent wheezing, coughing, trouble breathing and chest tightness.
Contraindications include increased risk of skin thinning and bruising. Asthma medication may also affect
children’s growth.
Delivery Systems for Asthma Medication
Metered-Dose Inhaler
A metered-dose inhaler is a small, handheld aerosol canister with a mouthpiece. It is designed to allow patients to
inhale a specific amount of asthma medication into the lungs in one puff. A spacer, a tube attached to an inhaler
that serves as a reservoir for the medication, may be present.
Dry Powder Inhaler
A dry powder inhaler (DPI) is similar to a metered-dose inhaler. A DPI is a handheld device that delivers a dry
powder form of the medication inside a small capsule, disc or compartment inside the inhaler. Some dry powders
may have no taste, while others are mixed with lactose to give them a sweet taste. The DPI is administered by
breathing in quickly to activate the inhaler, so there is no depressing of the inhaler.
Small-Volume Nebulizer
A small-volume nebulizer is designed to administer aerosolized medication (mist) over a few minutes, ensuring
the efficacy of drug delivery during treatment will not be jeopardized, even if the patient takes a single ineffective
breath. Nebulizers are common for children under the age of 5, those who have difficulty using inhalers and those
with severe asthma.
Other Delivery Systems for Asthma Medication
Asthma medication can also be taken in pill or liquid form. Most recently, asthma medication can be given through
an injection just under the skin.
Peak Flowmeter
A peak flowmeter is a handheld asthma management tool that tracks a person’s breathing. It assists in warning
the person if their asthma is worsening, and helps show how they are responding to treatment. A peak flowmeter
measures the person’s ability to push air out of the lungs in one quick breath.
Continued on next page
Chapter 10: Airway and Ventilation | 253
ENRICHMENT
Assisting the Patient with Asthma continued
Assisting a Patient in the Use of an Inhaler
When assisting a patient in the use of an asthma inhaler, always obtain consent then follow these general
guidelines, if local protocols allow:
1. If the patient has prescribed asthma medication, help the person take it first.
2. Shake the inhaler and then remove the cover from the mouthpiece. Position the spacer if you are using one.
3. Have the patient breathe out fully through the mouth and then place the lips tightly around the inhaler
mouthpiece.
4. The patient should inhale deeply and slowly as you or the patient depresses the inhaler canister to release the
medication, which is then inhaled into the lungs.
5. The patient should hold the breath for a count of 10. If using a spacer, the patient takes 5 to 6 deep breaths
with the spacer still in the mouth, without holding the breath.
6. Reassess the patient’s breathing.
7. Always wash your hands immediately after providing care.
Side Effects
Common side effects of asthma medication include:
Increased heart rate.
Palpitations.
Nausea.
Vomiting.
Nervousness.
Headache.
Sleeplessness.
Dry mouth.
Cough.
Hoarseness.
Headache.
Throat irritation.
Dose and Route
The effectiveness of treatment for asthma can vary based on the dose given to the patient, as well as the route by
which it is administered. In severe cases, this is tracked by the patient’s healthcare provider in order to find which
is the most effective.
Medical Control Role
Any time you assist a patient with an inhaler, you need to obtain an order from medical direction. The order can be
obtained through radio or phone contact with the medical director or through protocols and standing orders.
Always verify the order by restating the name of the medication. This helps reduce the chance of improper
medication or inappropriate dose or route. Know and follow local protocols for administration of inhalers.
254 | Emergency Medical Response
Skill Sheet
Skill Sheet 10-6
Assisting with an Asthma Inhaler
REMEMBER: Always obtain consent and wash your hands immediately after providing care. Read
and follow all instructions printed on the inhaler prior to administering the medication to the patient.
Always follow standard precautions when providing care.
If the person has medication for asthma, help them take it:
STEP 1
Help the patient sit up and rest in a position comfortable for breathing.
STEP 2
Ensure that the prescription is in the patient’s name and is prescribed for “quick relief” or
“acute” attacks.
■■ Ensure that the expiration date of the medication has not passed.
STEP 3
Shake the inhaler.
STEP 4
Remove the cover from the inhaler mouthpiece.
■■ If an extension tube (spacer) is available, attach and use it.
STEP 5
Tell the patient to breathe out as much as possible through the mouth.
▼ (Continued)
Chapter 10: Airway and Ventilation | 255
Skill Sheet
Skill Sheet 10-6
Assisting with an Asthma Inhaler Continued
STEP 6
Have the patient place their lips tightly around the mouthpiece
and take a long, slow breath.
■■ As the patient breathes in slowly, administer
the medication by quickly pressing down on the
inhaler canister, or the patient may self-administer
the medication.
■■ The patient should continue a full, deep breath.
■■ Tell the patient to try to hold their breath for a count of 10.
■■ When using an extension tube (spacer), have the patient
take 5 to 6 deep breaths through the tube without
holding their breath.
NOTE: The patient may use different techniques, such as holding
the inhaler two-finger lengths away from the mouth.
STEP 7
Note the time of administration and any change in the patient’s condition.
■■ The medication may be repeated once after 1 to 2 minutes.
NOTE: The medication may be repeated every 5 to 10 minutes thereafter, as needed,
for emergency calls in areas with long EMS response times such as rural locations.
▼ (Continued)
256 | Emergency Medical Response
Skill Sheet
Skill Sheet 10-6
Assisting with an Asthma Inhaler Continued
STEP 8
Call for more advanced medical care if difficulty breathing does not improve quickly.
NOTE: These medications might take 5 to 15 minutes to reach full effectiveness.
Chapter 10: Airway and Ventilation | 257
11 You Are the Emergency Medical Responder
AIRWAY
MANAGEMENT
As an emergency medical responder (EMR), you respond to a call at one of the docks for
an unconscious adult who collapsed for no apparent reason. You size up the scene and
notice that a middle-age male is lying face-up on the ground and not moving. The patient
is unresponsive with no severe bleeding. He is not breathing but has a pulse. You discover
that the patient’s chest does not rise when you attempt ventilations. What would you do
next? What do you think the problem is?
KEY TERMS
Airway adjunct: A mechanical device used to help the airway; may be used on a conscious or an
keep the tongue from obstructing the airway; unconscious patient.
can be either nasal or oral.
Oral (oropharyngeal) airway (OPA): An airway
Nasal (nasopharyngeal) airway (NPA): An airway adjunct inserted through the mouth and into the
adjunct inserted through the nostril and into the throat to help keep the tongue from obstructing the
throat to help keep the tongue from obstructing airway; used only with unconscious patients.
LEARNING OBJECTIVES
After reading this chapter, and completing the • List the circumstances when airway adjuncts
class activities, you will have the information should not be used.
needed to: • List some common causes of airway obstruction
• Explain the purposes and use of airway adjuncts. and describe appropriate care.
• Describe the two types of suctioning devices and • Describe how to provide care for a choking adult,
their use. child and infant who becomes unconscious.
SKILL OBJECTIVES
After reading this chapter, and completing the class • Demonstrate how to provide care for a choking
activities, you should be able to: adult, child and infant.
• Demonstrate how to insert an oral airway. • Demonstrate how to insert a nasal airway
(Enrichment skill).
• Demonstrate the techniques of suctioning.
INTRODUCTION side and sweep the mouth with a gloved finger.
However, finger sweeps should only be performed
Although most of the care you provide will not on an unconscious patient and only when material
require the use of breathing devices or airway is visible in the mouth. Another method of keeping
adjuncts, in some situations they can be used the airway clear is to place an unresponsive patient
effectively as part of your care. Breathing devices who is breathing in a recovery position. But a
and airway adjuncts can assist with: more effective method is to suction the airway
clear. Suctioning is the process of removing
Helping maintain an open airway.
foreign matter from the upper airway by means
Ventilating a patient.
of a mechanical or manual device.
Administering supplemental oxygen.
Suctioning is an important step, when fluids or
In this chapter, you will learn the purpose and foreign matter are present or suspected, because
use of airway adjuncts, suctioning and how to the airway must be open and clear in order for the
handle situations involving foreign body airway patient to breathe or for any CPR breathing barrier to
obstructions (FBAOs). be effective. Ensure that you always have a suction
device at the patient’s side when providing care.
SUCTIONING
Sometimes injury or sudden illness results in Suctioning Equipment
foreign matter, such as mucus, fluids or blood, There are two types of suction devices: mechanical
collecting in a patient’s airway. One method of and manual (Fig. 11-1, A–B). A variety of
clearing the airway is to roll the patient onto the mechanical and manual devices are used to
Chapter 11: Airway Management | 259
A B
Fig. 11-1, A–B: (A) Mechanical suctioning equipment; (B) manual suctioning equipment.
suction the airway. Not all suction units are able to How to Suction
remove solid objects like teeth, foreign bodies and To use a mechanical suctioning device:
food. Always follow standard precautions when
using a suctioning device. 1. Position the patient on the side with the mouth
open. If the patient has an obvious sign of
Mechanical suction units are electrically powered. injury, suction them in the position found,
They produce a vacuum that is powerful enough as appropriate.
to suction substances from the throat (see
2. Remove any visible large debris from the
Skill Sheet 11-1). Mechanical units operate on
mouth with a gloved finger if the patient is
batteries, which must be checked to ensure they
unconscious.
are fully charged, unless the units are of a type
with batteries that can be constantly charged. 3. Measure and check the suction tip.
Otherwise, there may be insufficient vacuum to 4. Turn on the machine and test it.
operate the unit effectively and for a sufficient 5. Suction the mouth of an adult for no more than
amount of time. Mechanical suction devices are 15 seconds at a time as you withdraw the
normally found on ambulances or other transport catheter using a sweeping motion. Suctioning
vehicles and use either battery-powered pumps for longer periods can starve the patient of air.
or oxygen-powered aspirators. This can create an environment that is too low
in oxygen to sustain life.
Manual suction units, as the term implies, are
operated by hand (see Skill Sheet 11-2). They are To use a manual suctioning device:
lightweight, compact and relatively inexpensive.
Because they do not require an energy source, 1. Position the patient on the side with the mouth
they avoid some of the problems associated with open. If the patient has an obvious sign of
mechanical units and are easily taken to the side injury, suction them in the position found,
of the patient in case they are needed. as appropriate.
2. Remove any visible large debris from the
For either type of unit, several sizes of sterile
mouth with a gloved finger if the patient is
suction catheters should be kept on hand for use,
unconscious.
depending on the size of the patient. An installed
suction unit should be powerful enough to provide 3. Measure and check the suction tip.
an airflow of > 40 liters per minute (LPM) at the 4. Suction the mouth of an adult for no more than
end of the delivery tube and, when clamped, 15 seconds at a time as you withdraw the
a vacuum of > 300 mmHg. catheter using a sweeping motion.
CRITICAL Suctioning is the process of removing foreign matter, such as mucus, fluids or
FACTS blood, from a patient’s upper airway. Suctioning can be done through mechanical
or manual devices.
260 | Emergency Medical Response
Pediatric Considerations information on NPAs, refer to the Enrichment at the
When using mechanical or manual suction end of this chapter.)
on a child or an infant, suction for no more
than 10 seconds at a time for a child and Airway adjuncts come in a variety of sizes
5 seconds at a time for an infant. (Fig. 11-2, A–B). The curved design fits the natural
contour of the mouth and throat. Once you have
positioned the device, you can use a resuscitation
BREATHING DEVICES mask or BVM to ventilate a nonbreathing patient.
Breathing devices allow the emergency
medical responder (EMR) to provide positive
pressure ventilations to patients in need of CPR, Oropharyngeal Airway
supplemental oxygen and/or artificial ventilations. As the name implies, this type of airway is inserted
These devices include CPR breathing barriers into the mouth (see Skill Sheet 11-3). When
such as face shields and resuscitation masks, properly positioned, the OPA keeps the tongue
bag-valve-mask (BVM) resuscitators and oxygen away from the back of the throat, thereby helping
equipment. CPR breathing barriers should have to maintain an open airway. An improperly placed
certain standard features such as a one-way airway device can compress the tongue into the
valve to reduce the possibility of direct contact back of the throat, further blocking the airway.
with, or exposure to, body fluids and a patient’s
exhaled breath. Such devices can help to deliver When preparing to insert an OPA, first be sure
life-sustaining ventilations when a patient is unable the patient is unconscious. OPAs are used only
to breathe on their own. See Chapter 10 for more on unconscious patients with no gag reflex.
information and how to use these devices. If a patient begins to gag, remove the airway
immediately. OPAs should not be used if the
patient has suffered oral trauma, such as broken
AIRWAY ADJUNCTS teeth, or has recently undergone oral surgery.
Follow local protocols for the use of OPAs.
The tongue is the most common cause of airway
obstruction in an unconscious person. Keeping Next, select the proper size of airway. Measure
the tongue from blocking the air passage is a the device on the patient to see that it extends
high priority. Mechanical airway adjuncts known from the angle of the jaw to the corner of the
as oral (oropharyngeal) airways (OPAs) and mouth (Fig. 11-3). To insert the airway, grasp the
nasal (nasopharyngeal) airways (NPAs) patient’s lower jaw and tongue and lift upward.
can help you accomplish this task. (For more With the patient’s jaw raised, insert the OPA with
A B
Fig. 11-2, A–B: (A) Oropharyngeal airways (OPAs); (B) nasopharyngeal airways (NPAs).
CRITICAL The tongue is the most common cause of airway obstruction in an unconscious
FACTS person. Keeping the tongue from blocking the air passage is a high priority.
Mechanical airway adjuncts known as OPAs and NPAs can help you accomplish
this task.
Chapter 11: Airway Management | 261
Fig. 11-3: A properly sized OPA extends from the angle of the
jaw to the corner of the mouth.
the curved end (tip) along the roof of the mouth
A
(Fig. 11-4, A). As the tip of the device approaches
the back of the throat, you will feel resistance.
Rotate it a half turn to drop it into the back of the
patient’s throat (Fig. 11-4, B). The OPA should
drop into the throat without resistance. The flange
end should rest on the patient’s lips (Fig. 11-4, C).
If the patient begins gagging as the device is
positioned in the back of the throat, remove the
device. Suction the airway, ensuring all debris
is removed from the airway. Thoroughly clean
the device and reinsert into the airway only if the
patient is still unconscious and does not have
a gag reflex.
Pediatric Considerations
The airway of a child or infant is smaller than
an adult’s. The size can also vary according
to the age of the child or infant, so it is B
important to use an appropriately sized OPA
for pediatric patients. Additionally, the palate
of a child and an infant is softer than that of an
adult. It can be injured if an OPA is inserted
with the tip pointing upward toward the roof
of the mouth and rotated 180 degrees as is
performed on an adult. Because of this risk
of injury, when inserting an OPA in a child or
an infant, the airway is inserted with the tip
of the device either sideways then rotated
90 degrees into position or, using a tongue
depressor, inserted with the tip of the device
pointing toward the back of the tongue and C
throat in the position it will rest after insertion
Fig. 11-4, A–C: (A) Insert an OPA with the curved tip along the
(Fig. 11-5, A–B). roof of the mouth. (B) Rotate it to drop it into the back of the throat.
(C) If inserted properly, the flange end should rest on the lips.
CRITICAL When preparing to insert an OPA, first be sure the patient is unconscious.
FACTS OPAs are used only on unconscious patients with no gag reflex.
262 | Emergency Medical Response
AIRWAY OBSTRUCTION
Types of Airway Obstruction
There are two types of airway obstruction,
anatomical and mechanical:
Anatomical obstruction occurs when an airway
is blocked by an anatomical structure, such as
the tongue or swollen tissues of the mouth or
throat. The tongue is a common cause of airway
obstruction in an unconscious patient because
the tongue relaxes when the body is deprived of
oxygen, causing the tongue to rest on the back of
the throat, blocking the flow of air to the lungs.
Mechanical obstruction, also known as foreign
A
body airway obstruction, occurs when foreign
objects, such as food or toys, or fluids, such as
vomit, block the airway.
Foreign Body Airway Obstruction
Foreign body airway obstruction (FBAO) causes
choking and commonly occurs because of poorly
chewed food; eating too fast; or laughing, talking,
running or walking while eating. A conscious
person who is clutching the throat is showing what
B is commonly called the “universal” sign of choking
Fig. 11-5, A–B: To insert an OPA in a pediatric patient: (A) Use (Fig. 11-6). A person with a mild FBAO, or partial
a tongue depressor and insert the OPA, with the device pointing airway obstruction, can still move some air to and
toward the back of the tongue; (B) ensure that the OPA rests in
proper position. from the lungs, often while wheezing. As long
Fig. 11-6: A conscious person who is clutching the throat is showing what is commonly called the
“universal” sign of choking.
CRITICAL There are two types of airway obstruction: anatomical (e.g., swollen tongue) and
FACTS mechanical (e.g., food, toys).
Chapter 11: Airway Management | 263
as the person can cough forcefully, encourage the object is dislodged and the patient can cough
continued coughing but do not provide first aid forcefully, speak or breathe, or until the patient
care for choking. Severe airway obstruction is becomes unconscious.
apparent when the person cannot cough, speak,
cry or breathe and requires immediate action. Abdominal thrusts may not be an effective
method of care for choking adults in cases where
you cannot reach far enough around the patient
FBAO in an Adult to give effective abdominal thrusts or if the
As an EMR, you must get consent before helping patient is obviously pregnant or known to
a choking adult. be pregnant. In these situations, you should
give back blows followed by chest thrusts
When caring for a choking adult, several skills—
(Fig. 11-8, A–B).
abdominal thrusts, back blows and chest thrusts—
have been shown to be effective at clearing an To perform abdominal thrusts:
obstruction (see Skill Sheet 11-4). Generally,
EMRs should provide abdominal thrusts to attempt 1. Stand behind the patient and use one or two
to clear an obstruction, but they may perform a fingers of one hand to find the navel.
combination of skills such as back blows followed 2. Make a fist with your other hand and place the
by abdominal thrusts based on local protocols thumb side of your fist against the middle of the
(Fig. 11-7). Each abdominal thrust, back blow patient’s abdomen, just above the navel.
or chest thrust should be a distinct attempt 3. Grab your fist with your other hand and give
to dislodge the object. Using more than one quick inward and upward thrusts.
technique is often necessary to dislodge an object
4. Continue providing abdominal thrusts until
and clear a patient’s airway. Continue performing
the patient begins to cough forcefully, speak
abdominal thrusts or a combination of skills until
or breathe, or until the patient becomes
unconscious.
To perform back blows:
1. Stand to the side and slightly behind the
patient.
2. Place one arm diagonally across the patient’s
chest (to provide support) and bend the patient
forward at the waist so their upper body is as
close to parallel to the ground as possible.
3. Firmly strike the patient between the scapulae
with the heel of your other hand.
4. Continue providing back blows until the patient
begins to cough forcefully, speak or breathe,
or until the patient becomes unconscious.
Fig. 11-7: Proper hand placement for abdominal thrusts.
A B
Fig. 11-8, A–B: If you cannot reach around the patient to give effective abdominal thrusts, or if the patient is pregnant, give (A) back
blows followed by (B) chest thrusts.
264 | Emergency Medical Response
To perform chest thrusts:
1. Stand behind the patient and make a fist with
one hand.
2. Place the thumb side of your fist against the
center of the patient’s chest.
3. Grab your fist with your other hand and give
quick inward thrusts.
4. Continue providing chest thrusts until the
patient begins to cough forcefully, speak
or breathe, or until the patient becomes
unconscious.
If a patient who is choking becomes unconscious,
carefully lower the patient to a firm, flat surface A
while protecting their head, send someone to
get an AED, and summon additional resources
if appropriate and you have not already done
so. Immediately begin CPR, starting with chest
compressions. (CPR will be discussed in detail
in Chapter 13.)
As you open the airway to give ventilations, look
in the patient’s mouth for any visible object. If you
can see an object, use a finger sweep motion to
remove it (Fig. 11-9, A–C). If you don’t see an
object, do not perform a blind finger sweep, but
continue CPR. Remember to never try more than
2 ventilations during one cycle of CPR, even if the
chest doesn’t rise.
Continuing cycles of 30 compressions and
2 ventilations is the most effective way to provide
care. Even if ventilations fail to make the chest rise,
compressions may help clear the airway by moving B
the blockage into the upper airway where it can be
seen and removed.
Science Note: Evidence suggests that it
may take more than one technique to relieve
an airway obstruction in the conscious
patient, and that abdominal thrusts, back
blows and chest thrusts are all effective.
Science Note: Based upon local protocols
or practice, it is permissible to provide a
series of back blows in addition to abdominal
thrusts to an adult or child who is choking.
Always follow local protocols, practice or
medical direction instructions.
C
Fig. 11-9, A–C: As you open the airway to give ventilations, look
in the patient’s mouth for any visible object. If you can see an
object, use a finger sweep motion to remove it.
Chapter 11: Airway Management | 265
Pediatric Considerations When an infant is choking and awake but unable
Children are prone to choking on small to cough, cry or breathe, you’ll need to perform
objects as well as food. Choking hazards a series of 5 back blows and 5 chest thrusts (see
among children include small objects such as Skill Sheet 11-5). Start with back blows. Hold the
coins, buttons, small toys, and parts of toys infant face-down on one arm using your thigh for
and balloons, as well as certain food items. support. Make sure the infant’s head is lower than
While hazardous for all children, these objects their chest and that you are supporting the infant’s
generally pose a larger threat to children under head and neck. With your other arm, give firm
4 years of age. Children under 4 do not have back blows with the heel of your hand between
a full set of teeth and cannot chew as well as the infant’s scapulae.
older children, so large chunks of foods may
lodge in the throat and cause choking. After 5 back blows, start chest thrusts. Turn the
infant over onto your other arm using your thigh for
The American Academy of Pediatrics (AAP) support. Make sure to support the head and neck
recommends that children younger than 4 not as you move the infant. Place two fingers in the
be fed any round, firm food unless it is cut center of the infant’s chest, just below the nipple
into small pieces no larger than one-half inch. line. Give 5 thrusts. Continue this cycle of 5 back
It further recommends keeping the following blows and 5 chest thrusts until the object is forced
foods away from children younger than 4: out; the infant can cough, cry or breathe; or the
infant becomes unconscious.
Hot dogs
Nuts and seeds If an infant does become unconscious while
Chunks of meat or cheese choking, carefully lower the infant onto a firm,
Whole grapes flat surface while protecting their head, send
someone to get an AED, and summon additional
Hard, gooey or sticky candy
resources if appropriate and you have not already
Popcorn
done so. Immediately begin CPR, starting with
Chunks of peanut butter chest compressions.
Raw vegetables
Raisins
Chewing gum PUTTING IT ALL TOGETHER
While food items cause the most choking As an EMR, you may need to know how to insert
injuries in children, toys and household items OPAs, use a suctioning device and care for a
can also be hazardous. Balloons, when not conscious or an unconscious patient who is
inflated or when broken, can choke or suffocate choking. Breathing devices and airway adjuncts
young children who try to swallow them. allow the EMR to help maintain an open airway,
According to the Consumer Product Safety ventilate a patient and supply supplemental
Commission (CPSC), more children have oxygen.
suffocated on non-inflated balloons and pieces
OPAs can help maintain an open airway by keeping
of broken balloons than any other type of toy.
the tongue away from the back of the throat. An
As an EMR, you must get consent from OPA can be used on an unconscious patient who
a parent or legal guardian, if present, does not have a gag reflex and requires an airway
before helping a choking child or infant. adjunct. Suction equipment helps clear the upper
airway of substances, such as fluids, blood, saliva
For a conscious child, the process of relieving
or vomit. You should also know the difference
an obstructed airway is similar to that of an
between a mechanical and anatomical obstruction
adult. However, responders should use less
and the actions required to assist a patient who is
force when giving abdominal thrusts or back
choking as a result.
blows. Using too much force may cause
internal injuries. Remember, you may need Special considerations must be given when
to kneel to provide care for an obstructed caring for a child or an infant, including the size
airway in a child. Continue care until the child of equipment used. You may need to alter your
can cough forcefully, speak, cry or breathe, positon based on the size of the child and use less
or until the child becomes unconscious. If a force to clear an obstructed airway.
child becomes unconscious, follow the same
general steps as you would for an adult.
266 | Emergency Medical Response
You Are the Emergency Medical Responder
You reposition the patient’s airway and attempt another ventilation, but the chest still does not
rise. How would you respond? After a few minutes of care, the patient’s chest begins to rise
and fall with the ventilations, but he is not breathing on his own. How would you continue to
provide care for this patient?
Chapter 11: Airway Management | 267
Skill Sheet
Skill Sheet 11-1
Using a Mechanical Suctioning Device
NOTE: Size up the scene for safety, and follow standard precautions. If needed, assemble the device
according to manufacturer’s instructions.
STEP 1
Position the patient. If the patient has an obvious sign of
injury, suction them in the position found, as appropriate.
■■ Roll the body as a unit onto one side.
■■ Open the mouth.
STEP 2
Remove any visible large debris from the mouth with a
gloved finger if the patient is unconscious.
STEP 3
Measure and check the suction tip.
■■ Measure from the angle of the patient’s jaw to the corner of the mouth.
■■ Note the distance to prevent inserting the suction tip too deeply.
▼ (Continued)
268 | Emergency Medical Response
Skill Sheet
Skill Sheet 11-1
Using a Mechanical Suctioning Device Continued
STEP 4
Turn on the machine and check that the suction is working
according to the manufacturer’s instructions.
STEP 5
Suction the mouth.
■■ Insert the suction tip into the back of the mouth.
■■ Apply suction as you withdraw the catheter using
a sweeping motion, if possible.
■■ Suction for no more than 15 seconds at a time for
an adult, 10 seconds for a child and 5 seconds for
an infant.
Chapter 11: Airway Management | 269
Skill Sheet
Skill Sheet 11-2
Using a Manual Suctioning Device
NOTE: Size up the scene for safety, and follow standard precautions. If needed, assemble the device
according to manufacturer’s instructions.
STEP 1
Position the patient. If the patient has an obvious sign of
injury, suction them in the position found, as appropriate.
■■ Roll the body as a unit onto one side.
■■ Open the mouth.
STEP 2
Remove any visible large debris from the mouth with
a gloved finger if the patient is unconscious.
STEP 3
Measure and check the suction tip.
■■ Measure from the angle of the patient’s jaw to the
corner of the mouth.
■■ Note the distance to prevent inserting the suction
tip too deeply.
■■ Check that the suction is working by placing your
gloved finger over the end of the suction tip as you
squeeze the handle of the device.
▼ (Continued)
270 | Emergency Medical Response
Skill Sheet
Skill Sheet 11-2
Using a Manual Suctioning Device Continued
STEP 4
Suction the mouth.
■■ Insert the suction tip into the back of the mouth.
■■ Squeeze the handle of the suction device
repeatedly to provide suction.
■■ Apply suction as you withdraw the catheter using
a sweeping motion, if possible.
■■ Suction for no more than 15 seconds at a time for
an adult, 10 seconds for a child and 5 seconds for
an infant.
Chapter 11: Airway Management | 271
Skill Sheet
Skill Sheet 11-3
Inserting an Oral Airway
NOTE: Size up the scene for safety, follow standard precautions and then perform a primary
assessment. Before inserting an oral airway (OPA), be sure the patient is unconscious, has no oral
trauma such as broken teeth and has not had recent oral surgery. If the patient gags, remove the
airway immediately.
STEP 1
Select the proper size.
■■ Measure the OPA from the angle of the patient’s jaw
to the corner of the mouth.
STEP 2
Open the patient’s mouth.
■■ Use the cross-finger technique to open the patient’s
mouth.
▼ (Continued)
272 | Emergency Medical Response
Skill Sheet
Skill Sheet 11-3
Inserting an Oral Airway Continued
STEP 3
Insert the OPA.
NOTE: When inserting an OPA in a child or an infant, the
OPA is inserted using a tongue blade or a tongue depressor,
then inserted with the tip of the device pointing toward the
back of the tongue and throat in the position it will rest in
after insertion.
■■ To insert the OPA, grasp the patient’s lower jaw
and tongue and lift upward.
■■ Insert the OPA with the curved end along the roof
of the mouth.
■■ As the tip approaches the back of the mouth,
rotate it one-half turn (180 degrees).
■■ Slide the OPA into the back of the throat.
NOTE: The alternative procedure for a child or an infant is
to insert the OPA sideways and then rotate it 90 degrees.
STEP 4
Ensure correct placement.
■■ The flange should rest on the patient’s lips.
■■ If the patient begins to gag, immediately remove
the OPA.
■■ If the patient vomits, remove and suction the airway,
ensuring all debris is removed from the airway.
Thoroughly clean the device and reinsert into the
airway only if the patient is still unconscious and
does not have a gag reflex.
Chapter 11: Airway Management | 273
Skill Sheet
Skill Sheet 11-4
Choking—Adult and Child
NOTE: Obtain consent from a choking adult. If a child is choking, obtain consent from the parent or
legal guardian if present. Tell the child’s parent or legal guardian your level of training and the care
you are going to provide. If the parent or legal guardian is not available, consent is implied. Always
follow standard precautions when providing care.
STEP 1
Ask the patient, “Are you choking?”
■■ Identify yourself and ask if you can help.
■■ If the patient is coughing forcefully, encourage continued coughing.
STEP 2
If the patient cannot cough, speak or breathe, have someone else
summon more advanced medical personnel.
▼ (Continued)
274 | Emergency Medical Response
Skill Sheet
Skill Sheet 11-4
Choking—Adult and Child Continued
STEP 3
Give abdominal thrusts.
■■ Stand behind the patient.
●● For a child, stand or kneel behind the child, depending on
the child’s size. Use less force on a child than you would
on an adult.
■■ Use one or two fingers of one hand to find the navel.
■■ Make a fist with your other hand and place the thumb side
of your fist against the middle of the patient’s abdomen, just
above the navel.
■■ Grab your fist with your other hand.
■■ Give quick inward and upward thrusts. Each thrust should be a
distinct attempt to dislodge the object.
Continue providing abdominal thrusts until:
■■ The patient begins to cough forcefully, speak or breathe on their own.
■■ The patient becomes unconscious.
If the patient becomes unconscious:
■■ Carefully lower the patient to a firm, flat surface while protecting their head.
■■ Immediately begin CPR, starting with compressions.
●● After 30 compressions, open their mouth and look for an object. If you see an
object, remove it with a finger sweep.
●● Attempt ventilations.
●● Continue CPR.
OPTION BASED ON LOCAL PROTOCOLS
Provide a combination of 5 back blows followed by 5 abdominal thrusts.
To perform back blows:
■■ Stand to the side and slightly behind the patient.
■■ Place one arm diagonally across the patient’s chest (to provide support) and bend the
patient forward at the waist so their upper body is as close to parallel to the ground
as possible.
■■ Firmly strike the patient between the scapulae with the heel of your other hand.
■■ Continue providing back blows until the patient begins to cough forcefully, speak or
breathe, or until the patient becomes unconscious.
NOTE: Some choking patients may need chest thrusts instead of abdominal thrusts.
Use chest thrusts if:
■■ You cannot reach far enough around the patient to give effective abdominal thrusts.
■■ The patient is obviously pregnant or known to be pregnant.
Chapter 11: Airway Management | 275
Skill Sheet
Skill Sheet 11-5
Choking—Infant
NOTE: If an infant is choking, obtain consent from the parent or legal guardian if present. Tell the
infant’s parent or legal guardian your level of training and the care you are going to provide. If the
parent or legal guardian is not available, consent is implied. Always follow standard precautions when
providing care.
STEP 1
If the infant cannot cough, cry or breathe, carefully position the infant face-down along your
forearm.
■■ Support the infant’s head and neck with your hand.
■■ Lower the infant onto your thigh, keeping the infant’s head lower than their chest.
STEP 2
Give 5 firm back blows.
■■ Use the heel of your hand.
■■ Give back blows between the infant’s scapulae.
■■ Each back blow should be a distinct attempt to dislodge
the object.
STEP 3
Position the infant face-up along your forearm.
■■ Position the infant between both of your forearms, supporting
the infant’s head and neck.
■■ Turn the infant face-up.
■■ Lower the infant onto your thigh with the infant’s head lower
than their chest.
▼ (Continued)
276 | Emergency Medical Response
Skill Sheet
Skill Sheet 11-5
Choking—Infant Continued
STEP 4
Give 5 chest thrusts.
■■ Put two fingers on the center of the chest, just below the
nipple line.
■■ Compress the chest 5 times about 1½ inches.
■■ Each chest thrust should be a distinct attempt to dislodge the
object.
Continue giving 5 back blows and 5 chest thrusts until:
■■ The infant begins to cough or breathe on their own.
■■ The infant becomes unconscious.
If the infant becomes unconscious:
Carefully lower the infant onto a firm, flat surface while protecting their head and immediately
begin CPR, starting with compressions.
■■ After 30 compressions, open their mouth and look for an object. If you see an object,
remove it with a finger sweep.
■■ Attempt ventilations.
■■ Continue CPR.
Chapter 11: Airway Management | 277
ENRICHMENT
Nasopharyngeal Airway
When properly positioned, the nasal (nasopharyngeal) airway (NPA) keeps the tongue out of the back of
the throat, thereby keeping the airway open. An NPA may be used on a conscious, responsive patient or an
unconscious patient. Unlike an oral airway, the NPA does not cause the patient to gag. NPAs must not be used
on a patient with suspected head trauma or a suspected skull fracture.
When using an NPA, select the proper size (see Skill Sheet 11-6). Measure the device on the patient to see
that it extends from the angle of the jaw to the tip of the nose. Also, make sure the diameter of the NPA is not
larger than the internal diameter of the nostril. To insert the NPA, lubricate the airway and the opening of the
nostril with a water-soluble lubricant. Insert the NPA into the right nostril, with the bevel toward the septum (the
wall of tissue that separates the nostrils). Advance the NPA gently, straight in, not upward, until the flange rests
on the nostril. If you feel even minor resistance, do not force the NPA. If you cannot get the NPA to pass easily,
remove it and try the other nostril. If you use the left nostril, you need to ensure that the bevel is inserted toward
the septum and the NPA is rotated as you advance it in, similar to the OPA.
278 | Emergency Medical Response
Skill Sheet
Skill Sheet 11-6
Inserting a Nasal Airway
NOTE: Size up the scene for safety, follow standard precautions and then perform a primary
assessment. NPAs must not be used on a patient with suspected head trauma or a suspected
skull fracture.
STEP 1
Select the proper size.
■■ Measure the NPA from the angle of the patient’s
jaw to the tip of the nostril. Ensure that the
diameter of the NPA is not larger than the
internal diameter of the nostril.
STEP 2
Lubricate the NPA and the opening of the nostril.
■■ Use a water-soluble lubricant to lubricate
the NPA prior to insertion.
STEP 3
Insert the NPA.
■■ Insert the NPA into the right nostril, with the bevel
toward the septum (center of the nose).
■■ Advance the NPA gently, straight in, following the
floor of the nose.
■■ If resistance is felt, do not force it.
■■ If you are experiencing problems, try the left nostril
and ensure that you rotate the NPA as you insert it
past the nasal structures.
▼ (Continued)
Chapter 11: Airway Management | 279
Skill Sheet
Skill Sheet 11-6
Inserting a Nasal Airway Continued
STEP 4
Ensure correct placement.
■■ The flange should rest on the nostril.
280 | Emergency Medical Response
12 SUPPLEMENTAL
OXYGEN
You Are the Emergency Medical Responder
A 45-year-old man is experiencing chest pain. When he finally calls for assistance, he states
that the pain started about 30 minutes ago as a mild, squeezing sensation. Now the pain
is severe and he is gasping for breath. You, as the responding member of your company’s
emergency response team, recognize that these signs and symptoms suggest a serious cardiac
condition. You complete a primary assessment, physical exam and SAMPLE history. The patient
has no known history of hypertension or heart disease. While waiting for an ambulance or
other transport vehicle to arrive, you help the patient get into the most comfortable position for
breathing, keep him from getting chilled or overheated, and ask him to remain still. You open a
nearby window to circulate fresh air into the stuffy room. What else can you do to help?
KEY TERMS
Flowmeter: A device used to regulate, in liters per Oxygen cylinder: A steel or alloy cylinder that
minute (LPM), the amount of oxygen administered contains 100 percent oxygen under high
to a patient. pressure.
Hypoxia: A condition in which insufficient oxygen Pressure regulator: A device on an oxygen cylinder
reaches the body’s cells. that reduces the delivery pressure of the oxygen
to a safe level.
Nasal cannula: A device used to administer oxygen
through the nostrils to a breathing person. Supplemental oxygen: Oxygen delivered to
a patient from an oxygen cylinder through a
Non-rebreather mask: A type of oxygen mask used delivery device; can be given to a nonbreathing
to administer high concentrations of oxygen to a or breathing patient who is not receiving
breathing person. adequate oxygen from the environment.
“O-ring” gasket: Plastic, O-shaped ring that makes
the seal of the pressure regulator on an oxygen
cylinder tight; can be a built-in or an attachable piece.
LEARNING OBJECTIVES
After reading this chapter, and completing the class • Describe the steps required to administer
activities, you will have the information needed to: supplemental oxygen.
• Identify when it is appropriate to administer • List precautions to take when using
supplemental oxygen. supplemental oxygen.
• List the delivery devices for use in administering
supplemental oxygen.
SKILL OBJECTIVES
After reading this chapter, and completing the nonbreathing patients using a nasal cannula,
class activities, you should be able to: non-rebreather mask, resuscitation mask and
bag-valve-mask (BVM) resuscitator.
• Demonstrate how to prepare the equipment
and administer oxygen to breathing and
INTRODUCTION using a bag-valve-mask (BVM) resuscitator, you
deliver that 21 percent oxygen to the patient.
When someone has a breathing or cardiac The expired air in your exhaled breath, however,
emergency, supplying supplemental oxygen contains about 16 percent oxygen, and this
can be critical. During such an emergency, the is the concentration delivered when using a
amount of oxygen carried by the blood cells to resuscitation mask. Neither of these percentages
the brain, heart and body is reduced, resulting in of oxygen alone may be adequate for the patient.
hypoxia. If breathing stops (respiratory arrest), By administering supplemental oxygen, you can
the brain and heart will soon be starved of oxygen, deliver a higher percentage of oxygen that an
resulting in cardiac arrest and ultimately death if injured or ill person may need.
not managed quickly and appropriately.
Supplemental oxygen can be given for many
The air you normally breathe contains about breathing and cardiac emergencies. It can be given
21 percent oxygen. When you provide ventilations to nonbreathing patients, sometimes in conjunction
282 | Emergency Medical Response
with an airway adjunct. If a patient is breathing respond to, variable-flow-rate oxygen is practical.
but has no obvious signs or symptoms of injury or To deliver supplemental oxygen using a variable-
illness, oxygen may be considered for: flow-rate system, you must assemble the equipment.
An adult breathing fewer than 12 breaths or
more than 20 breaths per minute. Fixed-Flow-Rate Oxygen
A child breathing fewer than 15 breaths or Some supplemental oxygen systems have the
more than 30 breaths per minute. regulator set at a fixed-flow rate. Most fixed-
flow-rate tanks are set at 15 LPM; however,
An infant breathing fewer than 25 breaths or
an emergency medical responder (EMR) may
more than 50 breaths per minute.
come across tanks set at 6 LPM, 12 LPM or
Administer oxygen based on local protocols another rate. In some cases, the fixed-flow-rate
to all patients with respiratory distress or systems may have a dual (high/low) flow setting.
respiratory failure with low oxygen saturation Fixed-flow-rate oxygen systems typically come
or signs and symptoms of hypoxia, as these with the delivery device, regulator and cylinder
conditions are usually caused by abnormal already connected to each other (Fig. 12-1). This
oxygen levels to the tissues. Always administer eliminates the need to assemble the equipment,
oxygen for suspected CO poisoning and all smoke- which makes it quick and very simple to deliver
inhalation cases. oxygen. A drawback to using fixed-flow-rate
oxygen systems is that you cannot adjust the
Oxygen should be delivered with properly flow rate to different levels. This limits both the
sized equipment for the patient and appropriate type of delivery device you can use and the
flow rates for the delivery device. For step-by-step concentration of oxygen you can deliver. For
instructions on oxygen delivery, see Skill Sheet 12-1. example, a fixed-flow-rate unit with a preset flow
of 6 LPM can only be used with a nasal cannula or
resuscitation mask, while a preset flow rate of
ADMINISTERING SUPPLEMENTAL 12 LPM only allows the use of a resuscitation
OXYGEN mask or non-rebreather mask.
To deliver supplemental oxygen, you must have:
An oxygen cylinder.
A pressure regulator with flowmeter.
A delivery device.
According to the U.S. Food and Drug
Administration (FDA), oxygen units may be
marketed without a prescription when used for
emergency resuscitation and when administered
by an individual who is authorized, certified or
licensed by state authorities. Such units must
deliver a minimum flow rate of 6 liters of oxygen
per minute for a minimum of 15 minutes (90 liters).
Labeling for emergency oxygen for OTC use may
not contain references to any medical conditions,
disorders or diseases. The filling and refilling
of empty or spent oxygen cylinders is strictly
controlled by state and local regulations. Local
protocols must always be followed.
Variable-Flow-Rate Oxygen
Variable-flow-rate oxygen systems allow the
responder to vary the flow of oxygen. Because of
the large amount of oxygen emergency medical
services (EMS) systems deliver and the variety
of equipment and emergency situations they Fig. 12-1: A fixed-flow-rate oxygen system.
Chapter 12: Supplemental Oxygen | 283
Because of the simplicity of the preconnected
fixed-flow-rate systems and the lifesaving
benefits of oxygen, these systems are becoming
increasingly popular in the workplace, schools
and other places where EMRs may have to
respond to on-site emergencies.
Oxygen Cylinders
Oxygen cylinders are made to be easily
recognizable. These cylinders, made of steel
or alloy, can hold between 350 and 625 liters
of oxygen, and have internal pressures of
Fig. 12-2: Oxygen cylinders are marked with a yellow diamond approximately 2000 pounds per square inch
that says “Oxygen” and, in the United States, typically have green (psi). Oxygen cylinders are labeled “U.S.P.”
markings.
and are marked with a yellow diamond that says
“Oxygen” (Fig. 12-2). The U.S.P. stands for
United States Pharmacopeia, which indicates
the oxygen is medical grade. In the United States,
oxygen cylinders typically have green markings,
such as a green top; however, the color scheme
is not regulated. Different manufacturers and
other countries may use different color markings.
Oxygen cylinders are under high pressure and
must be handled carefully; do not drop. Ensure
oxygen cylinders have proper hydrostatic testing
and are marked appropriately.
Pressure Regulator and Flowmeter
The pressure inside an oxygen cylinder is far
too great to allow you to open the cylinder and
administer the oxygen. Therefore, a device called
a pressure regulator is attached to the cylinder
to reduce the delivery pressure of the oxygen to a
safe level (Fig. 12-3). The pressure regulator
reduces the pressure from approximately 2000 psi
inside the cylinder to a safe pressure range of 30 to
70 psi. The amount of pressure inside the cylinder
is indicated on a gauge. By checking the gauge,
you can determine how full a cylinder is. A full
cylinder will show 2000 psi, while a nearly
empty cylinder will show about 200 psi. Always
monitor the pressure in the oxygen cylinder to make
sure it is above 200 psi. When the cylinder reaches
200 psi, replace the oxygen cylinder with a
Fig. 12-3: A pressure regulator is attached to an oxygen cylinder new tank.
to reduce the pressure of oxygen to a safe level.
CRITICAL Oxygen cylinders have U.S.P. and yellow diamond labels that make them easy to
FACTS recognize. In the United States, oxygen cylinders typically have green markings.
284 | Emergency Medical Response
A pressure regulator typically has two metal
prongs that fit into the valve at the top of the
oxygen cylinder. This is called the pin index safety
system. It is standard on any type of tank that has
these pins; a different pin placement depending
on the type of tank prevents unintentional use.
To ensure a tight seal between the regulator and
the tank, a gasket, commonly called an “O-ring”
gasket, must be used (Fig. 12-4). Never lubricate
any part of an oxygen system.
A flowmeter controls the amount of oxygen
administered in LPM, with a normal delivery
rate from 1–25 LPM. Fig. 12-4: An O-ring gasket.
Oxygen Delivery Devices
An oxygen delivery device is the piece of equipment
a patient breathes through when receiving oxygen.
Tubing carries the oxygen from the regulator to the
delivery device. When delivering oxygen, make sure
the tubing does not get tangled or kinked so as to
stop the flow of oxygen to the mask. These devices
can include nasal cannulas, simple face masks,
non-rebreather masks, BVMs and resuscitation
masks (Table 12-1). Various sizes of these devices
are available for adults, children and infants.
Appropriate sizing is important to ensure
adequate airway management.
Nasal Cannula
The nasal cannula is used only on breathing
patients and delivers oxygen through the patient’s
nostrils (Fig. 12-5). A plastic tube is held in place
over the patient’s ears, and oxygen is delivered
through two small prongs inserted into the nostrils.
Nasal cannula use is limited, as it normally delivers
oxygen at a flow rate of 1–6 LPM, which provides
a peak oxygen concentration of approximately
44 percent. Flow rates above 4 LPM are not
commonly used because of the tendency to
quickly dry out mucous membranes and cause
nosebleeds and headaches. Fig. 12-5: A nasal cannula.
Table 12-1:
Oxygen Delivery Devices
COMMON OXYGEN
DELIVERY DEVICE FUNCTION
FLOW RATE CONCENTRATIONS
Nasal cannula 1–6 LPM 24 to 44 percent Breathing patients only
Resuscitation mask 6–15 LPM 25 to 55 percent Breathing and nonbreathing patients
Non-rebreather mask 10–15 LPM up to 90 percent Breathing patients only
BVM 15+ LPM 90+ percent Breathing and nonbreathing patients
Chapter 12: Supplemental Oxygen | 285
Because of these limitations, the nasal cannula
is commonly used for patients with only minor
breathing difficulty or for those who have a
history of respiratory medical conditions. Patients
experiencing a serious breathing emergency
generally breathe through the mouth and need
a device that can supply a greater concentration
of oxygen. The nasal cannula can be ineffective
for patients who have a nasal airway obstruction,
nasal injury or a bad cold causing blocked sinus
passages. It is useful for patients who cannot
tolerate a mask over their face.
Fig. 12-6: A resuscitation mask with oxygen inlet.
Resuscitation Mask with Oxygen Inlet
The resuscitation mask with an oxygen inlet can
be used with supplemental oxygen to deliver
oxygen to a nonbreathing patient (Fig. 12-6). It
also can be used to deliver oxygen to someone
who is breathing but still requires oxygen. Some
resuscitation masks come with elastic straps to
place over the patient’s head to keep the mask in
place. If the mask does not have a strap, you or the
patient can hold it in place.
With a resuscitation mask, set the oxygen flow rate
at 6–15 LPM. A resuscitation mask can deliver up
to 55 percent oxygen to a breathing person, when
delivered at 6 LPM or more. When used on a
nonbreathing patient while you perform ventilations,
it will deliver an oxygen concentration of approximately
35 percent. The oxygen concentration is reduced
because oxygen mixes with your exhaled breath as
you perform mouth-to-mask ventilations.
Non-Rebreather Mask
A non-rebreather mask is used to deliver high
concentrations of oxygen to breathing patients
(Fig. 12-7, A–B). It consists of a face mask with an
attached oxygen reservoir bag and a one-way valve
A
between the mask and bag to prevent the patient’s
B
Fig. 12-7, A–B: A non-rebreather mask.
286 | Emergency Medical Response
CRITICAL Oxygen devices, such as nasal cannulas, simple face masks, non-rebreather
FACTS masks, BVMs and resuscitation masks, allow the patient to effectively receive
supplemental oxygen.
exhaled air from mixing with the oxygen in the protective covering over the tank opening. Remove
reservoir bag. The patient inhales oxygen from the this covering. If it is not built into the tank, remove
bag, and exhaled air escapes through flutter valves the O-ring gasket. While pointing the cylinder away
on the side of the mask. To inflate the reservoir from you, open the cylinder for 1 second. This will
bag, cover the one-way valve with your gloved remove any dirt or debris from the cylinder valve.
thumb before placing it on the patient’s face. The If necessary, reposition the O-ring gasket.
oxygen reservoir bag should be sufficiently inflated
(about two-thirds full) so as not to deflate when the Next, examine the pressure regulator to be sure it
patient inhales. If this happens, increase the flow is designed for delivering supplemental oxygen.
rate of the oxygen to refill the reservoir bag. The It may be labeled “Oxygen Regulator.” Check to
flow rate should be set at 10–15 LPM. When using see that the pin index corresponds to an oxygen
a non-rebreather mask with a high flow rate of tank. Attach the pressure regulator to the cylinder,
oxygen, up to 90 percent oxygen concentration can seating the prongs inside the holes in the valve.
be delivered to the patient. Hand-tighten the screw until the regulator is snug.
Open the cylinder one full turn and listen for leaks.
BVM Check the pressure gauge to determine how
A BVM can be used on a breathing or nonbreathing much pressure is in the cylinder. A full cylinder
patient. With a BVM, the oxygen flow rate should should have approximately 2000 psi. Attach the
be set at 15 LPM or more. The BVM with an chosen delivery device to the oxygen port near
oxygen reservoir bag is capable of supplying the flowmeter, using the appropriate tubing.
90 percent or more oxygen concentration when
used at 15 LPM or more (Fig. 12-8). Squeeze the
bag between each breath for patients breathing
Oxygen Administration
less than 10 times per minute. To assist a person To administer oxygen using a variable-flow-rate
breathing more than 30 times per minute, squeeze system, follow the steps described earlier, then
the bag on every second breath. turn on the flowmeter and adjust it to the desired
flow rate. Listen and feel to make sure that oxygen
is flowing into your delivery device. If you are using
Assembly for a Variable-Flow-Rate a non-rebreather mask, ensure that the reservoir
System bag is two-thirds full before placing the device on
Begin by examining the cylinder to be certain that the patient. Finally, place the delivery device on
it is labeled “Oxygen.” The cylinders come with a the patient.
Fig. 12-8: A bag-valve-mask resuscitator.
Chapter 12: Supplemental Oxygen | 287
Check for the physical presence of rust or
corrosion on a cylinder or cylinder neck.
Any foreign substances or residues, such as
adhesive tape around the cylinder neck, oxygen
valve or regulator assembly, can hamper oxygen
delivery and in some cases may have the
potential to cause a fire or explosion.
Ensure that all oxygen cylinders have proper
hydrostatic testing and are marked appropriately.
Be aware of the specific testing requirements
of steel and aluminum tanks (e.g., 10 years
initial testing for steel cylinders and 5 years for
Fig. 12-9: Use the “blow-by” technique for children and infants aluminum cylinders).
who are frightened by having oxygen masks on their faces.
SAFETY PRECAUTIONS
If young children and infants are frightened by a When preparing and administering oxygen,
mask being placed on their face, use a “blow-by” safety is a major concern. Use oxygen equipment
technique. To perform this technique, you, a parent according to the manufacturer’s instructions and
or legal guardian holds the mask about 2 inches in a manner consistent with federal and local
from the child’s or infant’s face waving it slowly regulations.
from side-to-side as if you are playing a game,
thus allowing the oxygen to pass over the face Also, follow these recommended guidelines:
and be inhaled (Fig. 12-9).
Be sure that oxygen is flowing before putting the
You should monitor the effectiveness of the oxygen delivery device over the patient’s face.
delivery; a pulse oximeter can be used to do so. Do not use oxygen around flames or sparks
including smoking materials, such as cigarettes,
cigars and pipes. Oxygen causes fire to burn
Assembly and Administration more rapidly and intensely.
for a Fixed-Flow-Rate System
To operate a fixed-flow-rate system, simply turn it on
Do not use grease, oil or petroleum products to
lubricate or clean the regulator. This could cause
according to the manufacturer’s instructions, check an explosion.
that oxygen is flowing and place the delivery device
on the patient. You can also use the “blow-by” Do not stand oxygen cylinders upright unless they
are well secured. If a cylinder falls, the regulator
technique using a fixed-flow-rate system by
or valve could become damaged or cause injury
following the same procedure outlined above.
due to the intense pressure in the tank.
Securing and Handling Cylinders
Do not drag or roll cylinders.
Do not carry a cylinder by the valve or regulator
Never attempt to refill an oxygen cylinder; only an (Fig. 12-10, B).
appropriately licensed professional should do this.
When high-pressure oxygen cylinders have been
Do not hold on to protective valve caps or
guards when moving or lifting cylinders.
emptied, close the cylinder valve, replace the valve
protection cap or outlet plug where provided, and Do not deface, alter or remove any labeling or
markings on the oxygen cylinder.
mark or tag the cylinder as EMPTY. Then return the
cylinder promptly, to be refilled according to state Do not attempt to mix gases in an oxygen cylinder
and local regulations. or transfer oxygen from one cylinder to another.
Specific attention should be given to the following If defibrillating using an automated external
areas concerning oxygen cylinders: defibrillator (AED), make sure that no one is
touching or is in contact with the patient or the
Check for cylinder leaks, abnormal bulging, and resuscitation equipment. Do not defibrillate
defective or inoperative valves or safety devices someone when around flammable materials,
(Fig. 12-10, A). such as free-flowing oxygen or gasoline.
288 | Emergency Medical Response
A B
Fig. 12-10, A–B: Because they are highly pressurized, special care should be taken when handling oxygen cylinders. Be sure to
(A) check for defects before use and (B) carry them appropriately by the body of the cylinder, not the valve.
PUTTING IT ALL TOGETHER face masks, non-rebreather masks and BVMs.
The resuscitation mask and BVM are the most
Administering supplemental oxygen to someone appropriate devices for EMRs, as they can be used
experiencing a breathing emergency can help with breathing and nonbreathing patients. These
improve hypoxia. It can also help reduce pain devices can significantly increase the oxygen
and breathing discomfort. When using oxygen, concentration that an injured or ill person needs,
follow safety precautions and use the equipment help ventilate a nonbreathing patient and reduce
according to the manufacturer’s instructions. the likelihood of disease transmission.
An oxygen delivery device is the piece of Be familiar with the unique features and benefits
equipment a patient breathes through when of these devices as well as their appropriate flow
receiving oxygen. These delivery devices include rates and situations in which they should be used
nasal cannulas, resuscitation masks, simple based on local protocols.
You Are the Emergency Medical Responder
The 45-year-old man who was experiencing chest pain and difficulty breathing is now slightly
cyanotic (skin has a bluish color), is gasping for air and is breathing 26 times per minute.
What breathing devices could you use to help this patient? After a couple of minutes, the man
complains of having a mask on his face but is still gasping for air. How would you change your
care for this patient?
Chapter 12: Supplemental Oxygen | 289
Skill Sheet
Skill Sheet 12-1
Oxygen Delivery
STEP 1
Make sure the oxygen cylinder is labeled “U.S.P.” (United
States Pharmacopeia) and marked with a yellow diamond
that says “Oxygen.”
STEP 2
Clear the valve.
■■ Remove the protective covering.
■■ Remove and save the O-ring gasket, if necessary.
■■ Turn the cylinder away from you and others before
opening.
■■ Open the cylinder valve for 1 second to clear the
valve of any debris.
STEP 3
Attach the regulator.
■■ Put the O-ring gasket into the valve on top of the
cylinder, if necessary.
■■ Make sure that it is designed for delivering
supplemental oxygen and that the O-ring gasket
is secure.
■■ Check to see that the pin index corresponds to an oxygen tank.
■■ Secure the regulator on the cylinder by placing the two metal prongs into the valve.
■■ Hand-tighten the screw until the regulator is snug.
(Continued)
290 | Emergency Medical Response
Skill Sheet
Skill Sheet 12-1
Oxygen Delivery Continued
STEP 4
Open the cylinder counterclockwise one full turn.
■■ Check the pressure gauge.
■■ Determine that the cylinder has enough pressure
(more than 200 psi). If the pressure is lower than
200 psi, do not use.
STEP 5
Attach the delivery device.
■■ Attach the plastic tubing between the flowmeter
and the delivery device.
STEP 6
Adjust the flowmeter.
■■ Turn the flowmeter to the desired flow rate.
●● With a nasal cannula, set the rate at 1–6 LPM.
●● With a resuscitation mask, set the rate at
6–15 LPM.
●● With a non-rebreather mask, set the rate
at 10–15 LPM.
❑❑ Ensure that the oxygen reservoir bag is two-thirds inflated by placing your
thumb over the one-way valve at the bottom of the mask until the bag is
sufficiently inflated.
●● With a BVM, set the rate at 15 LPM or more.
(Continued)
Chapter 12: Supplemental Oxygen | 291
Skill Sheet
Skill Sheet 12-1
Oxygen Delivery Continued
STEP 7
Verify the oxygen flow.
■■ Listen for a hissing sound and feel for oxygen flow
through the delivery device.
STEP 8
Place the delivery device on the patient and continue care
until more advanced medical personnel take over.
STEP 9
Break down the oxygen equipment.
■■ To break down the tank, reverse the steps from above, being sure to bleed the
pressure regulator by turning on the flowmeter after the tank has been turned off.
292 | Emergency Medical Response
UNIT 4
Circulation
13 Circulation and Cardiac Emergencies�����������������294
13 CIRCULATION
AND CARDIAC
EMERGENCIES
You Are the Emergency Medical Responder
A man suddenly collapses. He is lying on the floor and does not appear to be moving.
You, as a police officer trained in emergency medical response, recognize the
emergency, activate the emergency response plan and perform a primary assessment.
The emergency medical services (EMS) system has been activated. You determine
that the man is unresponsive; has no severe, life-threatening bleeding; is not breathing
normally and does not have a pulse. You have an automated external defibrillator (AED)
in your patrol car. How would you respond?
KEY TERMS
Acute coronary syndrome (ACS): Term that the brain and other vital organs for a person whose
describes a range of clinical conditions, including heart and normal breathing have stopped.
unstable angina and myocardial infarction, that are
due to insufficient blood supply to the heart muscle Cardiovascular disease: A disease affecting the
resulting from coronary heart disease (CHD). heart and blood vessels.
Acute myocardial ischemia: An episode of chest Chest compressions: A technique used in CPR
pain due to reduced blood flow to the heart muscle. in which external pressure is placed on the chest
to help circulate oxygen-rich blood through the
Angina pectoris: Pain in the chest that comes and arteries and to the vital organs.
goes at different times; caused by a lack of oxygen
reaching the heart; can be stable (occurring under Cholesterol: A fatty substance made by the liver
exertion or stress) or unstable (occurring at rest, and found in foods containing animal or animal
without reason). products; diets high in cholesterol contribute to
the risk of heart disease.
Arrhythmia: Electrical disturbances in the regular
rhythmic beating of the heart. Commotio cordis: Sudden cardiac arrest from a
blunt, non-penetrating blow to the chest, of which
Asystole: A condition where the heart has stopped the basis is ventricular fibrillation (V-fib) triggered
generating electrical activity. by chest wall impact immediately over the heart.
Atherosclerosis: A condition in which deposits of Congestive heart failure: A chronic condition in
plaque, including cholesterol (a fatty substance which the heart no longer pumps blood effectively
made by the liver and found in foods containing throughout the body.
animal or animal products) build up on the inner
walls of the arteries, causing them to harden Coronary heart disease (CHD): A disease in which
and narrow, reducing the amount of blood that cholesterol and plaque build up on the inner walls
can flow through; develops gradually and can go of the arteries that supply blood to the heart; also
undetected for many years. called coronary artery disease (CAD).
Atrial fibrillation: Irregular and fast electrical Defibrillation: An electrical shock that disrupts the
discharges from the left or right atrium of the heart electrical activity of the heart long enough to allow
that lead to an irregular heartbeat; one of the most the heart to spontaneously develop an effective
common types of abnormal cardiac rhythm. rhythm on its own.
Atrioventricular (AV) node: A cluster of cells in Electrocardiogram (ECG or EKG): A diagnostic
the center of the heart, between the atria and test that measures and records the electrical
ventricles; serves as a relay to slow down the activity of the heart.
signal received from the sinoatrial (SA) node Heart: A fist-sized muscular organ that pumps blood
before it passes through to the ventricles. throughout the body.
Automated external defibrillator (AED): A High-performance CPR: Providing high-quality
portable electronic device that analyzes the heart’s chest compressions as part of a well-organized
electrical rhythm and, if necessary, can deliver an team response to a cardiac arrest.
electrical shock to a person in cardiac arrest.
Hypertension: Another term for high blood pressure.
Cardiac arrest: A condition in which the heart has
stopped or beats too irregularly or weakly to pump Implantable cardioverter-defibrillator (ICD):
blood effectively. A miniature version of an AED, implanted under
the skin, that acts to automatically recognize and
Cardiac Chain of Survival: A set of five critical help correct abnormal heart rhythms.
steps that, when performed in rapid succession,
increase the patient’s chance of surviving cardiac Myocardial infarction (MI): The death of cardiac
arrest; each link of the chain depends on, and is muscle tissue due to a sudden deprivation of
connected to, the other links. circulating blood; also called a heart attack.
Cardiopulmonary resuscitation (CPR): A Normal sinus rhythm (NSR): The normal, regular
technique that combines chest compressions and rhythm of the heart, set by the SA node in the right
ventilations to circulate blood containing oxygen to atrium of the heart.
(Continued)
Chapter 13: Circulation and Cardiac Emergencies | 295
KEY TERMS continued
Pacemaker: A device implanted under the skin, Sudden cardiac arrest: A condition where the
sometimes below the right collarbone, to help heart’s pumping action stops abruptly, usually
regulate the heartbeat in someone whose natural due to abnormal heart rhythms called arrhythmias,
pacemaker (the sinoatrial node) is not functioning most commonly ventricular fibrillation (V-fib) or
properly, causing the heart to skip beats or beat too ventricular tachycardia (V-tach); unless an effective
fast or too slow. heart rhythm is restored, death follows within a
matter of minutes.
Return of spontaneous circulation (ROSC):
A term to describe the successful resuscitation Transdermal medication patch: A patch on the
of a patient in cardiac arrest; a return of a pulse skin that delivers medication; commonly contains
during resuscitative efforts. nitroglycerin, nicotine or other medications; should
Risk factors: Conditions or behaviors that increase be removed prior to placing defibrillation pads on
the chance that a person will develop a disease. the chest.
Silent heart attack: A heart attack during which Ventricular fibrillation (V-fib): A life-threatening
the patient has either no symptoms or very mild heart rhythm in which the heart is in a state of
symptoms that the person does not associate with totally disorganized electrical activity.
heart attacks; mild symptoms include indigestion
Ventricular tachycardia (V-tach): A life-threatening
or sweating.
heart rhythm in which there is very rapid
Sinoatrial (SA) node: A cluster of cells in the right contraction of the ventricles.
atrium that generates the electrical impulses that
set the pace of the heart’s natural rhythm.
LEARNING OBJECTIVES
After reading this chapter, and completing the • Describe how to perform two-responder CPR for
class activities, you will have the information an adult, a child and an infant.
needed to: • Define defibrillation and describe how it works.
• Describe how to recognize and care for a patient • Identify the abnormal heart rhythms commonly
who may be experiencing a heart attack. present during cardiac arrest.
• Describe how to care for a patient who may be • Describe the role and importance of early
experiencing cardiac arrest. defibrillation in cardiac arrest.
• List the reasons for the heart to stop beating. • List the general steps for using an automated
• Describe the skill components of CPR. external defibrillator (AED).
• List the steps of one-responder CPR for an adult, • Identify precautions for using an AED.
a child and an infant. • Identify special situations that may arise when
• Explain when it is appropriate to stop using an AED.
performing CPR.
SKILL OBJECTIVES
After reading this chapter, and completing the class • Demonstrate two-responder CPR for an adult,
activities, you should be able to: a child and an infant.
• Demonstrate one-responder CPR for an adult, • Demonstrate how to use an AED for adult and
a child and an infant. pediatric patients in cardiac arrest.
296 | Emergency Medical Response
INTRODUCTION
In this chapter, you will learn how to recognize and
provide care for a patient who is experiencing signs
and symptoms of a heart attack or whose heart
stops beating. A heart attack occurs when blood
vessels supplying the heart become blocked and Left Atrium
fail to provide the heart enough blood and oxygen
necessary to function properly. The condition in Right Atrium
which the heart stops functioning is known as
cardiac arrest. It can sometimes result from a heart Left Ventricle
attack but cardiac arrest can also be caused by Right Ventricle
sudden, irregular electrical activity of the heart as
well as many other causes. To provide care for a
patient in cardiac arrest, you need to know how to
perform cardiopulmonary resuscitation (CPR) and
use an automated external defibrillator (AED). CPR
can keep a patient’s vital organs supplied with
blood containing oxygen until more highly trained
personnel arrive to provide advanced life support Fig. 13-1: The heart.
care. In many cases, however, CPR by itself cannot
correct the underlying problem. An AED can heart’s four chambers. For the circulatory system
analyze the heart’s electrical rhythm and deliver to be effective, the respiratory system must also
a shock to help the heart to restore an effective be working so that the blood can pick up oxygen
rhythm. Sudden cardiac arrest can happen to in the lungs.
anyone at anytime, and although not common,
can occur in children and infants. Physiology of the Circulatory System
As an emergency medical responder (EMR), you
The Heart’s Electrical System
must assess patients quickly and be prepared An electrical system in the heart triggers the
to perform high-quality CPR and use an AED contraction or pumping action of the heart muscle.
in cases of cardiac arrest. This chapter covers In a healthy heart, an electrical impulse comes
the basic principles of how to recognize cardiac from a point near the top of the heart called the
emergencies and provide the appropriate care. sinoatrial (SA) node. The impulse travels through
the atria, the upper chambers of the heart, down to
the atrioventricular (AV) node, near the bottom
THE CIRCULATORY SYSTEM of the right atrium (Fig. 13-2).
Anatomy of the Circulatory System From the AV node, the impulse divides into two
The heart is a muscular organ, which functions branches, then into the right and left ventricles.
like a pump. About the size of the patient’s fist, it
lies between the lungs, in the middle of the chest,
behind the lower half of the sternum (breastbone)
(Fig. 13-1). The heart is protected by the ribs How the Heart
and sternum in front and by the spine in back.
It has four chambers and is separated into right Functions
and left halves. The right side of the heart has
Too often we take our hearts for granted. The
two chambers known as the right atrium, which
heart is extremely reliable. The heart beats
receives oxygen-depleted blood from the veins of
about 70 times each minute or more than
the body, and the right ventricle, which pumps the
100,000 times a day. During the average
oxygen-depleted blood to the lungs where waste
lifetime, the heart will beat nearly 3 billion
products are removed and oxygen is absorbed.
times. The heart moves about a gallon of
The now oxygen-rich blood returns to the left side blood per minute through the body. This
of the heart, where it enters the left atrium and is about 40 million gallons in an average
goes on to the left ventricle, where it is pumped lifetime. The heart moves blood through about
to all parts of the body. One-way valves direct 60,000 miles of blood vessels.
the flow of blood as it moves through each of the
Chapter 13: Circulation and Cardiac Emergencies | 297
between the pulse beats are the periods between
contractions. As the left ventricle relaxes, or is at
rest, blood refills the chamber and there is a pause
Atria between pulse beats.
SA node
An electrocardiogram (ECG or EKG) is
a diagnostic test that graphically measures
AV node
and records the electrical activity and rhythm
of the heart. Electrodes attached to an
electrocardiograph pick up electrical impulses
Ventricles and transmit them to a monitor. The peaks
and valleys of each wave, the size, shape and
Purkinje fibers
frequency, show the heart’s rhythm and how
the electrical system is functioning. The normal
conduction of electrical impulses without
any disturbances is known as normal sinus
Fig. 13-2: The heart’s electrical system.
rhythm (NSR).
These right and left branches become a network
Perfusion
of fibers, called Purkinje fibers, which spread
electrical impulses across the heart. Under normal As the blood flows through the arteries, oxygen
circumstances, these impulses reach the muscular and nutrients such as glucose are delivered to cells
walls of the ventricles causing the muscles to throughout the body, and as blood flows through
contract and force blood out of the heart to the veins, carbon dioxide and other wastes are
circulate throughout the body. The contraction taken away. This continuous process is called
of the left ventricle results in a pulse. The pauses perfusion (Fig. 13-3).
Vena cava Capillaries
Aorta
Right lung
Left lung
Heart
Capillaries
Fig. 13-3: Blood continuously flows through the arteries delivering oxygen and other
nutrients to the body’s cells. It also flows through the veins, taking away carbon dioxide and
other wastes. The process is called perfusion.
298 | Emergency Medical Response
walls. As this buildup worsens, the arteries become
narrower, reducing the amount of blood that can
flow through them and preventing the heart from
getting the blood or oxygen it needs (Fig. 13-4).
Patients who suffer from acute myocardial
ischemia (reduced blood flow to the cardiac
muscle) suffer chest pain, which usually results
from CHD and is referred to as acute coronary
syndrome (ACS). This reduced blood and oxygen
supply to the heart can cause symptoms of angina
pectoris or a heart attack.
A heart attack, or myocardial infarction (MI),
occurs when coronary blood vessels become
blocked by plaque buildup or a blood clot blocks
one of the arteries supplying the heart. This may
lead to an irregular heartbeat (arrhythmia) which
then causes the pumping action of the heart to
work less efficiently. A heart attack is one of the
leading causes of cardiac arrest, which is when
Fig. 13-4: In atherosclerosis, a buildup of cholesterol and fatty the heart ceases to function as a pump. As the
deposits on inner artery walls results in hardened, narrowed
arteries. reduction of blood flow or blockage progresses,
some people experience symptoms such as
chest pain, pressure or discomfort, an early
The primary gases exchanged are oxygen and warning sign that the heart is not receiving
carbon dioxide. All cells require oxygen to function. enough oxygen-rich blood. Others may suffer a
Cells also require energy to function. Glucose, heart attack or even cardiac arrest without any
a simple sugar molecule, is the main source of warning signs or symptoms. If a blockage in a
energy inside the cell. coronary artery of the heart is not treated quickly,
the affected heart muscle tissue will die.
Pathophysiology of the
Circulatory System Pediatric Considerations
Cardiovascular disease is an abnormal Cardiac Pathophysiology
condition that affects the heart and blood vessels. Heart problems in children and infants are
An estimated 90 million Americans suffer from almost always secondary to airway and
some form of the disease. It remains the number respiratory problems but can also be related
one killer in the United States and a major cause to congenital heart conditions. When cardiac
of disability. The most common conditions caused arrest occurs in children and infants, it is often
by cardiovascular disease include coronary heart caused by:
disease (CHD), also known as coronary artery Airway and breathing problems.
disease (CAD), and stroke. (See Chapter 14 for Traumatic injuries or other incidents
more information on stroke.) (e.g., motor-vehicle collision, drowning,
electrocution or poisoning).
CHD occurs when the arteries that supply blood to
the heart muscle become hardened and narrowed, A hard blow to the chest (e.g., commotio
a process called atherosclerosis. This damage cordis).
occurs gradually, as cholesterol and fatty Congenital heart disease.
deposits called plaque build up on the inner artery Sudden infant death syndrome (SIDS).
CRITICAL Cardiovascular disease afflicts approximately 90 million Americans and is the
FACTS number one killer in the United States. Common conditions caused by this disease
include CHD and stroke.
Chapter 13: Circulation and Cardiac Emergencies | 299
Considerations for Older Adults Congestive Heart Failure
Cardiac Pathophysiology Also called heart failure, congestive heart failure
In older adult patients, a general decrease is a chronic condition in which the heart no longer
in pain perception may cause a different pumps blood effectively throughout the body. This
reaction to a heart attack. Older adults often may cause high blood pressure and a buildup of fluid
suffer what is known as a “silent heart throughout the body, resulting in difficulty breathing
attack,” meaning that there is an absence of and weight gain. Fluid buildup and swelling usually
chest pain or pressure. The symptoms of a occur in the face, hands, legs, ankles and feet.
heart attack most commonly shown by older
adult patients include general weakness or
Hypertension
fatigue, aching shoulders and abdominal pain
or indigestion. Also known as high blood pressure, hypertension
is one of the main risk factors for heart attack
and stroke. A patient is considered to have
Other Specific Cardiovascular hypertension when blood pressure is higher than
Emergencies 140/90 mmHg. The causes of hypertension are
Angina Pectoris not clear; however, certain medications, sodium
A medical term for “pain in the chest,” angina intake and stress can contribute to a rise in blood
pectoris develops when the heart needs more pressure. Secondary hypertension is caused by an
oxygen than it gets, because the arteries leading underlying condition such as a kidney abnormality
to it are too narrow. Angina pectoris is normally a or tumor of the adrenal gland.
transient condition. When a person with angina
exercises, gets excited or is emotionally upset, the Diabetes
heart might not get enough oxygen. This lack of Diabetes can affect the nerves; therefore, people
oxygen can cause chest discomfort or pain. People with diabetes may not experience the classic
with angina usually have medicine they can take to heart attack sign of chest pain and may suffer
stop the pain. Stopping physical activity or easing a “silent heart attack.” People who experience
the distress and taking the medicine usually end silent heart attacks may have no warning signs or
the discomfort or pain. they may have very mild signs. When this occurs,
the diagnosis of a heart attack may have to be
Arrhythmias confirmed by special tests. (See Chapter 14 for
Arrhythmias are electrical disturbances in the more information on diabetes.)
regular rhythmic beating of the heart. Some
people have heart arrhythmias that do not cause Women and Heart Attacks
problems. In others, they can indicate a more Although women may experience chest pain,
serious problem that leads to heart disease, pressure or discomfort during a heart attack,
stroke or sudden cardiac death. they are more likely to experience some of the
other warning signs and symptoms, particularly
Atrial Fibrillation shortness of breath; nausea or vomiting; stomach,
Atrial fibrillation is one of the most common back or jaw pain; or unexplained fatigue or malaise.
types of abnormal cardiac rhythm. When someone When they do experience chest pain, women may
experiences atrial fibrillation, the two upper chambers have a greater tendency to have atypical chest
of the heart (the atria) beat out of coordination pain: sudden, sharp but short-lived pain outside
with the two lower chambers (the ventricles). This the breastbone. As a result, women often will delay
causes an irregular and often rapid heart rate that telling others about their symptoms.
leads to the inability to adequately deliver blood to
the ventricles. Atrial fibrillation can be controlled Assessment of Cardiac Emergencies
with medication and other treatments. Although not The sooner you recognize the signs and symptoms
usually life threatening, atrial fibrillation is a risk factor of a heart attack and act, the better chance you
for stroke and heart attack. have to save a life. Many people will deny they are
CRITICAL A heart attack is caused by blockages from plaque buildup or blood clots, which
FACTS affect the ability of the heart to pump effectively. A heart attack is one of the leading
causes of cardiac arrest, which is when the heart ceases to function as a pump.
300 | Emergency Medical Response
having a heart attack. Summon more advanced
medical personnel if the patient shows some or all
of the following signs and symptoms:
Discomfort, pressure or pain. The major
symptom is persistent discomfort, pressure
or pain in the chest that does not go away.
Unfortunately, it is not always easy to distinguish
heart attack pain from the pain of indigestion,
muscle spasms or other conditions. This often
causes people to delay getting medical care.
Brief, stabbing pain or pain that gets worse when
you bend or breathe deeply is not usually caused
by a heart problem but may be associated with
other serious medical conditions.
The pain associated with a heart attack can
range from discomfort to an unbearable
crushing sensation in the chest. The patient may
describe it as pressure, squeezing, tightness,
aching or heaviness in the chest. Many heart
attacks start slowly, as mild discomfort, pressure
or pain often felt in the center of the chest
(Fig. 13-5). It may spread to the shoulder, arm,
neck, jaw, stomach or back. The discomfort or
pain becomes constant. It is usually not relieved
by resting, changing position or taking medicine.
When interviewing the patient, ask open-ended
questions, such as “Can you describe how you
feel for me?” so you can hear the symptoms Fig. 13-5: Some people experience symptoms such as chest
described in the patient’s own words. pain, pressure or discomfort during a heart attack.
Any chest discomfort or pain that is severe,
to get much-needed oxygen to the heart. A patient
lasts longer than a few minutes (about 3–5
minutes), goes away and comes back or persists who is sitting upright and learning forward with
even during rest requires immediate medical hands on knees in the tripod position is struggling
care. Even people who have had a previous to breathe. Difficulty breathing also includes noisy
heart attack may not recognize the signs and breathing and shortness of breath.
symptoms, because each heart attack can have Other signs and symptoms include pale or
entirely different signs and symptoms. ashen skin, especially around the face. The
patient also may be damp with sweat. Some
Pain that comes and goes, such as with angina
people suffering from a heart attack sweat
pectoris. Some people with CHD may have
chest pain or pressure that comes and goes heavily, feel dizzy or lightheaded and/or may
and is usually treated with a medication called lose consciousness. Nausea is also a sign
nitroglycerin. Nitroglycerin is prescribed in and symptom of a heart attack.
several forms including tablets, spray, paste or
patches. This medication dilates blood vessels, Providing Care for Cardiac
including the coronary arteries, to help reduce Emergencies
the workload of the heart.
If you think someone is having a heart attack:
Difficulty breathing is another sign of a
heart attack. The patient may be breathing Take immediate action and summon more
faster than normal because the body tries advanced medical personnel.
CRITICAL The key to saving the life of a patient having a heart attack is early recognition of
FACTS signs and symptoms, including chest discomfort, pressure or pain that does not go
away or comes and goes, and difficulty breathing.
Chapter 13: Circulation and Cardiac Emergencies | 301
If the patient answers no to all of these questions,
administration of two to four 81-mg low-dose (162
mg to 324 mg) aspirins or one 5-grain (325-mg)
adult aspirin tablet should be considered based on
local protocols. Have the patient chew the aspirin
completely, which speeds up the absorption of the
aspirin into the bloodstream.
Be sure that only aspirin is given and not
acetaminophen (e.g., Tylenol®) or nonsteroidal anti-
inflammatory drugs (NSAIDs), such as ibuprofen
(e.g., Motrin® or Advil®) and naproxen (e.g., Aleve®).
Likewise, products meant for multiple symptoms/
Fig. 13-6: If you think someone is having a heart attack, uses, such as cold, fever and headache, should not
summon more advanced medical personnel and have the patient be used. Coated aspirin may be administered as
stop any activity and rest.
long as the patient completely chews the aspirin.
Have the patient stop any activity and rest
(Fig. 13-6). CARDIAC ARREST
Loosen any tight or uncomfortable clothing. When the heart stops beating, or beats too
Closely monitor the patient until more ineffectively to circulate blood to the brain and other
advanced medical personnel take over. vital organs, this is called cardiac arrest. The beats
Notice any changes in the patient’s or contractions of the heart become ineffective if they
appearance or behavior. are weak, irregular or uncoordinated, because, at that
point, the blood no longer flows through the arteries
Comfort the patient.
to the rest of the body.
If medically appropriate and local protocols
or medical direction permit, give aspirin if the When the heart stops beating properly, the body
patient can chew, swallow and has no known cannot survive. Normal breathing will stop soon
contraindications. Be sure the patient has not after, and the body’s organs will no longer receive
been told by their physician to not take aspirin. the oxygen they need to function. Without oxygen,
Assist the patient with their prescribed brain damage can begin in about 4 to 6 minutes,
medication and administer supplemental oxygen and the damage can become irreversible after
if the patient is hypoxic and it is available, about 8 to 10 minutes.
according to local protocols.
A person in cardiac arrest is not breathing normally
Be prepared to perform CPR and use an AED.
and has no pulse. The heart has either stopped
beating or is beating weakly and irregularly so that
Aspirin Can Lessen Heart a pulse cannot be detected.
Attack Damage
You may be able to help a conscious patient who Cardiovascular disease is the primary cause of
is showing early signs of a heart attack by offering cardiac arrest, but not the only cause. About
an appropriate dose of aspirin when the signs first 610,000 people in the United States die each
begin. Local protocols regarding administration of year from all forms of the disease. Other causes
medicines, such as aspirin, may vary for EMRs and of cardiac arrest include drowning, choking,
should be followed. Aspirin should never take the drug overdose, severe injury, brain damage and
place of more advanced medical care. If the patient electrocution.
is conscious and able to take medicine by mouth, Cardiac arrest can happen suddenly, without any
ask if they: of the warning signs usually seen in a heart attack.
This is known as sudden cardiac arrest or
Are allergic to aspirin.
sudden cardiac death and accounts for more than
Have a stomach ulcer or stomach disease.
350,000 deaths annually in the United States.
Are taking any blood thinners, such as warfarin Sudden cardiac arrest is caused by abnormal,
(Coumadin®). chaotic electrical activity of the heart (known as
Have been told by a physician to not take arrhythmias). The most common life-threatening
aspirin. abnormal arrhythmia is ventricular fibrillation (V-fib).
302 | Emergency Medical Response
Cardiac Chain of Survival
Adult Cardiac Chain of Survival
The five links in the Adult Cardiac Chain of Survival are:
1. Recognition of a cardiac emergency and activation of the emergency response system. The sooner
more advanced medical personnel are called, the sooner EMS personnel will respond and provide
care to the patient.
2. Early CPR. CPR helps supply blood containing oxygen to the brain and other vital organs to help
prevent brain damage and death.
3. Early defibrillation. An electrical shock called defibrillation may help restore an effective heart rhythm
and significantly increase the patient’s chance for survival.
4. Advanced life support. Advanced medical personnel can provide the proper tools and medication
needed to continue the lifesaving care.
5. Integrated post-cardiac arrest care. Integrated care to optimize ventilation and oxygenation and treat
hypotension immediately after the return of spontaneous circulation (ROSC).
Pediatric Cardiac Chain of Survival
The five links in the Pediatric Cardiac Chain of Survival are:
1. Prevention of arrest.
2. Early high-quality CPR.
3. Rapid activation of the EMS system or response team to get help on the way quickly—no matter the
patient’s age.
4. Pediatric advanced life support.
5. Integrated post-cardiac arrest care.
Chapter 13: Circulation and Cardiac Emergencies | 303
Cardiac Chain of Survival HIGH-QUALITY CPR
During the primary assessment, you learned to Cardiopulmonary resuscitation (CPR)
identify and care for life-threatening conditions. circulates blood that contains oxygen to the vital
As an EMR, you must learn how to provide care organs of a patient in cardiac arrest when the heart
for cardiac emergencies, such as heart attack and normal breathing have stopped. CPR includes
and cardiac arrest. To effectively respond to chest compressions and ventilations as well as
cardiac emergencies, it helps to understand the the use of an AED (see Skill Sheets 13-1 to 13-3).
importance of the Cardiac Chain of Survival. For adult patients, CPR consists of 30 chest
Following the links in the Cardiac Chain of Survival compressions followed by 2 ventilations.
gives a patient in cardiac arrest the greatest
chance of survival. See the Cardiac Chain of To ensure optimal patient outcomes, high-quality
Survival sidebar for more information. CPR must be performed. You can ensure high-
quality CPR by providing high-quality chest
For each minute CPR and defibrillation are delayed, compressions, making sure that the:
the patient’s chance for survival is reduced
between 7 and 10 percent. Patient is on a firm, flat surface to allow for
adequate compression. In a non-healthcare
In the adult and pediatric Cardiac Chain of Survival, setting this would typically be on the floor or
each link of the chain depends on and is connected ground, while in a healthcare setting this may be
to the other links. The layperson or bystander is on a stretcher or bed with a CPR board or CPR
the first link in the cardiac chain of survival and can feature applied.
greatly influence the first three links, which, when
performed rapidly, have demonstrated to improve
Chest is exposed to ensure proper hand placement
and the ability to visualize chest recoil (Fig. 13-7).
outcomes. But for this five-step sequence to work
and ensure the greatest chance of survival, it is very Hands are correctly positioned, with the heel
of one hand in the center of the chest on the
important to quickly recognize the emergency and
lower half of the sternum with the other hand on
call for help, start CPR promptly and continue until
top. Most responders find that interlacing their
an AED is ready to use or more advanced medical
fingers makes it easier to provide compressions
personnel arrive and coordinate care.
while keeping the fingers off the chest.
Laypersons should be informed through community Arms are as straight as possible, with the
outreach programs and public awareness campaigns shoulders directly over the hands to promote
that by taking quick action, including calling 9-1-1 effective compressions. Locking elbows will
or the designated emergency number, starting CPR help maintain straight arms.
immediately and using an AED if one is available, it is Compressions are given at the correct rate
more likely a person in cardiac arrest will survive. of at least 100 per minute to a maximum of
Fig. 13-7: To provide high-quality chest compressions, the chest should be exposed to ensure proper
hand placement and the ability to visualize chest recoil.
304 | Emergency Medical Response
120 per minute, and at the proper depth of at limits for the rate and depth of compressions
least 2 inches, but no more than 2.4 inches for exist to improve patient outcomes, but it is also
an adult to promote adequate circulation. critical to maintain a rate between 100 and
Chest must be allowed to fully recoil between 120 compressions per minute and a depth
each compression to allow blood to flow back of at least 2 inches. Both rate and depth of
into the heart following the compression. compressions are best measured using a
feedback device if available.
Science Note: Evidence shows that a
rate of chest compressions that exceeds Chest Compressions
120 compressions per minute begins to Effective chest compressions are essential for
detrimentally impact compression depth high-quality CPR. While not fully understood,
by causing responders to be less likely to it is believed the compressions increase the
compress the chest at least 2 inches for level of pressure in the chest cavity, which
an adult. Additional evidence shows that depth squeezes the heart and stimulates a contraction,
of chest compressions greater than 2.4 inches causing oxygenated blood to circulate through
leads to increased non-life-threatening the arteries to the brain and other vital organs
injuries, such as rib fractures, in the average (Fig. 13-8, A–B). Chest compressions can
adult and should be avoided. These upper also increase the likelihood that a successful
A B
Fig. 13-8, A–B: To perform chest compressions correctly: (A) Push straight down at least 2 inches with a smooth
movement; and (B) after each compression, completely release the pressure on the chest, allowing it to fully return
to its normal position.
CRITICAL The five links in the Adult Cardiac Chain of Survival are: recognition of a cardiac
FACTS emergency and activation of the emergency response system, early CPR, early
defibrillation, advanced life support and integrated post-cardiac arrest care.
A patient who is unconscious, not breathing normally and has no pulse is in
cardiac arrest and needs CPR. CPR is a combination of chest compressions and
ventilations that circulates blood containing oxygen to the brain and other vital
organs for a person whose heart and breathing have stopped.
Chapter 13: Circulation and Cardiac Emergencies | 305
shock can be delivered to a patient suffering on the sternum when compressing the chest. Try to
a sudden cardiac arrest, especially if more keep your fingers off the chest by interlacing them or
than several minutes have elapsed since the holding them upward. Applying pressure with your
patient’s collapse. fingers can cause inefficient chest compressions or
unnecessary injury to the chest. Positioning the hands
The effectiveness of compressions can be reduced if: correctly allows for the most effective compressions
Compressions are too shallow. and decreases the chance of causing injury.
Compression rate is too slow or too fast.
There is sub-maximum recoil (not letting the Position of the Responder
chest come all the way back up). Your body position is important when giving chest
compressions. Compressing the chest straight
There are frequent interruptions.
down provides the best blood flow. The correct
The patient is not on a firm, flat surface.
body position is also less tiring for you.
Correct Hand Position Kneel at the patient’s side opposite the chest with
Keeping your hands in the correct position allows your hands in the correct position. Keep your elbows
you to give the most effective compressions. The as straight as possible, with your shoulders directly
correct position for your hands is over the lower over your hands (Fig. 13-10). When you press down
half of the sternum (breastbone) in the middle of in this position, you are pushing straight down onto
the chest (Fig. 13-9). At the lowest point of the the patient’s sternum. Keeping your arms as straight
sternum is an arrow-shaped piece of hard tissue as possible prevents you from tiring quickly.
called the xiphoid process. Avoid pressing directly
Compressing the chest requires less effort in this
on the xiphoid process, which can break off and
position. When you press down, the weight of your
puncture underlying organs and tissues causing
upper body creates the force needed to compress
potentially serious injury.
the chest. Push with the weight of your upper body,
To find the correct hand position, place the heel of not with the muscles of your arms. Push straight
one hand on the center of the exposed chest, along down. Do not rock back and forth. Rocking results
the sternum, and then place the other hand on top. in less effective compressions and wastes energy.
Use only the heel of your hand to apply pressure If your arms and shoulders tire quickly, you are not
using the correct body position.
Compression Technique
Rate of Compression
Give compressions at a rate of at least 100 per
minute to a maximum of 120 per minute. You can
help yourself maintain the right pace by counting
either aloud or in your head: one (as you press
down) and (as you release the pressure) two
(pressing down again) and (release again) and so
on. When you get to 13, you can drop the “and”
as it may be tiring and may alter the timing of
compressions. Use a feedback device if available
as it may help you to maintain a steady rhythm.
Count the number of compressions, then give
ventilations, before starting another cycle of
compressions and ventilations.
Depth of Compressions
Each time you push down, the breastbone of
Xyphoid Process an adult should move at least 2 inches. The
downward movement should be smooth, not
Fig. 13-9: Place the heel of one hand on the center of the jerky. Maintain a steady down-and-up rhythm
exposed chest, along the sternum, and then place the other hand
on top. Try to keep your fingers off the chest by interlacing them
and do not pause in between. If your hands slip
or holding them upward. out of position, follow the steps listed earlier to
306 | Emergency Medical Response
Fig. 13-10: Performing chest compressions with the appropriate body position ensures their effectiveness
and prevents you from tiring quickly.
quickly reposition them. To avoid possible injury Hands-Only CPR
to the patient’s ribs and sternum, try to limit the
Hands-only CPR, or continuous chest
maximum compression depth to 2.4 inches if using
compressions, is a simplified form of CPR
a feedback device. If in doubt, always press harder
that eliminates ventilations or rescue breaths.
to ensure you reach at least 2 inches.
It has its roots in dispatcher-assisted cardiac
emergency situations where the caller is
Recoil untrained, unwilling, unsure or otherwise unable
After each compression, completely release the to perform full CPR (chest compressions
pressure on the chest. It is not necessary to break with ventilations or rescue breaths). Providing
contact with the chest; simply allow the chest to instruction on how to give chest compressions
fully return to its normal position (full recoil) before alone is less complex than trying to explain full
you start the next compression. It is during this CPR. The main focus of hands-only CPR is on the
phase of CPR that the chambers of the heart will untrained layperson or a bystander who witnesses
refill with blood, ready to be circulated throughout the sudden collapse of an adult. EMRs should
the body with the next compression. The heart also be aware that if they come upon a bystander
receives its supply of oxygenated blood during this giving chest compressions only, that person is
phase, making full recoil crucial. performing CPR correctly.
Chest compressions alone may provide effective
Interruptions circulation of blood containing oxygen in the first
It is critical to minimize interruptions in giving few minutes of an out-of-hospital cardiac arrest.
chest compressions. If compressions must be The same quality compression techniques of full
interrupted, do so for no more than 10 seconds. CPR apply to compression-only CPR, including
For example, you may need to move the patient hand position, compression depth, speed, full
to a location where CPR can be more effectively recoil and minimal interruptions. Hands-only CPR
administered. Chest compressions are more does not affect the use of an AED.
effective when the patient is on a firm, flat surface.
If the patient is on a softer surface such as a bed,
couch or pressure-relieving mattress, carefully
Ventilations
position the patient face-up on the floor or a Artificial ventilation is a way of forcing air into the
backboard. CPR may also be interrupted briefly lungs of a patient who is not breathing. The oxygen
for defibrillation, insertion of an advanced airway in the air will be absorbed by blood flowing through
or when responders change positions between the lungs and carried to tissues and the body’s
compressions and ventilations. vital organs.
Chapter 13: Circulation and Cardiac Emergencies | 307
CRITICAL When giving ventilations during CPR, if the chest does not rise after the first
FACTS breath, reopen the airway, make a seal and try a second breath. If the breath is
not successful, move directly back to compressions and check the airway for an
obstruction before attempting subsequent ventilations. If an obstruction is found,
remove it and attempt ventilations. However, NEVER perform a blind finger sweep.
Different methods of providing ventilations are concentration of 0 percent with a high
covered in Chapters 10 and 12, including: concentration of carbon dioxide (CO2).
Mouth-to-mask ventilations. Providing ventilations can save a patient’s life,
Ventilations using a bag-valve-mask (BVM) but overventilation can be potentially harmful,
resuscitator. especially for a patient in cardiac arrest.
For example, if the ventilation is given too
In addition, if a resuscitation mask or BVM are not forcefully, or at too fast a rate, the pressure
available, you may need to provide mouth-to-mouth in the patient’s chest will remain too high
ventilations based on local protocols and your even between breaths. This stops the blood
willingness to do this without a barrier device. To from returning to the right side of the heart,
provide mouth-to-mouth ventilations: and means that less blood is available to be
pumped to other vital organs and tissues as
Open the airway past a neutral position using
the head-tilt/chin-lift maneuver. CPR continues.
Pinch the nose shut and make a complete seal
Compression and Breathing Cycles
over the patient’s mouth with your mouth (for an
infant, make a seal over the infant’s mouth and When performing CPR on an adult, child or infant,
nose with your mouth). it is delivered in cycles of chest compressions
followed by ventilations (Fig. 13-11, A–B).
Give ventilations by blowing into the patient’s
Complete the compressions, then re-establish an
mouth. Ventilations should be given one at
a time. Take a break between breaths by open airway by tilting the patient’s head and lifting
breaking the seal slightly between ventilations the chin, and then provide ventilations. When you
and then taking a breath before resealing over are finished giving ventilations, quickly reposition
the mouth. your hands on the center of the exposed chest
and start another cycle of compressions and
If you are unable to make a complete seal over a ventilations. The pause to provide 2 ventilations
patient’s mouth, you may need to use mouth-to- should take less than 10 seconds from the last
nose ventilations: compression to the first compression of the next
cycle of CPR.
With the head tilted back, close the mouth by
pushing on the chin.
Seal your mouth around the patient’s nose and One-Responder and Two-Responder
breathe into the nose. CPR—Adult
If possible, open the patient’s mouth between When performing CPR on an adult, certain
ventilations to allow air to escape. components are the same regardless of the
number of responders present (see Table 13-1).
Science Note: With mouth-to-mouth
ventilations, the patient receives a One-Responder CPR
concentration of oxygen at approximately When performing one-responder CPR on an
16 percent compared to the oxygen adult patient, the lone responder is responsible
concentration of ambient air at approximately for conducting the scene size-up and the primary
20 percent. Giving individual ventilations can assessment, and for performing all the steps of
help maintain this oxygen concentration level. CPR including the use of the AED, if available.
However, if you do not break the seal and take CPR can be exhausting, and attempts should
a breath between ventilations, the second be made to find additional resources as early as
ventilation may contain an oxygen possible during the scene size-up.
308 | Emergency Medical Response
A B
Fig. 13-11, A–B: CPR is delivered in cycles of (A) chest compressions and (B) ventilations.
Table 13-1:
One- and Two-Responder Adult CPR
ONE-RESPONDER CPR TWO-RESPONDER CPR
Hand position Hands centered on lower half of Hands centered on lower half of
sternum sternum
Compression rate Between 100 and 120 Between 100 and 120
compressions per minute compressions per minute
Compression depth At least 2 inches but no more than At least 2 inches but no more than
2.4 inches 2.4 inches
Compression/ventilation ratio 30:2 30:2
Two-Responder CPR When the AED is ready to analyze, Responder
When two responders are available, Responder 1 1 should move to the patient’s head, and
performs the scene size-up and primary Responder 2 should prepare to provide chest
assessment, and begins the process of providing compressions and get into the hovering position.
CPR, starting with chest compressions. Responders should continue providing cycles of
Meanwhile, Responder 2 calls for additional chest compressions and ventilations, switching
resources and gets/prepares the AED, if positions about every 2 minutes or when the
available. Responder 1 continues to provide responder performing compressions begins to
high-quality CPR with 30 compressions to 2 fatigue. Given that AEDs prompt to analyze every
ventilations until Responder 2 is ready to assist 2 minutes, the AED analyze period is an ideal time
and/or the AED is ready to analyze. for responders to switch positions. Responders
Chapter 13: Circulation and Cardiac Emergencies | 309
CRITICAL Once you begin CPR, do not stop. If you must, do so for no more than 10 seconds.
FACTS Reasons to discontinue CPR include more advanced medical personnel taking over
for you, seeing obvious signs of life, an AED being available and ready to use, or
being too exhausted to continue.
call for a position change by using an agreed-upon of a drowning and that the patient is hypoxic. The
term (such as “Switch”) at the start of the last sequence of care for suspected drowning patients
compression cycle. The responder providing of all ages is different than the sequence of care
compressions should count out loud and raise the for other cardiac arrests. Prior to starting CPR,
volume of their voice as they near the end of each responders should deliver 2 initial ventilations to
cycle (… 21 … 22 … 23 … 24 … 25 … 26 … 27 suspected drowning patients of all ages if there is
… 28 … 29 … 30). The responder at the chest no normal breathing or only gasping and no pulse.
will move to give ventilations while the responder
at the head will move to the chest to provide
compressions.
Stopping CPR
Once you have started providing CPR to an adult,
In a healthcare setting, often there will be more continue with 30 compressions followed by 2
than two responders. It is the responsibility of the ventilations (1 cycle = 30:2) until:
team leader to orchestrate movements between
responders to ensure no one responder becomes You see signs of return of spontaneous
fatigued and that all critical areas are addressed: circulation (ROSC) such as patient movement
compressions, ventilations and AED. For example, or normal breathing.
additional responders may be assimilated into An AED is ready to analyze the patient’s heart
roles of compressor or ventilator, allowing the team rhythm.
leader to monitor performance and ensure that high- Other trained responders take over and
quality CPR is maintained. Additionally, if a BVM is relieve you from compression or ventilation
available, ideally it is prepared by a third responder responsibilities.
positioned at the top of the head with one responder
squeezing the bag while another responder
You are presented with a valid do not resuscitate
(DNR) order.
maintains an open airway and seals the mask.
You are alone and too exhausted to continue.
The scene becomes unsafe.
Advanced Airways
When a patient has an advanced airway such as
a supraglottic airway device or an endotracheal AUTOMATED EXTERNAL
tube, CPR must be performed a little differently. A DEFIBRILLATION
supraglottic airway device (e.g., a laryngeal mask Each year, more than 350,000 Americans die
airway) is an advanced airway that does not enter and suddenly of cardiac arrest. CPR can help by
directly protect the trachea like an endotracheal tube, supplying blood containing oxygen to the brain
but it allows for improved ventilation. At a minimum, and other vital organs. In many cases, however,
two responders must be present. One responder an AED is needed to correct an abnormal electrical
gives 1 ventilation every 6 seconds, which is about problem and allow the heart to restore an effective
10 ventilations per minute. At the same time, the rhythm. Sudden cardiac arrest can happen to
second responder continues giving compressions anyone at any time, and although less common,
at a rate of between 100 and 120 compressions per it can occur in children and infants.
minute. There is no pause between compressions
or ventilations, and responders do not use the 30
compressions to 2 ventilations ratio. This process AUTOMATED EXTERNAL
is a continuous delivery of compressions and
ventilations with no interruption.
DEFIBRILLATORS
Automated external defibrillators (AEDs)
are portable electronic devices that analyze the
Drowning heart’s rhythm and can deliver an electrical shock,
When a patient is removed from the water, responders known as defibrillation, which helps the heart
should assume the nature of arrest was the result to re-establish an effective rhythm (Fig. 13-12).
310 | Emergency Medical Response
They can greatly increase the likelihood of survival AEDs monitor the heart’s electrical activity through
if the shock is administered soon enough. For two electrodes (i.e., AED pads) placed on the
every minute lifesaving care, including CPR and chest. The computer determines the need for a
defibrillation, is delayed, it is estimated that survival shock by looking at the pattern, size and frequency
declines between 7 and 10 percent. Different of EKG waves. If the EKG waves resemble a
types of AEDs are available, but all are similar in shockable rhythm, such as V-fib or V-tach, the
operation and have some common features, such machine readies an electrical charge. When the
as electrode (AED or defibrillation) pads, voice electrical charge disrupts the irregular heartbeat,
prompts, visual displays and/or lighted buttons it is called defibrillation. This allows the heart’s
that help guide the responder through the steps natural electrical system to correct itself and begin
of the AED operation. to fire off electrical impulses that will cause the
heart to beat effectively.
History of Defibrillation
The presence of cardiac arrhythmias or The vast majority of states recognize defibrillator
disturbances of the heart’s electrical system, and training for EMTs, EMRs and other responders.
the ability to correct fibrillation with electrical shock, All states and the District of Columbia have
has been known since the mid-19th century.1 enacted AED Good Samaritan protection for lay
Electrical-shocking devices, or defibrillators, were responders.4 Today, AEDs are widely dispersed
first developed during the 1920s. A portable and can be found in areas where large groups
version was introduced onto mobile coronary units of people gather, such as convention centers,
in Belfast, Northern Ireland, in 1966.2 Defibrillation airports, stadiums, shopping malls, large
by emergency medical technicians (EMTs) without businesses, schools and industrial complexes.
the presence of a physician was first performed in
Portland, Oregon, in 1969. The most common abnormal heart rhythm that
causes sudden cardiac arrest occurs when the
As technology improved over the years, newer ventricles simply quiver, or fibrillate, without
generations of more compact, simple-to-operate, any organized rhythm. This condition is called
semi-automatic defibrillators known as AEDs ventricular fibrillation (V-fib). In V-fib, the
evolved allowing EMTs and EMRs, as well as electrical impulses fire at random, creating chaos
trained lay responders and the general public, and preventing the heart from pumping and
to provide this lifesaving technology. With these circulating blood.
devices, a computer analyzes the heart’s rhythm
and advises whether a shock is needed. Typically, Another less common life-threatening heart
the responder is guided through the steps of rhythm, called ventricular tachycardia
providing defibrillation by voice instructions and (V-tach), occurs when the heart beats too fast. In
visual prompts from the AED. This includes V-tach, an abnormal electrical impulse controls the
placing the electrode (defibrillation) pads on the heart, originating in the ventricles instead of in the
person’s chest, analyzing the heart’s rhythm, SA node. This abnormal impulse fires so quickly
delivering a shock if needed and reminders to that the heart’s chambers do not have time to fill,
perform CPR when appropriate. Some AEDs and the heart is unable to pump blood effectively.
can be configured to deliver lower energy levels With little or no blood circulating, there may be no
considered appropriate for children and infants. pulse. As with V-fib, there is no breathing or pulse.
When EMRs and other responders are trained Bocka, JJ MD: Automatic external defibrillation, eMedicine,
1
to use AEDs, they can significantly reduce April 3, 2006.
the amount of time it takes to administer a 2
Pantridge JF, Geddes JS: A mobile intensive care unit in the
first shock in a sudden cardiac arrest, researchers treatment of myocardial infarction, Lancet 2:271, 1967.
say. In Eugene and Springfield, Oregon, 3
Graves JR, Austin D Jr, Cummins RO: Rapid Zap:
AEDs were placed on every fire truck, and Automated Defibrillation. Englewood Cliffs, NJ,
Prentice-Hall, 1989.
all firefighters were trained to use them.
Researchers saw these communities’ survival
4
American Heart Association: AED Legislation/
Good Samaritan Laws by State. Reviewed/updated
rates for cardiac arrest increase by 18 percent July 16, 2008.
in the first year.3
Chapter 13: Circulation and Cardiac Emergencies | 311
Fig. 13-12: AEDs.
Delivering an electrical shock with an AED Using an AED
disrupts all electrical activity long enough to
When a cardiac arrest occurs, an AED should
allow the heart to spontaneously develop an
be used as soon as it is available and ready to
effective rhythm on its own. If V-fib or V-tach is
use. If the AED advises that a shock is needed,
not corrected, all electrical activity will eventually
follow protocols to give 1 shock followed by
cease, a condition called asystole. Asystole
about 2 minutes of CPR. If CPR is in progress,
cannot be corrected by defibrillation.
chest compressions should not be interrupted
You cannot tell what, if any, rhythm the heart has until the AED is turned on, the defibrillation pads
by feeling for a pulse. CPR, started immediately are applied and the AED is ready to analyze the
and continued until defibrillation, helps maintain heart rhythm.
a low level of circulation in the body until
Chest compressions can increase the likelihood
defibrillation, and increases the likelihood that the
that a defibrillation shock will be successful. Always
defibrillation shock will allow the heart to correct
follow local protocols and medical direction when
the abnormal rhythm.
using an AED and performing CPR. Be thoroughly
Use an AED when the following conditions are familiar with the manufacturer’s operating instructions
present: and maintenance guidelines for the device that you
will be operating.
The patient is unresponsive.
The general steps of operating an AED include:
There is no normal breathing.
You do not detect a pulse. 1. Turning on the AED and preparing it for use.
Once the AED is turned on, it will guide the
CRITICAL V-fib is the most common cause of sudden cardiac arrest. In V-fib, heart ventricles
FACTS quiver instead of beating properly, due to erratic electrical impulses.
AEDs are portable electronic devices that analyze the heart’s rhythm and can
deliver an electrical shock, known as defibrillation, which helps the heart to
re-establish an effective rhythm.
When a cardiac arrest occurs, an AED should be used as soon as it is available
and ready to use. If the AED advises that a shock is needed, follow protocols to
give 1 shock followed by about 2 minutes of CPR.
312 | Emergency Medical Response
responder through all the steps of operation with check to see that the AED pads are connected
voice and visual prompts. Some models have a properly to the device and placed on the
power button that must be pressed or a handle patient’s chest with good adhesion, according
that has to be pulled, while others will activate to the manufacturer’s instructions and local
upon opening the case or lid. protocols. Spare batteries should be available in
2. Exposing the patient’s chest and wiping case of a “low battery” warning, but shocks can
the chest dry if necessary. The AED pads still be delivered with a low battery warning on
must be applied to the patient’s bare, dry some models.
chest. If the patient’s chest is moist or wet, it
After a shock is delivered or if no shock is
should be wiped with a small towel or gauze
indicated, immediately perform about 2 minutes
pads to ensure the best adhesion of the
of CPR, starting with compressions, before the
AED pads.
AED begins analyzing the heart rhythm again.
3. Attaching the AED pads to the patient’s This pause is automatically programmed into the
bare, dry chest. Remove the AED pads from device and will be preceded by a voice prompt to
their sealed packaging. Peel the backing off resume CPR. You do not need to wait for the AED
from each pad, one at a time, to expose the prompts to finish to begin chest compressions
adhesive, conductive surface of the pad before after a shock was delivered or a no shock advised
it is applied to the patient’s bare chest. Many prompt. If at any time you notice a sign of ROSC,
AED pads have illustrations on them that show such as normal breathing, stop CPR and monitor
correct pad placement. Some AED pads are the patient’s condition.
preconnected to the device, and some must be
plugged into the device before rhythm analysis
can begin. The pads should be appropriate to Special AED Situations
the patient. For example, pediatric AED pads Some situations require responders to pay special
must not be used on an adult patient because attention when using an AED. These include using
the lower energy levels may not be enough to AEDs around water, on patients with implantable
defibrillate the patient, but if no pediatric pads devices, on patients with transdermal patches
are available, adult pads can be used on a child and on patients with jewelry or body piercings.
or infant. Be familiar with these situations and know how to
4. Analyzing the heart rhythm. Most AEDs will respond appropriately. Always use common sense
automatically begin analysis when the pads when using an AED and follow the manufacturer’s
are attached to the patient and connected to the recommendations.
device, while others have an “analyze” button
that must be pushed. No one should touch or Pacemakers and Implantable
bump into the patient during the rhythm analysis Cardioverter-Defibrillators
as this could produce faulty readings. Sometimes patients may have had a pacemaker
5. Delivering a defibrillation shock. Once the implanted. These small implantable devices are
analysis of the rhythm is complete, the AED sometimes located in the area below the right or
will advise either to shock or not to shock the left collarbone. There may be a small lump that can
patient. If a shockable rhythm is detected, the be felt under the skin.
AED will cycle up an electrical energy charge
that will supply the shock to the patient. Some Other patients may have an implantable
models can deliver the shock automatically, cardioverter-defibrillator (ICD), a miniature
while others have a “shock” button that must version of an AED, which acts to automatically
be manually pushed to deliver the shock. No recognize and restore abnormal heart rhythms.
one should be in contact with the patient when Sometimes, a patient’s heart beats irregularly,
the shock is delivered, because they could even if the patient has a pacemaker or an ICD.
also receive a shock and thereby reduce the
If the implanted device is visible or you know that
effectiveness of the defibrillation shock by
the patient has one, do not place the defibrillation
absorbing some of the electrical energy. After
pad directly over the device (Fig. 13-13). This may
a shock is delivered, or if no shock is advised,
interfere with the delivery of the shock. Adjust pad
a period of time is programmed to allow for
placement if necessary and continue to follow
CPR until the next rhythm analysis begins. If
established protocols. If you are not sure, use
the AED prompts to troubleshoot a problem
the AED as needed. It will not harm the patient
such as “check electrodes” or “check pads,”
or responder.
Chapter 13: Circulation and Cardiac Emergencies | 313
Fig. 13-13: Scars and/or a small lump may indicate that the patient has had some sort of device
implanted. Photo: courtesy of Ted Crites.
Responders should be aware that it is possible to Transdermal Medication Patches
receive a mild shock if an implantable ICD delivers Some patients may use a transdermal
a shock to the patient while CPR is performed. medication patch. The most common of
This risk of injury to responders is minimal, and the these patches is the nitroglycerin patch, used
amount of electrical energy involved is low. Much by those with a history of cardiac problems.
of the electrical energy is absorbed by the patient’s Since nitroglycerin or other medications can be
own body tissues. Some protocols may include absorbed by a responder, remove the patch
temporarily deactivating the shock capability of from the patient’s chest with a gloved hand before
an ICD with a donut magnet or other precautions. placing the defibrillation pads on the chest.
EMRs should be aware of and follow any special Nicotine patches used to stop smoking look similar
precautions associated with ICDs, but delays in to nitroglycerin patches. To avoid wasting time
delivering CPR and defibrillation shocks from an trying to identify patches, remove any patch you
AED should not occur. see on the patient’s chest with a gloved hand
(Fig. 13-14). Never place AED electrode pads
AEDs Around Water directly on top of medication patches.
If the patient is in freestanding water, remove
the patient before defibrillation. A shock delivered Hypothermia
in water could conduct to responders or Some patients who have experienced hypothermia
bystanders. Once you have removed the patient have been resuscitated successfully even after
from the water, be sure there are no puddles of
water around you, the patient or the AED. Remove
wet clothing from the chest for proper pad
placement, if necessary. Dry the patient’s chest
and attach the AED pads.
If it is raining, ensure that the patient is as dry
as possible and sheltered from the rain. Wipe
the patient’s chest dry. Minimize delaying
defibrillation when taking steps to provide for
a dry environment. The electrical current of an
AED is very directional between the pads. AEDs
are quite safe, even in rain and snow, when
all precautions and manufacturer’s operating
instructions are followed. Fig. 13-14: Remove any type of transdermal medication patch
from the patient’s chest with a gloved hand before defibrillation
pads are placed on the chest.
314 | Emergency Medical Response
prolonged exposure. If you do not feel a pulse, Do not use pediatric AED pads on an adult,
begin CPR until an AED becomes available. Follow as they may not deliver enough energy for
local protocols as to whether an AED should be defibrillation.
used. If the patient is wet, dry their chest and Do not touch the patient while the AED is
attach the AED pads. If a shock is indicated, deliver analyzing. Touching or moving the patient
a shock and follow the instructions of the AED. may affect the analysis.
If there are no obvious signs of life, continue CPR.
Continue CPR and protect the patient from further
Before shocking a patient with an AED, make
sure that no one is touching or is in contact
heat loss. Wet garments should be removed, if with the patient or the resuscitation equipment.
possible. The patient should not be defibrillated in
water. CPR or defibrillation should not be withheld Do not touch the patient while defibrillating.
You or someone else could be shocked.
to rewarm the patient. EMRs should handle
hypothermia patients gently, as shaking them Do not defibrillate someone when around
could result in V-fib. flammable or combustible materials such as
gasoline or free-flowing oxygen.
Trauma Do not use an AED in a moving vehicle.
Movement may affect the analysis.
If a patient is in cardiac arrest resulting from
traumatic injuries, an AED may still be used. Do not use an AED on a patient who is in
Defibrillation should be administered according contact with freestanding water. Move the
to local protocols. patient away from puddles of water or swimming
pools, or out of the rain, before defibrillating.
Chest Hair Do not use an AED on a patient wearing a
nitroglycerin patch or other medication patch
Some patients have excessive chest hair that may on the chest. With a gloved hand, remove any
cause difficulty with pad-to-skin contact. Since patches from the chest before attaching the
time to first shock is critical, and chest hair rarely defibrillation pads.
interferes with pad adhesion, attach the pads and
analyze the heart’s rhythm as soon as possible. Press
firmly on the pads to attach them to the patient’s AED MAINTENANCE
chest. If you get a “check pads” or similar message
For defibrillators to function optimally, they must be
from the AED, remove the pads and replace with
maintained like any other machine. AEDs require
new ones. The pad adhesive may pull out some of
minimal maintenance. These devices have various
the chest hair, which may solve the problem. If you
self-testing features. However, it is important that
continue to get the “check pads” message, remove
operators be familiar with any visual or audible
the pads, shave the patient’s chest and attach new
prompts the AED may have to warn of malfunction
pads to the patient’s chest. Spare defibrillation pads
or a low battery. It is important that you read the
and a safety razor should be included in the AED kit.
operator’s manual thoroughly and check with the
manufacturer to obtain all necessary information
Jewelry and Body Piercings regarding maintenance.
Jewelry and body piercings do not need to be
removed when using an AED. These are simply In most instances, if the machine detects any
distractions that do no harm to the patient, but malfunction, you should contact the manufacturer. The
taking time to remove them delays delivery of the device may need to be returned to the manufacturer
first shock. Do not delay the use of an AED to for service. While AEDs require minimal maintenance,
remove jewelry or body piercings. Do not place the it is important to remember the following:
defibrillation pad directly over metallic jewelry or
body piercings. Adjust pad placement if necessary Follow the manufacturer’s specific
and continue to follow established protocols. recommendations for periodic equipment checks.
Make sure that the batteries have enough
energy for one complete rescue. (A fully charged
AED PRECAUTIONS backup battery should be readily available.)
When operating an AED, follow these general Make sure that the correct defibrillation pads are
precautions: in the package and are properly sealed.
Do not use alcohol to wipe the patient’s chest Check any expiration dates on defibrillation pads
and batteries, and replace as necessary.
dry; alcohol is flammable.
Chapter 13: Circulation and Cardiac Emergencies | 315
After use, make sure that all accessories are the next action steps for yourself and other team
replaced and that the machine is in proper members. This coordinated team approach also
working order before placing it back in service. includes integrating and assimilating additional
If at any time the machine fails to work personnel, such as paramedics or a code team,
properly or warning indicators are recognized, who arrive on scene.
discontinue use, place it out of service and
To further your understanding of high-performance
contact the manufacturer immediately.
CPR, consider the example of an automotive
racing team. Each crew member has a specific role
High-Performance CPR when the race car arrives in the pit area. They are
High-performance CPR refers to providing supervised by a leader, who keeps the crew on task
high-quality chest compressions as part of a and gets the race car back on the track. The quality,
well-organized team response to a cardiac arrest. efficiency and swiftness of the crew’s actions can
Coordinated, efficient, effective teamwork is ultimately affect the outcome of how the race car
essential to minimize the time spent not in contact performs. The same is true for a team response
with the chest to improve patient outcomes. to CPR. All team members should have specific
roles during a resuscitation. Based on available
Think about all of the activities performed during a resources, potential roles include the following:
resuscitation. For example:
Team leader
AED pads are applied.
Compressor
AED must charge.
Responder managing the airway
Pocket mask or BVM may need to be
Responder providing ventilations
repositioned.
Airway may need to be reopened. Responder managing the AED
Other personnel arrive on scene. Recorder
Responders switch positions. Keep in mind that there are no national protocols
Advanced airway may need to be inserted. in place for high-performance CPR. How you
function within a team setting, including how
Pulse checks may be done, but unnecessarily.
additional personnel assimilate into the team, may
All of these activities could affect your ability to vary depending on your local protocols or practice.
maintain contact with the patient’s chest.
Integration of More
Science Note: Current research indicates Advanced Personnel
that survival following resuscitation is During resuscitation, numerous people may
significantly affected by the quality of be involved in providing care to the patient.
CPR performed. One important aspect Responders must work together as a team in a
is minimizing interruptions in chest coordinated effort to achieve the best outcomes for
compressions, which helps to maximize the the patient. Characteristics of effective teamwork
blood flow generated by the compressions. include well-defined roles and responsibilities;
clear, closed-loop communication; and respectful
Chest Compression Fraction treatment of others.
Chest compression fraction, or CCF, is the term
used to denote the proportion of time that chest Coordination becomes even more important when
compressions are performed. It represents the more advanced personnel, such as an advanced
fraction of time spent performing compressions, life support team or code team, arrive on the scene.
that is, the time that the responders are in contact This coordination of all involved is necessary to:
with the patient’s chest, divided by the total time
of the resuscitation, beginning with the arrival on Ensure that all individuals involved work as a team
to help promote the best outcome for the patient.
scene until the ROSC. Expert consensus identifies
a CCF of at least 60 percent to promote optimal Promote effective perfusion to the vital organs.
outcomes, with a goal of 80 percent. Minimize interruptions of chest compressions,
which have been shown to improve survival.
To achieve the best CCF percentage, a
coordinated team approach is needed, with each Ultimately, it is the team leader who is responsible
member assuming pre-assigned roles, anticipating for this coordination. When more advanced
316 | Emergency Medical Response
personnel arrive on scene, it is the team leader decisions. It was developed as a result of several
who communicates with advanced personnel, airline disasters as a way to prevent future
providing them with a report of the patient’s incidents. Crew resource management has been
status and events. The team leader also sets clear shown to help avoid medical errors in healthcare.
expectations, prioritizes, directs, acts decisively,
encourages team input and interaction, and To effectively communicate via crew resource
focuses on the big picture. management, team members should get the
attention of the team leader, and state their
concern, the problem as they see it and a solution.
Crew Resource Management Working together, the team should then be sure to
During resuscitation, crew resource management obtain direction from the team leader.
helps to promote effective and efficient teamwork
(Fig. 13-15). Crew resource management is a
communication process that centers around PROVIDING CPR/AED FOR
the team leader, who coordinates the actions CHILDREN AND INFANTS
and activities of team members so that the team
functions effectively and efficiently. For example,
CPR/AED Differences Between
when new individuals arrive on the scene or when Children and Adults
team members switch roles during an emergency, When performing CPR on a child, there are some
it is the team leader who is responsible for subtle differences in technique. These differences
coordinating these activities. include opening the airway, compression depth,
the ratio of compressions to ventilations depending
During resuscitation, the team leader directs and on the number of responders, and AED pads and
coordinates all the working elements, including pad placement.
team members, activities and actions, as well as
equipment, to focus on providing high-quality CPR, Airway
the goal of any resuscitation effort.
To open the airway of a child, you would use
Crew resource management also guides team the same head-tilt/chin-lift maneuver as for an
members to directly and effectively communicate adult. However, you would only tilt the head
to a team leader about dangerous or time-critical slightly past a neutral position, avoiding any
Fig. 13-15: During resuscitation, crew resource management helps to promote effective and efficient teamwork.
Chapter 13: Circulation and Cardiac Emergencies | 317
Table 13-2:
Airway and Ventilation Differences: Adult and Child
CHILD (Age 1 through onset
ADULT
of puberty)
Airway
Head-tilt/chin-lift maneuver
Past neutral position Slightly past neutral position
Ventilations
Respiratory arrest
1 ventilation every 5 to 6 seconds 1 ventilation every 3 seconds
hyperextension or flexion in the neck. Table 13-2 Compressions-to-Ventilations Ratio
illustrates airway and ventilation differences for When you are the only responder, the ratio of
an adult and child. compressions to ventilations for a child is the
same as for an adult, that is, 30 compressions
Compressions to 2 ventilations (30:2). However, in two-responder
The positioning and manner of providing situations, this ratio changes to 15 compressions
compressions to a child are also very similar to to 2 ventilations (15:2).
an adult. Place your hands in the center of the
exposed chest on the lower half of the sternum Science Note: Most child-related cardiac
and compress at a rate of between 100 and arrests occur as a result of a hypoxic event
120 compressions per minute. such as an exacerbation of asthma, an
airway obstruction or a drowning. As such,
However, the depth of compression is different. ventilations and appropriate oxygenation
For a child, compress the chest only about are important for a successful resuscitation.
2 inches, which is 1⁄3 the anterior-posterior In these situations, laryngeal spasm may
diameter of the chest, instead of at least 2 inches, occur, making passive ventilation during
but no more than 2.4 inches, as you would for chest compressions minimal or nonexistent.
an adult. For smaller children, you may need Therefore, it is critical to correct the
to compress the chest with only one hand. oxygenation problem by providing high-quality
Ensure you are able to compress the chest CPR prior to leaving the child or infant.
about 2 inches.
318 | Emergency Medical Response
Science Note: Based on local protocols to ventilations depending on the number of
or practice, it is permissible to provide two responders and AED pad placement.
ventilations prior to initiating CPR after the
primary assessment if a hypoxic event is Primary Assessment
suspected.
Variations: Infant
When assessing the infant’s level of consciousness,
AEDs you should shout, “Are you okay?” or use the
AEDs work the same way regardless of the infant’s name if known, and tap the bottom of
patient’s age, but there are differences in the the foot rather than the shoulder as part of the
pads used for children as well as the pad “shout-tap-shout” sequence. Another variation for
placement based on the size of the child. For the infant involves the pulse check. For an infant,
children over the age of 8 years and weighing check the brachial pulse with two fingers on the
more than 55 pounds, you would continue to inside of the upper arm. Be careful not to use your
use adult AED pads, placing them in the same thumb because it has its own detectable pulse.
location as for an adult—one pad to the right of You will need to expose the arm to accurately feel
the sternum and below the right clavicle, with a brachial pulse.
the other pad on the left side of the chest on the
midaxillary line a few inches below the left armpit.
Science Note: AVPU is not as accurate
However, for children 8 years of age or younger
in infants and children as it is in adults. The
or weighing less than 55 pounds, use pediatric
pediatric assessment triangle—Appearance,
AED pads if available. Be aware that some
Effort of breathing, and Circulation—can give
AEDs use a switch or key instead of changing
you a more accurate depiction of an infant’s
pads, so follow the directions from the AED
status. Regardless of what tool is used,
manufacturer on how to care for pediatric
the recognition of an unresponsive infant
patients with their device.
is the priority.
At no time should the AED pads touch each other
when applied. If it appears that the AED pads Airway
would touch each other based on the size of the
To open the airway of an infant, use the same head-
child’s chest, use an anterior and posterior pad
tilt/chin-lift maneuver as you would for an adult
placement as an alternative. Apply one pad to the
or child. However, only tilt the head to a neutral
center of the child’s chest on the sternum and one
position, taking care to avoid any hyperextension
pad to the child’s back between the scapulae.
or flexion in the neck. Be careful not to place your
Table 13-3 summarizes the differences for CPR
fingers on the soft tissues under the chin or neck to
and AED for adults and children.
open the airway. Table 13-4 illustrates airway and
ventilation differences for an adult, child and infant.
CPR/AED DIFFERENCES
FOR INFANTS Compressions
Although the rate of compressions is the same for
Like with children, several differences need an infant as for an adult or child, the positioning
to be addressed when providing CPR to an and manner of providing compressions to an infant
infant. These differences include the primary are different because of the infant’s smaller size.
assessment (assessing the level of consciousness Positioning also differs based on the number of
and checking the pulse), opening the airway, responders involved.
compression depth, the ratio of compressions
CRITICAL In the absence of pediatric pads or a pediatric setting on the AED, you may
FACTS use adult pads for the child. Be sure that the pads will not touch each other if
considering a traditional pad placement on the anterior chest. Use the anterior and
posterior pad placement if the pads may touch each other. Remember: because
the energy supplied by pediatric pads is reduced, they would not be effective for
an adult patient and should not be used. Always follow local protocols, medical
direction and the manufacturer’s instructions.
Chapter 13: Circulation and Cardiac Emergencies | 319
Table 13-3:
CPR/AED Differences: Adult and Child
CHILD (Age 1 through
ADULT
onset of puberty)
Compressions
Hand position Hands centered on lower half of sternum Hands centered on lower half of sternum
Compression Between 100 and 120 compressions Between 100 and 120 compressions
rate per minute per minute
Compression At least 2 inches (but no more than About 2 inches (or 1/3 the anterior-
depth 2.4 inches) posterior diameter of the chest)
Compression/ ••One-responder CPR: 30:2 ••One-responder CPR: 30:2
ventilation ratio ••Two-responder CPR: 30:2 ••Two-responder CPR: 15:2
AED
AED pads Adult pads: age > 8 years, weight > 55 ••Pediatric pads: age 1–8 years,
pounds weight < 55 pounds
••Adult pads if pediatric pads not available
AED pad
placement
••Upper right chest below right clavicle to ••Upper right chest below right clavicle to
the right of sternum the right of sternum
••Left side of chest several inches below ••Left side of chest several inches below
left armpit on midaxillary line left armpit on midaxillary line
••If pads risk touching each other—
anterior/posterior placement
320 | Emergency Medical Response
Table 13-4:
Airway and Ventilation Differences: Adult, Child and Infant
CHILD (Age 1 through
ADULT INFANT (Birth to age 1)
onset of puberty)
Airway
Head-tilt/
chin-lift
maneuver
Past neutral position Slightly past neutral Neutral position
position
Ventilations
Respiratory
arrest
1 ventilation every 5 to 6 1 ventilation every 3 seconds 1 ventilation every 3 seconds
seconds
The firm, flat surface necessary for providing closest to the infant’s feet in the center of the
compressions is also appropriate for an infant. exposed chest, just below the nipple line on
However, that surface can be above the ground, the sternum. The fingers should be oriented so
such as a stable table or countertop. Often it is that they are parallel, not perpendicular to the
easier for the responder to provide compressions sternum. Responders may use either their index
from a standing position rather than kneeling at the finger and middle finger or their middle finger and
patient’s side. fourth finger to provide compressions. Fingers
that are more similar in length tend to make
Compressions are delivered at the same rate for the delivery of compressions easier. The ratio
adults and children, that is, at a rate of at least of compressions to ventilations is the same for
100 per minute to a maximum of 120 compressions an adult or child, that is, 30 compressions to
per minute. However, for an infant, only compress 2 ventilations (30:2).
the chest about 1½ inches (or 1/3 the anterior-
posterior diameter of the chest). Two-Responder CPR
When two responders are caring for an
One-Responder CPR infant in cardiac arrest, the positioning of the
To perform compressions when one responder responders and the method of performing chest
is present, place two fingers from your hand
Chapter 13: Circulation and Cardiac Emergencies | 321
A B
Fig. 13-16, A–B: (A) Anterior placement of an AED pad for an infant; (B) posterior placement
of the pad.
compressions differ from that of an adult or child. When applying the pads, place one pad in the
The responder performing chest compressions center of the anterior chest and the second pad
will be positioned at the infant’s feet while the in the posterior position centered between the
responder providing ventilations will be at the scapulae (Fig. 13-16, A–B). Just as with a child,
infant’s head. Compressions are delivered using if no pediatric pads are available, use adult AED
the encircling thumbs technique. To provide pads. Table 13-5 summarizes the differences in
compressions using this technique: CPR and AED for adults, children and infants.
Place both thumbs on the center of the infant’s
Pediatric Consideration—
exposed chest side by side, just below the
nipple line. Poor Perfusion
When a child or an infant is not breathing
Have the other fingers encircling the infant’s normally and has a pulse less than or equal to
chest toward the back, providing support. 60 beats per minutes, perform compressions
While positioned at the infant’s head, the responder (CPR) if there are signs of poor perfusion.
providing ventilations will open the airway using two Recheck breathing and pulse every 2 minutes.
hands and seal the mask using the E-C technique. If there is no pulse, provide CPR.
With two responders, the ratio of compressions
to ventilations changes to that of a child, that is, Additional Resources
15 compressions to 2 ventilations (15:2).
While it is rare in the professional setting to be
alone with a child or infant, there is a slight change
AEDs of when you should call for additional resources
While the need to deliver a defibrillation for an when you are alone. After determining that an adult
infant occurs less often than for an adult, the is unresponsive and you are alone, you should
use of an AED remains a critical component of
immediately call for additional resources and get
infant cardiac arrest care. As with a child patient,
an AED. With children, it is more important to
use pediatric AED pads if available. Keep in mind
that similar to a child, some AEDs use a switch provide about 2 minutes of CPR before leaving
or key instead of changing pads, so follow the them to call for additional resources or get an
directions from the AED manufacturer on how to AED unless the arrest is witnessed and believed
care for pediatric patients with their device. to be cardiac in origin.
322 | Emergency Medical Response
Table 13-5:
CPR/AED Differences: Adult, Child and Infant
CHILD (Age 1
ADULT through onset INFANT (Birth to age 1)
of puberty)
Compressions
Hand position
One responder: Two responders:
Hands centered Hands centered Two fingers Thumbs centered
on lower half of on lower half of centered on on chest side by
sternum sternum sternum, just side, just below
below nipple line nipple line.
Compression Between 100 and Between 100 and Between 100 and 120 compressions per
rate 120 compressions 120 compressions minute
per minute per minute
Compression At least 2 inches, About 2 inches (or About 1½ inches (or 1/3 the anterior-
depth but no more than 1/3 the anterior- posterior diameter of the chest)
2.4 inches posterior diameter
of the chest)
Compression/ ••One-responder ••One-responder ••One-responder CPR: 30:2
ventilation CPR: 30:2 CPR: 30:2 ••Two-responder CPR: 15:2
ratio ••Two-responder ••Two-responder
CPR: 30:2 CPR: 15:2
AED
AED pads Adult pads: age > 8 ••Pediatric pads: ••Pediatric pads
years, weight > 55 age 1 to 8 years, ••Adult pads if pediatric pads not available
pounds weight < 55
pounds
••Adult pads if
pediatric pads not
available
(Continued)
Chapter 13: Circulation and Cardiac Emergencies | 323
Table 13-5: continued
CHILD (Age 1
ADULT through onset INFANT (Birth to age 1)
of puberty)
AED
AED pad
placement
••Upper right chest below ••Upper right chest below ••Anterior/posterior
right clavicle to the right of right clavicle to the right of placement:
sternum sternum ••Middle of chest
••Left side of chest several ••Left side of chest several ••Back between scapulae
inches below left armpit inches below left armpit
on midaxillary line on midaxillary line
••If pads risk touching
each other—anterior/
posterior placement
PUTTING IT ALL TOGETHER If two responders are available, begin two-responder
CPR as soon as possible. Change positions about
When the heart stops beating, or beats too every 2 minutes and continue CPR. Once you start
ineffectively to circulate blood to the brain and CPR, do not stop unnecessarily.
other vital organs, this is called cardiac arrest.
Irreversible brain damage is likely to occur after The heart’s electrical system controls the pumping
about 8 to 10 minutes from lack of oxygen. action of the heart. Damage to the heart from
By starting CPR immediately, and using an disease or injury can disrupt the heart’s electrical
AED, you can help keep the patient’s brain and system, resulting in an abnormal heart rhythm that
other vital organs supplied with oxygen and can stop circulation. The two most common treatable
help the heart restore an effective, pumping abnormal rhythms initially present in patients
rhythm. By summoning more advanced medical suffering sudden cardiac arrest are V-fib and V-tach.
personnel, you can increase the cardiac arrest
patient’s chances for survival. A patient who is An AED is a portable electronic device that
unconscious, not breathing normally and has no analyzes the heart’s rhythm and delivers an
pulse is in cardiac arrest and needs immediate electrical shock to the heart, called defibrillation.
CPR. When performing CPR, always remember Defibrillation disrupts the electrical activity of
the following points regarding the quality and V-fib and V-tach long enough to allow the heart
maximum effectiveness of CPR: to develop an effective rhythm on its own. AEDs
are used in conjunction with CPR.
Chest compressions should be given fast,
Use an AED as soon as one becomes available.
smooth and deep.
The sooner the shock is administered, the greater
Let the chest fully recoil or return to its
the likelihood of the patient’s survival. AEDs are
normal position after each compression
appropriate for use on adults, children and infants
before starting the downstroke of the next
in cardiac arrest. When using an AED, follow your
compression.
local protocols and the manufacturer’s operating
Minimize any interruptions in chest instructions, and be aware of AED precautions and
compressions. special situations.
324 | Emergency Medical Response
You Are the Emergency Medical Responder
The man who collapsed is unconscious, is not breathing normally and does not have a pulse.
He has no severe, life-threatening bleeding. You send another responder to summon more
advanced medical personnel and to bring the AED. You begin CPR. Once the AED arrives,
the other responder prepares the AED for use. How would you respond? When can you stop
performing CPR?
Chapter 13: Circulation and Cardiac Emergencies | 325
Skill Sheet
Skill Sheet 13-1
CPR/AED—Adult
STEP ACTION COMPETENCIES
1 Scene size-up:
••Scene safety* ••Sequence of these is not critical if all goals are
••Standard precautions* accomplished and verbalized. (PPE may be worn instead
••Number of patients of verbalized.)
••Nature of illness/mechanism of ••Resources may include: 9-1-1 or designated emergency
injury number, Advanced Life Support, Rapid Response
Team, Code Team, or additional personnel as needed or
••General impression, including
appropriate.
severe, life-threatening bleeding*
••Additional resources needed?
2 Primary assessment:
••Assesses level of consciousness ••LOC: Shouts, “Are you OK?” (or a reasonable facsimile) to
(LOC)* elicit a verbal stimuli
••Opens the airway ••LOC: Taps the patient’s shoulder to elicit painful stimuli and
••Checks breathing and carotid shouts again (shout-tap-shout)
pulse simultaneously for at least ••Airway: Opens using head-tilt/chin-lift maneuver past
5 seconds, but no more than 10 a neutral position or a modified jaw thrust
seconds* ••Breathing/pulse check: Checks for breathing and
carotid pulse simultaneously for at least 5 seconds,
but no more than 10 seconds
3 Chest compressions:
••Exposes chest ••Hand position: Centered on the lower half of the sternum
••Initiates 30 chest compressions ••Depth: At least 2 inches
using correct hand placement at ••Number: 30 compressions
the proper rate and depth, allowing ••Rate: Between 100 and 120 compressions per minute
for full chest recoil* (15–18 seconds)
••Full chest recoil: 26 of 30 compressions
4 Ventilations:
••Opens the airway* ••Airway: Head-tilt/chin-lift maneuver past a neutral position
••Gives 2 ventilations using a pocket ••Ventilations (2): 1 second in duration
mask* ••Ventilations (2): Visible chest rise
••Ventilations (2): Minimizes interruptions to less than
10 seconds
5 Continues CPR:
••Gives 30 chest compressions ••Hand position: Centered on the lower half of the sternum
using correct hand placement at ••Depth: At least 2 inches
the proper rate and depth, allowing ••Number: 30 compressions
for full chest recoil*
••Rate: Between 100 and 120 compressions per minute
••Opens the airway (15–18 seconds)
••Gives 2 ventilations with pocket ••Full chest recoil: 26 of 30 compressions
mask
*Denotes a Critical Action.
(Continued)
326 | Emergency Medical Response
Skill Sheet
Skill Sheet 13-1
CPR/AED—Adult Continued
STEP ACTION COMPETENCIES
6 Arrival of the AED and additional
responders: ••Continues care: Maintains uninterrupted CPR
••Initial responder continues care* ••Communicates relevant patient information including
••Communicates with additional patient age if known
responders ••Verbalizes compression count to coordinate ventilations
••Prepares for rotation upon AED with additional responders
analysis ••Verbalizes coordination plan to switch compressors upon
AED analysis
7 AED applied:
••Turns on machine ••AED on: Activates within 15 seconds of arrival
••Attaches AED pads* ••Pads: Pad 1—right upper chest below right clavicle and
••Plugs in connector, if necessary right of sternum; Pad 2—left side of chest several inches
••Continues compressions below left armpit on midaxillary line
8 AED analysis and rotation:
••Ensures all responders are clear ••Clear: Ensures no one is touching the patient during
while AED analyzes and prepares analysis
for shock* ••Rotation: Switches compressor during analysis
••Says, “Stand clear” ••Hover: Hovers hands (new compressor) a few inches
••Rotates responders during analysis above chest during analysis to prepare for CPR
to prevent fatigue
••Prepares BVM
9 Shock advised:
••Says, “Stand clear”* ••Clear: Ensures no one is touching the patient while shock
••Presses shock button to deliver is being delivered
shock* ••Delivers shock: Depresses shock button within
10 seconds
10 Resumes CPR:
••Continues with 5 cycles of CPR ••Resumes CPR: Immediately following shock, resumes
(30 compressions/2 ventilations)* CPR, starting with compressions, until prompted by the
••Performs compressions AED for analysis
(Responder 2) ••Hand position: Centered on the lower half of the sternum
••Manages airway and mask seal ••Depth: At least 2 inches
(Responder 1) ••Number: 30 compressions
••Provides ventilations using BVM ••Rate: Between 100 and 120 compressions per minute
(Responder 1) (15–18 seconds)
••Continues until AED prompts ••Full chest recoil: 26 of 30 compressions
11 Ventilations with BVM:
••Opens the airway from top of the ••Seal: Using the E-C technique
head ••Airway: Head-tilt/chin-lift maneuver past a neutral position
••Maintains mask seal ••Ventilations (2): 1 second in duration
••Compresses BVM to give ••Ventilations (2): Visible chest rise
2 ventilations
*Denotes a Critical Action.
(Continued)
Chapter 13: Circulation and Cardiac Emergencies | 327
Skill Sheet
Skill Sheet 13-1
CPR/AED—Adult Continued
STEP ACTION COMPETENCIES
••Ventilations (2): Minimizes interruptions to less than
10 seconds
••Ventilations (2): Bag squeezed enough to make chest
rise; does not fully squeeze bag (approximately 400–700 ml
of volume, avoiding overinflation)
12 Anticipates compressor change:
••Communicates with additional ••Verbalizes coordination plan to switch compressors prior
responders to AED analysis
••Prepares for rotation upon
AED analysis
13 AED analyzes:
••Says, “Stand clear” ••Clear: Ensures no one is touching the patient during
••No shock advised analysis
••Rotation: Switches compressor during analysis
••Hover: Hovers hands (new compressor) a few inches
above chest during analysis to prepare for CPR
14 Resumes CPR:
••Continues with 5 cycles of CPR ••Resumes CPR: Immediately following shock, resumes
(30 compressions/2 ventilations)* CPR, starting with compressions, until prompted by the
••Performs compressions AED for analysis
(Responder 3) ••Hand position: Centered on the lower half of the sternum
••Manages airway and mask seal ••Depth: At least 2 inches
(Responder 1) ••Number: 30 compressions
••Provides ventilations using BVM ••Rate: Between 100 and 120 compressions per minute
(Responder 2) (15–18 seconds)
••Continues until AED prompts ••Full chest recoil: 26 of 30 compressions
15 Anticipates compressor change:
••Communicates with additional ••Verbalizes coordination plan to switch compressors prior
responders to AED analysis
••Prepares for rotation upon AED
analysis
16 AED analyzes and rotation:
••Says, “Stand clear”* ••Clear: Ensures no one is touching the patient during
••No shock advised analysis
••Rotation: Switches compressor during analysis
••Hover: Hovers hands (new compressor) a few inches
above chest during analysis to prepare for CPR
17 Spontaneous patient
movement: ••Pulse check: Opens the airway and checks for breathing
••Checks for breathing and pulse and pulse simultaneously for at least 5 seconds, but no
more than 10 seconds
*Denotes a Critical Action.
328 | Emergency Medical Response
Skill Sheet
Skill Sheet 13-2
CPR/AED—Child
STEP ACTION COMPETENCIES
1 Scene size-up:
••Scene safety* ••Sequence is not critical if all goals are accomplished and
••Standard precautions* verbalized. (PPE may be worn instead of verbalized.)
••Number of patients ••Resources may include: 9-1-1 or designated emergency
••Nature of illness/mechanism number, Advanced Life Support, Rapid Response
of injury Team, Code Team, or additional personnel as needed or
appropriate.
••General impression, including
severe, life-threatening bleeding* ••Consent: States name, background, what they plan to do
and permission to treat
••Additional resources needed?
••Consent
2 Primary assessment:
••Assesses level of consciousness ••LOC: Shouts, “Are you OK?” (or a reasonable facsimile) to
(LOC)* elicit verbal stimuli
••Opens the airway ••LOC: Taps the patient’s shoulder to elicit painful stimuli and
••Checks breathing and carotid shouts again (shout-tap-shout)
pulse simultaneously for at least ••Airway: Opens using head-tilt/chin-lift maneuver slightly
5 seconds, but no more than past a neutral position or a modified jaw thrust
10 seconds* ••Breathing/pulse check: Checks for breathing and
carotid pulse simultaneously for at least 5 seconds, but no
more than 10 seconds
3 Chest compressions:
••Exposes chest ••Hand position: Centered on the lower half of the sternum
••Initiates 30 chest compressions ••Depth: About 2 inches or 1/3 the anterior-posterior
using correct hand placement at diameter of the chest
the proper rate and depth, allowing ••Number: 30 compressions
for full chest recoil* ••Rate: Between 100 and 120 compressions per minute
(15–18 seconds)
••Full chest recoil: 26 of 30 compressions
4 Ventilations: ••Airway: Head-tilt/chin-lift maneuver slightly past a neutral
••Opens the airway* position
••Gives 2 ventilations using a ••Ventilations (2): 1 second in duration
pocket mask* ••Ventilations (2): Visible chest rise
••Ventilations (2): Minimizes interruptions to less than
10 seconds
*Denotes a Critical Action.
(Continued)
Chapter 13: Circulation and Cardiac Emergencies | 329
Skill Sheet
Skill Sheet 13-2
CPR/AED—Child Continued
STEP ACTION COMPETENCIES
5 Continues CPR:
••Gives 30 chest compressions ••Hand position: Centered on the lower half of the sternum
using correct hand placement at ••Depth: About 2 inches or 1/3 the anterior-posterior
the proper rate and depth, allowing diameter of the chest
for full chest recoil* ••Number: 30 compressions
••Opens the airway ••Rate: Between 100 and 120 compressions per minute
••Gives 2 ventilations with pocket (15–18 seconds)
mask ••Full chest recoil: 26 of 30 compressions
6 Arrival of the AED and additional
responder(s): ••Continues care: Maintains uninterrupted CPR
••Initial responder continues care* ••Communicates relevant patient information including
••Communicates with additional patient age if known
responders ••Verbalizes compression count to coordinate ventilations
••Prepares for rotation upon AED with additional responder(s)
analysis ••Verbalizes coordination plan to switch compressors upon
AED analysis
7 AED applied:
••Turns on machine ••AED on: Activates within 15 seconds of arrival
••Attaches AED pads* ••Pads: Applies correct pads for age of child: Pad 1—right
••Plugs in connector, if necessary upper chest below right clavicle and right of sternum;
••Continues compressions Pad 2—left side of chest several inches below left armpit
on midaxillary line
8 AED analysis and rotation:
••Ensures all responders are clear ••Clear: Ensures no one is touching the patient during
while AED analyzes and prepares analysis
for shock* ••Rotation: Switches compressor during analysis
••Says, “Stand clear” ••Hover: Hovers hands (new compressor) a few inches
••Rotates responders during analysis above chest during analysis to prepare for CPR
to prevent fatigue
••Prepares BVM
9 Shock advised:
••Says, “Stand clear”* ••Clear: Ensures no one is touching the patient while shock
••Presses shock button to deliver is being delivered
shock* ••Delivers shock: Depresses shock button within
10 seconds
*Denotes a Critical Action.
(Continued)
330 | Emergency Medical Response
Skill Sheet
Skill Sheet 13-2
CPR/AED—Child Continued
STEP ACTION COMPETENCIES
10 Resumes CPR:
••Continues with 10 cycles of CPR ••Resumes CPR: Immediately following shock, resumes
(15 compressions/2 ventilations)* CPR, starting with compressions, until prompted by the
••Performs compressions AED for analysis
(Responder 2) ••Hand position: Centered on the lower half of the sternum
••Manages airway and mask seal ••Depth: About 2 inches or 1/3 the anterior-posterior
(Responder 1) diameter of the chest
••Provides ventilations using BVM ••Number: 15 compressions
(Responder 1) ••Rate: Between 100 and 120 compressions per minute
••Continues until AED prompts (7–9 seconds)
••Full chest recoil: 12 of 15 compressions
11 Ventilations with BVM:
••Opens the airway from top of the ••Seal: Using the E-C technique
head ••Airway: Head-tilt/chin-lift maneuver slightly past a neutral
••Maintains mask seal position
••Compresses BVM to give ••Ventilations (2): 1 second in duration
2 ventilations ••Ventilations (2): Visible chest rise
••Ventilations (2): Minimizes interruptions to less than
10 seconds
••Ventilations (2): Bag squeezed enough to make chest
rise; does not fully squeeze bag (avoiding overinflation)
12 Anticipates compressor change:
••Communicates with additional ••Verbalizes coordination plan to switch compressors prior
responders to AED analysis
••Prepares for rotation upon AED
analysis
13 AED analyzes:
••Says, “Stand clear” ••Clear: Ensures no one is touching the patient during
••No shock advised analysis
••Rotation: Switches compressor during analysis
••Hover: Hovers hands (new compressor) a few inches
above chest during analysis to prepare for CPR
*Denotes a Critical Action.
(Continued)
Chapter 13: Circulation and Cardiac Emergencies | 331
Skill Sheet
Skill Sheet 13-2
CPR/AED—Child Continued
STEP ACTION COMPETENCIES
14 Resumes CPR:
••Continues with 10 cycles of CPR ••Resumes CPR: Immediately following shock, resumes
(15 compressions/2 ventilations)* CPR, starting with compressions, until prompted by the
••Performs compressions AED for analysis
(Responder 3) ••Hand position: Centered on the lower half of the sternum
••Manages airway and mask seal ••Depth: About 2 inches or 1/3 the anterior-posterior
(Responder 1) diameter of the chest
••Provides ventilations using BVM ••Number: 15 compressions
(Responder 2) ••Rate: Between 100 and 120 compressions per minute
••Continues until AED prompts (7–9 seconds)
••Full chest recoil: 12 of 15 compressions
15 Anticipates compressor change:
••Communicates with additional ••Verbalizes coordination plan to switch compressors prior
responders to AED analysis
••Prepares for rotation upon AED
analysis
16 AED analyzes and rotation:
••Says, “Stand clear”* ••Clear: Ensures no one is touching the patient during
••No shock advised analysis
••Rotation: Switches compressor during analysis
••Hover: Hovers hands (new compressor) a few inches
above chest during analysis to prepare for CPR
17 Spontaneous patient movement:
••Checks for breathing and pulse ••Pulse check: Responder performing ventilations
opens the airway and checks for breathing and pulse
simultaneously for at least 5 seconds, but no more than
10 seconds
*Denotes a Critical Action.
332 | Emergency Medical Response
Skill Sheet
Skill Sheet 13-3
CPR/AED—Infant
STEP ACTION COMPETENCIES
1 Scene size-up:
••Scene safety* ••Sequence is not critical if all goals are accomplished and
••Standard precautions* verbalized. (PPE may be worn instead of verbalized.)
••Number of patients ••Resources may include: 9-1-1 or designated emergency
••Nature of illness/mechanism of injury number, Advanced Life Support, Rapid Response
••General impression, including severe, Team, Code Team, or additional personnel as needed or
life-threatening bleeding* appropriate.
••Additional resources needed? ••Consent: States name, background, what they plan to do
••Consent and permission to treat
2 Primary assessment:
••Positions infant on a firm, flat surface ••Position: Places infant on a firm, flat surface
••Assesses level of consciousness ••LOC: Shouts, “Are you OK?” (or a reasonable facsimile)
(LOC)* to elicit a verbal stimuli; uses infant’s name if available
••Opens the airway ••LOC: Taps the infant’s foot to elicit stimuli and shouts
••Checks breathing and brachial pulse again (shout-tap-shout)
simultaneously for at least 5 seconds, ••Airway: Opens using head-tilt/chin-lift maneuver to a
but no more than 10 seconds* neutral position
••Breathing/pulse check: Checks for breathing and
brachial pulse simultaneously for at least 5 seconds, but
no more than 10 seconds
3 Chest compressions:
••Exposes chest ••Finger position: Centered on the chest, just below the
••Initiates 30 chest compressions using nipple line
correct finger placement at the proper ••Depth: About 1½ inches or 1/3 the anterior-posterior
rate and depth, allowing for full chest diameter of the chest
recoil* ••Number: 30 compressions
••Rate: Between 100 and 120 compressions per minute
(15–18 seconds)
••Full chest recoil: 26 of 30 compressions
4 Ventilations:
••Opens airway* ••Airway: Head-tilt/chin-lift maneuver to a neutral position
••Gives 2 ventilations using an infant ••Ventilations (2): 1 second in duration
pocket mask* ••Ventilations (2): Visible chest rise
••Ventilations (2): Minimizes interruptions to less than
10 seconds
5 Continues CPR:
••Gives 30 chest compressions using ••Finger position: 2 fingers centered on the lower half of
correct finger placement at the proper the sternum, just below the nipple line.
rate and depth, allowing for full chest ••Depth: About 1½ inches or 1/3 the anterior-posterior
recoil* diameter of the chest
••Opens the airway ••Number: 30 compressions
••Gives 2 ventilations with an infant ••Rate: Between 100 and 120 compressions per minute
pocket mask (15–18 seconds)
••Full chest recoil: 26 of 30 compressions
*Denotes a Critical Action.
(Continued)
Chapter 13: Circulation and Cardiac Emergencies | 333
Skill Sheet
Skill Sheet 13-3
CPR/AED—Infant Continued
STEP ACTION COMPETENCIES
6 Arrival of the AED and additional
responder(s): ••Continues care: Maintains uninterrupted CPR
••Initial responder continues care* ••Communicates relevant patient information including
••Communicates with additional patient age if known
responders ••Verbalizes compression count to coordinate ventilations
••Prepares for rotation upon AED with additional responder(s)
analysis ••Verbalizes coordination plan to switch compressors
upon AED analysis
7 AED applied:
••Turns on machine ••AED on: Activates within 15 seconds of arrival
••Attaches AED pads* ••Pads: Applies correct pads for an infant: Pad 1—in the
••Plugs in connector, if necessary center of the anterior chest; Pad 2—on the infant’s back
••Continues compressions between the scapulae
8 AED analysis and rotation:
••Ensures all responders are clear ••Clear: Ensures no one is touching the patient during
while AED analyzes and prepares for analysis
shock* ••Rotation: Switches compressor during analysis and
••Says, “Stand clear” moves to a head and foot position for encircling thumbs
••Rotates responders during analysis to technique
prevent fatigue ••Hover: Hovers hands (new compressor) a few inches
••Prepares infant BVM above chest during analysis to prepare for CPR
9 Shock advised:
••Says, “Stand clear”* ••Clear: Ensures no one is touching the patient while
••Presses shock button to deliver shock is being delivered
shock* ••Delivers shock: Depresses shock button within
10 seconds
10 Resumes CPR:
••Continues with 10 cycles of CPR ••Resumes CPR: Immediately following shock, resumes
(15 compressions/2 ventilations)* CPR, starting with compressions, until prompted by the
••Performs compressions—encircling AED for analysis
thumbs technique (Responder 2) ••Thumb position: Thumbs centered on the chest
••Manages airway and mask seal side by side, just below the nipple line
(Responder 1) ••Depth: About 1½ inches or 1/3 the anterior-posterior
••Provides ventilations using the infant diameter of the chest
BVM (Responder 1) ••Number: 15 compressions
••Continues until AED prompts ••Rate: Between 100 and 120 compressions per minute
(7–9 seconds)
••Full chest recoil: 12 of 15 compressions
11 Ventilations with BVM: ••Seal: Using the E-C technique
••Open airway from top of the head ••Airway: Head-tilt/chin-lift maneuver to a neutral position
••Maintains mask seal ••Ventilations (2): 1 second in duration
*Denotes a Critical Action.
(Continued)
334 | Emergency Medical Response
Skill Sheet
Skill Sheet 13-3
CPR/AED—Infant Continued
STEP ACTION COMPETENCIES
••Compresses infant BVM to give ••Ventilations (2): Visible chest rise
2 ventilations ••Ventilations (2): Minimizes interruptions to less than
10 seconds
••Ventilations (2): Bag squeezed enough to make chest
rise; does not fully squeeze bag (avoiding overinflation)
12 Anticipates compressor change:
••Communicates with additional ••Verbalizes coordination plan to switch compressors
responders prior to AED analysis
•• Prepares for rotation upon AED analysis
13 AED analyzes:
••Says, “Stand clear” ••Clear: Ensures no one is touching the patient during
••No shock advised analysis
••Rotation: Switches compressor during analysis
••Hover: Hovers hands (new compressor) a few inches
above chest during analysis to prepare for CPR
14 Resumes CPR:
••Continues with 10 cycles of CPR ••Resumes CPR: Immediately following shock, resumes
(15 compressions/2 ventilations)* CPR, starting with compressions, until prompted by the
••Performs compressions AED for analysis
(Responder 3) ••Thumb position: Thumbs centered on the chest side by
••Manages airway and mask seal side, just below the nipple line
(Responder 1) ••Depth: About 1½ inches or 1/3 the anterior-posterior
••Provides ventilations using the infant diameter of the chest
BVM (Responder 2) ••Number: 15 compressions
••Continues until AED prompts ••Rate: Between 100 and 120 compressions per minute
(7–9 seconds)
••Full chest recoil: 12 of 15 compressions
15 Anticipates compressor change:
••Communicates with additional ••Verbalizes coordination plan to switch compressors
responders prior to AED analysis
•• Prepares for rotation upon AED analysis
16 AED analyzes and rotation:
••Says, “Stand clear”* ••Clear: Ensures no one is touching the patient during
••No shock advised analysis
••Rotation: Switches compressor during analysis
••Hover: Hovers hands (new compressor) a few inches
above chest during analysis to prepare for CPR
17 Spontaneous patient movement:
••Checks for breathing and pulse •• Pulse check: Responder performing ventilations opens
the airway and checks for breathing and brachial pulse
simultaneously for at least 5 seconds, but no more than
10 seconds
*Denotes a Critical Action.
Chapter 13: Circulation and Cardiac Emergencies | 335
ENRICHMENT
Preventing Coronary Heart Disease
Recognizing a heart attack and getting the necessary care as soon as possible may prevent a patient from
going into cardiac arrest. However, preventing a heart attack in the first place is even more effective—there is
no substitute for prevention. Heart attacks are usually the result of disease of the heart and blood vessels.
Coronary heart disease (CHD) develops slowly. Deposits of cholesterol, a fatty substance made by the
body and present in certain foods, build up on the inner walls of the arteries. As the arteries that carry blood to
the heart get narrower, less oxygen-rich blood flows to the heart. This reduced oxygen supply to the heart can
eventually cause a heart attack.
Although a heart attack may seem to strike suddenly, many people gradually put their hearts in danger from
cardiovascular disease. Because cardiovascular disease develops slowly, people may not be aware of it for many
years. Fortunately, it is possible to slow the progress of cardiovascular disease by making lifestyle changes.
Behavior that can harm the heart and blood vessels may begin in early childhood. Junk food, which is high
in cholesterol and saturated fats but has little real nutritional value, can contribute to cardiovascular disease.
Cigarette smoking also greatly contributes to cardiovascular disease and to other diseases. Many factors
increase a person’s chances of developing cardiovascular disease.
These are called risk factors. Some of them you cannot change. For instance, although more women than men
die each year from cardiovascular disease in the United States, heart disease generally affects men at younger
ages than it does women. Ethnicity also plays a role in determining the risk for heart disease. African-American
and Native American/American Indian populations statistically have higher rates of heart disease than do other
U.S. populations. A family history of heart disease also increases the risk.
Altering Risk Factors
Many risk factors can be altered, however. Cigarette smoking; uncontrolled diabetes, high blood cholesterol
or high blood pressure; obesity; and lack of regular exercise all increase the risk of heart disease. When you
combine one risk factor, such as smoking, with others, such as high blood pressure and lack of regular exercise,
the risk of heart attack is much greater.
It is never too late to take steps to control risk factors, thereby improving your chances for living a long and
healthy life. It is important to know how to perform CPR and use an AED. However, since the chances of surviving
cardiac arrest are poor, the best way to deal with cardiac arrest is to be aware of risk factors and take steps to
help prevent it, including exercise and quitting smoking.
336 | Emergency Medical Response
UNIT 5
Medical Emergencies
14 Medical Emergencies ������������������������������������������ 338
15 Poisoning ���������������������������������������������������������������� 364
16 Environmental Emergencies ������������������������������ 387
17 Behavioral Emergencies�������������������������������������� 422
14 MEDICAL
EMERGENCIES
You Are the Emergency Medical Responder
You are the emergency medical responder (EMR) responding to a scene on a downtown
street involving a male who appears to be about 60 years old. He is confused and
appears agitated. Several bystanders state that they saw the man wandering aimlessly
and that he appeared to be lost. Upon interviewing the patient, all you can learn is that
his name is Earl. He does not seem to know where he is or where he is going. During
your physical exam you note that the patient is sweating profusely but, other than his
diminished level of consciousness (LOC), his vital signs are normal. More advanced
medical personnel have been called. As an EMR, you want to provide proper care for the
patient. What other information would help you to provide proper care? What should you
do while waiting for advanced medical personnel?
KEY TERMS
Absence seizure: A type of generalized seizure in through the blood vessels until it gets stuck,
which there are minimal or no movements; patient preventing blood flow.
may appear to have a blank stare; also known as a
petit mal or nonconvulsive seizure. Epilepsy: A brain disorder characterized by
recurrent seizures.
Acute abdomen: The sudden onset of severe
abdominal pain that may be related to one of Fainting: Temporary loss of consciousness; usually
many medical conditions or a specific injury to related to temporary insufficient blood flow to the
the abdomen. brain; also known as syncope, “blacking out” or
“passing out.”
Altered mental status: A disturbance in a patient’s
level of consciousness (LOC) including confusion FAST: An acronym to help remember the symptoms
and delirium; causes include injury, infection, of stroke; stands for Face, Arm, Speech and Time.
poison, drug abuse and fluid/electrolyte imbalance. Febrile seizures: Seizure activity brought on by an
Aneurysm: An abnormal bulging of an artery due excessively high fever in a young child or an infant.
to weakness in the blood vessel; may occur in Generalized tonic-clonic seizures: Seizures that
the aorta (main artery of the heart), brain, leg or affect most or all of the brain; types include absence
other location. (petit mal) seizures and grand mal seizures.
Aphasia: A disorder characterized by difficulty or Gestational diabetes: A type of diabetes that
inability to produce or understand language, occurs only during pregnancy.
caused by injury to the areas of the brain that
control language. Glucometer: A medical device that measures the
concentration of glucose in the blood.
Aura phase: The first stage of a generalized seizure,
during which the patient experiences perceptual Glucose: A simple sugar that is the primary source of
disturbances, often visual or olfactory in nature. energy for the body’s tissues.
Blood glucose level (BGL): The level of glucose Grand mal seizure: A type of generalized seizure;
circulating in the blood; measured using involves whole-body contractions with loss
a glucometer. of consciousness.
Clonic phase: The third phase of a generalized Hemodialysis: A common method of treating
seizure, during which the patient experiences the advanced kidney failure in which blood is filtered
seizure itself. outside the body to remove wastes and extra fluids.
Complex partial seizure: A type of partial seizure Hyperglycemia: A condition in which too much
in which the patient may experience an altered sugar is in the bloodstream, resulting in higher
mental status or be unresponsive. than normal BGLs; also known as high blood
glucose.
Diabetes mellitus: A disease in which there are
high levels of blood glucose due to defects in Hyperkalemia: Abnormally high levels of potassium
insulin production, insulin action or both. in the blood; if extremely high, can cause cardiac
arrest and death.
Diabetic coma: A life-threatening complication of
diabetes in which very high blood sugar causes Hypervolemia: A condition in which there is an
the patient to become unconscious. abnormal increase of fluid in the blood.
Diabetic emergency: A situation in which a person Hypoglycemia: A condition in which too little sugar
becomes ill because of an imbalance of insulin and is in the bloodstream, resulting in lower than
sugar in the bloodstream. normal BGLs; also known as low blood glucose.
Diabetic ketoacidosis (DKA): An accumulation of Hypovolemia: A condition in which there is an
organic acids and ketones (waste products) in the abnormal decrease of fluid in the blood.
blood; occurs when there is inadequate insulin and
high blood sugar levels. Hypoxemia: A condition in which there are
decreased levels of oxygen in the blood; can
Embolism: A blockage in an artery or a vein caused disrupt the body’s functioning and harm tissues;
by a blood clot or fragment of plaque that travels may be life threatening.
(Continued )
Chapter 14: Medical Emergencies | 339
KEY TERMS continued
Insulin: A hormone produced by the pancreas to Simple partial seizures: Seizures in which a specific
help glucose move into the cells; in patients with body part experiences muscle contractions; does
diabetes, it may not be produced at all or may not not affect memory or awareness.
be produced in sufficient amounts.
Status epilepticus: An epileptic seizure (or repeated
Partial seizures: Seizures that affect only part of seizures) that lasts longer than 5 minutes without
the brain; may be simple or complex. any sign of slowing down; should be considered
life threatening and requires prompt advanced
Peritoneal dialysis: A method of treatment for medical care.
kidney failure in which waste products and
extra fluid are drawn into a solution which has Stroke: A disruption of blood flow to a part of the
been injected into the abdominal cavity and are brain which may cause permanent damage to
withdrawn through a catheter. brain tissue.
Physical counter-pressure maneuver (PCM): Syncope: A term used to describe the loss of
Physical maneuver used to hinder the progression consciousness; also known as fainting.
from presyncope to syncope.
Thrombus: A blood clot that forms in a blood
Post-ictal phase: The final phase of a generalized vessel and remains there, slowing the flow of
seizure, during which the patient becomes blood and depriving tissues of normal blood flow
extremely fatigued. and oxygen.
Presyncope: The medical term for “faintness” or Tonic phase: The second phase of a generalized
“feeling faint”; symptoms include light-headedness seizure, during which the patient becomes
or dizziness, blurry vision and nausea, while signs unconscious and muscles become rigid.
include sweating and pallor.
Transient ischemic attack (TIA): A condition
Seizure: A disorder in the brain’s electrical activity, that produces stroke-like symptoms but causes
sometimes marked by loss of consciousness and no permanent damage; may be a precursor to
often by uncontrollable muscle movement; also a stroke.
called a convulsion.
Type 1 diabetes: A type of diabetes in which the
Sepsis: A life-threatening illness in which the body pancreas does not produce insulin; formerly known
is overwhelmed by its response to infection; as insulin-dependent diabetes or juvenile diabetes.
commonly referred to as blood poisoning.
Type 2 diabetes: A type of diabetes in which
Shunt: A surgically created passage between two insufficient insulin is produced or the insulin is not
natural body channels, such as an artery and a used efficiently; formerly known as non-insulin-
vein, to allow the flow of fluid. dependent diabetes or adult-onset diabetes.
LEARNING OBJECTIVES
After reading this chapter, and completing the class • Identify the signs and symptoms of a diabetic
activities, you will have the information needed to: emergency.
• Identify a patient who has a general medical • Describe the care for a patient who has a diabetic
complaint. emergency.
• Describe the general care for a patient with a • Identify the different causes of a stroke.
general medical complaint. • Identify the signs and symptoms of stroke.
• Identify the signs and symptoms of an altered • Describe the care for a patient who has a stroke.
mental status. • Identify the signs and symptoms of abdominal pain.
• Describe the care for a patient who has an altered • Describe the care for a patient who has
mental status. abdominal pain.
• Describe the different types of seizures. • Describe the special considerations for a patient
• Identify the signs and symptoms of seizures. on hemodialysis.
• Describe the care for a patient who has a seizure.
340 | Emergency Medical Response
INTRODUCTION Size up the scene to ensure your own safety and
the safety of others.
As an emergency medical responder (EMR),
you could someday face a situation involving an Form a general impression of the patient as you
approach to determine if there are any obvious
unidentifiable medical emergency. Therefore, you
life-threatening conditions such as severe, life-
may feel uncertain about how to provide care.
threatening bleeding and if the patient appears
When you face an emergency that is unclear, it is to be conscious or unconscious.
normal to feel indecisive. Yet, like any EMR, you will Conduct your primary assessment to
still want to provide care to the best of your ability. identify and correct any immediately life-
You do not have to “diagnose” or choose among threatening conditions.
possible problems to provide appropriate care. Conduct a SAMPLE history and secondary
By following a few basic guidelines for care, you assessment to gather additional information,
can provide appropriate care until more advanced whenever possible.
medical personnel arrive. Because you know these Obtain vital signs.
guidelines for care, you can approach any medical
emergency with confidence. Summon more advanced medical personnel.
Help the patient rest comfortably.
Medical emergencies can develop rapidly (acute Keep the patient from getting chilled
conditions) or gradually (chronic conditions) and or overheated.
may persist for a long time. Sometimes, there are Provide reassurance.
no warning signs or symptoms to alert you or the
patient that something is about to happen. At other
Prevent further harm.
times, the only symptoms the patient complains of Administer supplemental oxygen if it is indicated
based on local protocols.
are feeling “ill” or feeling that “something is wrong.”
Symptoms may also be atypical; older adults or
those with diabetes, for example, may have a heart ALTERED MENTAL STATUS
attack without experiencing chest pain.
Causes
Medical emergencies have a wide range of causes, Altered mental status can result from many causes.
including chronic problems from diseases such Some of these include the following:
as heart disease and diabetes, allergies, seizures
from illnesses such as epilepsy, or overexposure Fever
to heat or cold. There can be a variety of signs and Infection
symptoms, including sudden, unexplained altered Poisoning or overdose, including substance
mental status. A patient may complain of feeling abuse or misuse
light headed, dizzy or weak. Or, the patient may Blood sugar/endocrine emergencies
feel nauseated or may vomit. Breathing, pulse and
skin characteristics may change. Ultimately, if a
Head injury
person looks and feels ill, there could be a medical Inadequate oxygenation or ventilation
emergency that requires immediate care. Any condition resulting in decreased blood flow
or oxygen to the brain
Cardiac emergencies
GENERAL MEDICAL COMPLAINTS Diabetic emergencies
Making the Assessment and Shock
Providing Care Stroke
The assessment and care of general medical Behavioral illness
complaints follow the same general guidelines: Seizures
CRITICAL Medical emergencies have a wide range of causes, including overexposure to
FACTS heat or cold; chronic problems from diseases such as heart disease and diabetes;
allergies; and seizures from illnesses such as epilepsy.
Chapter 14: Medical Emergencies | 341
Signs and Symptoms of Altered are more likely to faint when suddenly changing
Mental Status positions, for example when moving from lying
down to standing up. Whenever changes inside
Altered mental status is one of the most
the body momentarily reduce the blood flow to the
common medical emergencies. It is often
brain, fainting may occur.
characterized by a sudden or gradual change in a
person’s level of consciousness (LOC), including A person may faint with or without warning. Often,
drowsiness, confusion and partial or complete loss the person may first feel light headed or dizzy
of consciousness. (presyncope). There may be signs of shock,
such as pale or ashen, cool, moist skin. The
Providing Care for Altered person may have blurry vision, feel nauseated and
Mental Status complain of numbness or tingling in the fingers
and toes. The person’s breathing and pulse may
To care for patients with altered mental status,
become faster.
complete primary and secondary assessments,
vital signs and history as needed. Perform ongoing
assessments as you provide care. Make sure the Care for Presyncope and Syncope
airway is open, and place an unresponsive patient
A patient with presyncope will feel as if they are
who is breathing normally with no suspected
going to faint. To prevent a syncopal episode
head, neck, spinal, hip or pelvic injury in a side-
(fainting), help the patient lie down. While
lying recovery position following the assessment.
they are lying down, you should monitor their
If a head, neck, spinal, hip or pelvic injury is
breathing and level of consciousness. Have the
suspected, keep the patient in the supine (face-
patient perform a physical counter-pressure
up) position. Have suction equipment available if
maneuver (PCM):
needed. If the patient is conscious or becomes
conscious, do not give anything to eat or drink. Grip one hand at the fingers with the other and
Eating or drinking can increase the chance of try to pull them apart without letting go. They
vomiting. If possible, attempt to get information should hold the grip for as long as they can or
from the patient, family members or bystanders. until their symptoms disappear.
This is important, as a patient’s condition may
deteriorate rapidly in these situations, making
Hold a rubber ball or similar object in
their writing hand and then squeeze the
conversation impossible. Any information you can object for as long as they can or until their
obtain may help with the patient’s treatment upon symptoms disappear.
arrival at the hospital.
Cross one leg over the other and squeeze them
together tightly. Hold this position for as long as
Syncope they can or until their symptoms disappear.
Sometimes altered mental status is caused by a
temporary reduction of blood flow to the brain, Be sure to instruct the patient to avoid holding
such as occurs when blood collects or pools in the their breath while performing counter-pressure
legs and lower body. When the brain is suddenly maneuvers. An easy way to ensure this is to have
deprived of its normal blood flow, it momentarily the patient talk while performing the maneuver.
shuts down. This condition is called fainting, Physical counter-pressure maneuvers help raise
or syncope. the blood pressure through skeletal muscle
contraction and, in many cases, will resolve
Fainting can be triggered by an emotional shock, symptoms of faintness. If a person with faintness
such as the sight of blood. It may be caused by feels worse with PCM, simply discontinue the
pain, specific medical conditions like heart disease, maneuver. If a person complains of chest pain,
standing for a long time or overexertion. Some they should be provided care for chest pain, not
people, such as pregnant women or older adults, for presyncope.
CRITICAL Altered mental status is a common medical emergency often characterized by a
FACTS sudden or gradual change in a person’s LOC, including drowsiness, confusion and
partial or complete loss of consciousness.
342 | Emergency Medical Response
If a patient suffers a syncopal episode (faints), it SEIZURES
often resolves itself when the patient is moved
When the normal functions of the brain are
from a standing or sitting position to a lying-
disrupted by injury, disease, fever, infection,
down position, as normal circulation to the
metabolic disturbances or conditions causing a
brain often resumes. The patient usually regains
decreased oxygen level, a seizure may occur.
consciousness within a minute. Syncope alone
The seizure is a result of abnormal electrical activity
does not usually harm the patient, but an injury
in the brain and causes temporary involuntary
may occur from falling. Although a fainting patient
changes in body movement, function, sensation,
usually recovers quickly, you may not be able to
awareness or behavior.
determine if the fainting is associated with a more
serious medical condition. For this reason, more
advanced medical care is indicated and the EMS Types of Seizures
system should be activated. Generalized Seizures
Generalized tonic-clonic seizures, also called
Pediatric Considerations grand mal seizures, are the most well-known
Altered Mental Status in Pediatrics type of seizure. They involve both hemispheres
Children who are experiencing altered mental (halves) of the brain and usually result in loss of
status may exhibit a change in behavior, consciousness. The seizure activity is known as
personality or responsiveness beyond what tonic-clonic, which refers to the initial rigidity (tonic
is expected at their age. These children may phase) followed by rhythmic muscle contractions
exhibit anxiety, agitation, aggression and/ (clonic phase), or convulsions. This type of seizure
or combativeness. Alternatively, they may be rarely lasts for more than a few minutes.
difficult to rouse, sleepy or even unresponsive.
It is not unusual for altered mental status to Signs and Symptoms of
result in decreased muscle tone. Generalized Seizures
Common causes of altered mental status Before a generalized seizure occurs, the patient
requiring immediate medical attention include may experience an unusual sensation or feeling
respiratory failure, deficiency in oxygen called an aura. An aura can include a strange
concentration in arterial blood (hypoxemia), sound, taste, smell or an urgent need to get to
shock, hypoglycemia, brain injury (including safety. If the patient recognizes the aura, there may
shaken baby syndrome), seizures, poisoning, be time to warn bystanders and to sit or lie down
intentional overdose, sepsis, meningitis, before the seizure occurs.
hyperthermia and hypothermia.
Generalized seizures usually last 1 to 3 minutes
Left untreated, altered mental status can and can produce a wide range of signs and
lead to life-threatening problems, including symptoms. When a seizure occurs, the patient
inefficient respiration, hypoxemia, airway loses consciousness and can fall, causing injury.
obstruction and respiratory failure. For care of The patient may become rigid, and then experience
children with altered mental status, consider sudden, uncontrollable muscular contractions
the possibility of a spinal injury if the cause (convulsions), lasting several minutes. Breathing
is not clear or trauma is suspected. Treat any may become irregular and even stop temporarily.
breathing emergency and care for any other The patient may drool and the eyes may roll
injuries or conditions found. Obtain more upward. As the seizure subsides and the muscles
advanced medical care and provide ongoing relax, the patient may have a loss of bladder or
assessment and care. bowel control.
CRITICAL A seizure is temporary abnormal electrical activity in the brain caused by injury,
FACTS disease, fever, infection, metabolic disturbances or conditions that decrease
oxygen levels.
Generalized seizures, also called grand mal seizures or tonic-clonic seizures, are
the most easily recognized type of seizure.
Chapter 14: Medical Emergencies | 343
The stages of most generalized seizures are Complex partial seizures often begin with a blank
as follows: stare followed by random movements such as
smacking the lips or chewing. The patient appears
1. Aura phase—patient may sense something dazed, the movements are clumsy and the patient’s
unusual (not all patients will experience activities lack direction. They may be unable to
an aura) follow directions or answer questions. This type of
2. Tonic phase—unconsciousness then muscle seizure usually lasts for only a few minutes but it
rigidity may last longer. The patient cannot remember what
3. Clonic phase—uncontrollable muscular happened after the seizure is over, and may be
contractions (convulsions) confused. This is called the post-ictal phase.
4. Post-ictal phase—diminished
responsiveness with gradual recovery and Absence (Petit Mal) Seizures
confusion (patient may feel confused and Individuals may also experience an absence
want to sleep) seizure, also known as a petit mal seizure. These
are most common in children. During an absence
Partial Seizures seizure, there is brief, sudden loss of awareness
Partial seizures may be simple or complex. or conscious activity. There may be minimal or no
They usually involve only a very small area of one movement, and the person may appear to have a
hemisphere of the brain. Partial seizures are the blank stare. Most often these seizures last only a
most common type of seizure experienced by few seconds.
people with epilepsy. Partial seizures can spread
and become a generalized seizure. In simple Signs and Symptoms of Absence
partial seizures, the patient usually remains Seizures
aware. Complex partial seizures usually last Absence seizures cause the person to experience
for 1 to 2 minutes, though they may last longer loss of awareness for short periods that may be
and awareness is either impaired or lost while the mistaken for daydreaming. This type of seizure
patient remains conscious. may also be referred to as a nonconvulsive seizure,
because the body remains relatively still during
Signs and Symptoms of Partial Seizures the episode, though eye fluttering and chewing
With simple partial seizures, the patient usually movements may be seen.
remains aware, but someone experiencing a
complex partial seizure experiences altered mental Febrile Seizures
status or unresponsiveness. Young children and infants may be at risk for
febrile seizures, which are seizures brought on
In simple partial seizures, there may be involuntary, by a rapid increase in body temperature. They are
muscular contractions in one area of the body, most common in children under the age of 5.
for example the arm, leg or face. Some people
cannot speak or move during a simple partial Febrile seizures are often caused by ear, throat
seizure, although they may remember everything or digestive system infections and are most likely
that occurred. Simple partial seizures may produce to occur when a child or an infant runs a rectal
a feeling of fear or a sense that something bad is temperature of over 102° F (38.9° C). An individual
about to happen. Simple partial seizures can also experiencing a febrile seizure may experience some
produce odd sensations such as strange smells or or all of the following symptoms:
hearing voices. In rare instances, feelings of anger
and rage or joy and happiness can be brought Sudden rise in body temperature
on by the seizure. Auras are a form of simple Change in LOC
partial seizure. Rhythmic jerking of the head and limbs
CRITICAL Young children and infants may be at risk for febrile seizures, which are seizures
FACTS brought on by a rapid increase in body temperature.
Protecting the patient from injury and managing the airway are your priorities when
caring for a patient having a seizure.
344 | Emergency Medical Response
Loss of bladder or bowel control having a seizure. To help avoid injury, you should
Confusion move nearby objects, such as furniture, away from
the patient. People having seizures rarely bite the
Drowsiness
tongue or cheeks with enough force to cause any
Crying out
significant bleeding. Do not place anything in the
Becoming rigid mouth to prevent this type of injury. Foreign bodies
Holding the breath in the mouth may cause airway obstruction. Do
Rolling the eyes upward not put fingers into the mouth of an actively seizing
patient to clear the airway. During the seizure,
Epilepsy position the uninjured patient on their side in a
Epilepsy is a common neurological disorder, recovery position, if it is possible and safe to do,
estimated to affect approximately 3 million people in so that fluids (saliva, blood, vomit) can drain from
the United States alone. Epilepsy is not a specific the mouth. Keep the patient in a side-lying recovery
disease but a term used to describe a group of position until they regain consciousness after the
disorders in which the individual experiences post-ictal phase. It is important to have a suction
recurrent seizures as the main symptom. In about device available for all seizure patients.
one-third of all cases, seizures occur as a result of In many cases, the seizure will be over by the time
a brain abnormality or neurological disorder, but in you arrive. In this case, the patient may be drowsy
two-thirds there is no known cause. and disoriented; this is the post-ictal phase. Check
The risk of having epilepsy for young people (up to see if the patient was injured during the seizure.
to the age of 20) is approximately 1 percent, with Offer comfort and reassurance, especially if the
the greatest likelihood occurring during the first seizure occurred in public, as the patient may feel
year of life. People aged 20 to 55 may also develop embarrassed and self-conscious. If this is the case,
epilepsy but have a somewhat lower risk. The risk keep bystanders well back to provide maximum
increases again after the age of 65 and, in fact, privacy, and stay with the patient until they are fully
the highest rate of new epilepsy diagnoses are in conscious and aware of the surroundings.
this age group. The prevalence of epilepsy, or the Care for a child or an infant who experiences a
number of individuals suffering with it at any time, is febrile seizure is similar to the care for any other
estimated to be approximately 5 to 8 in every 1000 patient experiencing a seizure. Immediately after a
people. By age 75, approximately 3 percent of febrile seizure, cool the body by removing excess
people will have been diagnosed with epilepsy. clothing. Do not rapidly cool the patient with cold
People of any age can be affected by epilepsy. water as this could bring on other complications.
Patients who have epilepsy often can control the Contact a healthcare provider before administering
seizures with medication. Those with difficult-to- any medication, such as acetaminophen, to control
control seizures may also be treated with surgical fever. Do not give aspirin to a feverish child under
resection, which can be curative, or with implanted 18 years of age, as this has been linked to Reye’s
devices, such as the vagus nerve stimulator, syndrome, an illness that affects the brain and
that help reduce their seizure frequency. While other internal organs.
some patients require lifelong medical therapy,
sometimes medication may be reduced or even When to Call for More Advanced
eliminated over time. Some childhood epilepsies Medical Personnel
may resolve with age.
The patient will usually recover from a seizure
in a few minutes. If you discover the patient has
Providing Care for Seizures a medical history of seizures that is medically
Seeing someone have a seizure may be controlled, there may be no further need for
intimidating, but you can easily care for the medical attention. However, in the following cases,
patient. The patient cannot control any muscular more advanced medical care and transportation to
contractions that may occur and it is important a medical facility by ambulance should be provided:
to allow the seizure to run its course, because
attempting to stop it or restrain the patient can
The seizure lasts more than 5 minutes or a
seizure is followed by another seizure without a
cause musculoskeletal injuries. period of consciousness (status epilepticus).
Protecting the patient from injury and managing the This is the patient’s first seizure.
airway are your priorities when caring for a patient The patient appears to be injured.
Chapter 14: Medical Emergencies | 345
You are uncertain about the cause of the seizure. produce little or no insulin. Most people who have
The patient is pregnant. Type 1 diabetes have to inject insulin into their
bodies daily.
The patient is known to have diabetes.
The patient is a child or an infant. In type 2 diabetes, formerly known as non-
The seizure takes place in water. insulin-dependent diabetes or adult-onset
The patient fails to regain consciousness after diabetes, the body produces insulin, but either
the seizure. the cells do not use the insulin effectively or not
enough insulin is produced. This type of diabetes is
The patient is a young child or an infant who
more common than type 1 diabetes. Most people
experienced a febrile seizure brought on by a
high fever. with type 2 diabetes can regulate their blood
glucose level (BGL) sufficiently through diet,
The patient is an older adult and could have
and sometimes through oral medications, without
suffered a stroke.
insulin injections.
Status epilepticus is an epileptic seizure (or
People with diabetes must carefully monitor their
repeated seizures) that lasts longer than 5 minutes
BGL, diet and amount of exercise. People with
or a seizure that is followed by another seizure
diabetes must also regulate their use of insulin.
without the patient regaining consciousness.
When diet and exercise are not controlled, either
A status epilepticus seizure is a true medical
of two problems can occur: too much or too little
emergency that may be fatal. If you suspect the
sugar in the body. This imbalance of sugar and
patient is experiencing this type of seizure, call for
insulin in the blood causes illness.
more advanced medical personnel immediately.
During and after the seizure, place the patient on Some women develop diabetes in the late stages
the side and suction the airway, if possible. If the of pregnancy; this form usually goes away after
patient is having difficulty breathing, administer the baby is born. This type is called gestational
ventilations with a bag-valve-mask (BVM) diabetes and is caused by the hormones of
resuscitator, along with supplemental oxygen pregnancy or a shortage of insulin. Women
based on local protocols. who have had this condition have an increased
likelihood of developing type 2 diabetes later in life.
DIABETIC EMERGENCIES High Blood Glucose
Incidence When the insulin level in the body is too low, the
Diabetes mellitus is one of the leading causes sugar level in the blood is high. This condition
of death and disability in the United States today. is called hyperglycemia (Fig. 14-1). Sugar is
In 2016, 29 million Americans were living with present in the blood but cannot be transported
diabetes and 86 million had prediabetes, a serious from the blood into the cells without insulin,
health condition that increases a person’s risk of causing body cells to become starved for sugar.
type 2 diabetes and other chronic diseases. The body attempts to meet its need for energy by
using other stored food and energy sources, such
Diabetes contributes to other conditions, including as fats. However, converting fat to energy is less
blindness, kidney disease, heart disease, efficient, produces waste products and increases
periodontal (gum) disease, stroke and amputations. the acidity level in the blood, causing a condition
known as diabetic ketoacidosis (DKA). As
this occurs, the person becomes ill. The patient
Definition of Terms may have flushed, hot, dry skin and a sweet breath
Diabetes odor that can be mistaken for the smell of alcohol.
There are two major types of diabetes. Type 1 The patient may also appear restless or agitated,
diabetes, formerly known as insulin-dependent have abdominal pain or be thirsty. If this condition
diabetes or juvenile diabetes, causes the body to is not treated promptly, diabetic coma, a
CRITICAL Type 1 diabetes is characterized by the body’s inability to produce insulin. Type 2
FACTS diabetes is characterized by the body’s inability to use insulin effectively. Type 2
diabetes is more common.
346 | Emergency Medical Response
Fig. 14-1: A low insulin level results in high blood sugar, Fig. 14-2: A high insulin level results in low blood sugar,
called hyperglycemia. It can be life threatening if not called hypoglycemia. Like hyperglycemia, it can be life
quickly treated. threatening if not quickly treated.
life-threatening emergency in which very high blood bloodstream. However, sugar cannot pass freely
sugar causes the patient to become unconscious, from the blood into the body cells. Insulin, a
can occur. hormone produced in the pancreas, is needed
for sugar to pass into the cells. Without a proper
Low Blood Glucose balance of sugar and insulin in the blood, the
cells will starve and the body will not function
When the insulin level in the body is too high,
properly (Fig. 14-3).
the patient has a low sugar level, known as
hypoglycemia (Fig. 14-2). The blood sugar level Maintaining normal BGLs reduces the risk of eye,
can become too low if the person with diabetes: kidney, heart and nerve problems. Many people
with diabetes have blood glucose monitors,
Takes too much insulin.
called glucometers, that can be used to check
Fails to eat adequately. their BGL at home. Many hypoglycemic and
Over-exercises and burns off sugar faster hyperglycemic episodes are now managed at
than normal. home because of the rapid information these
Experiences great emotional stress. monitors provide.
In this situation, the small amount of sugar is used
up rapidly, so not enough sugar is available for the Signs and Symptoms of Diabetic
brain to function properly. If left untreated, even for Emergencies
a short time, hypoglycemia from an insulin reaction Although hypoglycemia and hyperglycemia are
can cause brain damage or death. Call for more different conditions, the major signs and symptoms
advanced medical care immediately. This condition are similar. These include:
is also known as insulin shock.
Changes in LOC, including dizziness,
drowsiness and confusion.
Role of Glucose
To function normally, body cells need sugar as an Irregular breathing.
energy source. Through the digestive process, Abnormal pulse (rapid or weak).
the body breaks down food into simple sugars, Feeling and looking ill.
such as glucose, which are absorbed into the Abnormal skin characteristics.
CRITICAL Hypoglycemia and hyperglycemia have similar signs and symptoms, including
FACTS changes in LOC, irregular breathing, abnormal pulse, feeling and looking ill and
abnormal skin characteristics.
Chapter 14: Medical Emergencies | 347
NORMAL DIABETIC
Pancreas
Pancreas
Insulin Insulin
Bloodstream Sugar
Bloodstream
Sugar Insulin Sugar
Sugar
Digestion Digestion
Body cells Body cells
Fig. 14-3: The hormone insulin enables sugar in the bloodstream or stored forms of sugar to be used by the body cells for energy.
Providing Care for Diabetic
Emergencies
To care for diabetic emergencies, first perform
a primary assessment and care for any life-
threatening conditions. If the patient is conscious,
conduct a physical exam and SAMPLE history,
looking for anything visibly wrong. Ask if the patient
has diabetes, and look for a medical identification
tag. If the patient is known to have diabetes and
exhibits the signs and symptoms previously stated,
then suspect a diabetic emergency.
If the patient is awake, is able to follow simple
commands and can safely swallow, give 15 to
20 grams of sugar, preferably in the form of glucose
tablets (Fig. 14-4). If glucose tablets are not
available, other forms of dietary sugars have been
found to be an effective substitute, including candies
containing glucose or sucrose that can be chewed,
jelly beans, orange juice, fructose-based fruit
strips and whole milk. If none of these options are
available, the patient can be given 4 to 5 teaspoons
of table sugar dissolved in a glass of water.
Fig. 14-4: Commercial oral glucose tablets are preferred for
Sometimes, patients with diabetes will be able to fast administration of glucose to a hypoglycemic patient who is
tell you what is wrong and will ask for something awake and can safely swallow.
with sugar in it. If the patient’s problem is low
sugar (hypoglycemia), the sugar you give will help
quickly. If the patient already has too much sugar from getting chilled or overheated, summon more
(hyperglycemia), the excess 15 to 20 grams sugar advanced medical personnel and administer
will do no immediate harm. supplemental oxygen based on local protocols.
If the patient is conscious but does not feel better
Do not try to assist the patient by administering within approximately 10 to 15 minutes after taking
insulin. Only give something by mouth if the patient sugar, summon more advanced medical personnel
is fully conscious. If the patient is unconscious, and consider giving the patient another 15 to
monitor the patient’s condition, keep the patient 20 grams of sugar based on local protocols.
348 | Emergency Medical Response
STROKE A transient ischemic attack (TIA), often
referred to as a “mini-stroke,” is a temporary
A stroke, also called a cerebrovascular accident episode that, like a stroke, is caused by reduced
(CVA), is a disruption of blood flow to a part of blood flow to a part of the brain. Unlike a stroke,
the brain, which may cause permanent damage the signs and symptoms of a TIA disappear within
to brain tissue if not appropriately treated within a few minutes or hours of its onset. If symptoms
several hours. persist after 24 hours, the event is not considered
a TIA but a stroke.
Causes
Although the indicators of TIA disappear quickly,
Most commonly, a stroke is caused by a blood the patient is not out of danger. In fact, someone
clot, called a thrombus or embolism, that forms who experiences a TIA has a nearly 10 times
or lodges in the arteries supplying blood to the greater chance of having a stroke in the future
brain (Fig. 14-5). Fat deposits lining an artery than does someone who has not experienced
(atherosclerosis) may also cause a stroke known as a TIA.
an ischemic stroke.
The risk factors for stroke and TIA are similar to
Another less common cause of stroke is bleeding those for heart disease. Some risk factors are
from a ruptured artery in the brain. Known as a beyond the patient’s control, such as age, gender
hemorrhagic stroke, this condition is brought or family history of stroke, TIA, diabetes or heart
on by high blood pressure or an aneurysm—a disease. Others can be controlled, such as blood
weak area in an artery wall that balloons out pressure, smoking, diet and exercise. Stroke
and can rupture (Fig. 14-6). Less commonly, a is common in the older adult population, but a
tumor or swelling from a head injury may cause person of any age, including children, can have
a stroke by directly compressing an artery or a stroke.
brain tissue.
Clot Rupture
Fig. 14-5: Strokes are most commonly caused by a blood Fig. 14-6: A less common cause of stroke is bleeding from a
clot in the arteries that supply blood to the brain. ruptured artery in the brain.
CRITICAL Two causes of stroke are blood clots that form or lodge in arteries supplying blood
FACTS to the brain and arteries in the brain that rupture and bleed. Blood clots are the
most common cause of stroke.
A TIA, sometimes called a “mini-stroke,” is caused by reduced blood flow to a part
of the brain, but unlike a stroke its signs and symptoms disappear within a few
minutes or hours of onset.
Chapter 14: Medical Emergencies | 349
Sudden Signs and Symptoms Sudden severe headache (unexplained and
of Stroke often described as the worst headache ever).
As with other sudden illnesses, looking or Dizziness, confusion, agitation, loss of
feeling ill or displaying abnormal behavior consciousness or other severe altered
are common signs of a stroke or TIA. Other mental status.
specific signs and symptoms of stroke come on Loss of balance or coordination, trouble walking
suddenly, including: or ringing in the ears.
Incontinence.
Facial droop or drooling (Fig. 14-7, A).
Weakness or numbness of the face, arm or leg, Stroke Alert Criteria
often on one side of the body (Fig. 14-7, B).
Two common stroke assessment scales used in the
Difficulty with speech. The patient may have prehospital setting are the Cincinnati Prehospital
trouble talking, getting words out or being Stroke Scale and the Los Angeles Prehospital
understood when speaking and may have Stroke Screen (LAPSS), which assess facial
trouble understanding (aphasia). droop, arm drift and speech. Both scales should be
Loss of vision or disturbed (blurred or dim) included in your assessment of the stroke patient and
vision in one or both eyes; pupils of the eyes reported to the medical facility. A Glasgow Coma
may be of unequal size. Score (GCS) also should be obtained on the patient
(see Chapter 7 for further information). Collecting
and reporting this information will help ensure the
required management of the stroke patient.
FAST
The FAST mnemonic is based on the Cincinnati
Prehospital Stroke Scale, which was originally
developed for EMS personnel in 1997. The scale
was designed to help paramedics identify strokes
in the field so that the emergency department
can be prepared before the patient arrives. The
FAST method for public awareness has been in
use in the community of Cincinnati, Ohio, since
A 1999, and has since been used in several other
variations of the message.
FAST stands for the following:
Face: Ask the patient to smile. Does one side of
the face droop?
Arm: Ask the patient to raise both arms. Does
one arm drift downward?
Speech: Ask the patient to repeat a simple
sentence such as, “The sky is blue.” Are the
words slurred? Can the patient repeat the
sentence correctly?
B Time: Try to determine the time of onset of
Fig. 14-7, A–B: (A) Sudden facial droop or drooling and
symptoms. If the patient shows any one sign or
(B) weakness or numbness of an arm or leg, often on one side symptom of a stroke, time is critical. Immediate
of the body, are signs and symptoms of a stroke. transport of the patient to a stroke-capable
medical facility is necessary.
CRITICAL As the common mnemonic for stroke identification, FAST stands for Face, Arm,
FACTS Speech and Time. Facial drooping, arm weakness and slurred speech are
distinctive symptoms, and timely advanced medical care is critical if any one sign or
symptom is present.
350 | Emergency Medical Response
LAPSS ABDOMINAL PAIN
The LAPSS mnemonic is another common one- Abdominal pain is felt between the chest and
page tool designed to help prehospital personnel groin, which is commonly referred to as the
rapidly identify strokes in the field. stomach region or belly. There are many organs
in the abdomen, so when a patient is suffering
Providing Care for Stroke from abdominal pain it can originate from any one
If the patient is unresponsive, ensure that their of them. These include digestive organs such as
airway is open, and care for any life-threatening the inferior end of the esophagus, stomach, small
conditions. If fluid or vomit is in the unresponsive and large intestines, liver, gallbladder, pancreas,
patient’s mouth, position the patient in a side-lying aorta, appendix, kidneys and spleen. Abdominal
recovery position to allow any fluids to drain out emergencies can be life threatening and require
of the mouth. You may have to remove some fluids immediate care to prevent shock, so they should
or vomit from the patient’s mouth using a finger or always be treated seriously. A sudden onset of
suctioning equipment. abdominal pain is called acute abdomen.
Stay with the patient and monitor their condition. Causes
If the patient is conscious, check for non-life-
threatening conditions. A stroke can make Abdominal pain can be difficult to pinpoint, as the
the patient fearful and anxious due to not pain may start from somewhere else and could be
understanding what has happened. Offer comfort a result of any number of generalized infections
and reassurance and have the patient rest in a including the flu or strep throat.
comfortable position. Do not give anything to eat or The intensity of the pain does not always
drink. Although a stroke patient may find it difficult reflect the seriousness of the condition. Severe
to speak, the patient may understand what you say. abdominal pain can be from mild conditions, such
If the patient is unable to speak, you may have to as intestinal gas, whereas relatively mild pain
use nonverbal forms of communication, such as or no pain may be present with life-threatening
hand squeezing or eye blinking (once for yes, twice conditions such as an ectopic pregnancy
for no) and communicate in ways that require a or appendicitis.
yes-or-no response.
In the past, a stroke almost always caused Signs and Symptoms
irreversible brain damage. Today, stroke of Abdominal Pain
management with new medications and medical
If you are called to see a patient who is
procedures can limit or reduce the damage
experiencing abdominal pain, assume the pain is
caused by stroke. Many of these new treatments
serious, as the patient or family members were
are time sensitive; therefore, you should
concerned enough to seek emergency medical
immediately call for more advanced medical
attention. Patients suffering from abdominal pain
personnel to get the best care for the patient. It
may show the following signs and symptoms:
is very important to interview the patient, family
members and bystanders to determine the time Colicky pain or cramps that come in waves
of the onset of symptoms or the time the patient
was last known to be well, and to transport the
Abdominal tenderness, local or diffuse
(spread out)
patient to an appropriate stroke-capable medical
facility immediately. Guarded position
CRITICAL Modern stroke management with medications and medical procedures can limit the
FACTS damage caused by stroke, but timely administration is crucial to reduce the effects
of stroke to the brain.
Chapter 14: Medical Emergencies | 351
Anxiety abdomen, using the navel as the center point,
A reluctance to move, for fear of pain to determine if it is rigid or soft (Fig. 14-8).
Examine the area the patient indicates as the
Loss of appetite
location of the pain last. Do not overpalpate, as
Nausea or vomiting this can aggravate the condition as well as cause
Fever more pain.
Rigid, tense or distended stomach
Signs of shock Providing Care for Abdominal Pain
Vomiting blood with a red or brownish appearance First, ensure there is no severe, life-threatening
Blood in the stool, appearing red or black bleeding and that the patient has an open airway.
Rapid pulse Call for transport to a medical facility. In the case
of abdominal pain, it is important to watch for signs
Blood pressure changes
of potential aspiration due to vomiting. In cases in
When conducting an assessment, monitor the which the patient is experiencing nausea, place
patient’s movements. Take note if the patient the patient on their side if it is not too painful.
is restless or quiet and if the patient feels pain Do not give the patient food, water or medication.
when moving. Check to see if the abdomen Watch for signs of shock. If vital signs and other
is distended and, if possible, confirm with the observations indicate the patient is in shock, place
patient whether the appearance of the stomach the patient on their back, maintain normal body
is normal. See if the patient is able to relax the temperature and administer supplemental oxygen
abdomen, and palpate the 4 quadrants of the based on local protocols.
Fig. 14-8: When assessing abdominal pain in a patient, palpate the stomach to determine if it is rigid or soft.
CRITICAL The source and causes of abdominal pain can be difficult to pinpoint, and intensity
FACTS of abdominal pain does not always reflect the seriousness of the condition.
352 | Emergency Medical Response
Pediatric Considerations Considerations for Older Adults
Abdominal Pain Abdominal Pain
Abdominal pain in children can indicate Understanding that older adult patients
a vast range of conditions. A sudden or may experience vague symptoms and have
progressive onset of pain, excessive vomiting non-specific findings on examination is
or diarrhea, blood noted in vomit or stool, important. Keep in mind that abdominal pain
abdominal distention, high blood sugar, may actually be caused by a heart attack
altered mental status and abnormal vital signs or other medical conditions. Many older
are all signs the child could be suffering from adult patients may have much less severe
a serious condition or illness. Vomiting and pain than expected for a particular illness
diarrhea in children are significant symptoms or disease, which can lead to patients with
as they may cause dehydration, which can serious conditions being misdiagnosed
lead to shock. with less serious conditions such as
gastroenteritis or constipation. Vomiting
To assess a child complaining of abdominal and diarrhea are significant symptoms in
pain, take the following steps: older adults, as they can cause dehydration
and shock.
Obtain a general impression of the child’s
appearance, breathing and circulation to Causes of abdominal pain in older adults may
determine urgency. include biliary tract disease, appendicitis,
Evaluate the child’s mental status, diverticulitis, mesenteric ischemia (reduced
airway, adequacy of breathing blood flow to the small intestines), bowel
and circulation. obstruction, abdominal aortic aneurysm,
Take the child’s history and perform peptic ulcer disease, malignancy
a hands-on physical examination, and gastroenteritis.
noting any injury, hemorrhage,
discoloration, distention, rigidity,
guarding or tenderness within the four Common Abdominal Emergencies
abdominal quadrants. Many different conditions can cause abdominal
If a life-threatening condition is pain, including inflammation of the appendix
noted, provide immediate treatment (appendicitis), bowel obstruction, inflammation
before continuing. of the gallbladder, abdominal aortic aneurysm,
diverticular disease, shingles, food allergies, food
Children of different ages tend to have poisoning, gastroenteritis and others. Consider the
different causes of pain. Causes in an situation an emergency when the abdominal pain
infant can include colic, allergy to cow’s restricts activity.
milk, reflux esophagitis, volvulus (bowel
obstruction) or Hirschsprung’s Disease
(congenital disease affecting the large GASTROINTESTINAL BLEEDING
intestine). In school-age children, the
most frequent cause of abdominal pain is There are multiple causes of gastrointestinal
gastroenteritis or “stomach flu,” which may bleeding, and these tend to be classified as
result in significant fluid loss. Also common either upper or lower, depending on the location
is the ingestion of toxic substances or of the problem within the gastrointestinal
food poisoning. tract. Bleeding in the upper gastrointestinal
tract originates in the esophagus, stomach
In adolescents, growth, development and or duodenum (first part of the intestine) and
fertility issues can cause problems such as may include such problems as peptic ulcers,
testicular torsion (twisting of the testicles), gastritis, stomach cancer or ingestion of caustic
ovarian torsion, ovarian cysts, pelvic poisons. Bleeding in the lower gastrointestinal
inflammatory disease, ectopic pregnancy tract originates in the small intestine, large
(pregnancy that occurs outside the womb), intestine, rectum or anus, and includes
inflammatory bowel disease, ulcerative colitis, diverticular disease, polyps, hemorrhoids and
Crohn’s disease, DKA, pneumonia and sickle anal fissures, as well as cancer and inflammatory
cell anemia. bowel disease.
Chapter 14: Medical Emergencies | 353
A patient with gastrointestinal bleeding may and how much fluid was removed before the
experience vomiting of blood, bloody bowel session was terminated.
movements or black, tarry stools. Symptoms that The general physical assessment should include
may accompany the bleeding include fatigue, fluid status, mental status, cardiac rhythm and
weakness, abdominal pain, pale appearance and shunt location.
shortness of breath.
NOTE: Shunts in the arm are common in long-
Severe gastrointestinal bleeding can have a term hemodialysis patients. If an active shunt is
significant impact on vital signs—for example, located in the patient’s arm, do not take blood
causing blood pressure to drop sharply and heart pressure using that arm. Old, nonfunctional
rate to increase. Summon more advanced medical shunts are not uncommon, and blood pressure
personnel, as the patient may require a blood can be taken on an arm with a nonfunctional
transfusion or surgery. shunt. Ask the patient about active and
nonfunctional shunt locations when taking a
history. Shunts can also be potential sites of
HEMODIALYSIS infection and/or blockage.
People with advanced renal failure, or kidney
failure, often need dialysis to filter waste products Pay attention for associated medical problems
such as arrhythmias, internal bleeding,
from the blood using a special filtering solution.
hypoglycemia, altered mental status and seizures.
There are two types of dialysis: peritoneal
dialysis, which injects a solution through the Be aware that, after dialysis, patients
abdominal wall and then withdraws it after a period may have hypovolemia (reduced blood
of time, and hemodialysis, which uses a machine volume) and exhibit cold, clammy skin; poor
to clean waste products from the blood. Dialysis skin turgor (elasticity); tachycardia; and
is often used on patients with renal disease while hypotension. Delayed dialysis patients will
they are waiting for a kidney transplant. have hypervolemia (increased blood volume)
and may have abnormal lung sounds such as
Complications of dialysis include hypotension crackles, generalized edema, hypertension or
(abnormally low blood pressure), disequilibrium jugular venous distension.
syndrome (a reduction of the blood urea level Be alert for altered mental status.
relative to the levels found in brain tissues),
hemorrhage (abdominal, gastrointestinal [GI] Be sure to assess cardiac rhythm.
and intracranial bleeding), introduction of an air
embolus or other foreign body into the patient’s Life-Threatening Emergencies
circulatory system due to equipment malfunction, Associated with Dialysis Patients
and complications caused by temporarily stopping Patients on dialysis can experience several
a patient’s medications during the dialysis process. types of complications, for example uremia
(accumulation of urinary waste products in
Special Considerations for the blood), fluid overload (reduction in the
Hemodialysis Patients body’s ability to excrete fluid through urine),
anemia (hemoglobin deficiency), hypertension,
The following details should be considered when hyperkalemia (excess potassium in the blood)
taking a history and physical exam with a patient and coronary artery disease. Emergencies also
who has renal failure: can occur as complications of the dialysis itself,
including hypotension, disequilibrium syndrome,
A comprehensive history should include
information about past dialysis and hemorrhage, equipment malfunction (e.g.,
complications; recent sodium, potassium introducing an air embolus or other foreign body
and fluid intake; information about the current into the circulatory system) or complications from
dialysis session; and the patient’s dry weight being temporarily removed from medications.
CRITICAL People with advanced renal failure, or kidney failure, often need dialysis to filter
FACTS waste products from the blood using a special filtering solution.
354 | Emergency Medical Response
PUTTING IT ALL TOGETHER care without knowing the exact cause, allowing
the patient to remain as comfortable and safe as
As is true of all emergencies, a medical emergency possible until arrival at a medical facility. You can
can strike anyone, at any time. The signs and also recognize the dangers and complications
symptoms for each of the medical emergencies of dealing with those with diabetes or renal
described in this chapter, such as changes in LOC, failure. And you have learned the importance of
sweating, confusion, weakness and appearing age considerations in many conditions, such as
ill, will indicate the necessary initial care you abdominal pain and seizure.
should provide.
Performing a proper assessment and following the
In most cases involving a medical emergency, your general guidelines of care for any emergency will
biggest challenge is that you may not know the help prevent the condition from becoming worse.
cause. In the case of a diabetic emergency, seizure, While it is not your role to diagnose the problem, it
stroke and fainting, the causes may be easier is your job to provide initial care to the patient until
to ascertain. However, you can provide proper a proper diagnosis can be made.
You Are the Emergency Medical Responder
As you continue monitoring the patient, he becomes even more confused and agitated.
You begin to notice signs of shock. As an EMR, what should you do while awaiting
EMS personnel?
Chapter 14: Medical Emergencies | 355
ENRICHMENT
Basic Pharmacology
Common Forms of Medication
Emergency medical responders (EMRs) are often called upon to help give or administer medications. These
medications come in several types and forms, including tablets, capsules, powders, liquids, creams, auto-
injectors and aerosol sprays. They also have a range of options regarding how they are administered and the
doses used in a given circumstance.
Basic Medication Terminology
Drug Name
Upon initial discovery, a drug is given a chemical name based on its chemical properties. It is then given a
generic, or non-proprietary name, usually a shorter version of the chemical name. This is the name used for the
Food and Drug Administration (FDA) approval application. Drugs are also given a brand or trade name, which
is used in marketing. It may or may not sound like the generic name, depending on the complexity of the generic
name and the drug’s purpose. For example, with a chemical name of N-acetyl-p-aminophenol, the generic name
of this drug is acetaminophen and the trade name is Tylenol®.
Drug Profile
A drug’s profile is a description of what it does, what it is or is not given for and any issues that may develop as a
result of taking it.
Actions: The action of a medication is what it does. If you are administering a drug, you should know
how the drug works. For example, does the medication dilate the blood vessels (vasodilator) to lower
blood pressure?
Indications: The indication of a drug is the intended use for a specific condition. Why is the drug given? What
are you trying to achieve? For example, the indication for nitroglycerin would be for chest pain or angina.
Contraindications: Not everyone can take every medication. Contraindications are the conditions in which
you would not administer a drug to a patient. This could be because the patient has a medical condition that
would be worsened by administration of the drug, because of adverse interactions with other medications
or because the patient may be allergic to the medication. For example, it would be contraindicated to
give morphine to a patient who is allergic to it, or to give a medication with a known effect of hypotension
(lowering blood pressure) to a patient whose blood pressure is already low.
Side effects: Side effects are reactions caused by the drug that were not intended. Side effects may or
may not cause problems. If they do cause problems, these are called adverse effects, adverse reactions
or untoward effects. These are the effects you must watch for when administering medications such as
nitroglycerin. Nitroglycerin works by dilating the blood vessels, but it can cause the sudden and possibly
harmful side effect of lowering blood pressure.
Dose: The usual dose is a range of an acceptable amount of the medication, given the patient’s age, weight
and reason for giving the drug. There are also times when the patient’s gender must be taken into account.
Administering an overdose, or too much of a drug, can result in severe, sometimes fatal, consequences.
Administering too little of a drug may cause the problem to worsen, because the drug will not have the desired
effect on the patient.
Route: You must know by which route a drug is to be given. Some medications can be given in different ways—
for example, by injection or intravenously. However, there is a significant difference in the dose given by each
route. If a patient receives a dose intravenously that was intended to be delivered by injection, this could result
in death.
356 | Emergency Medical Response
ENRICHMENT
Basic Pharmacology continued
Prescribing Information
Medication prescriptions must contain the following information:
Pharmacy’s name and address Patient’s name
Prescription’s serial number Directions for use, including any precautions
Date of the prescription (initial filling or refill date) Medication name and strength
Prescriber’s name Federal law inscription on transfer of drugs
Medication prescriptions also commonly contain the following additional information:
Patient’s address Drug’s expiration date
Pharmacist’s initials or name Manufacturer’s or distributor’s name
Pharmacy’s telephone number Quantity of medication dispensed
Manufacturer’s lot number Number of refills remaining
Routes of Administration
Medications can be given in many ways, including the following:
By mouth: Many medications, such as tablets, capsules, powders and liquids, may be given by mouth to be
absorbed by the stomach and intestines. The amount of time it takes for them to become effective can vary
considerably. The patient must be responsive enough to follow directions to swallow and be able to swallow.
Sublingually: These medications dissolve under the tongue and are absorbed into the bloodstream through the
mucous membrane.
By inhalation: Some medications are inhaled (i.e., through mouth, nose or tracheostomy) directly into the
lungs. These are usually medications for respiratory illnesses like asthma. Oxygen, which is inhaled, is also
considered a medication.
By injection: These medications are usually administered by a licensed healthcare professional or by a
caregiver. They can be given straight into the muscle or under the skin, depending on the product.
Topically: Topical medications are given by patch or gel and absorbed by the skin. EMRs must be careful when
encountering a patch on a patient’s skin, as the medication could be absorbed by the responder when trying to
remove the patch.
Intravenously: Medications given intravenously must be administered by a licensed healthcare professional. It is
one of the quickest ways to deliver fluids and medications, as substances are directly transmitted to the veins.
Vaginally: Some creams and suppositories must be given vaginally.
Rectally: Many medications are available in rectal suppository format.
Administering Medications Overview
The “Rights” of Drug Administration
Healthcare personnel who administer medication follow a concept called the “Five Rights.” These help ensure the
medication is being given correctly.
Right patient: If administering a patient’s own medication, you must ensure it truly is the patient’s medication.
Check the label for the correct name. An exception may be if medical direction calls for a medication that is
available but does not belong to the patient. If you are administering a stock medication (one that is kept on
hand until needed), you must understand the action and effects to be sure that it is right for this patient.
Right medication: When reaching for a medication, read the label properly and ensure that the medication in
the bottle is what the label says it is. If in doubt, do not give it. If you are reaching for a stock medication, read
the label as you remove it from your stock, while you remove the medication from the container and again as
you give it to the patient.
Continued on next page
Chapter 14: Medical Emergencies | 357
ENRICHMENT
Basic Pharmacology continued
Right route: Be sure you are administering the drug as prescribed. You may find a prescription for a drug given
by a route with which you are not familiar. When in doubt, double check.
Right dose: Double check the dosage of the drugs you give to patients. Some medications vary considerably in
dose between patients.
Right date: Medications have expiration dates. This is the first day of the month listed, unless otherwise
specified. Do not give expired drugs.
“Administration of Medication” Versus “Assistance with Medication”
Administering a medication means you are physically giving the medication to the patient. In some situations, the
patient is able to take medication alone, such as by a metered dose inhaler (MDI) for a respiratory emergency
(Fig. 14-9, A–B). In this case, you may assist by helping get the medication ready and perhaps holding the inhaler
while the patient presses the pump. Always follow medical direction, regulations and local protocols regarding
your role in administering or assisting patients with medications.
B
Fig. 14-9, A–B: To administer medication, (A) physically give it to the patient. (B) When
assisting, help get the medication ready and assist the patient in taking it, but do not
physically administer it.
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ENRICHMENT
Basic Pharmacology continued
Administration Routes
You may only administer medications by routes you have been licensed or authorized to administer. Generally, for
EMRs, this is by inhalation, orally or sublingually (under the tongue). There may be regulatory exceptions regarding
EMR use of auto-injectors and inhalers. Check local protocols and medical direction to know the medications that
you can deliver.
Reassessment
After administering a drug, you must always assess the effect. You will need to watch for:
Signs and symptoms of the original problem.
Improvement or deterioration in the patient’s condition, including the following:
yy Mental status yy Blood pressure
yy Respiratory status yy Skin color, temperature and condition
yy Pulse rate and quality yy Adverse effects
Documentation
Any time a drug is administered, from a patient’s supply or from your stock, this must be documented thoroughly.
You must document: 1) the reason for administration, 2) drug name, 3) dose, 4) route of administration, 5) time(s)
of administration, 6) any side effects noted, 7) how often administered, and 8) any improvement noted and any
changes in the patient’s status.
Role of Medical Oversight in Medical Administration
Medical direction, the oversight provided by a physician who assumes
responsibility for care, provides direction on what medication to
give, as well as the dose, route of administration and how often it
is given. When receiving medical direction, you must repeat back
the order for confirmation even if you are sure you understood
correctly (Fig. 14-10).
Administering Aspirin
Generic and Trade Names
Aspirin was the original trade name of acetylsalicylic acid (ASA). It has
been marketed under several trade names, such as Ecotrin® Enteric
Coated Aspirin, Excedrin® (which also contains acetaminophen),
Pravigard® and St. Joseph® (Fig. 14-11). In countries where aspirin is
trademarked (owned by Bayer), the term ASA is the generic name.
Indications
Aspirin, or ASA, was originally an analgesic, which is a type of pain
reliever. However, today healthcare providers often use it for its blood-
Fig. 14-10: When receiving medical direction
thinning capability to prevent blood clots. Aspirin is used to provide from a physician, always repeat back the order
relief for mild-to-moderate pain, including headache, menstrual pain, for confirmation.
muscle pain, minor pain of arthritis and toothache. It also reduces fever
and inflammation. Aspirin may also be given for angina and heart attack (see Chapter 13 for more information on
aspirin and heart attacks). A healthcare provider should be consulted before using aspirin to treat or prevent any
cardiovascular condition.
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Basic Pharmacology continued
Contraindications
Patients already on blood thinners should not take
aspirin. It should not be given to patients who have
a known allergy to non-steroidal anti-inflammatory
drugs (NSAIDs). Because of the rare complication
of Reye’s Syndrome, children and adolescents
who show flu-like symptoms or who may have a
viral illness such as chicken pox should not be
given aspirin or products that contain aspirin.
Women who are pregnant or nursing should avoid
taking aspirin unless they are instructed to by their
healthcare provider. Patients with asthma, ulcer
or ulcer symptoms; a recent history of stomach or
intestinal bleeding; or a bleeding disorder, such as
hemophilia, should not take aspirin. Aspirin will not Fig. 14-11: Aspirin.
prevent hemorrhagic strokes and should not be
given to someone showing signs and symptoms
of a stroke.
Actions
Aspirin acts to thin the blood by reducing the platelets’ ability to produce a chemical that helps form blood clots.
To relieve pain, aspirin reduces inflammation at the source, thereby reducing the pain.
Side Effects
The majority of side effects and complications associated with aspirin are due to taking too much of the
medication or from taking it for too long a period. However, side effects can occur with just a few doses in some
people. The most common side effects include heartburn, nausea, vomiting and gastrointestinal bleeding. Some
people are allergic to aspirin, so it is important to watch for an allergic reaction to the medication.
Expiration Date
It is important not to administer aspirin past its expiration date. The effect of the drug decreases if it is too old.
Therefore, by giving a dose of expired aspirin, you will not know how much of the drug the patient will actually
receive. Do not use the aspirin if there is a strong smell of vinegar as this may indicate the medication is expired.
Dosage
The dosages for pain relief and for blood thinning differ. The average adult dose for minor pain and fever relief is
one to two 325-milligram (mg) tablets about every 3 to 4 hours, not to exceed 6 doses a day. For the prevention
of a heart attack, the average adult dose is one 81-mg/low-dose tablet daily. For a patient experiencing chest pain
that suggests a heart attack, the dose is two to four 81-mg low-dose (162 mg to 324 mg) aspirins or one 5-grain
(325-mg) adult aspirin. Have the patient chew the aspirin completely, which speeds up the absorption of the
aspirin into the bloodstream.
A healthcare provider may recommend a stronger dosage of aspirin. Follow local protocols and medical
direction before giving aspirin to treat or prevent cardiovascular conditions.
Administration
Aspirin is most commonly available in oral form; however, it is also available as a rectal suppository and in a liquid
form for children.
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Basic Pharmacology continued
Administering Nitroglycerin
Generic and Trade Names
Nitroglycerin is the generic name for Nitrolingual® Pump Spray, Nitrostat® Tablets and the Minitran® Transdermal
Delivery System. It is also available by the generic name.
Indications
Nitroglycerin is given to patients with angina pectoris, a condition in which the blood vessels in the heart constrict
and do not allow enough blood and oxygen to circulate. This, in turn, causes chest pain.
Contraindications
Nitroglycerin should not be given to patients whose systolic blood pressure is below 90 mmHg. Also, it should
not be given more often than prescribed (usually one to three times is indicated, with 5 minutes spaced between
doses). Do not give nitroglycerin to patients taking sildenafil (Viagra®) or other similar phosphodiesterase type 5
(PDE) inhibitors, as this could lead to life-threatening complications such as a dangerous drop in blood pressure.
Nitroglycerin should not be given to individuals who have severe anemia or a brain injury, hemorrhage or tumor.
Nitroglycerin may be harmful to an unborn baby.
Actions
Nitroglycerin dilates the blood vessels, allowing blood to flow more freely, thus providing more oxygen to the
heart tissue.
Side Effects
Rapid dilation of the blood vessels can cause a severe and sudden headache. The headaches may become
gradually less severe as the individual continues to take nitroglycerin. Other side effects may include dizziness,
flushed skin of the neck and face, light-headedness and worsened angina pain.
Precautions
Nitroglycerin tablets are reactive to light and should be stored in a dry area in a dark-colored container to maintain
their potency.
Expiration Date
Check expiration dates for all types of nitroglycerin. Failure to do so may result in administering medication that is
no longer active, thereby delaying proper treatment.
Dosage and Administration
Nitroglycerin sprays and tablets are usually administered as one spray or pill under the tongue, and can be taken
by the patient up to three times, with 5 minutes between each dose, if there is no change in their condition.
Have the patient sit while taking nitroglycerin as it can cause dizziness or fainting. Nitroglycerin is a very potent
medication. It should never be given without a healthcare provider’s order.
Administering Oral Glucose
Action
Oral glucose acts by increasing the amount of blood glucose (sugar) in the bloodstream.
Continued on next page
Chapter 14: Medical Emergencies | 361
ENRICHMENT
Basic Pharmacology continued
Indication
Oral glucose is administered to patients who have diabetes
and whose blood sugar level has dropped below tolerable
levels (Fig. 14-12). At this point, the insulin has no glucose
to metabolize.
Contraindications
Oral glucose should not be given to patients with diabetes
whose blood sugar is within normal range or above normal
range. It also should not be given to patients who are
unresponsive and unable to follow instructions to swallow safely.
Side Effects
Side effects may include nausea, heartburn and bloating.
Dose
The product comes as glucose tablets that are 4 to 5 Fig. 14-12: Administer oral glucose to patients with
grams each. diabetes whose blood sugar has dropped below
tolerable levels. Photo: courtesy of the Canadian
Red Cross.
Route
Oral glucose is given by mouth.
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Blood Glucose Monitoring
Blood glucose monitoring refers to the measurement of blood sugar (glucose). Everyone’s blood has some
glucose in it because our bodies turn the food we eat into this form of sugar, which is transported throughout the
body. Insulin, a hormone from the pancreas, helps get the glucose into our cells to be used for energy. Without
insulin (e.g., in patients with type 2 diabetes), the BGL rises, leading to long-term health complications if untreated.
In patients taking insulin, low blood glucose creates critical health risks and must be treated immediately.
Testing BGL with a Glucometer
Patients with diabetes check their BGLs regularly, often using a
portable device called a glucometer (Fig. 14-13). Monitoring can be
done at any time using a glucometer. The test requires a drop of blood
on a test strip containing a chemical substance, which is then inserted
into the glucometer. The drop of blood is obtained by piercing the skin
of a finger pad with a sharp sterile device such as a lancet or needle.
Using a Glucometer
Ensure your hands are clean and the glucometer is in good
working order.
Wipe the pad of the patient’s finger with an alcohol swab, or clean
the finger with soap and water. Allow the skin to dry completely.
Using a sterile lancet, prick the pad of the finger and allow a blood
drop to form.
Collect a drop of blood on the test strip. Fig. 14-13: A glucometer.
Insert the test strip into the glucometer, read and record the
numerical result.
Read the owner’s manual for the glucometer carefully, and only use the test strips specified for that meter.
Otherwise, the device may fail to give results or may generate an inaccurate reading.
What the Numbers Mean
Although the result may vary depending upon the patient and the testing device used, it is generally accepted that
the normal range before meals is 90–130 milligrams per deciliter (mg/dL) and after meals is less than 180 mg/dL.
Low blood glucose, also called hypoglycemia, occurs when the BGL drops below 70 mg/dL. This requires
immediate treatment. If the patient is conscious, provide 15 to 20 grams of glucose (4 to 5 glucose tablets,
depending on the manufacturer) and recheck the blood glucose level after 10 to 15 minutes. If the patient is
unconscious or unable to swallow, seek advanced life support immediately.
Pediatric Considerations
Blood Glucose Monitoring
The American Diabetes Association (ADA) warns of the problems that could be caused by blood sugar
levels that are too low in children under 7 years of age. Young children require higher blood sugar levels than
do adults for brain development. Also, children’s food intake and activity level tend to vary quite a bit from
day to day, causing blood sugar levels to fluctuate, so they are more at risk of blood sugar levels falling too
low. Further, it may be difficult for very young children to report and describe symptoms of low blood sugar,
so this may go undetected.
Also keep in mind that, before reaching puberty, children seem to be at lower risk of the complications of
diabetes even when blood sugar levels are abnormally high. The ADA recommends aiming for the safe adult
range of BGL only when children grow older and can recognize the early symptoms of BGLs dropping too low.
Chapter 14: Medical Emergencies | 363
15 You Are the Emergency Medical Responder
POISONING
Your emergency medical services (EMS) unit is summoned to a residence on a report
of an unconscious person. When you arrive and size up the scene, you discover an
older couple. The wife is distraught and says that her husband had been drinking
alcoholic beverages heavily earlier in the day. Shortly after taking his prescribed
Valium®, she says he became drowsy and incoherent, and then collapsed. Unable
to get him to respond, she called 9-1-1. On assessing the patient, you find that he is
unconscious, his breathing is shallow and slow, his heart rate is slow and his pulse is
weak. How would you respond?
KEY TERMS
Absorbed poison: A poison that enters the body Injected poison: A poison that enters the body
through the skin. through a bite, sting or syringe.
Addiction: The compulsive need to use a substance; Naloxone: A medication used to reverse the effects
stopping use would cause the user to suffer of an opioid overdose.
mental, physical and emotional distress.
Opioid narcotics: Drugs often derived from opium
Anabolic steroid: A drug sometimes used or opium-like compounds; used to reduce pain
by athletes to enhance performance and and can alter mood and behavior; also known
increase muscle mass; also has medical use in as opioids.
stimulating weight gain for people unable to gain
weight naturally. Overdose: The use of an excessive amount of a
substance, resulting in adverse reactions ranging
Antidote: A substance that counteracts and from mania (mental and physical hyperactivity) and
neutralizes the effects of a poison. hysteria, to coma and death.
Antihistamine: A type of drug taken to treat Poison: Any substance that can cause injury, illness
allergic reactions. or death when introduced into the body, especially
by chemical means.
Anti-inflammatory drug: A type of drug taken to
reduce inflammation or swelling. Poison Control Center (PCC): A specialized health
center that provides information on poisons and
Cannabis products: Substances such as marijuana suspected poisoning emergencies.
and hashish that are derived from the Cannabis
sativa plant; can produce feelings of elation, Stimulant: A substance that affects the central
distorted perceptions of time and space, and nervous system and speeds up physical and
impaired motor coordination and judgment. mental activity.
Carbon monoxide (CO): An odorless, colorless, Substance abuse: The deliberate, persistent,
toxic gas produced as a byproduct of combustion. excessive use of a substance without regard to
health concerns or accepted medical practices.
Dependency: The desire or need to continually use
a substance. Substance misuse: The use of a substance for
unintended purposes or for intended purposes but
Depressant: A substance that affects the central in improper amounts or doses.
nervous system and slows down physical and
mental activity; can be used to treat anxiety, Synergistic effect: The outcome created when two
tension and high blood pressure. or more drugs are combined; the effects of each
may enhance those of the other.
Designer drugs: Potent and illegal street drugs
formed from a medicinal substance whose drug Tolerance: A condition in which the effects of a
composition has been modified (designed). substance on the body decrease as a result of
continued use.
Drug: Any substance, other than food, intended to
affect the functions of the body. Toxicology: The study of the adverse effects
of chemical, physical or biological agents on
Hallucinogen: A substance that affects mood, the body.
sensation, thinking, emotion and self-awareness;
alters perceptions of time and space; and Toxin: A poisonous substance produced by
produces hallucinations or delusions. microorganisms that can cause certain diseases
but is also capable of inducing neutralizing
Ingested poison: A poison that is swallowed. antibodies or antitoxins.
Inhalant: A substance, such as a medication, that a Withdrawal: The condition of mental and physical
person inhales to counteract or prevent a specific discomfort produced when a person stops using
condition; also a substance inhaled to produce or abusing a substance to which the person is
mood-altering effects. addicted.
Inhaled poison: A poison breathed into the lungs.
Chapter 15: Poisoning | 365
LEARNING OBJECTIVES
After reading this chapter, and completing the class • Have a basic understanding of drug interactions.
activities, you will have the information needed to: • Define substance abuse and misuse.
• List the four ways poisons enter the body. • Identify factors related to substance abuse and
• Identify the signs and symptoms of poisoning. misuse, and list prevention strategies.
• Describe general care guidelines for a poisoning • List information resources available to responders
emergency. and the general public from Poison Control
Centers (PCCs).
• Describe specific care for different types of
poisoning emergencies.
INTRODUCTION poisoning can be self-inflicted—in the case of a
suicide—or caused by another person intending to
A poison is any substance that causes injury,
harm or kill the person. The severity of a poisoning
illness or death if it enters the body. A person can
depends on the type and amount of the substance;
be poisoned by ingesting or swallowing poison,
the time that has elapsed since the poison entered
breathing it, absorbing it through the skin or by
the body; and the patient’s age, size (build), weight
injecting it into the body.
and medical conditions. Many substances that are
In 2014, Poison Control Centers (PCCs) received not poisonous in small amounts are poisonous in
more than 2.1 million calls from people who had larger amounts. Medications (prescription or over-
come into contact with a poison. Over 91 percent the-counter [OTC]) can be poisonous if they are
of these poisonings took place in the home and not taken as prescribed or directed.
48 percent involved children under age 6. Poisoning
In a manufacturing facility, Safety Data Sheets
deaths in children under age 6 represented about
(SDSs) are required on site for every product/
1.4 percent of the total deaths from poisoning,
chemical in use. Formerly called Material Safety
while the 20- to 59-year-old age group represented
Data Sheets (MSDSs), SDSs consist of 16
about 66 percent of all deaths from poisoning.
standardized sections, arranged in a strict
Child-resistant packaging for medications and
order and based on the Globally Harmonized
preventive actions by parents and others who
System (GHS) of Classification and Labelling of
care for children have resulted in a decline in child
Chemicals. In the case of a poisoning, the SDS
poisonings. At the same time, there has been an
should go with the patient to the hospital, as it will
increase in adult poisoning deaths, which is linked
give emergency medical services (EMS) personnel
to an increase in both suicides and drug-related
and hospital staff more detailed information as to
poisonings.
the treatment of the exposed worker.
A toxin is a poisonous substance produced by
In this chapter, you will learn about the four ways
microorganisms that can cause certain diseases
in which poisons can enter the body—ingestion,
but is also capable of inducing neutralizing
inhalation, absorption and injection. You will also
antibodies or antitoxins. Toxicology is the
learn about the types of poisons that fall into each
scientific study of poisons and antidotes and
of these categories, how to recognize the signs
how they affect people. Some poisons—including
and symptoms of each type of poisoning and how
many medications—are not deadly or harmful in
to provide care for each. You will learn about how
small doses, but become dangerous if taken into
and when to contact the national Poison Help line
the body in larger amounts. When a dangerously
or summon more advanced medical personnel.
large amount of a drug is taken, this is called
This chapter also provides an overview of
an overdose.
substance abuse and substance misuse: the types
Poisons can be solid, liquid, spray or fumes (gases of substances that can be abused or misused,
and vapors). A solid or liquid substance may turn how they enter the body and how to provide care
into a gas if heated or under pressure. Poisonings for someone who has been exposed to, inhaled or
can be accidental or intentional, and intentional ingested a poisonous substance.
366 | Emergency Medical Response
POISON CONTROL CENTERS HOW POISON ENTERS
Poison Control Centers (PCCs) are specialized THE BODY
health centers that provide information on poisons Poisons are generally placed in four categories,
and suspected poisoning emergencies. A network based on how they enter the body: ingestion,
of PCCs exists throughout the United States. inhalation, absorption and injection.
Medical professionals in these centers have
access to information about virtually all poisonous
substances and can tell you how to care for Ingested Poison
someone who has been poisoned. The American Types of Ingested Poisons
Association of Poison Control Centers operates a Ingested poisons are poisons that are
24-hour national Poison Help line, which is staffed swallowed and include items such as foods (e.g.,
by pharmacists, physicians, nurses and toxicology certain mushrooms and shellfish), drugs (e.g.,
specialists and can be reached at 800-222-1222. alcohol), medications (e.g., aspirin) and household
items (e.g., cleaning products, pesticides and even
PCCs answer over 2 million calls about poisoning
household plants).
each year. Since many poisonings can be treated
without the help of EMS personnel, PCCs help Young children tend to put almost everything
prevent overburdening of the EMS system and in their mouths, so they are at a higher risk of
hospitals. Approximately 70 percent of poison ingesting poisons, including household cleaners
exposure cases can be managed over the phone and medications (Fig. 15-1). Older adults may make
without a referral to a healthcare facility. For more medication errors if they are prone to forgetfulness
information, visit the American Association of or have difficulty reading the small print on
Poison Control Centers website at aapcc.org. medicine container labels.
Call for more advanced medical personnel if
you are unsure about what to do, you are unsure
about the severity of the problem or if it is a life-
threatening condition. Otherwise, call the national
Poison Help line for assistance.
In general, call for more advanced medical
personnel if the patient:
Is unconscious, confused or has an altered
mental status.
Has trouble breathing or is breathing irregularly.
Has persistent chest pain or pressure.
Has pressure or pain in the abdomen that does
not go away.
Is vomiting blood or passing blood.
Has a seizure, severe headache or slurred
speech. Fig. 15-1: Young children are at a higher risk of ingesting
poisons because they tend to put almost everything into their
Acts violently. mouths.
CRITICAL A poison is any substance that causes injury, illness or death if it enters the body. A
FACTS person can be poisoned by ingesting or swallowing poison, breathing it, absorbing
it through the skin or by injecting it into the body.
A toxin is a poisonous substance produced by microorganisms that can cause
certain diseases but is also capable of inducing neutralizing antibodies or antitoxins.
PCCs are specialized healthcare centers that provide information on poisons and
suspected poisoning emergencies.
Chapter 15: Poisoning | 367
CRITICAL The national Poison Help line—which is staffed by pharmacists, physicians, nurses
FACTS and toxicology specialists—can be reached at 800-222-1222.
Call for more advanced medical personnel if you are unsure about what to do, you
are unsure about the severity of the problem or if it is a life-threatening condition.
Otherwise, call the national Poison Help line for assistance. Several scenarios
warrant calling for more advanced medical personnel, including unconsciousness,
breathing problems, chest or abdominal pain or pressure, vomiting blood or passing
blood, seizures or violent behavior.
Poisons are generally placed in four categories, based on how they enter the body:
ingestion, inhalation, absorption and injection.
In 2011, the Centers for Disease Control and a patient has been poisoned, seek immediate
Prevention (CDC) estimated that 48 million people medical assistance. Signs and symptoms to look
contract foodborne illnesses each year in the for include:
United States. Approximately 128,000 people
are hospitalized and more than 3000 die from Nausea, vomiting or diarrhea.
foodborne illness. Chest or abdominal pain.
Two of the most common categories of food Difficulty breathing.
poisoning are bacterial and chemical food Sweating.
poisoning. Bacterial food poisoning typically occurs Changes in level of consciousness (LOC).
when bacteria grow on food that is allowed to stand Seizures.
at room temperature after being cooked, which Headache or dizziness.
releases toxins into the food. Foods most likely to
cause bacterial food poisoning are meats, fish and
Weakness.
dairy or dairy-based foods. Chemical food poisoning Irregular pupil size.
typically occurs when foods with high acid content, Double vision.
such as fruit juices or sauerkraut, are stored in Abnormal skin color.
containers lined with zinc, cadmium or copper or Burn injuries around the lips or tongue or on the
in enameled metal pans. Another primary source of skin around the mouth.
chemical food poisoning is lead, which is sometimes
found in older pipes that supply drinking and The symptoms of food poisoning, which can begin
cooking water. Mercury, a heavy metal, can also be between 1 and 48 hours after eating contaminated
a source of food poisoning. Fish and shellfish, such food, include nausea, vomiting, abdominal pain,
as shark and swordfish, are a major dietary source diarrhea, fever and dehydration. Severe cases
of mercury. However, mercury can also come from of food poisoning can result in shock or death,
other dietary items and contact with mercury metal particularly in children, older adults and those with
or its compounds (e.g., a mercury thermometer). an impaired immune system.
Two of the most common causes of food poisoning
are salmonella bacteria (most often found in poultry Providing Care for Ingested Poisons
and raw eggs) and Escherichia coli (E. coli) (most If the patient is fully conscious and alert,
often found in raw meats and unpasteurized milk immediately call the national Poison Help line
and juices). The most deadly type of food poisoning and follow the directions given. DO NOT give the
is botulism, which is caused by a bacterial toxin patient anything to eat or drink unless you are told
usually associated with home canning. to do so. If you do not know what the poison was
and the patient vomits, save some of the vomit. The
hospital may analyze it later to identify the poison.
Signs and Symptoms of
Ingested Poisons In some cases of ingested poisoning, the PCC
A person who has ingested poison generally looks may instruct you to induce vomiting. Vomiting
ill and displays symptoms common to other sudden may prevent the poison from moving to the small
illnesses. If you have even a slight suspicion that intestine, where most absorption takes place.
368 | Emergency Medical Response
However, vomiting should be induced only if indicates a lack of oxygen, may signal CO
advised by a medical professional. The PCC or a poisoning. Other signs and symptoms of inhaled
medical professional will advise you exactly how to poisons include:
induce vomiting. In some instances, vomiting should
not be induced. This includes when the patient: Difficulty breathing or respiratory rate faster or
slower than normal.
Is unconscious. Chest pain or tightness.
Is having a seizure. Burning in the nose or eyes.
Is pregnant (in the last trimester). Nausea or vomiting.
Has ingested a corrosive substance (such as Cyanosis.
drain or oven cleaner) or a petroleum product
(such as kerosene or gasoline).
Headaches, dizziness, confusion.
Coughing, possibly with excessive secretions.
Is known to have heart disease.
Seizures.
Examples of such poisons are caustic or corrosive Altered mental status with possible
chemicals, such as acids, that can eat away or unresponsiveness.
destroy tissues. Vomiting these corrosives could
burn the esophagus, throat and mouth. Diluting Providing Care for Inhaled Poisons
the corrosive substance decreases the potential When providing care to a patient who may
for burning and damaging tissues. DO NOT give have inhaled poison, follow appropriate safety
the patient anything to eat or drink unless medical precautions to ensure that you do not also become
professionals tell you to do so. poisoned. Toxic fumes may or may not have an
Some people who have contracted food poisoning odor. If you notice clues at an emergency scene
may require antibiotic or antitoxin therapy. that lead you to suspect toxic fumes are present—
Fortunately, most cases of food poisoning can be such as a strong smell of fuel (sulfur or skunk
prevented by proper food handling and preparation. smell) or a hissing sound (which could indicate
gas escaping from a pipe or valve)—you may not
be able to reach the patient without risking your
Inhaled Poison own safety. In cases like this, call for specialized
services instead of entering the scene. Let EMS
Types of Inhaled Poisons professionals know what you discovered, and only
Poisoning by inhalation occurs when a person enter the scene if you are told it is safe to do so or
breathes in poisonous gases or fumes. A commonly if you are trained to do so.
inhaled poison is carbon monoxide (CO),
which is present in substances such as car exhaust All patients who have inhaled poison need
and tobacco smoke. CO can also be produced supplemental oxygen as soon as possible based
by fires (gas and natural), defective gas cooking on local protocols. If you can remove the patient
equipment, defective gas furnaces, gas water from the source of the poison without endangering
heaters and kerosene heaters. CO, which is yourself, then do so. You can help a conscious
colorless, odorless and tasteless, is highly lethal patient by getting them to fresh air and then calling
and can cause death after only a few minutes for more advanced care personnel. If you find
of exposure. an unconscious patient, remove the patient from
the scene if it is safe to do so, and call for more
Other common inhaled poisons include carbon advanced medical personnel. Then provide care for
dioxide, chlorine gas, ammonia, sulfur dioxide, any life-threatening conditions.
nitrous oxide, chloroform, dry cleaning solvents, fire
extinguisher gases, industrial gases and hydrogen
sulfide. Paints and solvents produce fumes that Absorbed Poison
some people deliberately inhale to get high, as do Types of Absorbed Poisons
certain drugs, such as crack cocaine.
An absorbed poison enters through the skin
or the mucous membranes in the eyes, nose and
Signs and Symptoms mouth. Absorbed poisons come from plants, as
of Inhaled Poisons well as from chemicals and medications. Millions
Look for paint or solvent around the mouth and of people each year suffer irritating effects after
nose of the patient if you suspect deliberate touching or brushing against poisonous plants
inhalation. A pale or bluish skin color, which such as poison ivy, poison oak and poison sumac
Chapter 15: Poisoning | 369
(Fig. 15-2, A–C). Other poisons absorbed through medications or transdermal patches, can also be
the skin include dry and wet chemicals, such as absorbed through the skin.
those used in flea collars for dogs and in yard and
garden maintenance products, which may also Signs and Symptoms
burn the skin. Some medications, such as topical of Absorbed Poisons
Some of the signs and symptoms of absorbed
poisons include:
Traces of the liquid, powder or chemical on the
patient’s skin.
Skin that looks burned, irritated, red or swollen.
Blisters that may ooze fluid, or a rash.
Itchy skin.
Providing Care for Absorbed Poisons
To care for a patient who has come into contact
with a poisonous plant, follow standard precautions
and then immediately rinse the affected area
thoroughly with water. Using soap cannot hurt, but
A
soap may not do much to remove the poisonous
plant oil that causes the allergic reaction. Before
washing the affected area, you may need to
have the patient remove any jewelry. This is only
necessary if the jewelry is contaminated or if it
constricts circulation due to swelling. Rinse the
affected areas for at least 20 minutes, using a
shower or garden hose if possible. If a rash or
weeping lesion (an oozing sore) develops, advise
the patient to seek the opinion of a pharmacist
or healthcare provider about possible treatment.
Medicated lotions may help soothe the area.
Antihistamines may also help dry up the
lesions and help stop or reduce itching. OTC
antihistamines are available at pharmacies and
grocery stores and should be used according
to the manufacturer’s directions. If the condition
worsens or if large areas of the body or the face
B
are affected, the patient should see a healthcare
provider, who may administer anti-inflammatory
drugs, such as corticosteroids, or other
medications to relieve discomfort.
If the poisoning involves dry chemicals, brush off
the chemicals using gloved hands before flushing
with tap water (under pressure). Take care not to
inhale any of the chemical or get any of the dry
chemical on you, in your eyes, or in the eyes of
the patient or any bystanders. Many dry chemicals
are activated by contact with water. However, if
continuous running water is available, it will flush
the chemical from the skin before the activated
C
chemical can do harm. If wet chemicals contact the
skin, flush the area continuously with large amounts
Fig. 15-2, A–C: (A) Poison ivy; photo: Shutterstock.com/
Tim Mainiero; (B) poison oak; photo: Shutterstock.com/Dwight of cool, running water. Running water reduces the
Smith; (C) poison sumac; photo: courtesy of www.poison-ivy.org. threat to you and quickly and easily removes the
370 | Emergency Medical Response
substance from the patient. Continue flushing for life, animals and snakes, or as drugs or misused
at least 20 minutes or until more advanced medical medications injected with a hypodermic needle.
personnel arrive (Fig. 15-3). Insect and animal bites and stings are among the
most common sources of injected poisons. See
If poison has been in contact with the patient’s eye Chapter 16 for more information about the signs of
or eyes, irrigate the affected eye or eyes, from the these bites and how to provide care for them.
nose side of the eye, not directly onto the middle of
the cornea of the eye, with clean water for at least
15 minutes. If only one eye is affected, make sure Signs and Symptoms
you do not let the water run into the unaffected eye. of Injected Poisons
To ensure this, tilt the head so the water runs from Some of the signs and symptoms of injected
the nose side of the eye downward to the ear side poisons include:
(Fig. 15-4). Continue care while transporting the
patient if you can. Bite or sting mark at the point of entry.
A stinger, tentacle or venom sac in or near the
entry site.
Injected Poison
Redness, pain, tenderness or swelling around
Types of Injected Poisons the entry site.
Injected poisons enter the body through the Signs of allergic reaction, including localized
bites or stings of certain insects, spiders, marine itching, hives or rash.
Signs of a severe allergic reaction (anaphylaxis),
including weakness, nausea, dizziness, swelling
of the throat or tongue, constricted airway or
difficulty breathing.
Providing Care for Injected Poisons
Size up the scene and follow standard precautions.
Perform a primary assessment and care for
conditions found. Applying a cold pack can
reduce pain and swelling of the bitten area. To
provide specific care for certain bites and stings,
see Chapter 16. Call for more advanced medical
personnel if there are signs and symptoms of
anaphylaxis, and assist the patient with their
prescribed epinephrine auto-injector if protocols
allow and you are trained to do so.
Fig. 15-3: If the poisoning involves chemicals, flush the
exposed area continuously with cool, running water for at least
20 minutes. SUBSTANCE ABUSE
AND MISUSE
A drug is any substance, other than food,
intended to affect body functions. A drug given
therapeutically to prevent or treat a disease or
otherwise enhance mental or physical well-being is
a medication. Substance abuse is the deliberate,
persistent and excessive use of a substance without
regard to health concerns or accepted medical
practices. Substance misuse refers to the use
of a substance for unintended purposes or for
appropriate purposes but in improper amounts
or doses. Because of the publicity they receive,
we tend to think of illegal (also known as illicit or
controlled) drugs when we hear of substance
Fig. 15-4: Flush an eye that has come in contact with poison
with clean water from the nose side toward the ear side, being abuse. However, legal substances (also called licit
sure not to contaminate the unaffected eye. or noncontrolled substances) are among those most
Chapter 15: Poisoning | 371
CRITICAL Substance abuse is the deliberate, persistent and excessive use of a substance
FACTS without regard to health concerns or accepted medical practices. Substance
misuse refers to the use of a substance for unintended purposes or for appropriate
purposes but in improper amounts or doses.
often abused or misused. These include nicotine substance to which they are addicted. Stopping
(found in tobacco products), alcohol, and OTC the use of a substance may occur as a deliberate
medications such as sleeping pills and diet pills. decision or because the person is unable to
obtain the specific drug. Withdrawal from certain
In the United States, substance abuse costs substances, such as alcohol, can cause severe
tens of billions of dollars each year in medical mental and physical distress. Because withdrawal
care, insurance and lost productivity. Even may become a serious medical condition, medical
more important, however, are the lives lost or professionals often oversee the process.
permanently impaired each year from injuries or
medical emergencies related to substance abuse When someone continually uses a substance, its
or misuse. In 2014, drug overdose resulted in a effects on the body often decrease—a condition
total of 47,055 deaths in the United States. Drug called tolerance. The person then has to increase
overdose is the leading cause of accidental death the amount and frequency of use to obtain the
in the country, resulting in even more deaths than desired effect.
motor-vehicle collisions. Experts estimate that as
An overdose occurs when someone uses an
many as two-thirds of all homicides and serious
excessive amount of a substance. Symptoms
assaults occurring annually involve alcohol. Other
can vary but may range from mania and hysteria
problems directly or indirectly related to substance
to coma and death. Specific reactions include
abuse include dropping out of school, adolescent
changes in blood pressure and heartbeat,
pregnancy, suicide, involvement in violent crime and
sweating, vomiting and liver failure. An overdose
transmission of the human immunodeficiency virus
may occur unintentionally if a person takes too
(HIV).
much medication at one time. For example, an
If you think someone has taken an overdose or older adult might forget about taking one dose of
has another substance abuse problem requiring a medication and thus take an additional dose. An
medical attention or other professional help, size overdose may also be intentional, as in a suicide
up the scene for safety, then check the person. If attempt. Sometimes the patient takes a sufficiently
you have good reason to suspect a substance was high dose of a substance to be certain to cause
taken, call the national Poison Help line and follow death. In other cases, the patient may take enough
the directions given. of a substance to need medical attention but not
enough to cause death.
Forms of Substance Abuse
and Misuse Abused and Misused Substances
Many substances that are abused or misused Substances are categorized according to
are legal. Other substances are legal only when their effects on the body (Table 15-1). The six
prescribed by a healthcare provider. Some are illegal major categories are stimulants, hallucinogens,
only for those under a certain age, such as alcohol. depressants, opioid narcotics, inhalants and
Any drug can cause dependency, or the desire cannabis products. The category to which a
to continually use the substance. Those with drug- substance belongs depends mostly on the effects
dependency issues feel that they need the drug it has on the central nervous system or the way the
to function normally. Those with a compulsive substance is taken. Some substances depress
need for a substance and those who would suffer the nervous system, whereas others speed up its
mental, physical and emotional distress if they activity. Some are not easily categorized because
stopped taking it are said to have an addiction to they have various effects or may be taken in a
that substance. variety of ways. A heightened or exaggerated effect
may be produced when two or more substances
The term withdrawal describes the condition are used at the same time. This is called a
produced when people stop using or abusing a synergistic effect, which can be deadly.
372 | Emergency Medical Response
Table 15-1:
Commonly Abused and Misused Substances
CATEGORY SUBSTANCES COMMON NAMES POSSIBLE EFFECTS
Stimulants Caffeine Coke, snow, nose Increase mental and physical activity
Cocaine, crack cocaine candy, blow, flake, Produce temporary feelings of alertness
Amphetamines Big C, lady, white, Prevent fatigue
Methamphetamine snowbirds, powder,
Suppress appetite
Dextroamphetamine foot, crack, rock,
cookies, freebase
Nicotine
rocks, speed, uppers,
Ephedra ups, bennies, black
OTC diet aids beauties, crystal, meth,
Asthma treatments crank, crystal meth,
Decongestants ice, ma huang
Hallucinogens Diethyltryptamine Psychedelics, acid, Cause changes in mood, sensation,
(DET) white lightning, sugar thought, emotion and self-awareness
Dimethyltryptamine cubes, angel dust, Alter perceptions of time and space
(DMT) hog, loveboat, peyote, Can produce profound depression,
LSD buttons, cactus, mesc, tension and anxiety, as well as visual,
mushrooms, magic auditory or tactile hallucinations
PCP
mushrooms, ’shrooms,
Mescaline STP (serenity,
Peyote tranquility and peace)
Psilocybin
4-Methyl-2,5-
dimethoxyamphetamine
(DOM)
Depressants Barbiturates Valium®, Xanax®, Decrease mental and physical activity
Benzodiazepines downers, barbs, Alter level of consciousness
Narcotics goofballs, yellow Relieve anxiety and pain
jackets, reds,
Alcohol Promote sleep
Quaaludes, ludes,
Antihistamines club drugs, date Depress respiration
Sedatives rape drugs, special Relax muscles
Tranquilizers K, vitamin K, roofies, Impair coordination and judgment
OTC sleep aids roach, rope, liquid
Ketamine ecstasy, soap, vita-G
Rohypnol®
GHB
Opioid Morphine Pectoral syrup, Relieve pain
narcotics Codeine Oxycontin®, Produce stupor or euphoria
Heroin Percodan®, Percocet®, Can cause coma or death
smack, horse, mud,
Oxycodone Highly addictive
brown sugar, junk,
Methadone black tar, big H
Opium
(Continued)
Chapter 15: Poisoning | 373
Table 15-1: continued
CATEGORY SUBSTANCES COMMON NAMES POSSIBLE EFFECTS
Inhalants Medical anesthetics Laughing gas, Alter mood
Lacquer and varnish whippets, glue, lighter Produce a partial or complete loss of
thinners fluid, nail polish feeling
Propane remover, gasoline, Produce effects similar to drunkenness,
kerosene, aerosol such as slurred speech, lack of inhibitions
Toluene
sprays and impaired motor coordination
Butane
Acetone Can cause damage to the heart, lungs,
brain and liver
Fuel
Propellants
Cannabis Hashish Hash, pot, grass, Produce feelings of elation
products Marijuana weed, reefer, ganja, Increase appetite
THC mary jane, dope K2, Distort perceptions of time and space
spice
Synthetic cannabinoids Impair motor coordination and judgment
Irritate throat
Redden eyes
Increase heart rate
Cause dizziness
Other MDMA Ecstasy, E, XTC, Elevate blood pressure
Adam, essence Produce euphoria or erratic mood swings,
rapid heartbeat, profuse sweating,
agitation and sensory distortions
Anabolic steroids Androgens, hormones, Enhance physical performance
juice, roids, vitamins Increase muscle mass
Stimulate appetite and weight gain
Chronic use can cause sterility,
disruption of normal growth, liver cancer,
personality changes and aggressive
behavior
Aspirin Relieves minor pain
Reduces fever
Impairs normal blood clotting
Can cause inflammation of the stomach
and small intestine
Laxatives and emetics Ipecac syrup, Senna Relieve constipation or induce vomiting
Can cause dehydration, uncontrolled
diarrhea and other serious health problems
Decongestant nasal Relieve congestion and swelling of nasal
sprays passages
Chronic use can cause nosebleeds and
changes in the lining of the nose, making
it difficult to breathe without sprays
374 | Emergency Medical Response
Stimulants Other stimulants used for medical purposes are
Stimulants are drugs that affect the central asthma medications or decongestants that can be
nervous system by speeding up physical and taken by mouth or inhaled.
mental activity. They produce temporary feelings of
alertness and prevent fatigue. They are sometimes Hallucinogens
used for weight reduction because they also Hallucinogens, also known as psychedelics,
suppress appetite, or to enhance exercise routines are substances that cause changes in mood,
because they provide bursts of energy. sensation, thought, emotion and self-awareness.
They alter one’s perception of time and space and
Many stimulants are ingested as pills, but some produce visual, auditory and tactile (relating to the
can be absorbed or inhaled. Amphetamine, sense of touch) delusions.
dextroamphetamine and methamphetamine
are stimulants. On the street, an extremely Among the most widely abused hallucinogens are
addictive, dangerous and smokable form of lysergic acid diethylamide (LSD), called “acid”;
methamphetamine is often called “crystal meth” psilocybin, called “mushrooms”; phencyclidine
or “ice.” The street term “speed” usually refers to (PCP), called “angel dust”; mescaline, called
amphetamine or methamphetamine. Other street “peyote,” “buttons” or “mesc”; and ketamine, called
terms for amphetamines are “uppers,” “bennies,” “special K” or “vitamin K.” These substances are
“black beauties,” “crystal,” “meth” and “crank.” usually ingested, but PCP is also often inhaled.
Cocaine is one of the most publicized and powerful Hallucinogens often have physical effects similar
stimulants. It can be taken into the body in different to stimulants but are classified differently because
ways. The most common way is sniffing it in powder of the other effects they produce. Hallucinogens
form, known as “snorting.” In this method, the drug sometimes cause what is called a “bad trip.” A
is absorbed into the blood through capillaries in bad trip can involve intense fear, panic, paranoid
the nose. Street names for cocaine include “coke,” delusions, vivid hallucinations, profound depression,
“snow,” “blow,” “flake,” “foot” and “nose candy.” tension and anxiety. The person may be irrational and
A potent and smokable form of cocaine is called feel threatened by any attempt others make to help.
“crack.” The vapors of crack are inhaled into the
lungs, reach the brain and cause almost immediate Depressants
effects. Crack is highly addictive. Street names for Depressants are substances that affect the
crack include “rock” and “freebase rocks.” central nervous system by slowing down physical
Ephedra, also known as “ma huang,” is a stimulant and mental activity. Depressants are commonly
plant that has been used in China and India for over used for medical purposes. All depressants alter
5000 years. Until it was banned by the Food and consciousness to some degree. They relieve
Drug Administration (FDA) in 2004, it was a common anxiety, promote sleep, depress respiration, relieve
ingredient in dietary supplements sold in the United pain, relax muscles, and impair coordination and
States. The dried stems and leaves are put into judgment. Like other substances, the larger the dose
capsules, tablets, extracts, tinctures or teas, and then or the stronger the substance, the greater its effects.
ingested. It is used for weight loss, increased energy
Common depressants are barbiturates,
and to enhance athletic performance.
benzodiazepines (e.g., Valium®, Xanax®), narcotics
The FDA banned ephedra because it appears and alcohol. Most depressants are ingested or
to have little effectiveness, along with some injected. Their street names include “downers,”
substantial health risks. Taking ephedra can cause “barbs,” “goofballs,” “yellow jackets,” “reds” or
nausea, anxiety, headache, psychosis, kidney “ludes.”
stones, tremors, dry mouth, irregular heart rhythms,
Two depressants that have gained popularity as
high blood pressure, restlessness and sleep
club drugs (so called because they are used at
problems. It has been found to increase the risk of
all-night dance parties) include Rohypnol® (also
heart problems, a stroke and even death.
referred to as “roofies,” “roach” or “rope”), a
Interestingly, the most common stimulants in benzodiazepine that is illegal in the United States;
America are legal. Leading the list is caffeine, and gamma-hydroxybutyrate (GHB) (also referred to
present in coffee, tea, high-energy drinks, many as “liquid ecstasy,” “soap” or “vita-G”), an illicit drug
kinds of sodas, chocolate, diet pills and pills that has depressant, euphoric and body-building
used to combat fatigue. The next most common effects. These drugs are particularly dangerous
stimulant is nicotine, found in tobacco products. because they are often used in combination or with
Chapter 15: Poisoning | 375
other depressants (including alcohol), which can coma or death. The most common natural opioid
have deadly effects, and because they are the “date narcotics are morphine and codeine. Most other
rape drugs” of choice. As such, they are sometimes opioid narcotics, including heroin, are synthetic
slipped to others unnoticed. or semi-synthetic. Oxycodone, also known by
the trade names Oxycontin® or Percocet®, is a
Alcohol is the most widely used and abused powerful semi-synthetic opioid narcotic that has
substance in the United States. In small amounts, its recently gained popularity as a street drug.
effects may be fairly mild. In higher doses, its effects
can be toxic. Alcohol is like other depressants in its Opioid narcotic abuse has become a major
effects and risks for overdose. Frequent drinkers health concern in the United States and throughout
may become dependent on the effects of alcohol the world. Of the 47,055 deaths in the United
and increasingly tolerant of those effects. Alcohol States in 2014 attributed to drug overdose,
poisoning occurs when a large amount of alcohol is 28,647 (61 percent) involved some type of opioid
consumed in a short period of time and can result in narcotic.
unconsciousness and, if untreated, death.
While there are many factors in treating this
Drinking alcohol in large or frequent amounts can epidemic, including increased awareness
have many unhealthy consequences. Alcohol can and education, a medication that can reverse
irritate the digestive system and even cause the the effects of opioid narcotics is becoming
esophagus to rupture, or it can injure the stomach increasingly available. This medication, called
lining. Chronic drinking can also affect the brain naloxone, is commonly used by EMS personnel
and cause memory loss, apathy and a lack of to reverse the effects of opioid drugs. Recent
coordination. Other problems include liver disease, legislation has allowed individuals in some
such as cirrhosis. In addition, many psychological, states who are being prescribed opioids by their
family, social and work problems are related to physician to also be given a prescription for
chronic drinking. naloxone. In fact, in some states this medication
can even be obtained directly from the pharmacist
without a prescription.
Opioid Narcotics
While they have a depressant effect, opioid Naloxone typically comes as a nasal spray
narcotics (which are often derived from opium) (atomizer) or an injectable (Fig. 15-5). Auto-
are used mainly to relieve pain. Opioid narcotics injectors, similar to those used to deliver
are so powerful and highly addictive that all are epinephrine, are also being manufactured for use
illegal without a prescription, and some are not in the treatment of opioid poisoning. Before using
prescribed at all. When taken in large doses, naloxone, it is important to be trained in how to
opioid narcotics can produce euphoria, stupor, recognize when to administer it and how to give it
Fig. 15-5: The nasal administration of naloxone using a nasal atomizer device.
376 | Emergency Medical Response
using the different methods of administration. Signs states and is available in others for limited medical
and symptoms of opioid overdose include: use to help alleviate symptoms of certain conditions
such as multiple sclerosis. Marijuana and its legal
Slowed and/or shallow breathing (or no breathing). synthetic versions are used as an anti-nausea
Extreme drowsiness or becoming unconscious. medication for people undergoing chemotherapy for
Small pupils. cancer, for treating glaucoma, for treating muscular
weakness caused by multiple sclerosis, and to
Severe opioid poisoning is a life-threatening combat the weight loss caused by cancer and
emergency; in severe cases, the patient may be acquired immunodeficiency syndrome (AIDS).
unconscious, not breathing, and have bluish skin
(cyanosis) and a faint or absent heartbeat. If you Newer, more potent synthetic marijuana-like
suspect opioid overdose in a patient, the most products have been available in the United States
important thing to do is to call for more advanced since the early 2000s. These products are known as
personnel. If used appropriately, based on local synthetic marijuana or synthetic cannabinoids. Street
protocols, naloxone can reverse all of the effects of names include “K2” and “spice.” These products are
opioid poisoning, including unconsciousness and typically smoked or taken orally. They are not a safe
breathing difficulties. alternative to marijuana and, in fact, have more side
effects than marijuana and can cause hallucinations,
Inhalants seizures, stupor, coma or death.
Substances inhaled to produce mood-altering
effects are called inhalants. Inhalants also Other Substances
depress the central nervous system. In addition, Some other substances do not fit neatly into these
inhalant use can damage the heart, lungs, brain and categories. These substances include designer
liver. Inhalants include medical anesthetics, such drugs, steroids and OTC substances, which can
as amyl nitrite and nitrous oxide (also known as be purchased without a prescription.
“laughing gas”), as well as hydrocarbons, known as
solvents. The effects of solvents are similar to those Designer Drugs
of alcohol. People who use solvents may appear Designer drugs are variations of other
to be drunk. Other effects of inhalant use include substances, such as narcotics and amphetamines.
swollen mucous membranes in the nose and mouth, Through simple and inexpensive methods, the
hallucinations, erratic blood pressure and pulse, molecular structure of substances produced for
and seizures. Solvents include toluene, found in medicinal purposes can be modified into extremely
glues; butane, found in lighter fluids; acetone, found potent and dangerous street drugs; hence the term
in nail polish removers; fuels, such as gasoline and “designer drug.” When the chemical makeup of a
kerosene; and propellants, found in aerosol sprays. drug is altered, the user can experience a variety of
unpredictable and dangerous effects. The people
Cannabis Products who modify these drugs may have no knowledge of
Cannabis products, including marijuana, hash the effects a new designer drug might produce.
oil, tetrahydrocannabinol (THC) and hashish, One of the more commonly used designer drugs is
are all derived from the plant Cannabis sativa. methylenedioxymethamphetamine (MDMA). Another
Marijuana is the most widely used illicit drug in the popular club drug, it is often called “ecstasy” or “E.”
United States. Street names include “pot,” “grass,” Although ecstasy is structurally related to stimulants
“weed,” “reefer,” “ganja” and “dope.” It is typically and hallucinogens, its effects are somewhat
smoked in cigarette form or in a pipe, but it can different from either category. Ecstasy can evoke
also be ingested. The effects include feelings of a euphoric high that makes it popular. Other signs
elation, distorted perceptions of time and space, and symptoms of ecstasy use range from the
and impaired judgment and motor coordination. stimulant-like effects of high blood pressure, rapid
Marijuana irritates the throat, reddens the eyes, and heartbeat, profuse sweating and agitation to the
causes dizziness and often an increased appetite. hallucinogenic-like effects of paranoia, sensory
Depending on the dose, the person and many other distortion and erratic mood swings.
factors, cannabis products can produce effects
similar to those of substances in any of the other
Anabolic Steroids
major substance categories.
Anabolic steroids are drugs sometimes
Marijuana, although still illegal throughout much used by athletes to enhance performance and
of the United States, has been legalized in some increase muscle mass. Their medical uses include
Chapter 15: Poisoning | 377
stimulating weight gain for persons unable to gain Emetics are drugs that induce vomiting. Ipecac
weight naturally. They should not be confused syrup is an emetic that has been used in the past
with corticosteroids, which are used to counteract to induce vomiting following the ingestion of some
toxic effects and allergic reactions. Chronic use of toxic substances. The administration of ipecac
anabolic steroids can lead to sterility, liver cancer and syrup for ingested poisons is not recommended.
personality changes, such as aggressive behavior. Use of ipecac can be quite dangerous and may
Steroid use by younger people may also disrupt cause recurrent vomiting, diarrhea, dehydration,
normal growth. Street names for anabolic steroids pain and weakness in the muscles, abdominal
include “androgens,” “hormones,” “juice,” “roids” and pain and heart problems. Over time, the recurrent
“vitamins.” vomiting can erode tooth enamel, causing dental
problems. For these reasons, it is no longer
widely available in the United States, and the
OTC Substances American Academy of Pediatrics and the American
Aspirin, nasal sprays, laxatives and emetics are Association of Poison Control Centers do not
among the most commonly abused or misused recommend that ipecac syrup be stocked at home.
OTC substances (Fig. 15-6). Aspirin is an effective
minor pain reliever and fever reducer that is found The abuse of laxatives and emetics is frequently
in a variety of medicines. People use aspirin for associated with attempted weight loss and eating
many reasons and conditions. In recent years, disorders, such as anorexia nervosa or bulimia.
cardiologists have praised the benefits of low- Anorexia nervosa is a disorder that most often
dose aspirin for the treatment of heart disease and affects young women and is characterized by
stroke prevention. As useful as aspirin is, misuse a long-term refusal to eat food with sufficient
can have toxic effects on the body. Typically, aspirin nutrients and calories. People with anorexia
can cause inflammation of the stomach and small typically use laxatives and emetics to keep from
intestine that can result in bleeding ulcers. Aspirin gaining weight. Bulimia is a condition in which
can also impair normal blood clotting. people gorge themselves with food, then purge
by vomiting (sometimes with the aid of emetics)
Decongestant nasal sprays can help relieve the or using laxatives. For this reason, the behavior
congestion of colds or hay fever. If misused, they associated with bulimia is often referred to as
can cause physical dependency. Using the spray “binging and purging.” Anorexia nervosa and
over a long period can cause nosebleeds and bulimia have underlying psychological factors that
changes in the lining of the nose that make it contribute to their onset. The effect of both of
difficult to breathe without the spray. these eating disorders can be severe malnutrition,
which can result in death.
Laxatives are used to relieve constipation. They
come in a variety of forms and strengths. If used
Considerations for Older Adults
improperly, laxatives can cause uncontrolled
Substance Abuse and Misuse
diarrhea that may result in dehydration, the
Among Older Adults
excessive loss of water from the body tissues.
Substance abuse and misuse does occur in
The very young and older adults are particularly
older populations. Older adults are likely to
susceptible to dehydration.
suffer from chronic diseases or conditions
that require multiple prescription medications.
These medications can interact with each
other or with alcohol, and cause adverse
reactions. The slower metabolisms of older
adults can cause alcohol and medications
to remain in the body longer, increasing
the chance of an overdose. Sometimes,
because of failing eyesight, an older adult
may unintentionally take a drug at the wrong
time or consume the wrong dosage and
experience an overdose. Mixing medications
or mixing drugs with alcohol and failing to
follow directions are also factors in substance
abuse and misuse among older people.
Fig. 15-6: Many OTC substances, such as pain relievers,
decongestants, laxatives and emetics, are abused or misused.
378 | Emergency Medical Response
Adolescents and Substance Abuse Specific signs and symptoms of hallucinogen abuse,
and Misuse as well as abuse of some designer drugs, may
include sudden mood changes and a flushed face.
Adolescents and young adults are more likely to be
The patient may claim to see or hear something not
involved in substance abuse and misuse. Males are
present, or may be anxious and frightened.
somewhat more likely to use illicit drugs and alcohol
than females, although they are almost equally likely Specific signs and symptoms of depressant
to use psychotherapeutic drugs for nonmedical abuse may include drowsiness, confusion, slurred
purposes. Middle and high school students are speech, slow heart and breathing rates, and poor
also likely to abuse or misuse prescription drugs coordination. A person who abuses alcohol may
such as narcotic pain killers, sedatives or stimulants smell of alcohol. A person who has consumed a
because they can access them easily at home, from great deal of alcohol in a short time may become
people they know or on the Internet. unconscious or hard to arouse. The person may
vomit violently. Specific signs and symptoms of
alcohol withdrawal, a potentially dangerous condition
Signs and Symptoms of Substance
that can be life threatening, include confusion and
Abuse and Misuse restlessness, trembling, hallucinations and seizures.
Many of the signs and symptoms of substance
abuse and misuse are similar to those of other A telltale sign of cannabis use is red, bloodshot
medical emergencies. Do not necessarily assume eyes, while those abusing inhalants may appear
that individuals who are stumbling, disoriented or drunk or disoriented in a similar manner to a person
have a fruity, alcohol-like odor on the breath are abusing hallucinogens.
intoxicated by alcohol or other drugs, as this may
also be a sign of a diabetic emergency. Providing Care for Substance
As in other medical emergencies, you do not have
Abuse and Misuse
to diagnose substance abuse or misuse to provide Always summon more advanced medical personnel
care. It can be helpful, however, if you detect clues if you suspect a patient is suffering from alcohol
that suggest the nature of the problem. Such clues withdrawal or from any form of substance abuse.
help you provide more complete information to Since substance abuse and misuse are forms of
more advanced medical personnel so that they can poisoning, care follows the same general principles
provide prompt and appropriate care. as for other types of poisoning. As in other medical
emergencies, however, people who abuse or
Often these clues will come from the patient, misuse substances may become aggressive or
bystanders or the scene. Look for containers, pill uncooperative when you try to help. If the person
bottles, drug paraphernalia and signs of other becomes agitated or makes the scene unsafe in
medical problems. If the patient is incoherent any way, retreat until the scene can be secured.
or unconscious, try to get information from any Provide care only if you feel the patient is not a
bystanders or family members. Since many of the danger to you and others.
physical signs of substance abuse mimic other
conditions, you may not be able to determine Your initial care for substance abuse or misuse
that a patient has overdosed on a substance. does not require that you know the specific
To provide care, you only need to recognize substance taken. Follow these general principles
abnormalities in breathing, skin color and moisture, as you would for any poisoning:
body temperature and behavior, any of which may
indicate a condition requiring professional help. Size up the scene to be sure it is safe.
Perform a primary assessment to check for any
The abuse or misuse of stimulants can have many life-threatening conditions.
unhealthy effects on the body that mimic other
conditions. For example, a stimulant overdose
Summon more advanced medical personnel.
can cause moist or flushed skin, sweating, chills, Perform a physical exam.
nausea, vomiting, fever, headache, dizziness, Take a SAMPLE history (signs and symptoms,
rapid pulse, rapid breathing, high blood pressure allergies, medications, pertinent medical history,
and chest pain. In some instances, it can cause last oral intake and events leading up to the
respiratory distress, disrupt normal heart rhythms or incident) to try to find out what substance
cause death. The patient may appear very excited, was taken, how much was taken and when
restless, talkative or irritable, or may suddenly it was taken.
lose consciousness. Stimulant abuse can lead to Calm and reassure the patient.
addiction and can cause a heart attack or stroke. Keep the patient from getting chilled or overheated.
Chapter 15: Poisoning | 379
Keep the patient’s airway clear. Read the product information and use only as
If the patient is having difficulty breathing, directed.
administer supplemental oxygen based on Ask your healthcare provider or pharmacist
local protocols. about the intended use and side effects of
prescription and OTC medication. If you are
taking more than one medication, check for
Preventing Substance Abuse
possible interaction effects.
and Misuse
Experts in the field of substance abuse generally Never use another person’s prescribed
medications; what is right for one person is
agree that prevention efforts are far more cost seldom right for another.
effective than treatment. Yet preventing substance
abuse is a complex process that involves many Always keep medications in their original,
marked containers.
underlying factors. Various approaches, including
educating people about substances and their Discard all out-of-date medications. Time can
effects on health and attempting to instill fear alter the chemical composition of medications,
of penalties, have not by themselves proved causing them to be less effective and possibly
particularly effective. It is becoming clearer that, to even toxic.
be effective, prevention efforts must address the Always keep medications out of the reach of
various underlying issues of substance abuse and children.
ways to approach it.
The following factors may contribute to substance PUTTING IT ALL TOGETHER
abuse:
Poisonings can occur in four ways: ingestion,
A lack of parental supervision inhalation, absorption and injection. Substance abuse
and misuse are types of poisoning that can occur in
The breakdown of traditional family structure
any of these ways. Substance abuse and misuse can
A wish to escape unpleasant surroundings and
produce a variety of signs and symptoms, most of
stressful situations
which are common to other types of poisoning. You
The widespread availability of substances do not need to determine the cause of a poisoning to
Peer pressure and the basic need to belong provide appropriate initial care.
Low self-esteem, including feelings of guilt or shame
If you see any of the signs and symptoms of
Media glamorization, especially of alcohol
sudden illness, follow the basic guidelines of
and tobacco, promoting the idea that using
care for any medical emergency. For suspected
substances enhances fun and popularity
poisonings, contact the national Poison Help line
A history of substance abuse in the home or or summon more advanced medical personnel.
community environments Beyond following the general guidelines for
Recognizing and understanding these factors providing care for a suspected poisoning, medical
may help in the prevention and treatment of professionals may advise you to provide some
substance abuse. specific care, such as neutralizing the poison.
Some poisonings from medications occur when Six major categories of substances, when abused
patients knowingly increase the dosage beyond or misused, can produce a variety of signs and
what is directed. Medications should be taken only symptoms, some of which are indistinguishable
as directed. On the other hand, many poisonings from those of other medical emergencies.
from medications are not intentional. Remember, you do not have to know the specific
condition to provide care. If you suspect that the
The following guidelines can help prevent patient’s condition is caused by substance abuse
unintentional misuse or overdose: or misuse, provide care for a poisoning emergency.
You Are the Emergency Medical Responder
Based on your findings, you suspect that the patient ingested a combination of drugs and
alcohol. What initial care can you provide? What else should you do and why? Is this a case of
substance misuse? Why or why not?
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Administering Nasal Naloxone
With a growing epidemic of opioid (commonly fentanyl, heroin and oxycodone) overdoses in the United States,
local and state departments of health have increased access to the medication naloxone, which can counteract
the effects of an opioid overdose including respiratory arrest. Naloxone (also referred to by its trade name
NarcanTM) has few side effects and can be administered intranasally. Trained and authorized responders should
assist with the administration of naloxone or administer the drug when the patient is in respiratory arrest or is
unconscious and an opioid overdose is suspected. Other signs and symptoms of overdose include small pupils,
respiratory depression, such as slowed or shallow breathing, as well as the presence of drug paraphernalia.
Responders should always follow local protocols and regulations for the administration of naloxone including
dosing, timing and route of administration.
One of the most common and available routes of administration for naloxone is intranasal, using a nasal
atomizer device attached to a syringe containing 2.0 mg of naloxone. To reverse the effects of the opioid, 1.0 mg
of naloxone is administered into each nostril of the patient. While naloxone has very few side effects and is
considered generally safe for any patient, emergency medical responders should ensure that more advanced
medical personnel have been called as the half-life of naloxone (the amount of time the medication will have the
desired effect) is often shorter than the half-life of the opioid causing the overdose.
Other complications can occur if the patient has overdosed on several medications at one time. Responders
should be ready for different reactions from patients, from improving respiratory effort to regaining consciousness
to acting out violently or vomiting. It is important to remember that the purpose of naloxone is to improve a
patient’s respiratory effort. In other words, ensure that they are breathing normally on their own. It is not necessary
to wake up the patient.
All EMRs should follow local protocols when considering the administration of naloxone.
If authorized to assist with or administer intranasal naloxone, always follow local protocols and the following steps:
Ensure scene safety.
Maintain appropriate body substance isolation (BSI) precautions.
Maintain an open airway and assist with ventilations if the patient has a pulse but is not breathing.
Suction the airway, as needed.
Assess the level of consciousness and vital signs.
Summon advanced medical personnel by calling 9-1-1 or the designated emergency number.
Assist with the administration of Naloxone 2.0 mg Nasal via atomizer (1.0 mg per nostril).
yyRemove the caps from both ends of the needle-free syringe.
yyRemove the cap from the naloxone vial.
yyScrew the open end of the vial into the syringe; it will become difficult to turn when it is sufficiently
threaded.
yyAttach the nasal atomizer to the opposite end.
yyGive ventilations using a BVM.
yyAssess the patient to ensure their nasal cavity is free of blood or mucus.
yyControl the patient’s head with one hand.
yyGently but firmly place the atomizer in one nostril, carefully occluding the opposite nostril.
yyAim slightly upward and toward the ear on the same side as the nostril.
yyBriskly compress the syringe to administer up to 1.0 mg of atomized spray.
yyRepeat in the other nostril. (Note: using both nostrils doubles the surface area available for absorption.)
Continue giving ventilations as needed.
If the patient’s mental status and respiratory effort do not improve after 3 to 5 minutes, give a second 2.0 mg
dose, if available and local protocols allow.
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Administering Activated Charcoal
If a patient has ingested poison, activated charcoal may be recommended by the PCC or medical control. Ideally,
this will be administered within 1 hour of the patient swallowing the poison (Fig. 15-7).
Activated charcoal should only administered if the patient is fully conscious and alert and you have been
directed by medical control or the PCC. A patient who is not able to swallow should not be given activated
charcoal, nor should it be given to a patient who has overdosed on cyanide, swallowed acids or swallowed alkalis
(including hydrochloric acid, bleach and ammonia).
Many patients experience black stools after taking activated charcoal. Vomiting is another common side effect,
especially if the patient is already feeling nauseated. If the patient does vomit, ask medical control or the PCC
for permission to give a second dose of the activated charcoal, and arrange to take the patient to the hospital
immediately.
The PCC or local medical authority will give you instructions on how to administer the activated charcoal. The
container should also list instructions. Generally, you will be told to shake the bottle to mix the activated charcoal
with water. Give it to the patient to drink. Using a straw or opaque container may make it easier for the patient to
tolerate the mixture’s less-than-appetizing appearance. If the charcoal settles, shake it again to mix it thoroughly;
then let the patient finish drinking.
Medical control or the PCC may give you directions about the dose. In general, the dosage is calculated at
1 gram of activated charcoal per kilogram of the patient’s weight or 1 g/kg. An adult dose is usually between
30 and 100 grams; for a child or an infant, the dose is between 12 and 25 grams. Follow the correct dosage that
is given by the PCC or by local protocols.
Fig. 15-7: Activated charcoal.
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Carbon Monoxide and Cyanide Poisoning
Carbon monoxide (CO) and cyanide poisoning can result from disasters such as fires and industrial incidents,
terrorist attacks and the use of weapons of mass destruction. As with all emergency responses, in cases of
inhaled poison, it is essential that responders ensure their own safety before performing rescues.
Carbon Monoxide
Thousands of individuals die each year in the United States, and thousands more are hospitalized, due to CO
poisoning. People often think about CO as related to car exhaust. However, CO is the byproduct of many
combustible types of machinery, several of which people have in their homes, including wood stoves and
barbecues. It is also the byproduct of larger fires, such as industrial or building fires. CO, which is present in
substances such as tobacco smoke, can also be produced by defective cooking equipment, defective furnaces
and kerosene heaters. CO is also found in indoor skating rinks and when charcoal is used indoors.
Everyday items that emit CO include:
Heating systems, large or small (including portable types), that burn coal, gasoline, kerosene, oil, propane and
wood; this includes camping stoves.
Barbecues or grills, both propane and charcoal.
Natural gas water heaters.
Gas lawn mowers or any gas-powered vehicle.
Portable generators, often used during power outages.
Kitchen stoves, when used for heating homes or house trailers.
CO poisoning is the leading cause of death by poisoning in the United States. Its colorless and odorless
presentation increases its danger, as patients may never be aware of its presence before succumbing to its
poisonous effects. CO is highly lethal and can cause death after only a few minutes of exposure. CO detectors,
which work much like smoke detectors, are widely available for use in homes and businesses (Fig. 15-8). CO is
lighter than air, which is why detectors should be placed in homes near sleeping areas at as high an elevation as
possible, consistent with the manufacturer’s operating instructions.
Fig. 15-8: A CO detector.
Continued on next page
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Carbon Monoxide and Cyanide Poisoning continued
Signs and Symptoms of CO Poisoning
The initial symptoms of CO poisoning, such as a dull or throbbing headache, nausea and vomiting, can easily be
mistaken for something benign. Other signs and symptoms of CO poisoning include:
Bluish skin color. Impaired judgment.
Chest pain. Irritability.
Confusion. Loss of consciousness.
Convulsions. Low blood pressure.
Dizziness. Muscle weakness.
Drowsiness. Rapid or abnormal heartbeat.
Fainting. Shock.
Hyperactivity. Shortness of breath.
Providing Care for CO Poisoning
Because of the danger of CO, it is essential that responders are properly outfitted for safety and that the patient is
removed from the situation as quickly as possible. If a patient experiences symptoms of CO poisoning, get the patient
to fresh air immediately by opening doors and windows, turning off combustion appliances and leaving the building.
If CO poisoning is suspected, make sure emergency department staff and physicians are aware. Questions to
ask the patient should include:
Where the symptoms occurred.
Whether symptoms disappear or decrease away from that location (e.g., home).
Whether anyone else in the building is complaining of similar symptoms and whether those symptoms
appeared at about the same time.
Whether there are any fuel-burning appliances in the location.
Whether these appliances have been inspected recently to ensure they are working properly.
If CO poisoning has occurred, the patient may be asked to undergo a blood test, which is done soon after
exposure to confirm the diagnosis.
Everyone present in the area of the poisoning, even if they do not display any signs or symptoms, should be
monitored or treated. The only treatment for CO poisoning that can be administered on the scene is providing
supplemental oxygen, based on local protocols.
Cyanide Poisoning
Cyanide poisoning makes your body unable to utilize oxygen and can quickly cause death. It can occur through
the digestive and respiratory tracts and through the skin. It can also be injected.
Cyanide poisoning is generally thought of as a weapon used in terrorism or wartime. However, cyanide is found
naturally in some everyday foods, such as apricot pits; in other products, such as cigarettes; and as byproducts
of production such as plastic manufacturing. Cyanide is also used in some production processes such as making
paper and textiles, developing photographs, cleaning metal and in rodent poisons.
Signs and Symptoms of Cyanide Poisoning
The signs and symptoms of cyanide poisoning depend on the extent of the exposure and the route by which it
enters the body. If exposure is through eating products that have naturally occurring cyanide or by absorbing it
through the skin, symptoms may include sudden onset of:
Dizziness. Rapid heart rate.
Headache. Restlessness.
Nausea and vomiting. Weakness.
Rapid breathing.
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Carbon Monoxide and Cyanide Poisoning continued
Patients who were subjected to larger, concentrated or more intense exposure to cyanide, such as from an
industrial incident or a terrorist attack, could display symptoms such as:
Convulsions.
Loss of consciousness.
Low blood pressure.
Lung injury.
Respiratory failure leading to death.
Slow heart rate.
Exams and Tests for Cyanide Poisoning
There is no quick, simple blood test that will confirm a patient is suffering from cyanide poisoning at the scene of
an incident or at a fire. There are several cyanide detectors available to test for cyanide in the air, but they are often
delayed to the scene. Cyanide poisoning must therefore be assumed when it is likely based on circumstances,
so that lifesaving care may be started quickly. You should suspect cyanide poisoning at the scene of a fire if the
patient has been exposed to smoke in a confined space, whether or not the patient has been burned. If the patient
has soot around the mouth and nose and an altered LOC, the probability of cyanide toxicity is greater. The most
likely set of symptoms in someone who has suffered cyanide toxicity is altered mental status, abnormal pupil
dilation (widening), low respiratory rate, low systolic blood pressure with increased heart rate, metabolic acidosis
(increased plasma acidity) and a large increase in lactate levels in the plasma.
Providing Care for Cyanide Poisoning
Hydrogen cyanide can enter the body through inhalation or ingestion, or by being absorbed into the skin or eyes.
Avoid all contact. If you or someone else is exposed, seek medical attention immediately.
If there is a risk of inhalation, seek ventilation or local exhaust, or use breathing protection with a gas mask that
has a hydrogen cyanide (HC) canister (escape). The use of positive-pressure self-contained breathing apparatus
(SCBA) or SCBA CBRN (chemical, biological, radiological and nuclear), if available, is recommended when
responding to nonroutine emergency situations (Fig. 15-9). Use a CBRN, full face-piece air purifying respirator
(APR), when available, in nonroutine, emergency situations, environments less than immediately dangerous
to life or health concentrations, but above recommended exposure limit or permissible exposure limit levels.
If you or someone else is exposed to hydrogen cyanide via inhalation, seek fresh air and rest in a half-upright
position. Avoid mouth-to-mouth resuscitation, and administer supplemental oxygen if it is available, based on
local protocols.
If there is risk of absorption into the skin, use butyl rubber gloves and Teflon® or Tychem® protective clothing as
appropriate. If you or someone else has been exposed through absorption into the skin, remove the contaminated
clothing and rinse the skin with plenty of water or use a shower to rinse. Wear protective gloves when
administering first aid, and seek medical attention immediately.
Hydrogen cyanide vapor can be absorbed through the eyes. For prevention, wear safety goggles, a face shield
or eye protection in combination with breathing protection. If the eyes are exposed, rinse with plenty of water for
several minutes. If you or the patient exposed is wearing contact lenses, remove them if easily possible. Seek
medical attention immediately.
Hydrogen cyanide can also be ingested. To prevent such an exposure, do not eat, drink or smoke during work,
and wash your hands before eating. If you are exposed by ingestion, rinse your mouth and follow the same steps
as for inhalation. Do not induce vomiting. Seek medical attention immediately.
Hydrogen cyanide poses several hazards associated with fire. It is extremely flammable, and the fire emits
toxic or irritating gases. To prevent fire around this gas, ensure that there is no smoking and there are no open
flames or sparks. If fire does break out, shut off the gas supply. If this is not possible and there are no risks to the
surrounding environment, let the fire burn out on its own. If you can extinguish it, use powder, water spray, foam or
carbon dioxide.
Continued on next page
Chapter 15: Poisoning | 385
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Carbon Monoxide and Cyanide Poisoning continued
Fig. 15-9: Patients from an industrial incident or terrorist attack can be subjected to larger,
concentrated or more intense exposure to cyanide. Photo: courtesy of Captain Phil Kleinberg,
EMT-P.
When mixed with air, hydrogen cyanide also poses a risk of explosion. Keep the area closed and well
ventilated, and use explosion-proof electrical equipment and lighting. To prevent an explosion, if there is a fire,
keep the cylinder cool by spraying it with water. If you do have to fight the fire, do so from a sheltered position.
If a patient is suspected of exposure to hydrogen cyanide, the SAMPLE history and scene size-up will be vital.
The hospital will administer blood tests, X-rays, other diagnostic tests and IV lines. It is important to accurately
convey details about the scene to healthcare providers, as they will use this information, along with the patient’s
presentation and the test results, to determine if the patient has indeed suffered from cyanide poisoning. Also,
because cyanide poisoning is rare, healthcare providers may not consider the possibility unless you report it, and
treatment may come too late.
386 | Emergency Medical Response
16 ENVIRONMENTAL
EMERGENCIES
You Are the Emergency Medical Responder
As the nearest park ranger in the area, you are summoned to a campsite for an
incident involving a possible venomous snakebite. When you arrive and size up the
scene, you find several campers assisting one of the others, a young adult male.
As you begin your primary assessment and investigate the patient’s chief complaint,
you see two puncture wounds and swelling on his right hand. The patient described
the snake as having a triangular-shaped head and distinct diamond-shaped patterns
on its body. It struck him like “a bolt of lightning” when he bent down to move some
rocks beside the stream. He says the pain is about an 8 or a 9, on a scale of 1 to 10.
There is a medical facility at the park headquarters and a regional medical center with
antivenom nearby. How would you respond?
KEY TERMS
Anaphylaxis: A form of distributive shock caused by legs, arms and abdomen; painful involuntary muscle
an often sudden severe allergic reaction, in which spasms occur during or after physical exertion,
air passages may swell and restrict breathing; also particularly in high heat and humidity, possibly due to
referred to as anaphylactic shock. loss of electrolytes and water from perspiration; not
associated with an increase in body temperature.
Antivenom: A substance used to counteract the
poisonous effects of venom. Exertional heat exhaustion (EHE): An inability
to cope with heat and characterized by fatigue,
Arterial gas embolism: A condition in which air nausea and/or vomiting, loss of appetite,
bubbles enter the bloodstream and subsequently dehydration, exercise-associated muscle cramps,
travel to the brain; results from a rapid ascent dizziness with possible fainting, elevated heart
from deep water, which expands air in the lungs and respiratory rate, and skin that is pale, cool
too quickly. and clammy or slightly flushed; if a core body
temperature can be obtained, it is typically higher
Barotrauma: Injury sustained because of pressure
than 104° F (40° C). The person may be weak
differences between areas of the body and the
and unable to stand but has normal mental status;
surrounding environment; most commonly occurs
often results from strenuous work or wearing
in air travel and SCUBA diving.
too much clothing in a hot, humid environment,
Conduction: One of the ways the body loses or and may or may not occur with dehydration and
gains heat; occurs when the skin is in contact with electrolyte imbalance.
something with a lower or higher temperature.
Exertional heat stroke (EHS): The most serious
Convection: One of the ways the body loses or form of heat-related illness; life threatening and
gains heat; occurs when air moves over the skin develops when the body’s cooling mechanisms
and carries away or increases heat. are overwhelmed and body systems begin to
fail. People with EHS have exaggerated heat
Core temperature: The temperature inside the body. production and an inability to cool themselves.
Decompression sickness: A sometimes fatal Free diving: An extreme sport in which divers
disorder caused by the release of gas bubbles into compete underwater without any underwater
body tissue; also known as “the bends”; occurs breathing apparatus.
when SCUBA divers ascend too rapidly, without
allowing sufficient time for gases to exit body Frostbite: A condition in which body tissues freeze;
tissues and be removed through exhalation. most commonly occurs in the fingers, toes, ears
and nose.
Dehydration: Inadequate fluids in the body’s tissues.
Heat index: An index that combines the air
Drowning: An event in which a victim experiences temperature and relative humidity to determine the
respiratory impairment due to submersion in water. perceived, human-felt temperature; a measure of
Drowning may or may not result in death. how hot it feels.
Electrolytes: Substances that are electrically Heat stroke: The most serious form of heat-related
conductive in solution and are essential to the illness; life threatening and develops when the
regulation of nerve and muscle function and fluid body’s cooling mechanisms are overwhelmed and
balance throughout the body; include sodium, body systems begin to fail; can be classified as
potassium, chloride, calcium and phosphate. classic heat stroke or exertional heat stroke.
Evaporation: One of the ways the body loses heat; Hyperthermia: Overheating of the body; includes
occurs when the body is wet and the moisture exercise-associated muscle cramps, exertional
evaporates, cooling the skin. heat exhaustion and heat stroke (exertional
and classic).
Exercise-associated muscle cramps: Formerly
known as heat cramps, these muscle spasms can Hypothalamus: Control center of the body’s
be intense and debilitating and typically occur in the temperature; located in the brain.
(Continued )
388 | Emergency Medical Response
KEY TERMS continued
Hypothermia: The state of the body being colder Radiation: One of the ways the body loses heat;
than the usual core temperature, caused by either heat radiates out of the body, especially from the
excessive loss of body heat and/or the body’s head and neck.
inability to produce heat.
Tetanus: An acute infectious disease caused by a
Metabolism: The physical and chemical processes bacterium that produces a powerful poison; can
of converting oxygen and food into energy within occur in puncture wounds, such as human and
the body. animal bites; also called lockjaw.
Rabies: An infectious viral disease that affects the
nervous system of humans and other mammals;
has a high fatality rate if left untreated.
LEARNING OBJECTIVES
After reading this chapter, and completing the class • Identify the signs and symptoms of anaphylaxis.
activities, you will have the information needed to: • Describe the care provided to a patient
• Identify the signs and symptoms of a experiencing anaphylactic shock.
heat-related illness. • Identify the signs and symptoms of the most
• Describe how to care for a patient who has a common types of bites and stings.
heat-related illness. • Describe how to provide general care for various
• Identify the signs and symptoms of a bites and stings.
cold-related emergency. • Describe various methods of rescuing a victim in
• Describe how to care for a patient who has a the water.
cold-related emergency.
SKILL OBJECTIVES
After reading this chapter, and completing the class • Demonstrate appropriate handling and disposal of
activities, you should be able to: an epinephrine auto-injector.
• Demonstrate the use of an epinephrine
auto-injector.
INTRODUCTION may get caught without shelter and proper clothing
during a sudden downpour while on a hike, an
Environmental emergencies include a wide range of older adult may collapse from dehydration during
situations—from exertional heat stroke and frostbite, a heat spell or a bathtub may be the cause of a
to snakebites and drowning. They range from minor to drowning for a small child.
life threatening. In some cases, the same problem—
such as a bee sting—can result in minor pain and In this chapter, you will learn how to recognize and
discomfort in one patient while causing a life- care for heat-related illnesses and cold-related
threatening condition in another, such as anaphylaxis. emergencies, bites and stings, anaphylaxis and
drowning incidents.
Environmental emergencies often occur during the
course of everyday events. For example, a teenager
Chapter 16: Environmental Emergencies | 389
BODY TEMPERATURE If the body starts to become too cold, it responds
by constricting (closing up) the blood vessels
The human body usually keeps itself at a constant close to the skin so it can keep the warmer blood
core temperature (internal temperature) of near the center of the body (Fig. 16-1). This helps
98.6° F, or 37° C. The control center of body keep the organs warm. If this does not work,
temperature is in the brain and is called the the body then begins to shiver. The shivering
hypothalamus. The hypothalamus receives motion increases body heat because it is a form
information and adjusts the body’s function of movement.
accordingly. The body needs to be kept within a
specific range of temperatures for the cells to stay
alive and healthy (97.8° F to 99° F, or 36.5° C to How the Body Stays Cool
37.2° C). It is vital the body responds properly to In a warm or hot environment, the hypothalamus
temperature signals. detects an increase in blood temperature. Blood
vessels near the skin dilate (widen), to bring more
How the Body Stays Warm blood to the surface, which allows heat to escape
(Fig. 16-2).
Heat is a byproduct of metabolism, the
conversion of food and drink into energy. The body
also gains heat with any kind of physical activity.
Skin surface
Skin surface
Constricted blood vessel
Dilated blood vessel
Fig. 16-1: The body stays warm by constricting blood vessels Fig. 16-2: The body stays cool by dilating blood vessels
close to the skin. If this does not work, it begins to shiver. near the skin so heat can escape.
CRITICAL The human body usually keeps itself at a constant core temperature (internal
FACTS temperature) of 98.6° F, or 37° C.
In a warm or hot environment, the hypothalamus detects an increase in blood
temperature. Blood vessels near the skin dilate (widen), to bring more blood to the
surface, which allows heat to escape.
390 | Emergency Medical Response
There are five general ways in which the body can Have a pre-existing health problem, such
be cooled: as diabetes or heart disease. Pre-existing
health problems can increase susceptibility
Radiation: This process involves the transfer of to a heat-related illness. Medications taken
heat from one object to another without physical for these conditions can also cause dehydration.
contact. The body loses the majority of heat
through radiation, mostly from the head, hands Have had a previous heat-related illness or
cold-related emergency.
and feet.
Convection: This process occurs when cold air Take medications to eliminate water from the
body (diuretics). Diuretics increase the risk of
moves over the skin and carries the skin’s heat
dehydration, which, in turn, causes an increase
away. The faster the air is moving, the faster the
in core body temperature by preventing
body will be cooled. Convection is what makes
adequate blood flow to remove excess heat.
warm skin feel cooler in a breeze. Convection
also assists in the evaporation process. Consume other substances that have a
diuretic effect, such as fluids containing
Conduction: This occurs when the body
caffeine, alcohol or carbonation.
is in direct contact with a substance that is
cooler than the body’s temperature. Through Live in a situation or environment that does not
conduction, the body’s heat is transferred to the provide them with enough heating or cooling,
cooler substance (e.g., if you are swimming in depending on the season.
cold water or sitting on a cool rock in the shade). Do not maintain adequate hydration by drinking
enough water to counteract the loss of fluids
Evaporation: This is the process by which a
through perspiration, exertion or exposure to
liquid or solid becomes a vapor. When body
heat causes one to perspire and the perspiration heat and humidity.
evaporates, the heat that was absorbed into sweat Wear clothing inappropriate for the weather.
dissipates into the air which cools off the skin.
Heat-related illnesses and cold-related emergencies
Respiration: Heat is also lost through occur more frequently among older adults,
respiration, another term for breathing. Before air especially those living in poorly ventilated or poorly
is exhaled, it is warmed by the lungs and airway. insulated buildings, or buildings with poor heating
Respiration normally accounts for approximately or cooling systems. Young children and people with
10 to 20 percent of heat loss. health problems are also at greater risk because
their bodies do not respond as effectively to
temperature extremes.
PEOPLE AT RISK FOR HEAT-
RELATED ILLNESSES AND
COLD-RELATED EMERGENCIES HEAT-RELATED ILLNESSES
Although anyone can be at risk for heat-related There are several types of illness related to
illnesses and cold-related emergencies, some overheating of the body, or hyperthermia,
people are at even greater risk than others. People including exercise-associated muscle cramps,
who are susceptible to a heat-related illness or exertional heat exhaustion and heat stroke
cold-related emergency include those who: (exertional or classic). Heat-related illnesses
can happen to anyone, but several predisposing
Work or exercise strenuously in a warm or hot factors can put some people at higher risk.
and humid environment or a cold environment.
CRITICAL Heat-related illnesses and cold-related emergencies occur more frequently among
FACTS older adults, especially those exposed to poor living conditions. The young and
those with health problems are also considered high-risk groups.
There are several types of illness related to overheating of the body, or
hyperthermia: exercise-associated muscle cramps, exertional heat exhaustion and
heat stroke (exertional or classic).
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CRITICAL Dehydration can be a serious and even life-threatening situation. The people at
FACTS highest risk of dying from dehydration are the very young and the very old.
These factors include: Drugs and/or medications. Medications
or substances, such as alcohol and
Climate. In very warm or hot and humid weather, diuretics, cause an increase in blood vessel
the body may not be able to cool off sufficiently. If constriction, increase urination, increase
the temperature is high, the body is not as able to the risk of dehydration and increase
lower its temperature through radiation. The more core temperature.
humid the air, the less the body is able to cool
down through sweating. Evaporation decreases
as the relative humidity increases because the air Dehydration
contains excessive moisture (Fig. 16-3). Dehydration refers to inadequate fluids in the
Exercise and activity. Exercise or strenuous body’s tissues. Dehydration can be a serious
labor in the heat does not allow the body to cool and even life-threatening situation. The people at
off, particularly since exercise itself increases highest risk of dying from dehydration are the very
body temperature. When combined with a high young and the very old.
heat index, there is a much greater risk of
increasing the core temperature as it becomes Signs and Symptoms of Dehydration
more difficult to cool the body. The signs and symptoms of dehydration worsen
Age. The very young and very old are not as as the body becomes dryer. The first signs of
able to regulate body temperature as others are. dehydration include:
Infants and young children, for example, may
not be able to get the fluids they need, move Fatigue.
away from the heated area, or speak up and tell Weakness.
someone they are too warm. Headache.
Pre-existing illness and/or conditions. Certain Irritability.
illnesses and conditions can make someone feel Nausea.
the heat more than others. Examples include
people with diabetes, infections (which can
Dizziness.
cause fever, increasing the body temperature Excessive thirst.
even more), obesity and heart disease. Dry lips and mouth.
Fig. 16-3: Humidity is a main factor that could contribute to heat-related illnesses or a rise in body temperature.
392 | Emergency Medical Response
As dehydration worsens, symptoms can include: Signs and Symptoms of Exercise-
Associated Muscle Cramps
Disorientation or delirium.
Exercise-associated muscle cramps are painful
Loss of appetite.
spasms of skeletal muscles. While they usually
Severe thirst. affect the legs, arms and abdomen, they can
Dry mucous membranes. occur in any voluntary muscle. The person’s body
Sunken eyes. temperature is usually normal and the skin moist.
Lowered blood pressure.
Rapid pulse. Providing Care for Exercise-Associated
Dry skin that does not spring back if pinched, Muscle Cramps
creating a “tenting” effect. Exercise-associated muscle cramps must be taken
Lack of tears (particularly important among seriously, particularly if there is a history of heart
young children). disease or the patient is on a low-sodium diet.
To care for exercise-associated muscle cramps,
Decrease in perspiration.
the most important initial action is to reduce the
Dark, amber urine or complete lack of urine output.
cramps and remove the patient from the heat.
Unconsciousness. Have the patient rest, then gently massage and
lightly stretch the cramped muscles to ease the
Providing Care for Dehydration discomfort. To replace what was lost to perspiration,
To care for a patient who is dehydrated, you need encourage the patient to drink an electrolyte- and
to help them replace the lost fluid. If the patient is carbohydrate-containing fluid such as a commercial
still awake and able to swallow, encourage them to sports drink, fruit juice or milk. Water also may be
drink small amounts of a commercial sports drink or, given if the drinks are not available.
if not available, water. The patient should be allowed While the patient should rest as long as possible, if
to drink until their thirst sensation is quenched. the cramping has gone away and the patient feels
However, do not let the patient gulp the fluid down; better, activity can be resumed with caution. Advise
instead, have them sip it at a slow pace. If the patient the patient to rest frequently and drink fluids to
drinks too quickly, vomiting may occur. If dehydration prevent further dehydration and cramping.
is severe, the patient will likely need more advanced
medical care to receive fluids intravenously.
Exertional Heat Exhaustion
Exercise-Associated Muscle Cramps Exertional heat exhaustion (EHE) is a form
of heat-related illness. EHE results when fluid lost
The exact cause of exercise-associated through perspiration is not replaced by other fluids.
muscle cramps is not known, although it is This results in the body pulling the blood away from
believed to be a combination of loss of fluid and the surface areas of the body to protect the vital
electrolytes from heavy sweating. Exercise- organs, such as the heart and brain.
associated muscle cramps develop fairly rapidly
and usually occur after heavy exercise or work in Anyone can be at risk for developing EHE from
warm or even moderate temperatures. exposure to a hot or humid environment. However,
CRITICAL To care for dehydration, if the patient is still awake and able to swallow, encourage
FACTS them to drink small amounts of a commercial sports drink or, if not available, water.
Exercise-associated muscle cramps are painful, involuntary muscle spasms, most
often in the legs and abdomen, caused by loss of fluids and electrolytes after
physical exertion, especially (but not always) in high heat. Exercise-associated
muscle cramps may indicate severe heat-related illness.
To care for exercise-associated muscle cramps, reduce the cramps and remove the
patient from the heat. Have the patient rest, then gently massage and lightly stretch
the cramped muscles to ease the discomfort. Encourage the patient to drink an
electrolyte- and carbohydrate-containing fluid such as a commercial sports drink,
fruit juice or milk. Water also may be given if the drinks are not available.
Chapter 16: Environmental Emergencies | 393
it happens most often to those engaged in intense Dizziness with possible fainting.
physical activity—such as firefighters, construction Elevated heart and respiratory rate.
or factory workers and athletes. Simply being in a
hot and humid environment while overdressed with
Muscle cramps.
heavy clothes can also cause EHE.
Providing Care for Exertional Heat
Exhaustion
Signs and Symptoms of Exertional
Care for exertional heat exhaustion includes
Heat Exhaustion
the following:
The signs and symptoms of exertional heat
exhaustion include: Move the patient from the hot environment to a
cooler environment with circulating air.
Cool, pale, clammy or slightly flushed skin.
Loosen or remove as much clothing as possible.
Fatigue.
Apply cool, wet cloths, such as towels or sheets,
Nausea and/or vomiting. taking care to remoisten the cloths periodically.
Loss of appetite. Spraying the patient with water and fanning
Dehydration. also can help increase the evaporative cooling
(Fig. 16-4).
Fig. 16-4: Applying cool, wet cloths to the skin, fanning and encouraging rehydration are all effective ways to help a patient
with exertional heat exhaustion.
CRITICAL Exertional heat exhaustion is a more severe form of heat-related illness. Exertional heat
FACTS exhaustion results when fluid lost through perspiration is not replaced by other fluids.
To provide care for exertional heat exhaustion, move the patient out of the heat to a
cooler area and loosen or remove as much clothing as possible. Spray the person with
cool water, apply cool wet cloths or towels to the skin, and fan the person. If the patient
is awake and able to swallow, encourage them to drink small amounts of a commercial
sports drink or fruit juice; if these are not available, milk or water may also be given.
394 | Emergency Medical Response
If the patient is awake and able to swallow, Classic heat stroke is normally caused by
give them small amounts of a cool fluid such environmental changes and often occurs during the
as a commercial sports drink or fruit juice to summer months. Classic heat stroke most often
restore fluids and electrolytes. Milk or water occurs in infants, children, older adults, those with
also may be given. Do not let the patient drink chronic medical illnesses and those who suffer
too quickly. from inefficient body heat-regulation mechanisms—
Let the patient rest in a comfortable position, such as those in poor socioeconomic settings
and watch carefully for changes in their with limited access to air conditioning and those
condition. The patient should not resume normal on certain medications (e.g., antihistamines,
activities the same day. amphetamines, diuretics, and blood pressure and
heart medicines). Typically, classic heat stroke
If the patient’s condition does not improve, or
develops slowly, over a period of several days,
they refuse fluids, have a change in level of
consciousness or vomit, call for more advanced with the person presenting with minimally elevated
medical personnel, as these are indications that core temperatures.
the patient’s condition is getting worse. Stop Exertional heat stroke is the opposite of classic
giving fluids and place the patient on their side heat stroke and is experienced more frequently
in a recovery position if needed. Watch for signs than classic heat stroke. Exertional heat
and symptoms of breathing problems. Keep the stroke—which primarily affects younger, active
patient lying down and continue to cool the body individuals, such as athletes (recreational
any way you can (see Providing Care for Heat and competitive), military recruits and heavy
Stroke for cooling methods). laborers—occurs when excess heat is generated
Low blood pressure and rapid, weak pulse are through exercise and exceeds the body’s ability
signs of shock, so take steps to prevent or minimize to cool off. Exposure to factors such as high air
shock. Refer to Chapter 18 for more information on temperature, high relative humidity and dehydration
how to care for shock. increases the risk for developing exertional
heat stroke.
Heat Stroke
The most serious of heat-related illnesses is Signs and Symptoms of Heat Stroke
heat stroke. Heat stroke is a life-threatening Heat stroke is a serious medical emergency. You
condition that most often occurs when people must recognize the signs and symptoms of heat
ignore the signs and symptoms of exertional stroke and give care immediately. The signs and
heat exhaustion or do not act quickly enough to symptoms include:
give care. Heat stroke develops when the body
systems are overwhelmed by heat and begin to Changes in level of consciousness,
including confusion, agitation, disorientation
stop functioning. Sweating may stop when body
or unconsciousness.
fluid levels are low (i.e., dehydration) but may also
still be present for a person suffering from heat Trouble seeing.
stroke. The body’s exaggerated heat production, Seizures.
combined with an inability to cool itself, causes Extremely high body temperature (above 104° F,
body temperature to rise quickly, soon reaching a or 40° C).
level at which the brain and other vital organs, such Flushed or red skin that can be either dry
as the heart and kidneys, begin to fail. If the body is or moist.
not cooled, convulsions, coma and death will result.
Rapid, shallow breathing.
Two types of heat stroke are typically reported— Throbbing headache.
classic heat stroke and exertional heat stroke. Dizziness, nausea or vomiting.
CRITICAL The most serious of heat-related illnesses is heat stroke. Heat stroke is a life-
FACTS threatening condition that occurs when the body has become overheated and is no
longer able to cool itself down.
Chapter 16: Environmental Emergencies | 395
Providing Care for Heat Stroke As the body cools, an abnormal heart rhythm
Since heat stroke is life threatening, you should (ventricular fibrillation, or V-fib) may develop. If this
immediately call for more advanced medical happens, the heart will eventually stop and the
personnel. Your next priority is to begin rapid patient will die if not cared for.
cooling of the patient’s body, to bring the core
temperature down. The quicker you can get the Contributing Factors
body temperature down, the better the outcome. As with heat-related illnesses, anyone can
Bring down the patient’s body temperature quickly, develop hypothermia, but predisposing factors
to reduce the possibility of brain damage, organ put some people at a higher risk. These
failure or death. factors include:
Perform a primary assessment and then provide
care by using any of the following techniques to
A cold environment. Even if the ambient
temperature is not extremely low, hypothermia
cool the patient rapidly: can occur if a person is not adequately
protected from the cold.
Immerse the patient in cold water up to their
neck (preferred method) if it is safe to do so and A wet environment. The presence of
the resources are available. moisture (e.g., perspiration, rain, snow
or water) will increase the speed at which
Douse the patient with ice water-soaked towels
body heat is lost.
over the entire body, frequently rotating the cold,
wet towels, spraying with cold water, fanning the Wind. Wind makes the environment a lot
patient or covering the patient with ice towels or colder than the ambient temperature indicates.
bags of ice placed over the body. The higher the wind chill effect, the lower the
temperature actually is (Fig. 16-5).
If you are not able to measure and monitor the
patient’s core temperature, apply rapid cooling Age. The very young and the very old may
methods for 20 minutes or until the patient’s have difficulty keeping warm in cool or cold
LOC improves. conditions. Infants may not yet be able to
shiver effectively. Older adults may not have
Low blood pressure and rapid pulse are signs of enough body mass to retain body heat. Both
shock, so take steps to prevent or minimize shock. age groups may be unable to help themselves
Refer to Chapter 18 for more information on care stay warm by removing themselves from the
for shock. A person in heat stroke may experience cold environment or by protecting themselves
respiratory or cardiac arrest. Be prepared to give with warmer clothing. In addition, many older
ventilations or perform CPR, if needed. adults have impaired circulation.
Medical conditions. People with certain medical
conditions, such as generalized infection,
COLD-RELATED EMERGENCIES hypoglycemia, shock and head injury, may be at
Hypothermia (Generalized higher risk of developing hypothermia.
Cold Exposure) Alcohol, drugs and poisoning. Alcohol and
Hypothermia is the state of the body being colder certain types of drugs or poisons can reduce
than the usual core temperature. It is caused by either a patient’s ability to feel the cold, or can
excessive loss of body heat and/or the body’s inability cloud judgment and impede rational thought,
to produce heat. Hypothermia can come on gradually preventing the patient from taking proper
or it can develop very quickly. In hypothermia, body precautions to stay warm.
temperature drops below 95° F (35° C). Clothing inappropriate for the weather.
CRITICAL In cases of heat stroke, call for more advanced medical personnel immediately.
FACTS Your next priority is to begin rapid cooling methods, such as cold water immersion.
The quicker you can get the body temperature down, the better the outcome.
Hypothermia is the state of the body being colder than the usual core temperature.
It is caused by either excessive loss of body heat and/or the body’s inability to
produce heat.
396 | Emergency Medical Response
-9˚
9˚
32˚
Fig. 16-5: Wind speed is a main factor that could contribute to cold-related emergencies or
a decrease in body temperature.
Signs and Symptoms of Hypothermia Providing Care for Hypothermia
The signs and symptoms of hypothermia include: Your priority is to move the patient into a warmer
environment, if possible. Be careful to move the
Shivering (may be absent in later stages patient gently, as any sudden movements can cause
of hypothermia). a heart arrhythmia and possibly cardiac arrest. Then:
Numbness.
Glassy stare. Perform a primary assessment, including a pulse
check for up to 30 to 45 seconds based on
Apathy or decreasing LOC.
local protocols.
Weakness.
Call for more advanced medical personnel.
Impaired judgment.
Remove any wet clothing and dry off the patient.
In cases of severe hypothermia, the patient may Passively rewarm the patient by wrapping all
be unconscious. Breathing may have slowed or exposed body surfaces with anything at hand,
stopped. The body may feel stiff as the muscles such as warm blankets, clothing or newspapers.
become rigid. Be sure to also cover the head, since a
CRITICAL For hypothermia, your first priority is to move the patient to a warmer environment.
FACTS Other critical care steps include removing wet clothing, drying the patient, passively
rewarming the patient with dry clothes or blankets, giving the patient warm liquids,
administering supplemental oxygen based on local protocols and monitoring the
patient’s condition.
Chapter 16: Environmental Emergencies | 397
Fig. 16-6: When providing care for a patient with hypothermia, your priority is to move the patient into a
warmer environment and begin the process of passive rewarming.
significant amount of body heat is lost through Frostbite (Localized Cold Exposure)
the head (Fig. 16-6).
Frostbite is the freezing of body tissues,
If you are far from definitive healthcare, you may usually the nose, ears, fingers or toes. In both
begin active rewarming. Place the patient near superficial and deep frostbite, the situation
a heat source and apply heat pads, hot water is serious and could result in loss of the
bottles or chemical hot packs lightly wrapped in body part. In fact, frostbite of the fingers and
a towel or fabric to the wrists, ankles, armpits, toes can cause enough damage to warrant
groin and back of the neck to warm the blood in amputation of hands and feet, and even arms
major blood vessels. Active rewarming should and legs.
not delay definitive care.
Do not immerse the patient in warm water. In early (or superficial) frostbite, only the first layers
of skin are frozen. In late (or deep) frostbite, the
Do not rub or massage the extremities.
skin and underlying tissues are frozen.
Give warm, not hot, liquids that do not contain
alcohol or caffeine if the patient is alert and able
to swallow. Signs and Symptoms of Frostbite
Provide supplemental oxygen based on Signs and symptoms of frostbite include:
local protocols.
Lack of feeling in the affected area.
Monitor the patient’s condition. Capillary refill is
Swelling.
affected by cold environments, so refill may be
slow and therefore may not be an ideal method Skin that appears waxy, is cold to the touch or is
for assessing circulation. For more on capillary discolored (flushed, white, yellow, blue or black)
refill, see Chapters 7 and 8. (Fig. 16-7).
Continue to warm the patient. In more serious cases, blisters may form and the
Be prepared to perform CPR and use an affected part may turn black and show signs of
automated external defibrillator (AED), if necessary. deep tissue damage.
CRITICAL Frostbite is the freezing of body tissues, usually the nose, ears, fingers or toes.
FACTS Frostbite can cause serious damage, including loss of the body part or the need
for amputation.
398 | Emergency Medical Response
100 - 105 ºF
Fig. 16-7: Frostbitten skin features waxy skin that is cold to the
touch and flushed or appears white, yellow, blue or black. Photo:
courtesy of Nigel Vardy and Nottingham University Hospitals
NHS Trust.
Providing Care for Frostbite
As with hypothermia, the priority is to get the
patient out of the cold. Once the patient is removed
from the cold, you should also do the following: B
Fig. 16-8, A–B: (A) Gently warm the affected area by soaking
Handle the area gently. Rough handling can it in warm, not hot, water. (B) If the patient’s fingers or toes
damage the body part. Never rub the affected are frostbitten, place dry, sterile gauze between them to keep
them separated.
area, as this can cause skin damage.
If there is a chance the body part may refreeze
or if you are close to a medical facility, do not
attempt to rewarm the frostbitten area. Loosely bandage the area with dry,
sterile dressings.
For minor frostbite, rapidly rewarm the affected
If the fingers or toes are frostbitten, place
part using skin-to-skin contact such as with a
dry, sterile gauze between them to keep them
warm hand.
separated (Fig. 16-8, B). If the damage is to the
For a more serious injury, rewarm the body feet, do not allow the patient to walk.
part by gently soaking it in water not warmer
than about 105° F (41° C). If you do not have Avoid breaking any blisters.
a thermometer, test the water temperature Take precautions to prevent hypothermia.
yourself. If the temperature is uncomfortable to Monitor the person and care for shock.
your touch, it is too warm. Keep the frostbitten Do not give any ibuprofen or other nonsteroidal
part in the water until normal color returns and it anti-inflammatory drugs (NSAIDs) when caring
feels warm (for 20 to 30 minutes) (Fig. 16-8, A). for frostbite.
CRITICAL Your priority in caring for a frostbite patient is getting the patient out of the cold.
FACTS Handle the frostbitten area carefully. Rewarm in warm water, but only if there is no
risk of the body part refreezing and you are not close to a medical facility. Loosely
bandage the area. If fingers and toes are frostbitten, place dry, sterile gauze
between them. Avoid breaking blisters and take precautions to prevent hypothermia.
Chapter 16: Environmental Emergencies | 399
PREVENTING HEAT-RELATED ANAPHYLAXIS
ILLNESSES AND COLD-RELATED Severe allergic reactions to poisons are
EMERGENCIES rare, but when one occurs, it is truly a life-
threatening medical emergency. This reaction,
Generally, illnesses caused by overexposure to
called anaphylaxis, is a form of shock. It
extreme temperatures are preventable. The easiest
can be caused by an insect bite or sting, or
way to prevent illness caused by temperature
contact with certain drugs, medications, foods
extremes is to avoid being outside during the parts
and chemicals. Anaphylaxis can result from
of the day when temperatures are most extreme.
any of the four modes of poisoning (ingested,
For instance, if working outdoors in hot weather, it
inhaled, absorbed and injected) described in
is safer if the work can be done in the early morning
Chapter 15.
and evening hours when the sun is not as strong.
In cold weather, outside work is safer during the Every year in the United States, fewer than
warmer part of the day. 100 deaths are caused by anaphylaxis. Fortunately,
some deaths can be prevented if anaphylaxis is
Appropriate clothing for the weather and activity
recognized immediately and cared for quickly.
level adds protection against illness. It is best to
wear light-colored clothing in the heat, which helps
reflect the sun’s rays. In the cold, the best clothing Allergic Reactions
is made of tightly woven fibers, such as wool, to Our immune systems help to keep us healthy by
trap warm air against the body. Head coverings fighting off harmful pathogens that can cause
should be worn in both heat and cold. A hat or cap disease. But sometimes our immune systems
protects the head from the sun’s rays in the summer overreact and try to fight off ordinary things
and prevents heat from escaping in the winter. that are not usually harmful, such as certain
Also, other areas of the body, such as the fingers, foods, grass or pet dander (tiny flakes of skin
toes, ears and nose, should be protected from cold that animals shed). A person can have an
exposure by wearing protective coverings. allergy to almost anything. Common allergens
(allergy triggers) include venomous insect
Take additional precautions, such as changing stings, certain foods, animal dander, plant
activity level and taking frequent breaks. For pollen, certain medications (such as penicillin
instance, in very hot conditions, it is best to and sulfa drugs) and latex. Over 15 million
exercise only for brief periods, then rest in a cool, people in the United States have food allergies.
shaded area. Frequent breaks allow the body to Every year in the United States, over 200,000
readjust to normal body temperature, enabling visits to emergency departments are because
it to better withstand brief periods of exposure of food-related allergies. Certain types of
to temperature extremes. Avoid heavy exercise food commonly cause an allergic reaction in
during the hottest or coldest part of the day. individuals with sensitivities to those foods.
Extremes of temperature promote fatigue, which Peanuts and tree nuts cause the most cases of
hampers the body’s ability to adjust to changes in fatal and near-fatal allergic reactions to food.
the environment. Other common food allergens include cow’s
milk, eggs, seafood (especially shellfish), soy
Whether in the heat or cold, it is important to
and wheat.
drink enough fluids. Drinking at least six 8-ounce
glasses of fluids daily is the most important way
to prevent heat-related illness and cold-related Signs and Symptoms of Anaphylaxis
emergency. It is best to drink fluids when taking a An allergic reaction can range from mild to very
break. Drink cool fluids in the summer and warm severe. A person who is having a mild to moderate
fluids in the winter. Cool and warm fluids help allergic reaction may develop a skin rash, a stuffy
the body maintain a normal temperature. If cool nose, or red, watery eyes. The skin or area of the
or warm drinks are not available, drink plenty of body that came into contact with the allergen
water. Avoid beverages containing caffeine or usually swells and turns red.
alcohol, which hinder the body’s temperature-
regulating mechanism.
400 | Emergency Medical Response
A person who is having a severe, life-threatening (e.g., epinephrine) used for the emergency
allergic reaction (anaphylaxis) may develop one or treatment of anaphylaxis, offer to help them use
more of the following signs and symptoms within the medication. If you are alone, help the patient
seconds or minutes of coming into contact with administer the medication and then call for
the allergen: additional resources. While you wait for advanced
medical personnel to arrive, make sure the patient
Trouble breathing is sitting in a comfortable position, or have the
Swelling of the face, neck, tongue or lips patient lie down if they are showing signs of shock.
A feeling of tightness in the chest or throat
Skin reactions (such as hives, itchiness or flushing) Epinephrine
Stomach cramps, nausea, vomiting or diarrhea Epinephrine is a drug that slows or stops the effects
Dizziness of anaphylaxis. If a patient is known to have an allergy
that could lead to anaphylaxis, they may carry an
Loss of consciousness
epinephrine auto-injector (a syringe system, available
Signs and symptoms of shock (such as
by prescription only, that contains a single dose
excessive thirst; skin that feels cool or moist
of epinephrine). Devices are available containing
and looks pale or grayish; an altered level of
different doses because the dose of epinephrine
consciousness; and a rapid, weak heartbeat)
is based on weight (0.15 mg for children weighing
To determine if a patient is having a severe, life- between 33 and 66 pounds, and 0.3 mg for children
threatening allergic reaction (anaphylaxis), look and adults weighing more than 66 pounds). Many
at the situation as well as the patient’s signs and healthcare providers advise that people with a
symptoms (Table 16-1). known history of anaphylaxis carry an anaphylaxis
kit containing at least two doses of epinephrine (i.e.,
two auto-injectors) with them at all times (Fig. 16-9).
Care for Anaphylaxis
This is because more than one dose may be needed
If you know that the patient has had a severe to stop the anaphylactic reaction. A second dose is
allergic reaction before, and the patient is administered only if emergency medical responders
having trouble breathing or is showing signs and are delayed and the patient is still having signs
symptoms of anaphylaxis, call for more advanced and symptoms of anaphylaxis 5 to 10 minutes after
medical personnel. If the patient carries medication administering the first dose.
Table 16-1:
How Do I Know If It Is Anaphylaxis?
SITUATION LOOK FOR
You do not know if the patient has been ••Any skin reaction (such as hives, itchiness or flushing) OR
exposed to an allergen. ••Swelling of the face, neck, tongue or lips PLUS
••Trouble breathing OR
••Signs and symptoms of shock
You think the patient may have been Any TWO of the following:
exposed to an allergen. ••Any skin reaction
••Swelling of the face, neck, tongue or lips
••Trouble breathing
••Signs and symptoms of shock
••Nausea, vomiting, cramping or diarrhea
You know that the patient has been exposed ••Trouble breathing OR
to an allergen. ••Signs and symptoms of shock
Chapter 16: Environmental Emergencies | 401
Fig. 16-9: It is advisable to carry a kit containing at least two doses of epinephrine because more than one dose may be needed to stop
anaphylaxis. EpiPen® is a registered trademark owned by the Mylan companies.
It is important to act fast when a patient is having
an anaphylactic reaction because difficulty
breathing and shock are both life-threatening
conditions. If the patient is unable to self-administer
the medication, you may need to help. You may
assist a patient with using an epinephrine auto-
injector when the patient has a previous diagnosis
of anaphylaxis and has been prescribed an
epinephrine auto-injector; the patient is having
signs and symptoms of anaphylaxis; the patient
requests your help using an auto-injector; and your
state laws permit giving assistance. Where state
and local laws allow, some organizations (such as
Fig. 16-10: Pushing the auto-injector against the leg activates
public safety agencies or schools) keep a stock the device. It should be used on the muscular area of the
epinephrine auto-injector for designated staff person’s mid-outer thigh.
members who have received the proper training
to use it in an anaphylaxis emergency. If you are
using a stock epinephrine auto-injector, follow the patient’s mid-outer thigh (Fig. 16-10). Once
your organization’s emergency action plan, which activated, the device injects the epinephrine
may include verifying that the patient is showing into the thigh muscle. The device must be held
signs and symptoms of anaphylaxis, ensuring that in place for the recommended amount of time
the patient has been prescribed epinephrine in (e.g., 3 seconds, although the recommended time
the past as appropriate and making sure to use a may vary by device) to deliver the medication.
device containing the correct dose based on the Some medication may still remain in the auto-
patient’s weight. injector even after the injection is complete. After
removing the auto-injector, massage the injection
Different brands of epinephrine auto-injectors are site for several seconds (or have the patient
available, but all work in a similar fashion. Begin massage the injection site). Handle the used device
by holding the patient’s leg firmly just above the carefully to prevent accidental needlestick injuries.
knee to help prevent injury to the patient, and When placing the used auto-injector in a sharps
then activate the device by pushing it against container, hold it with one hand and avoid touching
402 | Emergency Medical Response
the tip. If a sharps container is not available,
give the auto-injector to the transporting EMS
personnel when they arrive so they can properly
dispose of the discharged device. For step-by-
step instructions on helping a patient to use an
epinephrine auto-injector, see Skill Sheet 16-1.
If a patient is awake and able to use the auto-
injector, help them in any way they ask you to.
This might include getting the auto-injector from
a purse, car, home, or out of a specially designed
carrier or belt; taking it out of the plastic tube; or
assisting with or administering the injection.
Fig. 16-11: Remove an insect stinger by scraping it away from
the skin with the edge of a rigid item, such as a plastic card.
BITES AND STINGS
Cleanse the site and cover with a dressing. A cold
Insects pack may be applied to the area to reduce pain
Between 0.5 and 5 percent of the American and swelling. Ask if the patient has any history of
population is severely allergic to substances in allergies to insect bites or stings and observe for
the venom of bees, wasps, hornets and yellow signs of an allergic reaction, even if there is no
jackets. For highly allergic people, even one known history. An allergic reaction can range from
sting can result in anaphylaxis, a life-threatening a minor localized skin rash to anaphylaxis. Look for
condition. Such highly allergic reactions account signs of anaphylaxis, including:
for an average of 34 reported deaths from insect
stings each year. For most people, however, insect Difficulty breathing, wheezing or shortness
stings may be painful or uncomfortable but are not of breath.
life threatening. Tight feeling in the chest and throat.
Swelling of the face, neck or tongue.
Providing Care for an Insect Sting Weakness, dizziness or confusion.
To care for an insect sting, follow standard Rash or hives.
precautions and examine the sting site to see if the Low blood pressure.
stinger is in the skin. Remove it, if it is still present.
Scrape the stinger away from the skin with the
Shock.
edge of a tongue depressor or plastic card, such If anaphylaxis occurs, provide emergency
as a credit card (Fig. 16-11). With a bee sting, the care immediately, including assisting with the
venom sac may still be attached to the stinger and patient’s prescribed epinephrine auto-injector
can continue to release venom for up to several or administering an epinephrine auto-injector, if
minutes afterward. Do not use tweezers to grasp local protocols allow. (For more information on
the stinger or the venom sac that could still be administering an epinephrine auto-injector, see the
attached to the stinger. Grasping the stinger or section on anaphylaxis.) Administer supplemental
venom sac could squeeze it, resulting in more oxygen based on local protocols and call for more
venom being released. advanced medical personnel.
CRITICAL In the United States, up to 5 percent of the population is severely allergic to insect
FACTS stings. Such allergic reactions account for approximately 34 reported deaths
each year.
If anaphylaxis occurs, provide emergency care immediately, including assisting with
the patient’s epinephrine auto-injector or administering an epinephrine auto-injector
if local protocols allow. Administer supplemental oxygen based on local protocols,
and call for more advanced medical personnel.
Chapter 16: Environmental Emergencies | 403
A B
Fig. 16-12, A–B: (A) A tick, such as this deer tick that spreads Lyme disease, can be as small as the head of a pin. Photo:
iStockphoto.com/Martin Pietak. (B) A person with Lyme disease may develop a rash. Photo: iStockphoto.com/Heike Kampe.
Ticks skin as possible. Pull slowly, steadily and firmly
(Fig. 16-13).
Ticks can contract, carry and transmit serious
diseases to humans. These include Rocky Mountain Do not try to burn the tick off.
spotted fever and Lyme disease (Fig. 16-12, A–B).
For signs and symptoms of these diseases, see
Do not apply petroleum jelly or nail polish to
the tick.
Table 16-2.
Place the tick in a jar containing rubbing alcohol
Providing Care for Tick Bites to kill it. Clean the bite area with soap and water,
If a tick is still embedded in the skin, it must be and apply antiseptic or antibiotic ointment if
removed. With a gloved hand, grasp the tick protocols allow and the patient has no known
with fine-tipped, pointed, nonetched, nonrasped allergies or sensitivities to the medication. Advise
(smooth inside surface) tweezers as close to the the patient to seek medical advice, because of the
risk of contracting a tickborne disease. If the tick
cannot be removed, the patient should seek more
advanced medical care.
Table 16-2:
Infections from Ticks Spiders and Scorpions
Few spiders in the United States have venom that
INFECTIOUS causes serious illness or death. However, the
SIGNS AND SYMPTOMS
DISEASE bites of black widow and brown recluse spiders
Rocky Fever, nausea, vomiting, muscle
Mountain pain, lack of appetite, severe
spotted fever headache, rash, abdominal pain,
joint pain and diarrhea
Babesia Nonspecific flu-like symptoms,
infection such as fever, chills, sweats,
headache, body aches, loss
of appetite, nausea or fatigue,
and anemia which can lead to
jaundice and dark urine
Ehrlichiosis Fever, headache, fatigue,
muscle aches, nausea, vomiting,
diarrhea, cough, joint pains,
confusion and occasional rash
Lyme disease Fever, headache, fatigue and
a characteristic skin rash (e.g., Fig. 16-13: Remove a tick that is still embedded in the skin by
“bull’s-eye”) pulling slowly, steadily and firmly on the tick with a pair of
fine-tipped, pointed, nonetched, nonrasped tweezers.
404 | Emergency Medical Response
can, in rare instances, be fatal (Fig. 16-14, A–B). Bites usually occur on the hands and arms of
The venom of recluse spiders (known as brown people reaching into places where spiders are
recluse, fiddle back or violin) is necrotizing (tissue residing. The bite of the black widow spider and
destroying), while the venom of widows (black, its relatives is the more painful and often the more
red and brown) contains neurotoxin and affects deadly, especially in very young and older adult
neuromuscular function. Symptoms will vary patients. The bite usually causes an immediate
depending on the amount of venom injected and sharp pinprick pain, followed by a dull pain in the
the patient’s sensitivity to the venom. Most spider area of the bite. Sometimes, however, no pain is
bites resolve on their own with no adverse effects felt initially. Other signs and symptoms may include
or scarring. Signs and symptoms of venomous muscular rigidity in the shoulders, chest, back
spider bites can mimic other conditions. The only and abdomen; restlessness; anxiety; dizziness,
sure way of knowing a person has been bitten by a headache and profuse sweating; weakness; and
spider is to have witnessed it. drooping or swelling of the eyelids.
A brown recluse spider bite may produce little
or no pain initially, but localized pain develops an
hour or more later. The brown recluse is also called
the “fiddle back” or “violin” spider because of the
distinctive violin-shaped pattern on the back of
its front body section. A blood-filled blister forms
under the surface of the skin, sometimes in a
target or bull’s-eye pattern. Over time, the blister
increases in size and eventually ruptures, leading to
tissue necrosis (destruction) and a black scab.
Another potentially dangerous spider is the
northwestern brown, or hobo, spider. It can
produce an open, slow-healing wound similar to
that of the brown recluse.
An antivenom to counteract the poisonous
effects of the venom is available for black widow
bites. Antivenom is used mostly for children and
older adults, and is rarely necessary when bites
occur in healthy adults.
Scorpions typically live in dry regions of the
southwestern United States and Mexico, but they
are also common in other southern regions of the
United States including Florida. They are usually
A about 3 inches long and have 8 legs and a pair of
crablike pincers (Fig. 16-15). At the end of the tail
B
Fig. 16-14, A–B: (A) Black widow spider. Photo: ©iStockphoto.com/
Mark Kostich; (B) brown recluse spider. Photo: Department of
Entomology, The Ohio State University. Fig. 16-15: Scorpion. Photo: iStockphoto.com/John Bell.
Chapter 16: Environmental Emergencies | 405
is a stinger, used to inject venom. Scorpions live Providing Care for Spider Bites
in cool, damp places, such as basements, junk and Scorpion Stings
piles, woodpiles and under the bark of living or If a patient has been bitten by a spider or stung
fallen trees. They are most active in the evening by a scorpion, wash the wound thoroughly and
and at night, which is when most stings occur. bandage it. Additionally, consider applying a
Like spiders, only a few species of scorpions topical antibiotic ointment to the bite to prevent
have a potentially fatal sting, and these are infection, if protocols allow and the patient
mostly found in the southwest. Scorpions from has no known allergies or sensitivities to the
the southeastern part of the country are usually medication. Apply a cold pack to the site to
nonpoisonous. Their sting can cause localized reduce swelling and pain. The patient should
allergic reactions similar to a bee sting and can be seek medical attention or, if severe symptoms
cared for in the same way. However, because it is are present, should be transported to a medical
difficult to distinguish highly poisonous scorpions facility, keeping the bitten area elevated and as
from nonpoisonous scorpions, all scorpion stings still as possible.
should be treated as medical emergencies. If it
is possible and safe to do so, carefully attempt to
capture the scorpion so that it could possibly be Venomous Snakes
identified as poisonous or nonpoisonous by the Snakebites kill few people in the United States.
Poison Control Center. Of the estimated 7000 to 8000 people reported
bitten annually, fewer than five die. Most deaths
General signs and symptoms of spider bites and occur because the person has an allergic reaction,
scorpion stings may include: is in poor health or because too much time
passes before the person receives medical care.
A mark indicating a possible bite or sting.
Fig. 16-16, A−D shows the four kinds of venomous
Severe pain in the sting or bite area.
snakes found in the United States. Rattlesnakes
A blister, lesion or swelling at the entry site. account for most snakebites and nearly all deaths
Nausea and vomiting. from snakebites.
Stiff or painful joints.
Signs and symptoms of a venomous
Chills or fever.
snakebite include:
Difficulty breathing or swallowing or signs
of anaphylaxis. One or two distinct puncture wounds,
Sweating or salivating profusely. which may or may not bleed. The exception
is the coral snake, whose teeth leave a
Irregular heart rhythms.
semicircular mark.
Muscle aches or severe abdominal or
back pain. Severe pain and burning at the wound
site immediately after or within 4 hours of
Dizziness or fainting.
the incident.
Chest pain.
Swelling and discoloration at the wound
Elevated blood pressure and heart rate. site immediately after or within 4 hours of
Infection of the bite. the incident.
CRITICAL If a patient has been bitten by a spider or stung by a scorpion, wash and bandage
FACTS the wound. Consider applying a topical antibiotic if no known allergies or
sensitivities to the medication exist and local protocols allow. Apply a cold pack to
reduce swelling and pain.
The patient should seek medical attention. Severe symptoms require immediate
transportation to a medical facility. While seeking more advanced medical attention,
keep the bitten area elevated and as still as possible.
406 | Emergency Medical Response
A B
C D
Fig. 16-16, A–D: (A) Rattlesnake. Photo: ©Audrey Snider-Bell, 2010, Used under license from Shutterstock.
com; (B) cottonmouth. Photo: ©Leighton Photography & Imaging, 2010, Used under license from Shutterstock.com;
(C) copperhead. Photo: Rauch, Ray/USFWS; (D) coral snake. Photo: iStockphoto.com/Mark Kostich.
Providing Care for Snakebites While considered controversial based on available
If the bite is from a venomous snake such as a evidence, some local protocols recommend the
rattlesnake, copperhead, cottonmouth or coral use of a pressure immobilization bandage (elastic
snake, call for more advanced medical personnel. bandage) to slow the spread of venom through
To give care until help arrives: the lymphatic system for all venomous snakes in
North America. However, evidence supports the
Wash the site with soap and water. Keep use of a pressure immobilization bandage only for
the injured area still and lower than the the coral snake when access to advanced care
heart. Consider splinting the extremity if and antivenom is delayed. To apply a pressure
feasible. The patient should walk only immobilization bandage follow these steps:
if absolutely necessary.
For any snakebite: Check for feeling, warmth and color of the limb
and note changes in skin color and temperature.
yy Do not apply ice.
Place the end of the bandage against the skin
yy Do not cut the wound. and use overlapping turns.
yy Do not apply suction.
The wrap should cover a long body section, such
yy Do not apply a tourniquet. as an arm or a calf, beginning at the point farthest
yy Do not use electric shock, such as from from the heart. For a joint, such as the knee or
a car battery. ankle, use figure-eight turns to support the joint.
CRITICAL To care for a venomous snakebite, wash the wound and keep the injured area still
FACTS and lower than the heart.
For any snakebite, never apply ice, cut the wound, apply suction, apply a tourniquet
or administer an electric shock.
Chapter 16: Environmental Emergencies | 407
Check above and below the injury for feeling, Get a lifeguard to remove the patient from
warmth and color, especially fingers and toes, the water as soon as possible. If a lifeguard
after you have applied an elastic roller bandage. is not available, use a reaching assist, if
By checking before and after bandaging, you possible. Avoid touching the patient with your
may be able to tell if any tingling or numbness is bare hands, which could expose you to the
from the elastic bandage or the injury. stinging tentacles.
Check the snugness of the bandaging—a Use gloves or a towel when removing any
finger should easily, but not loosely, pass under tentacles. A credit card edge or shell can be
the bandage. used to gently scrape away remaining tentacles.
Keep the injured area still and lower than the If you know the sting is from a jellyfish, irrigate
heart. Transport the patient via stretcher or the injured part with large amounts of seawater
carry the patient. The patient should walk only if as soon as possible for at least 30 seconds.
absolutely necessary. This can help to remove the tentacles and stop
the injection of venom.
Marine-Life Stings Do not rub the wound or apply a pressure
The stings of some forms of marine life are not immobilization bandage, aluminum sulfate, meat
only painful but can also make you sick and, in tenderizer or other remedies because these may
some parts of the world, can kill you (Table 16-3). increase pain.
The side effects include allergic reactions that Once the stinging action is stopped and
can cause breathing and heart problems, as well the tentacles are removed, care for pain
as paralysis and death. The lifeguards and public by hot-water immersion. Have the patient
safety officials in your area should know the types take a hot shower if possible for at least
of marine life that may be present. 20 minutes. The water temperature should be
as hot as can be tolerated (non-scalding) or
Signs and Symptoms of about 113° F (45° C) if the temperature can
Marine-Life Stings be measured.
Signs and symptoms of marine-life stings include: Pain from most jellyfish stings in U.S. waters
resolves within 20 minutes. If pain persists,
Rash, which may be red, raised or purplish in the consider applying a topical over-the-counter
shape of tentacles. lidocaine gel or cream.
Tentacles stuck to the skin. If you know the sting is from a stingray, sea
Puncture wounds (from stingrays or sea urchins). urchin or spiny fish, flush the wound with
tap water. Seawater also may be used. Keep
Pain or itching.
the injured part still and soak the affected
Swelling.
area in non-scalding hot water (as hot as the
Signs and symptoms of an allergic reaction. patient can stand) for at least 20 minutes
or until the pain goes away. If hot water is
Providing Care for Marine-Life Stings not available, packing the area in hot sand
Call for advanced life support resources if the patient may have a similar effect if the sand is hot
does not know what stung them, has a history of enough. Carefully clean the wound and apply
allergic reactions to marine-life stings, is stung on a bandage. Watch for signs and symptoms of
the face or neck, or starts to have trouble breathing. infection and check with a healthcare provider
Additional steps to take if you encounter someone to determine if a tetanus shot or additional care
who has sustained a marine-life sting include: is needed.
CRITICAL The stings of some forms of marine life are not only painful, but they can make you
FACTS sick, and in some parts of the world, can kill you. The side effects of a marine-life
sting can include allergic reactions that can cause breathing and heart problems, as
well as paralysis and death.
For stingray, sea urchin or spiny fish stings, flush the wound with tap or ocean
water, immobilize the injured part, and soak it in water as hot as the patient can
stand for 30 minutes or until the pain subsides.
408 | Emergency Medical Response
Table 16-3:
Venomous Marine Life
MARINE LIFE USUALLY FOUND
Jellyfish East and west coasts of the continental United States
Portuguese man-of-war (bluebottle jellyfish) Tropical and subtropical waters
Stingray Tropical and subtropical waters
Sea urchin Oceans all over the world (warm and cold water)
In rock pools and mud, on wave-exposed rocks, on coral reefs,
in kelp forests and in sea grass beds
Photos: jellyfish, iStock.com/Mshake; Portuguese man-of-war (bluebottle jellyfish), Yann Hubert/Shutterstock.com; stingray, iStock.com/naturediver;
sea urchin, iStock.com/naturediver.
Chapter 16: Environmental Emergencies | 409
Domestic and Wild Animals As with animal bites, if the wound is minor, clean
it with large amounts of saline or clean water
The bite of a domestic or wild animal carries
and control any bleeding. Advise the patient to
the risk of infection, as well as soft tissue injury.
seek follow-up care by a healthcare provider
Dog bites are the most common of all bites from
or medical facility. If the bite is severe, control
domestic or wild animals.
bleeding and prepare the patient for transport to a
medical facility.
Providing Care for Animal Bites
A patient who is bitten should be removed from the
situation if possible, but only without endangering WATER-RELATED EMERGENCIES
yourself or others. Do not restrain or capture the
animal. Your concerns should be for your own Drowning Incidents
safety and caring for the patient. Clean minor One of the most common water-related
wounds with large amounts of saline or clean water emergencies is drowning. Drowning occurs when
and control any bleeding. The patient should be a person experiences respiratory impairment due
transported or advised to see a healthcare provider to submersion in water. Drowning may or may
for more advanced medical care. If the wound is not result in death; however, it is the fifth most
bleeding heavily, control the bleeding and transport common cause of death from unintentional injury
the patient for further medical care. in the United States among all ages, and it rises
to the second leading cause of death among
Tetanus and rabies immunizations may be those 1 to 14 years of age. More than 3500
necessary, so it is vital that bites from any wild Americans die annually from drowning, and more
or unknown domestic animals be reported to the than 50 percent of drowning victims treated in
local health department or other agency according emergency departments require hospitalization
to local protocols. Follow local protocols regarding or transfer for further care. Children younger than
contacting animal control to capture the animal. 5 years of age have the highest rate of drowning.
Try to obtain and provide a description of the
animal and the area in which the animal was
Contributing Factors
last seen.
Drowning cannot just happen on its own. A person
must be in a situation that causes the submersion.
Humans These situations include:
Human bites are quite common and differ
from other bites because they may be more Young children left alone or unsupervised
contaminated, tend to occur in higher-risk areas around water (e.g., tubs, pools, lakes).
of the body (especially on the hands) and often Use of alcohol and recreational drugs, which
receive delayed care. Children are often the may cause people to do things they otherwise
inflictors and the recipients of human bite wounds. would not.
CRITICAL The bite of a domestic or wild animal carries the risk of infection, as well as
FACTS soft tissue injury. Dog bites are the most common of all bites from domestic or
wild animals.
Clean minor wounds from animal bites and control bleeding. Patients should seek
more advanced medical care. Heavy bleeding requires immediate control and
transportation to a medical facility.
Tetanus and rabies immunizations may be necessary. It is vital that wild or unknown
domestic animal bites are reported to the local health department or other agency
according to local protocols.
Human bites are common, tend to be more contaminated than other bites and occur
in higher-risk areas, and often receive delayed care. Caring for human bites is the
same as for animal bites.
410 | Emergency Medical Response
Traumatic injury, such as diving into a shallow Severity
body of water. Whether people die depends on how long they have
Condition or disability, such as heart disease, been submerged and are unable to breathe. It also
seizure disorder or neuromuscular disorder, can depend on the temperature of the water. Children
that may cause sudden weakness or loss of submerged in icy water have been successfully
consciousness while in the water. revived after considerable periods of time.
History of mental illness; for example,
Brain damage or death can begin to occur in as
depression, suicide attempt, anxiety or
panic disorder. little as 4 to 6 minutes. The sooner the drowning
process is stopped by getting the patient’s airway
out of the water, opening the airway and providing
resuscitation (ventilations or CPR), the better
Shallow Water the chances for survival without permanent brain
damage. If the submersion lasts any longer, often
Blackout the result is death. These times are estimates; brain
damage and/or death can occur more quickly.
The practice of voluntarily hyperventilating
(extremely rapid or deep breathing) followed
by holding one’s breath and then swimming Signs and Symptoms of Drowning
underwater or holding one’s breath for Signs of a drowning incident include:
extended periods of time is dangerous
and can be fatal. Some swimmers use this Persistent coughing.
technique to try to swim long distances Shortness of breath or no breathing at all.
underwater or to try to hold their breath for Disorientation or confusion.
an extended period while submerged in Unconsciousness, although the patient may
one place. have regained consciousness.
People mistakenly think that by taking a Vomiting.
series of deep breaths in rapid succession Respiratory and/or cardiac arrest.
and forcefully exhaling, they can increase Signs of a fatal drowning incident include:
the amount of oxygen they breathe, allowing
them to hold their breath longer underwater. Unconsciousness.
This is not true. Instead, it lowers the carbon No breathing.
dioxide level in the body. The level of carbon
dioxide in the blood is what signals a person
No pulse.
to breathe. Rigor mortis.
Because drowning victims may appear deceased
When a person hyperventilates and then
when they are not (imperceptible heart rate and
swims underwater, the oxygen level in the
breathing), CPR and emergency efforts are
blood can drop to a point where the swimmer
recommended in all cases.
passes out before the carbon dioxide
level is high enough to trigger the need
to inhale. When the need to inhale finally Water Rescues
does trigger instinctively, water rushes into Before beginning the rescue, consider the patient’s
the unconscious person’s mouth and nose, condition, the condition of the water and the
causing laryngospasm and allowing the resources available once you get the patient on dry
drowning process to begin. Even highly skilled land. Also consider the responders’ ability to affect
swimmers can die from this practice. a rescue safely. You should make every effort to
assist without entering the water.
CRITICAL Contributing factors for submersion incidents include children left alone or
FACTS unsupervised around or with access to water, use of alcohol and recreational drugs,
traumatic injury, sudden illness or mental illness.
Chapter 16: Environmental Emergencies | 411
Patient’s Condition Additional hazards. In floods or situations where
Ask yourself the following questions: a motor vehicle is submerged, there is the
potential for exposure to a hazardous material,
Is the patient responsive and able to cooperate such as oil or gas. Hazardous materials may also
with the rescue? If so, the safest method may be escape from buildings in a flood.
a reaching or throwing assist, such as by using a
pole or rope. Resources Available
What position is the patient in? If the patient Determine what other resources are available
is submerged, basic life support will likely to assist in a water rescue. Are you the
be needed right away. Submersion may also only responder? Will there be several other
make it difficult to find the patient in murky or responders available once you get the patient
cloudy water. on dry land? Are they all able to swim? Are there
Does the patient seem to be injured? If so, you sufficient personal flotation devices (PFDs) for
may have to remove the patient from the water each responder?
before providing care.
Is their condition potentially due to head or neck Rescuing the Victim
trauma (e.g., a diving incident)? If so, you may People who drown are not always in easy-to-
need to stabilize the spine while attempting to manage situations. If the patient is in the water,
remove the patient from the water. consider your own safety before all else when
attempting a water rescue.
Condition of the Water
As mentioned earlier, water rescues require special
There are several aspects of the water’s condition
training and should only be attempted by those
that will influence how you respond to a water
who are properly trained. To attempt a water
rescue, including:
rescue, you must be:
Visibility. Are you able to see the patient and
A good swimmer.
visualize any injuries? Are you able to see any
hazards under the water? Specially trained in water rescue.
Water temperature. You will need to continue Wearing a PFD.
resuscitation for a cold-water drowning until Accompanied by other qualified responders.
the patient is rewarmed at the hospital. Also,
If you are not trained in water rescue, do not
consider the type of clothing the patient
attempt one unless the patient is conscious and
is wearing. A wetsuit provides much more
close to shore and the emergency has taken place
protection against hypothermia than do
in open, shallow water with a stable bottom.
street clothes.
Movement of the water. How fast is the water Before entering the water, be sure you are secure
flowing? Fast-flowing water can be deceivingly so you will not be pulled in. Any sturdy object that
strong. If the water is above your knees, do can be grasped will do.
not attempt to wade through without being
harnessed. Otherwise, you could be swept Follow the “reach, throw, row then go” technique
away. Also, be aware that a patient’s location (Fig. 16-17, A–C). You can reach with an object,
can change in fast-moving water. such as an oar, a sturdy branch or even a large
towel. If the victim is too far for a reaching assist,
Depth of the water. Is the depth of the water
you can throw out a floating object for the victim
such that you will be able to stand or will you
to hang on to, such as a life preserver or even an
require additional equipment?
CRITICAL Submersion situations are not always easy to manage. Consider your own safety
FACTS above all else when working on a water rescue. Water rescues require special
training and should only be attempted by properly trained responders.
To perform a water rescue, follow the “reach, throw, row then go” technique. “Go” is
only for those who are trained to perform deep-water rescue.
412 | Emergency Medical Response
A B
C
Fig. 16-17, A–C: (A) Reaching assist; (B) throwing assist; (C) rowing assist. Consider your own safety before
following the “reach, throw, row then go” technique to rescue a person from the water. “Go” only if you are
trained to do so.
empty picnic cooler. Tie a rope to this object if Providing Care for Drowning
possible, so you can pull the victim to shore. Remove any victim of a drowning incident
If possible, use a boat to get closer (row), but from the water as soon as possible. How and
not close enough that the victim can grab the when to remove the victim depends on their
side of the boat and tip it. The “go” part of this overall condition (e.g., LOC), the victim’s size,
technique is only for those who are trained the potential for spinal injury, how soon help
and who can perform deep-water rescue. is expected to arrive and whether anyone can
Further training in water rescue is available help. The priority in providing care in a water
in other American Red Cross courses, such emergency is ensuring the patient’s face (mouth
as Lifeguarding. and nose) is out of the water and appropriate care
Chapter 16: Environmental Emergencies | 413
is given. Ventilations and/or CPR must be initiated PUTTING IT ALL TOGETHER
immediately on an unresponsive patient who
Environmental emergencies include a wide range
is not breathing and has no pulse. Ventilations
of situations that often occur during the course
may be started in the water; however, chest
of everyday events. As an emergency medical
compressions cannot. If CPR is required, the
responder (EMR), it is important you know how to
patient must be removed from the water first. If
identify the signs and symptoms of environmental
a spinal injury is suspected, minimize movement
emergencies and be able to provide appropriate care.
to the spine, but priority must be given to airway
management. Make sure additional personnel Maintaining body temperature is vital for proper cell
have been summoned. function. If the body temperature drops below or
rises above the acceptable level, the body tries to
Follow local protocols for spinal motion restriction.
protect itself but can only do so to a certain extent. If
This may include the application of a cervical
the body cannot protect itself, it begins to shut down.
collar (C-collar), as well as using a backboard or
Therefore, it is crucial for you to be able to identify
another extrication device to remove the patient
the various issues that can contribute to heat-related
from the water. Before you place the patient
illnesses and cold-related emergencies, including
on the backboard, make sure there are enough
who is at highest risk of falling ill and how to help a
responders helping you. Their role is to make sure
patient who is succumbing to such an emergency.
the patient’s face does not become submerged.
Once the head and neck are stabilized, slide the While there are many thousands of species
board under the patient. Let the board float up of snakes, spiders and insects, only a few are
until it is against the patient’s back. Secure the venomous and pose any danger to humans. Quick
patient to the backboard. action by the EMR can minimize or reduce the
effects of a sting or bite that has the potential to
Many patients who have been submerged
cause a serious reaction.
vomit because water has entered the stomach
or air has been forced into the stomach during Finally, with all the access to water in this country,
ventilations. If the patient vomits, roll them onto be it a bathtub, a bucket full of water, a creek or the
their side to prevent aspiration or choking. To ocean, people are constantly exposed to the danger
remove vomit from the mouth, use a finger or of drowning, particularly young children. As always, it
suction device. is essential that EMRs ensure their own safety before
Always take patients who have been involved in a they try to help others, so you must know your limits
when it comes to water rescues. You cannot help a
drowning incident to the hospital, even if you think
drowning person if you become a victim yourself.
the danger has passed. Complications can develop
as long as 72 hours after the incident and may Drownings can be caused by other emergencies,
be fatal. such as a spinal injury or a cardiac arrest. An EMR
For more information on water rescues, refer to must be prepared for any situation when it comes
to water rescue.
Chapter 32.
You Are the Emergency Medical Responder
Based on your findings, you suspect that the snake was venomous and the patient appears to
be reacting to the bite. What initial care can you provide? What else should you do and why?
414 | Emergency Medical Response
Skill Sheet
Skill Sheet 16-1
Administering an Epinephrine Auto-Injector
After conducting a scene size-up, checking the patient, and calling for more advanced medical
personnel, check the auto-injector:
■■ Remove the auto-injector from the carrier tube or package, if necessary.
■■ If applicable, confirm it is prescribed for the patient.
■■ Check the expiration date of the auto-injector. If it has expired, do not use the auto-injector.
■■ If the medication is visible, confirm that the liquid is clear and not cloudy. If it is cloudy,
do not use it.
Put on disposable latex-free gloves and make sure the patient is sitting or lying down.
NOTE: These instructions are based on the EpiPen®. If you are using a different device, follow the
manufacturer’s instructions.
If the patient is unable to self-administer the auto-injector, and if state regulations allow and you are
authorized by your organization to do so:
STEP 1
With the patient sitting or lying down, locate the outside middle of one thigh to use as an
injection site.
NOTE: If injecting through clothing, check that there are no obstructions at the injection site
(such as a pant seam, keys or a mobile phone).
STEP 2
Grasp the auto-injector firmly in one fist, and pull off the
safety cap with your other hand.
NOTE: Hold the auto-injector with the orange tip (needle
end) pointing down; pull straight up on the blue safety cap
without bending or twisting it.
NOTE: Never put your thumb, fingers or hand over the ends
of the auto-injector.
STEP 3
Hold the patient’s leg firmly just above the knee to limit movement during the injection. While
you are holding the patient’s leg, make sure your hands are a safe distance away from the
injection site.
▼ (Continued)
Chapter 16: Environmental Emergencies | 415
Skill Sheet
Skill Sheet 16-1
Administering an Epinephrine Auto-Injector Continued
STEP 4
Hold the auto-injector so that the needle end of the auto-
injector is against the patient’s outer thigh at a 90-degree
angle (perpendicular) to the thigh.
STEP 5
Quickly and firmly push the tip straight into the outer thigh. You will hear and/or feel a click
indicating that the spring mechanism in the auto-injector has been triggered.
STEP 6
Hold the auto-injector firmly in place for 3 seconds (counting “1-1000; 2-1000; 3-1000”) to
deliver the medication.
STEP 7
Remove the auto-injector from the thigh carefully and
massage (or have the patient massage) the injection area
with gloved hands for 10 seconds.
STEP 8
Encourage the patient to remain seated and to lean forward to make it easier for them to
breathe. If signs and symptoms of shock are present, encourage the patient to lie down and
provide reassurance to the patient while waiting for more advanced medical personal to arrive.
▼ (Continued)
416 | Emergency Medical Response
Skill Sheet
Skill Sheet 16-1
Administering an Epinephrine Auto-Injector Continued
STEP 9
Handle the used auto-injector carefully while placing it in a
sharps container with one hand, and avoid touching the tip
of the auto-injector. If a sharps container is not available,
give the auto-injector to the transporting EMS personnel
when they arrive so they can properly dispose of the
discharged device.
STEP 10
After administering the injection, ensure more advanced medical personnel has been called if
this has not already been done, and monitor the patient’s response as follows:
■■ Continue to reassure the patient.
■■ Ask the patient how they feel.
■■ Check the patient’s breathing.
If, after 5 to 10 minutes, more advanced medical personnel have not arrived and if symptoms of
anaphylaxis have not improved or they have improved but have gotten worse again, administer
a second dose of epinephrine in the other thigh.
Chapter 16: Environmental Emergencies | 417
ENRICHMENT
Lightning
On average, lightning causes more deaths annually in the United States than any other weather hazard, including
blizzards, hurricanes, floods, tornadoes, earthquakes and volcanic eruptions. The National Weather Service
(NWS) estimates that lightning kills nearly 100 people annually and injures about 300 others.
Lightning occurs when particles of water, ice and air moving inside a storm cloud lose electrons. Eventually,
the cloud becomes divided into layers of positive and negative particles. Most electrical currents run between
the layers inside the cloud. However, occasionally the negative charge flashes toward the ground, which has a
positive charge. An electrical current travels back and forth between the ground and the cloud many times in the
moment you see lightning flash. Anything with demonstrable height (e.g., a tower, tree or person) can provide a
path for electrical current.
Traveling at speeds of up to 300 miles per second, a lightning strike can hurl a person through the air, burn
clothes off and cause the heart to stop beating. The most severe lightning strikes carry up to 50 million volts of
electricity, enough to light 13,000 homes. Lightning can “flash” over a person’s body or, in its more dangerous
path, it can travel through blood vessels and nerves to reach the ground.
Besides burns, lightning can also cause neurological damage, fractures and loss of hearing or eyesight.
The patient sometimes acts confused and may describe the episode as getting hit on the head or hearing
an explosion.
People should use common sense during thunderstorms to prevent being struck by lightning. If a thunderstorm
threatens, the NWS advises individuals to:
Postpone activities promptly and not wait for rain to begin. Thunder and lightning can strike without rain.
Go quickly inside a completely enclosed building, not a carport, open garage or covered patio. If no
enclosed building is convenient, a cave is a good option outside, but move as far back as possible from the
cave entrance.
Watch cloud patterns and conditions for signs of an approaching storm.
Designate safe locations and move or evacuate to a safe location at the first sound of thunder. Every 5 seconds
between the flash of lightning and the sound of thunder equals 1 mile of distance.
Use the 30-30 rule where visibility is good and there is nothing obstructing your view of the thunderstorm.
When you see lightning, count the time until you hear thunder. If that time is 30 seconds or less, the
thunderstorm is within 6 miles. Seek shelter immediately. The threat of lightning continues for a much longer
period than most people realize. Wait at least 30 minutes after the last clap of thunder before leaving shelter.
If inside during a storm, keep away from windows. Injuries may occur from flying debris or glass if a
window breaks.
Stay away from plumbing, electrical equipment and wiring during a thunderstorm. Water and metal are both
excellent conductors of electricity.
Do not use a corded telephone or radio transmitter except for emergencies.
If people are caught in a storm outdoors and cannot find shelter, they should avoid:
Water.
High ground.
Open spaces, such as meadows, football fields and golf courses.
All metal objects, including electric wires, fences, machinery, motors and power tools.
Unsafe places, such as under canopies, under small picnic shelters or rain shelters, or near trees.
418 | Emergency Medical Response
ENRICHMENT
Lightning continued
If lightning is striking nearby when people are outside and cannot access shelter, they should:
Crouch down and limit the amount of the body that is touching the ground (Fig. 16-18). Feet should be placed
together. If possible, weight should be placed on only the balls of the feet. Hands can be placed over the ears
to minimize possible hearing damage from thunder.
Avoid proximity to other people. A minimum distance of 15 feet between people should be maintained.
If there is a tornado alert, a previously specified location (as indicated by a disaster plan) should be located as
soon as possible. This may be the basement or the lowest interior level of a building.
Fig. 16-18: If lightning is striking nearby when people are outside and cannot access shelter, they
should crouch down and limit the amount of the body that is touching the ground. Photo: courtesy of
the Canadian Red Cross.
Chapter 16: Environmental Emergencies | 419
ENRICHMENT
SCUBA and Free Diving Emergencies
The growing popularity of SCUBA (self-contained underwater breathing apparatus) and free diving has
increased the number of diving-related incidents that occur each year. Most of these incidents are the result
of complications arising from the fact that pressure underwater is greater than that on land, with the pressure
increasing relative to the depth.
SCUBA
Barotrauma simply means pressure-related (baro) injury (trauma), and results from the inability to equalize the
body’s internal pressure with that of the external environment. The most frequent examples of barotrauma occur
in air travel and SCUBA diving. The external pressure exerts a crushing type force on the body parts affected;
hence the nickname, “lung squeeze.” Barotrauma can affect multiple areas of the body. Signs and symptoms may
vary depending on the body part or parts affected. The most common areas affected are the lungs, face and ears,
with predominant signs and symptoms including pain in the affected area, disorientation, dizziness, nausea and
bleeding from the mouth, nose or ears.
Pulmonary Overinflation Syndrome
Pulmonary Overinflation Syndrome (POIS), or Pulmonary Overpressure Syndrome, occurs because gases under
pressure (including air) contract and take up less volume. The air inhaled at depth will expand during ascent as the
pressure decreases, and can go beyond the lungs’ capacity. If a SCUBA diver holds their breath while ascending,
the lungs can rupture, hence the common name “burst lung.” POIS can also result in arterial gas embolism, as
the excess volume of air created on ascent can be forced into the bloodstream and travel to the brain. Signs and
symptoms may include numbness or tingling of the skin, weakness, paralysis and loss of consciousness.
Under pressure, inert gases from inhaled air—mostly nitrogen—are absorbed into body tissues at higher
concentration than normal. The longer time spent at depth, the more this occurs. In addition, at increased depths,
more gases are forced into body fluids and tissues due to the increased pressure.
Decompression Sickness
Decompression sickness occurs when a diver ascends too quickly, without sufficient time for gases to exit
body tissues and be removed from the body through exhalation. These gases expand as pressure decreases
during ascent, creating bubbles in the body. Decompression sickness is often called “the bends” because when
these bubbles occur in joints (specifically the elbow, shoulder, knee and/or hip), the joint(s) involved feels better
when held bent rather than held straight. Type I decompression sickness signs and symptoms include:
Rash.
Dull, deep and/or throbbing pain in the body tissues or joints.
Itching or burning sensation of the skin or bubbles under the skin (subcutaneous emphysema).
Type II signs and symptoms can have delayed onset of up to 36 hours and include the following:
Pulmonary problems, such as:
yyA burning sensation in the chest upon inhalation
yyNon-productive coughing
yyRespiratory distress
Hypovolemic shock and neurological symptoms
420 | Emergency Medical Response
ENRICHMENT
SCUBA and Free Diving Emergencies continued
Nitrogen Narcosis
Another common danger to recreational divers is nitrogen narcosis. This condition occurs at depths over 100 feet
when the pressure causes nitrogen to dissolve into brain nerve membranes. This causes a temporary disruption
in nerve transmission, resulting in an altered LOC similar to intoxication. It is particularly dangerous because, like
any type of intoxication, judgment is impaired and bad judgment underwater can lead to the conditions mentioned
above or drowning.
Free Diving
Free diving is an extreme sport in which divers compete to see how deep they can dive without any underwater
breathing apparatus. This is accomplished through excessive breath holding and hyperventilation. It is a
dangerous activity because of the risk of loss of consciousness due to lack of oxygen to the brain (hypoxia),
and subsequent drowning. Some divers utilize buoyancy devices to pull them to the surface if they lose
consciousness, but this is not a reliable method of getting to oxygen in time. Other conditions associated with
free diving include barotrauma, ear perforation, nitrogen narcosis and drowning.
Providing Care
All of the conditions mentioned above are life threatening and require immediate medical attention. The diver
needs immediate medical attention if they lose consciousness, show paralysis or show symptoms of stroke within
10 minutes of surfacing.
If the patient is alert, place them in a supine position.
If their mental state is altered, place the patient in a supine (face-up) position.
If a spinal injury is suspected, maintain spinal motion restriction.
If breathing appears adequate, administer supplemental oxygen, if available, based on local protocols.
If breathing is inadequate, begin positive pressure ventilation and log the exact time of oxygen delivery.
If needed, initiate ventilations or CPR and apply the AED.
Try to obtain the patient’s diving log and bring it to the hospital. (Divers keep diving logs to mathematically track
how long they have been at a given depth in order to avoid decompression sickness.)
Transport immediately or call for more advanced medical personnel.
Medical control will determine if the patient should be transported directly to a facility with a recompression
(hyperbaric) chamber. The Divers Alert Network (DAN) maintains a list of recompression facilities
and can be reached around the clock at 919-684-9111 or 919-684-4326 collect; you can also visit
diversalertnetwork.org.
Chapter 16: Environmental Emergencies | 421
17 BEHAVIORAL
EMERGENCIES
You Are the Emergency Medical Responder
Your fire rescue unit responds to a local mall concerning a man who is threatening
violence to anyone who comes near him. When you arrive, police and security guards
have the man in protective custody and are trying to calm him down. As you begin
interviewing the man and taking a history, his mood abruptly swings to one of remorse
and sadness. The smell of alcohol on his breath is overpowering. How would you
respond to this patient and what are some things you can do to earn his trust?
KEY TERMS
Anxiety disorder: A condition in which normal Mania: An aspect of bipolar disorder characterized
anxiety becomes excessive and can prevent by elation, hyperexcitability and accelerated
people from functioning normally; types include thoughts, speech and actions.
generalized anxiety disorder, obsessive-compulsive
disorder, panic disorder, post-traumatic stress Panic: A symptom of an anxiety disorder,
disorder, phobias and social-anxiety disorder. characterized by episodes of intense fear and
physical symptoms such as chest pain, heart
Behavior: How people conduct themselves or palpitations, shortness of breath and dizziness.
respond to their environment.
Paranoia: A condition characterized by feelings of
Behavioral emergency: A situation in which persecution and exaggerated notions of perceived
a person exhibits abnormal behavior that is threat; may be part of many mental health
unacceptable or intolerable, for example violence disorders and is rarely seen in isolation.
to oneself or others.
Phobia: A type of anxiety disorder characterized by
Bipolar disorder: A brain disorder that causes strong, irrational fears of objects or situations that
abnormal, severe shifts in mood, energy and a are usually harmless; may trigger an anxiety or
person’s ability to function; the person swings from panic attack.
the extreme lows of depression to the highs of
mania; also called manic-depressive disorder. Rape: Non-consensual sexual intercourse often
performed using force, threat or violence.
Child abuse: Action that results in the physical or
psychological harm of a child; can be physical, Rape-trauma syndrome: The three stages a victim
sexual, verbal and/or emotional. typically goes through following a rape: acute,
outward adjustment and resolution; a common
Child neglect: The most frequently reported type of response to rape.
abuse in which a parent or legal guardian fails to
provide the necessary, age-appropriate care to a Schizophrenia: A chronic mental illness in which
child; insufficient medical or emotional attention or the person hears voices or feels that their thoughts
respect given to a child. are being controlled by others; can cause
hallucinations, delusions, disordered thinking,
Clinical depression: A mood disorder in which feelings movement disorders and social withdrawal.
of sadness, loss, anger or frustration interfere with
everyday life for an extended period of time. Self-mutilation: Self-injury; deliberate harm to one’s
own body used as an unhealthy coping mechanism
Elder abuse: Action that results in the physical to deal with overwhelming negative emotions.
or psychological harm of an older adult; can be
physical, sexual, verbal and/or emotional, usually Sexual assault: Any form of sexualized contact with
on someone who is disabled or frail. another person without consent and performed
using force, coercion or threat.
Elder neglect: A type of abuse in which a caregiver
fails to provide the necessary care to an older adult. Suicide: An intentional act to end one’s own life,
usually as a result of feeling there are no other
Hallucination: Perception of an object with no options available to resolve one’s problems.
reality; occurs when a person is awake and
conscious; may be visual, auditory or tactile.
LEARNING OBJECTIVES
After reading this chapter, and completing the class • Make appropriate decisions about care when given
activities, you will have the information needed to: an example of an emergency in which someone is
experiencing a behavioral emergency.
• Identify behavior that suggests a person may be
experiencing a behavioral emergency. • Identify risk factors for suicide.
• Describe how to approach and care for a • Describe how to assess a patient who is
patient experiencing a behavioral change or contemplating or has already attempted violence
psychological crisis. toward themselves.
Chapter 17: Behavioral Emergencies | 423
INTRODUCTION not necessarily mean that it is. A person may be
carrying a weapon or other object, or have one
Behavior is how people conduct themselves nearby, that could cause injury. Always be prepared
or respond to their environment. A behavioral for any potential threat, keep your eyes on the
emergency is a situation in which a patient person and never turn your back.
exhibits abnormal behavior that is unacceptable or
intolerable. Such is often the case with people who Observe the person’s general appearance and
become violent, attempt to take their own lives or behavior as you talk. Determine the person’s level
believe that other people are out to harm them. A of consciousness (LOC) and activity level. Is the
behavioral emergency can pose unique problems person active or subdued? How does the person
that, as an emergency medical responder (EMR), speak? Explain what you would like to do, including
you will have to manage. checking vital signs and providing care for any
injuries, such as external bleeding. If family or
friends of the patient are available, ask if the patient
BEHAVIORAL EMERGENCIES has a history of aggressive behavior or if there
A behavioral emergency can be present in are any underlying medical issues. A seemingly
someone who acts abnormally, or in ways that intoxicated person may have an underlying medical
are unacceptable or dangerous to themselves, condition that is triggering the behavior.
their family or the community at large. People
Signs and symptoms commonly seen during a
exhibiting abnormal behavior may be violent toward
behavioral emergency may present with a rapid
themselves or others. They may appear agitated or
onset and include:
speak in a rapid or incoherent manner, or they may
be subdued or withdrawn. They may also appear to Emotional reactions such as panic, anxiety, fear,
be intoxicated. agitation, depression, withdrawal, confusion and
anger.
Assessment Unusual appearance.
Assume that a patient with a behavioral emergency Unusual speech patterns.
has an altered mental status. Size up the scene Abnormal or bizarre behavior or thought
to gather information relevant to safety. Consider patterns.
the mechanism of injury (MOI) or nature of Loss of contact with reality.
illness. When it is safe to enter the scene, remain
cautious as you approach the person (Fig. 17-1).
Aggressive behavior including threats or intent
to harm self or others.
Just because the scene may appear safe does
Fig. 17-1: Approach a person having a behavioral emergency with caution.
424 | Emergency Medical Response
CRITICAL A behavioral emergency is a situation in which a patient exhibits abnormal behavior
FACTS that is unacceptable or intolerable. Such is often the case with people who become
violent, attempt to take their own lives or believe that other people are out to harm
them.
Signs and symptoms commonly seen during a behavioral emergency may present
with a rapid onset and can include emotional reactions, such as fear, panic or
anger; unusual appearance or speech; abnormal or aggressive behavior; loss of
bladder control and hallucinations.
Certain odors on the patient’s breath, such person copes or fails to cope can lead to an
as alcohol. emotional situation that the person cannot
Pupils that are dilated, constricted or that handle. People can react with uncontrollable
react unequally. crying, denial, anger or depression.
Excess salivation.
Other circumstances that can lead to altered
Loss of bladder control.
behavior include heat or cold exposure, diabetes,
Visual hallucinations.
low blood sugar, lack of oxygen, shock, head
trauma, brain infection, seizure disorders, poisoning
Behavioral Changes or drug overdose, withdrawal from alcohol or
Causes of Behavioral Emergencies drugs, mind-altering substance or substance
abuse and problems with the nervous system
The primary causes of behavioral emergencies
associated with aging.
include:
Some behavioral emergencies may pose a
Injury. Any condition that reduces the amount of
particular danger to the EMR, to the patient and
oxygen to the brain, such as a head injury, can
to others, including when the patient displays
result in a significant change in behavior. Too
agitation, bizarre thinking and behavior, danger to
little oxygen could make a normally calm person
themselves or danger to others.
suddenly become anxious or even violent.
Cognitive changes associated with head injury
can also be factors in behavioral change. Excited Delirium Syndrome
Physical illness. Excited delirium syndrome poses challenges for
Past history of behavioral emergency. police as well as EMS personnel. With excited
Alcohol or drug use or abuse. delirium, the person exhibits some or a combination
of the following signs and symptoms:
Noncompliance regarding taking prescribed
psychiatric medications.
Agitation
Adverse effects of prescribed medications.
Violent or bizarre behavior
Mental illness. Mental illnesses that can alter
Insensitivity to pain
behavior include depression, schizophrenia
and bipolar disorder. The exact cause of mental Extreme increase in body temperature
illness is not always known, but it is sometimes Individuals with excited delirium develop high body
the result of a chemical abnormality in the brain. temperatures. They may also exhibit increased
The behavior exhibited by a patient with a mental body strength. Unfortunately, this syndrome is life
illness can be bizarre and can include excited or threatening, and if immediate advanced medical
depressed behavior. intervention is not sought out, it usually ends in
Extreme stress. Extreme emotional distress, death. This syndrome is most often associated
such as grief at the loss of a loved one, can with incidents involving the police. It can be
trigger a change in an individual’s behavior. associated with drug use, particularly cocaine
People react differently to stressful situations. or methamphetamine, but can occur in non-drug
The impact of the incident and the way the users as well.
Chapter 17: Behavioral Emergencies | 425
PSYCHOLOGICAL EMERGENCIES A person having a phobic reaction, such as an
anxiety or panic attack, may display any of these
Anxiety and Panic behaviors:
While a certain amount of anxiety is a normal
reaction to stress, excessive anxiety may be Irrational fear
part of an anxiety disorder. There are several Unexplained, uncontrolled anxiety
types of anxiety and panic disorders, all with Desire to flee the situation or avoid the object
potential to have dramatic effects on the afflicted Inability to continue functioning as long as the
person. People having a severe anxiety or panic person is in the situation or the object is present
attack are in real distress and need assistance.
A person’s anxiety and panic are often based Acknowledgement that the fear reaction is out of
proportion to the situation or event
on the feeling that they have no control over
the situation and a fear of what may happen Physical symptoms such as heart palpitations,
difficulty breathing and sweating
next. Anxiety attacks can last any length of time,
but panic attacks generally last no longer than
30 minutes. Clinical Depression
Although clinical depression is a chronic illness,
Someone who is experiencing an anxiety attack
people who are clinically depressed can have an
may show any of these signs and symptoms:
emergency that may trigger thoughts of suicide.
Fatigue Depression is more than just “the blues.” It is a
recognized medical illness that may require not only
Headaches
psychological therapy but also medical intervention.
Muscle tension
Muscle aches It is important to keep in mind that there are many
Difficulty swallowing ways people can exhibit signs and symptoms
of depression, including thoughts of impending
Trembling or twitching
suicide. For more information about suicide, refer to
Irritability
the section later in this chapter.
Sweating
Hot flashes Signs and symptoms of clinical depression are
numerous. They include but are not limited to:
People experiencing a panic attack may have any of
the above signs and symptoms, as well as: Persistent feeling of being useless.
Loss of interest in regular activities.
Difficulty breathing.
Feeling hopeless or guilty.
Heart palpitations.
Unexplained sadness.
An out-of-control feeling.
Crying spells.
Phobias Irritability and restlessness.
Insomnia or sleeping too much.
Phobias are irrational fears of objects or events
that are usually harmless. They can cause an Lack of appetite or overeating (followed by
weight loss or gain).
anxiety or panic attack. When people have a
phobia about a certain situation or event, they may Inability to concentrate and make decisions.
display an exaggerated response of fear, referred to Physical aches and pains with no medical basis.
as a phobic reaction, when exposed to the situation Loss of sexual desire.
or event. Thoughts of suicide.
CRITICAL The primary causes of behavioral emergencies include injury, physical illness, past
FACTS history of behavioral emergencies, alcohol or drug use/abuse, noncompliance
regarding taking prescribed psychiatric medications, adverse effects of prescribed
medications, mental illness and extreme stress.
426 | Emergency Medical Response
Bipolar Disorder Patients who are paranoid may display behaviors
such as:
Bipolar disorder is a mental illness in which
the person swings from the extreme lows of Checking for wiretaps (bugs) in every room.
depression to the highs of mania. A person with
mania exhibits elation, hyperexcitability and
Accusing people of following them or listening
to their conversations.
accelerated thoughts, speech and actions. Bipolar
disorder is sometimes called manic-depression. Being suspicious of every person who
approaches them.
Because of the extreme mood swings, the person
can be in danger of self-harm when on either end Refusing to eat or drink anything that they have
of the spectrum. When depressed, the person may not prepared.
consider suicide. When manic, self-destructive
or risky behaviors could result in severe injury Schizophrenia
or death. Schizophrenia is a severe, chronic mental illness
Someone who is in a depressive episode would in which the person hears voices or feels that their
exhibit signs and symptoms of depression such as thoughts are being controlled by others. These
feeling useless or hopeless, alternating between voices or thoughts can instruct the person to do
sleeping too much or too little, being unable to go things they would otherwise not do, like becoming
to work and being unable to concentrate. When violent toward a family member or a stranger. For
experiencing the manic phase, the person could this reason, you must exercise particular caution
show signs and symptoms such as: when attempting to help a patient whom you know
or suspect suffers from schizophrenia.
Rapid speech and quickly changing thought
Someone with schizophrenia may display some or
patterns.
all of the following:
Inability to sit still and/or concentrate.
Inability to finish a task. Hallucinations (visual or auditory, but mostly
Euphoria. auditory)
Increased physical activity. Delusions
Participating in risky activities. Lack of personal care or hygiene
Inability to sleep. Inappropriate emotions for the situation or lack
of emotions altogether
Increased desire to have sex.
Agitation. Anger
Aggressive behavior. Suspicions and paranoid behavior
Social isolation
Paranoia
Paranoia is a condition characterized by VIOLENCE
feelings of persecution and exaggerated notions Behavioral emergencies require extra sensitivity.
of perceived threat. It may be part of many Every person copes in a different way and every
mental health disorders and, rarely, is seen in person has a breaking point. People experiencing
isolation. Paranoia is marked by irrational and a behavioral emergency may have no control over
delusional behavior. Paranoid individuals often what they are feeling at any given moment, and
believe that someone or several people are “out those feelings are real and valid. A behavioral
to get them.” Paranoia can be limited to believing emergency may cause a person to become violent
that they are being watched or followed, or it toward self or others. A head injury, low blood
can become more fantastical in nature, such sugar in someone with diabetes, a lack of oxygen,
as believing there are implants in the brain and mind-altering substances (such as alcohol,
being monitored by people who want to do the depressants, stimulants or narcotics) can all cause
paranoid person harm. Paranoia can also be a a person to act in a violent manner.
side effect of medication or recreational drug
use, particularly stimulants.
Patients Who Are Violent
If a patient is paranoid, it can be difficult for you to Toward Themselves
provide care because they may fear that you are Patients who are violent toward themselves may
part of the plot or group trying to cause harm. attempt or threaten suicide. Your primary concern
Chapter 17: Behavioral Emergencies | 427
CRITICAL People experiencing a behavioral emergency may have no control over what
FACTS they are feeling at any given moment and can become violent toward themselves
or others.
Males are about four times more likely to commit suicide than females, although
females are more likely to have suicidal thoughts. People of any age, race or
socioeconomic status are at risk of making suicide attempts.
as an EMR is to treat any injuries or medical Serious illness or death of a close family
conditions arising from the violence or suicide member or friend.
attempt and then transport the patient to a facility Serious, prolonged or chronic personal illness.
where they can receive medical and psychiatric
treatment. If it is necessary to prevent the patient
A long period of failure at work or school or a
long period of unemployment.
from harming you, themselves or others, you
may need to use medical restraints to transport Failure to achieve sufficient occupational,
educational or financial success.
the patient.
Dramatic change in the economy.
Suicide Feelings of isolation.
The term suicide refers to an intentional act to Mass suicides (e.g., in a group/cult setting).
end one’s own life. People who commit suicide Reluctance to seek help for mental-health
often feel they have no other option for resolving problems due to the stigma attached to suicidal
their problems but to end their own lives. Males thoughts, suicide attempts or general mental
are about four times more likely to commit suicide health problems.
than females, although females are more likely to Inability to access mental health services.
have suicidal thoughts. People of any age, race
When assessing a patient for suicide risk, keep the
or socioeconomic status are at risk of making
following in mind:
suicide attempts.
Those in the 15–34 age group are at the highest Take any threat of suicide seriously, ensure
the patient is transported for evaluation
risk of dying by suicide. Suicide is the second-
and ask the patient if they have ever
leading cause of death for people in this age group
considered suicide.
in the United States.
Address any injuries or medical conditions
related to a suicide attempt.
Assessing Suicide Risk
Many people who attempt suicide suffer some
Always listen carefully, as the patient may reveal
important information indirectly (Fig. 17-2).
form of mental or emotional problem or illness,
especially depression. Substance misuse or abuse, Do not dismiss what you may consider to be
unimportant feelings.
primarily of alcohol and other drugs, plays a major
role in attempted suicides. Be nonjudgmental and remember that people
react differently to different problems.
In any behavioral emergency, it is important to The patient may tell you that everything is fine
assess the patient’s risk for attempting suicide. but transport the patient anyway, as help may
Some risk factors include: still be needed.
Mental or emotional disorders, especially Make specific plans to help the patient, for
depression. example making arrangements for the patient
to meet with a particular healthcare worker
History of substance misuse or abuse.
or clergy.
Feelings of hopelessness.
Be careful not to show disgust or fear when
Impulsive or aggressive tendencies. caring for the patient. These feelings can
Past attempts at suicide. be revealed through your words and your
Failing or failed relationship with a spouse, family body language.
or friend.
428 | Emergency Medical Response
Fig. 17-2: When assessing the suicide risk of a patient, listen carefully for important information that may be
communicated indirectly and always take the patient seriously.
Never deny that the patient attempted suicide. Self-Mutilation
This may give the message that you are unable Self-mutilation, or self-injury, refers to
to accept the patient’s feelings. deliberately harming one’s own body, through
Never try to use strong emotions to either shock acts such as burning or cutting. It is not usually
the person out of attempting suicide or to call meant as an attempt to commit suicide, but is
the person’s bluff and provoke them. an unhealthy coping mechanism to deal with
overwhelming negative emotions such as tension,
To better assess the patient, ask the patient
anger and frustration. The individual experiences
questions to improve your understanding of the
momentary calmness and a release of tension but
situation. These questions include:
then quickly feels a sense of shame and guilt, in
How do they feel? addition to a return of the negative feelings the
person was trying to avoid. Self-mutilation may be a
Is the patient thinking of hurting or killing
component of a mental illness such as depression,
themselves or anyone else?
an eating disorder or a personality disorder.
Is the patient a threat to themselves or others?
Does the patient have a medical problem? Sometimes, a suicidal patient may have a last-
Is the patient suffering from a recent trauma? minute change of heart and inflict nonlethal wounds
(sometimes called hesitation marks) to receive
Does the patient have any weapons on them
help or to punish someone. Child abuse and
or nearby?
rape survivors may turn to self-mutilation such as
What interventions are necessary?
nonlethal cutting or burning as a way to cope with
CRITICAL There are many factors to consider when assessing a patient’s suicide risk. Risk
FACTS factors include mental or emotional disorders; history of substance abuse or
past suicide attempts; feelings of hopelessness or isolation; impulsiveness or
aggressiveness; failed relationships; personal illness; and failure at work, school
or in financial matters.
Chapter 17: Behavioral Emergencies | 429
the trauma. A patient who has committed self- physical and emotional trauma, and need to be
mutilation will need to be treated for bleeding, shock treated with sensitivity.
and other soft-tissue injuries.
Rape
Rape is defined as non-consensual sexual
Patients Who Are Violent to Others
intercourse often performed using force, threat or
Patients experiencing a behavioral emergency may violence. It is devastating, and many patients will go
become aggressive or violent. The violence may be into acute emotional distress and shock during and
caused by a medical emergency, a mental health after the attack.
issue, alcohol or drug intoxication, a lack of oxygen
or a head injury. Some common signs and symptoms include:
Violent behavior can take many forms, from verbal Confused, dazed state.
abuse to punching, kicking, biting and using Nausea, vomiting, gagging or urination.
weapons. While the violence may not be directed
toward you, you could easily become an indirect
Intense pain from assault and penetration.
victim caught in the middle. In some cases, these Psychological and physical shock and paralysis.
acts may be specifically targeted to people in Possible bleeding or body fluid discharge.
positions of authority, like you. Attempt to identify Torn or removed clothing.
exit or escape routes for your safety.
Because of the significant legal issues, it is vital to
A patient’s posture and comments can indicate manage the rape scene appropriately to preserve
potential violence. Threatening comments evidence that will be required for the police
and posture, such as clenching fists or investigation. If possible, the patient should be
assuming a fighting stance, may indicate the treated by someone of the gender of their choosing
patient’s intentions. to avoid further emotional trauma. If present, work
with the sexual assault nurse examiner (SANE). If
Be alert to the following signs: possible, transport the victim to a medical facility
that has a rape crisis unit and can take the proper
Agitation; the patient may pace or move
specimens as well as comfort the victim.
erratically
Rapid or incoherent speech Tell the patient what you will be doing and why you
Shouting or making threats are doing it. Encourage having the patient treated
on a clean white sheet. If the victim must remove
Clenched fists or a fighting stance
clothing or if clothing must be removed from the
Using objects as a weapon or throwing objects
patient in order to provide care, do so while on the
clean white sheet to catch any debris that was left
Sexual Assault on the patient during the crime. Try to determine
Sexual assault is defined as any form of the patient’s emotional state and complete a
sexual contact, against a person’s will, often by patient assessment, checking for trauma around
coercion, force or threat. Victims of rape and the lower abdomen, thighs, genital and anal areas.
sexual assault often know their attackers—a Do not clean the patient. Prevent the patient from
friend, a family member, a relative, a date or a showering, bathing, brushing teeth or urinating,
friend of the family. These patients suffer from since cleaning can destroy evidence. Police will be
CRITICAL Asking the patient questions will help you better assess the situation. These
FACTS questions can include: “How do you feel?”; “Are you thinking of hurting yourself or
anyone else?”; “Have you suffered a personal trauma recently?”; or “Do you have a
weapon nearby?”
Patients experiencing a behavioral emergency may become aggressive or violent.
Violent behavior can take many forms, from verbal abuse to punching, kicking,
biting and using weapons. Be alert to signs of violence, such as agitation, rapid or
incoherent speech, shouting, making threats, clenched fists or other aggressive
stances, throwing objects or using objects as a weapon.
430 | Emergency Medical Response
responsible for evidence collection. Any evidence Unexplained lacerations or abrasions,
you collect while treating the patient for injuries especially around the mouth, lips and eyes.
should be isolated, and each piece of evidence Injuries to the genitals; pain when the child
needs to be bagged individually in a paper bag sits down.
to prevent cross-contamination. Plastic bags do
not allow for air movement and cause the DNA to
More injuries than are common for a child
of the same age.
deteriorate due to moisture buildup. Follow local
protocols, and give the evidence to the police as Repeated calls to the same address.
soon as possible.
Child neglect is a type of abuse in which
Most victims of rape experience symptoms of the parent or legal guardian fails to provide
rape-trauma syndrome following a rape. the necessary, age-appropriate care to
a child.
There are three stages:
Signs and symptoms include:
Acute. This occurs immediately after the
rape, a time when the patient needs critical Lack of adult supervision.
support. Whether or not a patient suffered A child who appears to be malnourished.
physical injuries, a rape victim has experienced An unsafe living environment.
significant emotional trauma. This phase lasts
anywhere from a few days to a few weeks. Untreated chronic illness; for example, an
asthmatic child with no medications.
Outward adjustment. This phase may last
weeks or months after the attack. The victim When providing care for a child who may
resumes what appears to be their “normal” life, have been abused, your first priority is to
but is experiencing turmoil internally, including care for the child’s injuries or illness. An
depression, rage and flashbacks. abused child may be frightened, hysterical or
Resolution. Moving on from a rape may take withdrawn. The child may be unwilling to talk
months or years, and may involve professional about the incident in an attempt to protect
counseling to assist the patient in dealing with the abuser. If you suspect abuse, explain
the lasting emotional trauma. your concerns to responding police officers
or other emergency medical services (EMS)
personnel, if possible.
Pediatric Considerations
Child Abuse and Neglect If you think you have reasonable cause
You may encounter a situation involving an to believe that abuse has occurred, you
injured child in which you have reason to must report your suspicions to the proper
suspect child abuse. Child abuse is the authorities. Familiarize yourself with the
physical, verbal, psychological or sexual mandatory reporting laws in your state or
assault of a child resulting in injury and/ jurisdiction. Depending on your role and state,
or emotional trauma. Typically, the child’s you may be considered a mandatory reporter
injuries cannot be logically explained, and be required to report suspected incidents
or a parent or legal guardian gives an of abuse or neglect.
inconsistent or suspicious account of how Do not be afraid to report suspected abuse
the injuries occurred. because of fear of getting involved or of being
The signs and symptoms of child abuse sued. In most states, when you make a report
include: in good faith, you may be immune from civil or
criminal liability or penalty, even if you made a
Situations in which the description of the mistake. In this instance, “good faith” means
injury does not fit the cause. you honestly believe that abuse has occurred
Patterns of injury that include cigarette or the potential for abuse exists and a prudent
burns, whip marks and hand prints. and reasonable person in the same position
would also believe this. You do not need to
Obvious or suspected fractures in a child
identify yourself when you report child abuse,
less than 2 years of age.
although your report will have more credibility
Unexplained fractures.
if you do.
Injuries in various stages of healing,
especially bruises and burns. Refer to Chapter 25 for more information.
Chapter 17: Behavioral Emergencies | 431
Considerations for Older Adults Elder neglect is a type of abuse in which a
Elder Abuse and Neglect caregiver fails to provide the necessary care
As with child abuse, older adults are for an older adult.
also susceptible to abuse from the willful
infliction of injury by physical or sexual The signs and symptoms of elder neglect
assault, emotional mistreatment and neglect. include:
Elder abuse is a growing problem in the
United States as the population ages. EMRs
An unkempt appearance.
may encounter a situation that involves the Improper clothing for the weather
conditions.
possible abuse of an older adult.
Lack of availability of food, water or utilities.
The signs and symptoms of elder abuse An unsafe living environment.
include:
Dehydration.
Any unexplained injury or an injury that has Untreated or chronic medical conditions.
an unlikely explanation. Confusion or disorientation.
Burns, bruises or reddened areas that do Withdrawn, sad or fearful demeanor and
not go away. failure to make eye contact.
Abrasions on arms, legs or torso. Upset or fearful behavior when the abuser
Unexplained hair loss. enters the same room.
Injuries in various stages of healing
If you think you have reasonable cause to
(especially bruises and burns).
believe that elder abuse or neglect has
Scratches, cuts or bite marks. occurred, report your suspicions to the proper
Cuts and scratches around the breasts, authorities (Fig. 17-3). Familiarize yourself with
buttocks or genitals; vaginal or rectal the mandatory reporting laws in your state or
bleeding. jurisdiction. Depending on your role and state,
Withdrawn, sad or fearful demeanor and you may be considered a mandatory reporter
failure to make eye contact. and be required to report suspected incidents
Upset or fearful behavior when the abuser of elder abuse or neglect.
enters the same room.
Refer to Chapter 26 for more information.
Fig. 17-3: Elder neglect is a type of abuse in which a caregiver fails to provide the necessary care
for an older adult.
432 | Emergency Medical Response
PROVIDING CARE FOR Some patients may be experiencing hallucinations
or delusions. Do not play along with these or
BEHAVIORAL EMERGENCIES lie to the patient and say that you believe they
Scene Size-Up and Personal Safety are real.
When responding to a possible behavioral
Do not think that you can manage a situation
emergency, assess the scene to identify any
involving an emotional crisis by yourself. A suicidal
possible sources of harm to yourself, the patient or
person or a rape victim needs professional
any bystanders. Do not approach the scene unless
counseling. Summon more advanced personnel.
you feel confident that it is safe to do so. Be wary of
This could include law enforcement, EMS
sudden behavior changes in the patient, which are
personnel, or local mental health or rape crisis
the most common cause of injuries to responders.
center personnel. While waiting for others to arrive,
Be sure to identify and locate the patient before continue to talk with the patient.
you enter the scene. A disturbed individual may try
to jump you from behind or otherwise take you by Establishing Rapport
surprise. Attempt to identify exit or escape routes Once you have entered the scene, you will need to
for your safety and make sure you remain between establish rapport with the patient before getting too
the patient and an exit, so you can leave the scene close. To do this, speak directly to the patient and
if it is necessary for your own safety. As soon as maintain eye contact. Acknowledge that the patient
possible, clear the scene of any objects that can appears upset and state that you are there to
be used to injure the patient or others. Do not enter help. Tell the patient who you are and exactly what
the scene if the patient has any kind of weapon. you want to do to help. Use a calm, reassuring
Keep in mind there may be more than one patient voice, and keep your distance until the patient has
(as in a suicide pact). indicated it is acceptable to approach. Use slow,
Assessing the scene can also provide you with hints deliberate movements. Do not touch the patient
about what has happened to cause or contribute to without permission. Touch can be very disturbing
the crisis. Are there empty beer, liquor or pill bottles to some patients, particularly for those who are
lying around? Do you see drug paraphernalia or recent victims of an attack.
signs of injury, such as blood stains? Once you have established a rapport with the
As with other behavioral emergencies, your first patient, you can begin to communicate to find out
job upon arriving at a scene of a potential suicide what happened and determine what interventions
is to ensure your own safety. Selected methods are needed. Speak directly to the patient and be
supportive and empathetic, never threatening,
of suicide, such as carbon monoxide in fumes
judgmental or confrontational. Show you are
from a running vehicle engine in an enclosed
listening by repeating and rephrasing the patient’s
area or emissions from a gas stove, can create a
answers to your questions, nodding or stating
dangerous environment for responders. In addition,
phrases such as “go on” or “I understand.” Make
the suicidal individual may further endanger you
sure that no one interrupts, except in the case of
by attacking or attempting to attack you to prevent
medical necessity.
your interference.
CRITICAL When responding to a possible behavioral emergency, assess the scene to identify
FACTS any possible sources of harm to yourself, the patient or any bystanders.
Do not think that you can manage a situation involving an emotional crisis by
yourself. Summon more advanced personnel and continue to talk to the patient
while waiting for help to arrive.
Once you have entered the scene, you will need to establish rapport with the
patient before getting too close. Once you have established a rapport with the
patient, you can begin to communicate to find out what happened and determine
what interventions are needed.
Chapter 17: Behavioral Emergencies | 433
Patient Assessment Legal Considerations
Observe the patient and look for signs of Restraining a person without justification can give
disorientation or life-threatening conditions, rise to a claim of assault and battery. You may
such as a serious injury or difficulty breathing. be required to obtain police authorization before
Also, continue to observe the patient for signs you can use patient restraints. Be aware of the
of potential violence, such as a threatening laws regarding the use of patient restraints in your
posture or the possession of a weapon. Look for jurisdiction. Wait for someone who is authorized
signs of fear, anxiety, confusion, anger, mania, to use restraints if you are not legally allowed to
depression, withdrawal or loss of contact with do so. Seek medical direction and approval before
reality. Also look for sudden behavioral changes, applying restraints. Be aware of and follow local
such as quiet withdrawal followed by sudden, protocols involving the use of patient restraints.
explosive anger.
Be sure a restrained patient can breathe. The
Once you get the patient talking, try to find out patient should be placed in a face-up position,
what happened. Determine the level of orientation and breathing should be monitored regularly.
and responsiveness, and attempt to find out what A struggling patient who appears to calm down
the chief complaint is. If the patient allows, take may actually be suffering from breathing difficulties
a set of baseline vital signs. Also try to obtain a or may have lost consciousness.
SAMPLE history. If the patient is unconscious,
perform a rapid head-to-toe assessment and try For legal reasons, it is important to document
to obtain a SAMPLE history from family, friends or everything you do while participating in the use
other bystanders. of restraints.
Calming the Patient PUTTING IT ALL TOGETHER
In addition to maintaining a calm voice and slow,
Behavioral emergencies pose special challenges for
deliberate movements, several techniques can
EMRs. Patients experiencing behavioral emergencies
be used to help calm a patient. If the patient is
may act in unexpected ways, and may pose a danger
disoriented, explain who you are, where you are
to themselves or others by reacting in a violent or
and what is happening. Reassure the patient
aggressive manner. Behavioral emergencies can be
that the disorientation is temporary. Do not stand
triggered by injury, physical or mental illness, extreme
too close to the patient. If the patient’s friends
stress, or the use of alcohol or other drugs.
or family members are around, ask the patient if
it is okay to enlist others to help in calming the When responding to a patient with a behavioral
patient. Encourage the patient to tell you what the emergency, begin by assessing the scene to
problem is and explain that you are there to listen. identify any possible sources of harm to you, the
Never leave the patient alone, and stay alert to any patient or any bystanders. Do not enter the scene
changes in the patient’s emotional state. unless you feel confident that it is safe to do so. Be
wary of sudden behavioral changes in the patient,
Restraining the Patient which is a common cause of injury to responders.
When patients are so agitated or violent that Consider the need for law enforcement personnel.
they cannot be approached safely and may If a patient appears to be a threat to themselves
pose a danger to themselves or others, you may or others, or the patient appears to be a victim of
need to assist EMS personnel with the use of sexual assault, rape or child abuse, summon law
restraints. If this occurs, follow their instructions enforcement support immediately.
exactly. Try to stay clear of the patient’s arms
and legs. Do not use restraints unless instructed When dealing with a rape or sexual assault patient,
to do so by more advanced medical or law remember that emotional trauma will be present,
enforcement personnel. even when physical injuries are absent. Acute
emotional shock is a normal reaction. Be careful
When using restraints, the goal is to use the not to disturb any evidence found at the scene.
minimum force needed. Thus, the amount of force
used will depend on factors such as the patient’s Cases of child abuse or neglect need to be
strength and level of agitation. Soft leather or cloth carefully documented. You must follow local
straps are considered humane restraints, while protocols around mandatory reporting if you
metal cuffs are not. suspect the injuries are due to abuse or neglect.
434 | Emergency Medical Response
Assess both the patient’s physical and mental Restraining a patient should be a last resort,
status by asking specific questions in a calm and done in consultation with law enforcement and
reassuring manner. Evaluate the patient’s mental advanced medical direction. Use only as much
status by observing appearance, demeanor, level force as is necessary to restrain the patient,
of activity and speech. Ask bystanders if the and always follow local protocols. Ensure that
patient has underlying medical conditions, or a you clearly document all the circumstances if
history of mental issues or violent actions. Do not medical restraints are required, including the
leave the patient alone. Good communication names and contact information for any third-
skills, respect and empathy can defuse potentially party observers, law enforcement personnel and
explosive situations. medical personnel.
You Are the Emergency Medical Responder
As you continue to calmly interview the patient, you gradually earn his trust and soon learn
that he has had trouble sleeping and has not eaten much in the past 2 weeks. He says he
got out of drug rehab 3 months ago. He has not been taking his prescribed medication for
about a month and recently lost two very close relatives. The patient says he “sort of went
off the wagon.” What other steps must you consider in providing proper care for this patient?
What additional resources should you consider?
Chapter 17: Behavioral Emergencies | 435
UNIT 6
Trauma Emergencies
18 Shock ����������������������������������������������������������������������������437
19 Bleeding and Trauma������������������������������������������������444
20 Soft Tissue Injuries����������������������������������������������������463
21 Injuries to the Chest, Abdomen
and Genitalia ��������������������������������������������������������������483
22 Injuries to Muscles, Bones and Joints ����������������497
23 Injuries to the Head, Neck and Spine������������������529
18 You Are the Emergency Medical Responder
SHOCK
Your ambulance unit is the first to arrive on an isolated road where an 18-year-old male
driver lost control of a motor vehicle and collided with a tree. In the crash, the driver’s
legs were broken and he is pinned in the wreckage. You find the driver conscious,
restless and in obvious pain. After a couple of minutes, the patient’s condition has
changed. He begins to look ill. You notice he responds only to loud verbal stimuli,
is breathing fast and looks pale. His skin is cold and moist, and his pulse is rapid and
weak. What would you do to help the patient?
KEY TERMS
Cardiogenic shock: The result of the heart being where the blood vessel walls abnormally constrict
unable to supply adequate blood circulation to the and dilate, preventing relay of messages and
vital organs, resulting in an inadequate supply of causing blood to pool at the lowest point of the
nutrients; caused by trauma or disease. body.
Dilation: The process of enlargement, stretching Obstructive shock: A type of shock caused by any
or expansion; used to describe blood vessels. obstruction to blood flow, usually within the blood
vessels, such as a pulmonary embolism.
Distributive shock: A type of shock caused by
inadequate distribution of blood, either in the Psychogenic shock: A type of shock that is due to
blood vessels or throughout the body, leading to factors such as emotional stress that cause blood
inadequate volumes of blood returning to the heart. to pool in the body in areas away from the brain,
which can result in fainting (syncope).
Hypoglycemic shock: A type of shock that is a
reaction to extremely low blood glucose levels. Respiratory shock: A type of shock caused by the
failure of the lungs to transfer sufficient oxygen into
Hypoperfusion: A life-threatening condition in which the bloodstream; occurs with respiratory distress
the circulatory system fails to adequately circulate or arrest.
oxygenated blood to all parts of the body, resulting
in inadequate tissue perfusion; also referred to as Septic shock: A type of distributive shock that occurs
shock. when an infection has spread to the point that
bacteria are releasing toxins into the bloodstream,
Hypovolemic shock: A type of shock caused by an causing blood pressure to drop when the tissues
abnormal decrease in blood volume. become damaged from the circulating toxins.
Metabolic shock: A type of shock that is the result Shock: A life-threatening condition that occurs when
of a loss of body fluid, which can be due to severe the circulatory system fails to provide adequate
diarrhea, vomiting or a heat-related illness. oxygenated blood to all parts of the body, resulting
in inadequate tissue perfusion; also referred to as
Neurogenic shock: A type of distributive shock
hypoperfusion.
caused by trauma to the spinal cord or brain,
LEARNING OBJECTIVES
After reading this chapter, and completing the class • Describe how to provide care to minimize shock.
activities, you will have the information needed to: • Make appropriate decisions about care when
• List conditions that can result in shock. given an example of an emergency in which shock
is likely to occur.
• List the signs and symptoms of shock.
INTRODUCTION WHAT IS SHOCK?
Injuries and medical emergencies can become life Shock, or hypoperfusion, is a progressive
threatening as a result of shock. When the body condition in which the circulatory system fails to
experiences injury or sudden illness, it responds in a adequately circulate oxygenated blood to all parts of
number of ways. Survival depends on the body’s ability the body, resulting in inadequate tissue perfusion.
to adapt to the physical stresses of injury or illness. When vital organs, such as the brain, heart and
When the body’s measures to adapt fail, the injured or lungs, do not receive sufficient oxygenated blood,
ill person can progress into a life-threatening condition the body begins a series of responses to protect
called shock. Shock complicates the effects of injury those organs. The amount of blood circulating to
or sudden illness. In this chapter, you will learn to the less important tissues of the arms, legs and skin
recognize the signs and symptoms of shock and how is reduced so that more can go to the vital organs.
to provide care to minimize it. This reduction in blood circulation to the skin causes
438 | Emergency Medical Response
a person in shock to appear pale or ashen (grayish) related to disease (e.g., diabetes or cardiovascular
and feel cool. While, in the short term, this can disease), poisoning or respiratory distress.
protect the body’s most crucial organs, if the situation
is not treated quickly, shock can lead to death. Blood Vessels
When the body is healthy, three conditions are If blood vessels are not able to adequately constrict
necessary to maintain adequate blood flow: or become abnormally dilated, even though the
blood volume is adequate and the heart is beating
The heart must be working well. well, the vessels are not filled completely with
The blood vessels must be intact and able to blood. Since oxygen is absorbed into the body
adjust blood flow and pressure. through the walls of the blood vessels, this
An adequate amount of blood must be condition leads to less oxygen being available to the
circulating in the body. body. Abnormal dilation of the blood vessels can
be caused by a spinal cord injury, or by infection or
Injury or sudden illness can interrupt normal body anaphylaxis.
functions. In cases of minor injury or illness, this
interruption is brief, because the body is able to
compensate quickly. With more severe injuries or Blood
illnesses, however, the body is unable to adjust. Insufficient blood volume can lead to shock. Also,
When the body is unable to meet its demands for if the levels of some components of the blood,
oxygen because the blood fails to circulate such as plasma or fluids, become too low, blood
adequately, shock occurs. flow will be impaired and shock can result. These
conditions can occur due to bleeding, severe
vomiting, diarrhea and burns.
WHY SHOCK OCCURS
Shock results from inadequate delivery of oxygenated Chest and Airway
blood to the body’s tissues. There are several possible
reasons for shock to occur. It can be the result of: Shock can also occur following any injury to the
chest, obstruction of the airway or any other
Severe bleeding or loss of fluid from the body respiratory problem that decreases the amount of
through excessive vomiting and diarrhea. oxygen in the lungs. This means insufficient oxygen
Failure of the heart to pump enough oxygenated enters the bloodstream.
blood.
Abnormal dilation of the vessels.
TYPES OF SHOCK
Impaired blood flow to the organs and cells.
There are four major types of shock: hypovolemic,
The Heart obstructive, distributive and cardiogenic. All cause
a drop in blood pressure and have the same
The condition and functioning of the heart can have outcome if not treated quickly.
a significant impact on the likelihood of shock. If the
heart rate is too slow, the rate of new oxygenated
blood cells reaching each part of the body will not be Hypovolemic
enough to keep up with demand. If the heart beats Hypovolemic shock is due to a severe lack of
too rapidly (ventricular tachycardia [V-tach]) or if the blood and fluid within the body. Hemorrhagic
heartbeat becomes erratic (ventricular fibrillation shock is the most common type of hypovolemic
[V-fib]), the oxygenated blood is not sent throughout shock. It results from blood loss, either through
the body as it should be. Damage to the heart can external or internal bleeding, which causes a
lead to weak and ineffective contractions; this can be decrease in total blood volume.
CRITICAL Shock, or hypoperfusion, is a progressive condition in which the circulatory system
FACTS fails to adequately circulate oxygenated blood to all parts of the body.
There are several possible reasons for shock to occur. It can be the result of severe
bleeding or loss of fluid, failure of the heart to pump enough oxygenated blood,
abnormal dilation of the vessels, and impaired blood flow to the organs and cells.
Chapter 18: Shock | 439
Obstructive Other Types of Shock
Obstructive shock is caused by some type of Other types of shock include hypoglycemic,
obstruction to blood flow, usually within the blood metabolic, psychogenic and respiratory shock.
vessels, such as a pulmonary embolism, tension Hypoglycemic shock is a reaction to extremely
pneumothorax or cardiac tamponade. low blood glucose levels. Metabolic shock is the
result of a loss of body fluid, which can be due to
severe diarrhea, vomiting or a heat-related illness.
Distributive
Psychogenic shock is due to factors such as
Distributive shock refers to any type of shock emotional stress that cause blood to pool in the
caused by inadequate distribution of blood either in body in areas away from the brain, which can result
the blood vessels or throughout the body, leading in fainting (syncope). Respiratory shock is the
to inadequate volumes of blood returning to the failure of the lungs to transfer sufficient oxygen into
heart. It includes the following: the bloodstream and occurs with respiratory
distress or arrest.
Neurogenic shock is caused by spinal cord
or brain trauma. The blood vessel walls normally
constrict and dilate to circulate the blood
throughout the circulatory system. In neurogenic SIGNS AND SYMPTOMS
shock, the messages are not relayed, and the OF SHOCK
blood pools at the lowest point of the body. Because this is a progressive condition, the signs
Anaphylaxis (also referred to as anaphylactic and symptoms you see will depend on what stage
shock) occurs as a result of exposure to an of shock the person is in, and this will change
allergen. It is a whole-body reaction that over time (Fig. 18-1). At first, the signs and
causes dilation (enlargement, stretching or symptoms may seem minor, but responding to
expansion) of the blood vessels and constriction them promptly will increase the patient’s chance
(closing) of the airways, which in turn causes of survival.
blood to pool and trouble breathing. The airways
may close completely from inflammation. For Early Signs and Symptoms
more information on anaphylaxis, refer to
Chapter 16. You may observe that:
Septic shock occurs when an infection has The patient expresses feelings of apprehension
spread to the point that bacteria are releasing and anxiety.
toxins into the bloodstream. The blood pressure
drops when the tissues become damaged from
The patient’s body temperature is slightly lower
than normal.
the circulating toxins.
The patient is breathing quickly.
Cardiogenic The patient’s pulse is slightly increased.
Cardiogenic shock is the result of the heart
The patient’s blood pressure is normal or
slightly decreased.
being unable to supply adequate blood circulation
to the vital organs, resulting in an inadequate The patient’s skin is pale or ashen (grayish)
and cool.
supply of oxygen and nutrients. Disease, trauma or
injury to the heart causes this type of shock.
CRITICAL There are four major types of shock: hypovolemic, obstructive, distributive and cardiogenic.
FACTS All cause a drop in blood pressure and have the same outcome if not treated quickly.
Other types of shock include hypoglycemic, metabolic, psychogenic and
respiratory shock.
Early signs and symptoms of shock may include feelings of apprehension and
anxiety; slightly low body temperature; rapid breathing; slight increase in pulse rate;
normal or slightly decreased blood pressure; and pale, ashen and cool skin.
440 | Emergency Medical Response
Early Stages of Shock
• Apprehension and anxiety
• Slightly lower body temperature
• Rapid breathing
• Slightly increased pulse
• Slightly decreased or normal
blood pressure
• Pale, ashen, cool skin
Later Stages of Shock
• Listlessness and confusion
• Slow, shallow, irregular breathing
• Decreasing blood pressure
• Rapid but weak and irregular pulse
• Pale, cold and clammy skin
• Lower than normal blood pressure
• Dilated pupils
Fig. 18-1: Shock is a progressive condition, so the stage the person is in determines what signs and
symptoms you see.
Later Signs and Symptoms Pediatric Considerations
You may observe that: Early signs of shock may be absent in young
children or infants, because their bodies
The patient is listless and confused, and may can compensate for some of the factors
have difficulty speaking. that cause shock by maintaining blood
The patient’s breathing has slowed down and pressure at normal levels. If the conditions
is shallow and irregular. continue, however, the situation can suddenly
deteriorate into severe shock. Because a child
The patient’s blood pressure is decreasing;
is smaller than an adult, blood volume is less,
diastolic blood pressure may reach zero.
and losing what seems like a small amount
The patient’s pulse is rapid, but the pulse is
of blood can be serious, making children
weak and irregular.
more susceptible to shock. Do not wait for
The patient’s skin is pale, cold and clammy, and signs and symptoms of shock to develop
the body temperature is much lower than normal. when treating a young child or infant, but treat
The patient’s pupils are dilated and slow to promptly based on your assessment of the
respond to light. injuries or trauma.
CRITICAL Later signs and symptoms of shock can include listlessness; confusion; difficulty
FACTS speaking; irregular breathing; decreased blood pressure (diastolic blood pressure
may reach zero); rapid yet weak or irregular pulse; pale, cold and clammy skin with
a low body temperature; and dilated pupils.
Chapter 18: Shock | 441
A B
Fig. 18-2, A–B: (A) Administer supplemental oxygen to a patient who is showing signs and symptoms of shock based on local protocols.
(B) Cover a patient in shock with a blanket to prevent loss of body heat in order to maintain a normal body temperature.
PROVIDING CARE Do not give any food or drinks, even if the
patient asks for them. The patient is likely
Once you have assessed the patient and to be thirsty due to the fluid loss. However,
determined that there are signs and symptoms depending on the condition, surgery may
of shock present, quick response is essential: be needed and it is better for the patient’s
stomach to be empty if that is the case. More
Take steps to control any severe, life-threatening
bleeding and prevent further blood loss. advanced emergency medical personnel will be
able to provide fluid replacement intravenously
Ensure the patient’s airway is open and clear.
if appropriate.
Perform a primary assessment and call for
more advanced medical personnel. Administer Treat any specific injuries or conditions, and
supplemental oxygen based on local protocols, have the patient transported to a hospital as
and provide appropriate ventilatory support soon as possible.
(Fig. 18-2, A).
Since you may not be sure of the patient’s PUTTING IT ALL TOGETHER
condition, leave them in a supine position.
Any condition or trauma situation where the body’s
If you see any suspected broken bones or ability to get oxygenated blood to the vital organs
dislocated or damaged joints, immobilize is compromised can lead to shock. Left untreated,
them to prevent movement after ensuring shock is a progressive condition that can be
other life-threatening conditions have been fatal. Shock can be caused by loss of blood or
addressed. Broken bones or dislocated or body fluids, when the heart is not pumping blood
damaged joints can cause more bleeding effectively, by over-dilation of the blood vessels or
and damage. by damage to the chest or airways. If any of these
Cover the patient with a blanket to prevent loss conditions are present, it is important to watch the
of body heat (Fig. 18-2, B). It is important not patient for signs and symptoms of shock. These
to overheat the patient—your goal should be to include decreasing blood pressure; increasing
maintain a normal body temperature. If the patient heart rate; increasing respiratory rate; pale or
is lying on cold ground and if it is possible to do ashen, cool, clammy skin; pupils that are dilated
so without causing harm, you may want to put a and slow to respond; and anxiety and apprehension
blanket under the patient as well. at first, turning into confusion and listlessness as
Talk to the patient in a calm and reassuring shock progresses.
manner to reduce the harmful effects of
To treat shock, first control any severe, life-
emotional stress. If you can help the patient
threatening bleeding that may be present. Ensure
rest in a comfortable position and reduce the
the patient has an open and clear airway and
pain, this will also be beneficial; pain intensifies
is breathing. Call for more advanced medical
the body’s reactions and can accelerate the
personnel and transport the patient to a hospital
progression of shock.
442 | Emergency Medical Response
as soon as possible. Administer supplemental by covering the patient with a blanket. Reassure
oxygen or artificial ventilation as appropriate. and comfort the patient; try to keep the patient
Keep the patient in a supine position. Splint any comfortable and reduce any pain. Do not give
broken bones or joints and keep the patient warm food or drink.
You Are the Emergency Medical Responder
After extrication teams arrive, they finally free the driver from the vehicle and remove him from
the car. You notice that the patient looks worse. He now responds only to painful physical
stimuli. His breathing has become very irregular. You know that the hospital is 20 minutes
away. How would you respond? What should you do to provide care until the patient arrives
at the hospital?
Chapter 18: Shock | 443
19 You Are the Emergency Medical Responder
BLEEDING
AND TRAUMA
As a member of your company’s medical emergency response team (MERT), you are called
to assist a worker whose arm has been lacerated by a part that came loose from a lathe.
The man’s arm is bleeding severely. You arrive to find a co-worker attempting to stop the
bleeding. How would you respond?
KEY TERMS
Adult respiratory distress syndrome (ARDS): medical care to the patient as soon as possible
A lung condition in which trauma to the lungs within the hour can result in the best chance of
leads to inflammation, accumulation of fluid patient survival.
in the alveolar air sacs, low blood oxygen and
respiratory distress. Head-on collision: A collision in which a vehicle hits
an object, such as a tree or other vehicle, straight on.
Arteries: Large blood vessels that carry oxygen-
rich blood from the heart to all parts of the body, Hemorrhage: The loss of a large amount of blood in
except for the pulmonary arteries, which carry a short time or when there is continuous bleeding.
oxygen-poor blood from the heart to the lungs.
Hemostatic dressing: A dressing treated with an
Bandage: Material used to wrap or cover a part of agent or chemical that assists with the formation
the body; commonly used to hold a dressing or of blood clots; used with direct pressure to help
splint in place. control severe, life-threatening bleeding.
Bandage compress: A thick gauze dressing Internal bleeding: Bleeding inside the body.
attached to a gauze bandage.
Occlusive dressing: A special type of dressing that
Bleeding: The loss of blood from arteries, veins does not allow air or fluid to pass through.
or capillaries.
Perfusion: The circulation of blood through the body
Blood volume: The total amount of blood circulating or through a particular body part for the purpose
within the body. of exchanging oxygen and nutrients with carbon
dioxide and other wastes.
Capillaries: Tiny blood vessels linking arteries and
veins that transfer oxygen and other nutrients Pressure bandage: A bandage applied snugly to
from the blood to all body cells and remove create pressure on a wound, to aid in controlling
waste products. bleeding.
Clotting: The process by which blood thickens at a Roller bandage: A bandage made of gauze or
wound site to seal an opening in a blood vessel gauze-like material that is wrapped around a body
and stop bleeding. part, over a dressing, using overlapping turns until
the dressing is covered.
Contusion: An injury to the soft tissues that results
in blood vessel damage (usually to capillaries) Rollover: A collision in which the vehicle rolls over.
and leakage of blood into the surrounding tissues;
Rotational impact: A collision in which the impact
caused when blood vessels are damaged or
occurs off center and causes the vehicle to rotate
broken as the result of a blow to the skin, resulting
until it either loses speed or strikes another object.
in swelling and a reddish-purple discoloration on
the skin; commonly referred to as a bruise. Side-impact collision: A collision in which the
impact is at the side of the vehicle; also known as
Direct pressure: Pressure applied on a wound to
a broadside, t-bone or lateral collision.
control bleeding.
Dressing: A pad placed directly over a wound Tourniquet: A tight, wide band placed around an arm
to absorb blood and other body fluids and to or a leg to constrict blood vessels in order to stop
prevent infection. blood flow to a wound.
Elastic bandage: A bandage designed to keep Trauma dressing: A dressing used to cover very
continuous pressure on a body part; also called an large wounds and multiple wounds in one body
elastic wrap. area; also called a universal dressing.
External bleeding: Bleeding on the outside of the Trauma system: A regional or community-based
body; often, visible bleeding. system that provides definitive care for injured
(trauma) patients; provides patients with a
Golden Hour: A term that refers to the critical first seamless transition from prehospital care to acute
hour after a patient sustains a life-threatening and post-hospital care, leading to improved patient
traumatic injury; the highest risk of dying from outcomes. A comprehensive trauma system also
shock or bleeding occurs during this time; participates in community outreach activities,
providing early interventions and advanced including injury prevention programs.
(Continued)
Chapter 19: Bleeding and Trauma | 445
KEY TERMS continued
Triangular bandage: A triangle-shaped bandage Veins: Blood vessels that carry oxygen-poor blood
that can be rolled or folded to hold a dressing from all parts of the body to the heart, except for
or splint in place; can also be used as a sling to the pulmonary veins, which carry oxygen-rich
support an injured shoulder, arm or hand. blood to the heart from the lungs.
LEARNING OBJECTIVES
After reading this chapter, and completing the class • Explain the functions of dressing and bandaging.
activities, you will have the information needed to: • List the signs of internal bleeding.
• Describe the components of a trauma system. • Describe how to care for a patient who
• Differentiate among arterial, venous and exhibits the signs and symptoms of internal
capillary bleeding. bleeding.
• Describe how to care for external bleeding, • Make appropriate decisions about care when
including when and how to use a tourniquet given an example of an emergency in which
and hemostatic dressing. a patient is bleeding.
• List appropriate standard precautions to follow
when controlling external bleeding.
SKILL OBJECTIVES
After reading this chapter, and completing the class • Demonstrate how to control severe,
activities, you should be able to: life-threatening bleeding using a commercial
tourniquet.
• Demonstrate how to control external bleeding
with direct pressure, dressings and bandages,
including caring for shock.
INTRODUCTION INCIDENCE/SIGNIFICANCE
Bleeding is the loss of blood from arteries, OF TRAUMA
veins or capillaries. Bleeding is either internal The Golden Hour refers to the critical first hour
or external. External bleeding is usually obvious after a patient sustains a life-threatening traumatic
because it is typically visible. Internal bleeding injury. The highest risk of dying from shock or
is often difficult to recognize. Uncontrolled bleeding occurs during this time. Providing early
bleeding, whether internal or external, is a interventions and advanced medical care to the
life-threatening emergency. A large amount patient as soon as possible within the hour can
of bleeding occurring in a short time is called result in the best chance of patient survival.
a hemorrhage.
Trauma is a physical injury, wound or shock caused
If left untreated, severe bleeding can result in by an agent, force or mechanism. The trauma patient
shock and, eventually, death. Check for and control requires rapid assessment and care of the conditions
severe, life-threatening bleeding during the primary found. This is often done by a multidisciplinary
assessment before you check for breathing and a team, supported by the appropriate healthcare
pulse. You may not identify internal bleeding until providers, to minimize or eliminate the risk of death
you perform a more detailed check during the or permanent disability. A trauma system must
physical exam and history. determine the necessary level of care for the injury.
446 | Emergency Medical Response
TRAUMA SYSTEM In selecting the appropriate level of trauma center,
transport considerations must also be taken into
A trauma system is a regional or community- account. State and regional guidelines dictate the
based system that provides definitive care for maximum transport time depending on the acuity of
injured (trauma) patients. These systems consist
the patient; for example, whether the patient has an
of many different components that provide
uncontrolled hemorrhage or a compromised airway.
patients with a seamless transition from
Similar to adult patients, pediatric trauma patients
prehospital care to acute and post-hospital
are often transported to the nearest pediatric
care, leading to improved patient outcomes.
trauma center, even if it is farther away than other
A comprehensive trauma system also
hospitals, based on local trauma triage guidelines
participates in community outreach activities,
and local point-of-entry plans.
including injury prevention programs.
There are four primary levels of facilities for
trauma care: MULTI-SYSTEM TRAUMA
Patients who are subjected to significant forces
Level I trauma center: This facility must have are at an increased risk for injuries to multiple
the capability to deal with all levels and types of organs within the body at the same time. A
patient injury on a 24-hour basis. These facilities multi-system trauma is one involving more than
are leading medical care facilities, often university- one body system. For example, a patient who
based teaching hospitals, and must have an was in a major collision may have broken bones
adequate depth of resources and personnel to (skeletal system), but may also be experiencing
deal with all levels of patient care. These facilities difficulty breathing (respiratory system). Multi-
also conduct research and community outreach. system trauma patients are also at a greater risk
Level II trauma center: This facility is expected of developing shock (see Chapter 18). Suspect
to be able to provide definitive care to patients, multi-system trauma in any patient subjected to
despite the type of injury the patient may have significant external forces.
suffered. Its care capabilities are generally the
same as a Level I trauma center, but they may
not conduct research. PERFUSION
Level III trauma center: These facilities are often Perfusion is the circulatory system’s method of
found in smaller communities that do not have delivering oxygen and nutrients while eliminating
immediate access to larger Level I or Level II carbon dioxide and other wastes. The entire body
trauma centers. They can provide prompt requires perfusion, but different parts of the
assessment, resuscitation and emergency body require different amounts. Some organs are
operations, and arrange for transport to a especially sensitive to changes in the efficiency
Level I or II facility as required. of perfusion. For example, a major organ such
Level IV trauma center: These facilities are as the heart, when denied constant perfusion,
often rural clinics in remote areas and can cannot function properly. The brain can only last
generally only offer initial patient care until about 4 to 6 minutes without constant perfusion
arrangement for transportation can be made. before damage could begin to occur. Kidneys
Treatment protocols for resuscitation, transfer can last up to 45 minutes without perfusion.
protocols, data reporting and participation in The skeletal system can withstand a lack of
system performance improvement are essential perfusion for as long as 2 hours before damage
at a Level IV trauma center. becomes permanent.
CRITICAL Bleeding is the loss of blood from arteries, veins or capillaries. Bleeding is either
FACTS internal or external. External bleeding is usually obvious because it is typically
visible. Internal bleeding is often difficult to recognize.
A trauma system is a regional or community-based system that provides definitive
care for injured (trauma) patients. These systems consist of many different
components that provide patients with a seamless transition from prehospital care
to acute and post-hospital care, leading to improved patient outcomes.
Chapter 19: Bleeding and Trauma | 447
BLEEDING nutrients. External arterial bleeding can be caused
by both blunt and penetrating trauma. Arterial
General Considerations bleeding can also occur when organs and blood
To reduce the risk of disease transmission when vessels are damaged.
controlling bleeding, always follow standard
precautions, including: Arterial blood:
Avoiding contact with the patient’s blood, Is bright red.
directly or indirectly, by using barriers such as Spurts from the wound as it is being pushed by
disposable latex-free gloves and protective the heart’s pumping action.
eyewear. Will not clot or stop easily because of the
Avoiding eating, drinking and touching your pressure.
mouth, nose or eyes while providing care or Decreases in pressure as the patient’s blood
before washing your hands. pressure drops, due to decreased blood
Always washing your hands thoroughly before volume.
(if practical) and after providing care, even if you
wore gloves or used other barriers. Venous Bleeding
Changing gloves before you care for a different Venous bleeding is usually the result of an outside
patient, and cleaning equipment (e.g., handles) force causing trauma or an internal force breaking
and surfaces (e.g., zippers and door knobs) after through a vein, such as a broken bone or organ
providing care. damage (Fig. 19-1, B). The blood is returning to
the heart so it does not have as much pressure
The severity of blood loss can be estimated
to move it forward. Bleeding from a vein can
based on the signs and symptoms with which
be severe.
the patient presents, as well as your general
impression of the amount of blood loss. It is Venous blood:
important to control bleeding. Uncontrolled
bleeding, or significant blood loss, will lead to Is darker red than arterial blood.
shock and possibly death. Do not wait for shock Flows steadily, but the flow can still be quick
to develop before providing care to someone and severe.
who is injured or suddenly ill. May be easier to stop because it does not have
the same pressure as arterial bleeding.
Types of Bleeding
Bleeding is the loss of blood from arteries, veins Capillary Bleeding
or capillaries and can result in either internal or Capillary bleeding is not usually a concern in
external bleeding. The most severe of these is healthy people (Fig. 19-1, C). It is usually slow
arterial bleeding, followed by venous bleeding. because the vessels are small and the blood is
Hemorrhaging occurs when a large amount of under low pressure.
blood is lost in a short period of time or when
Capillary blood:
there is continuous bleeding.
Is darker red than arterial blood.
Arterial Bleeding Oozes from the capillaries.
Arterial bleeding is typically the most urgent type of
bleeding (Fig. 19-1, A). Arterial blood is oxygenated
Usually clots spontaneously or with direct
pressure.
and pumped from the heart to supply the body with
CRITICAL The most severe bleeding is typically arterial bleeding, followed by venous bleeding.
FACTS
Hemorrhaging occurs when a large amount of blood is lost in a short period of time
or when there is continuous bleeding.
448 | Emergency Medical Response
A B C
Fig. 19-1, A–C: (A) Arterial bleeding is typically the most severe type of bleeding, followed by (B) venous bleeding. (C) Capillary
bleeding is not usually a concern in healthy people.
DRESSINGS AND BANDAGES or hand over the gauze pad and apply firm, direct
pressure (Fig. 19-3). If you do not have gauze
All open wounds need some type of covering to available, apply pressure with your own gloved
help control bleeding, absorb drainage, and prevent hand or have the injured person apply pressure
contamination and infections. These coverings are with the hand.
commonly referred to as dressings and bandages.
There are many different types of both.
Dressings
Dressings are pads placed directly on the wound
to absorb blood and other fluids and to prevent
infection. To minimize the chance of infection,
dressings should be sterile. Most dressings are
porous, allowing air to circulate to the wound
to help promote healing. Standard dressings
include varying sizes of cotton gauze (sterile and
nonsterile), commonly ranging from 2- to 4-inch
squares (i.e., 2-inch x 2-inch pads). Much larger Fig. 19-2: Standard dressings include varying sizes of cotton
dressings, called universal dressings or trauma gauze, commonly ranging from 2- to 4-inch squares. Larger
dressings, called trauma dressings, are used to cover very large
dressings, are used to cover very large wounds wounds and multiple wounds in one body area.
and multiple wounds in one body area (Fig. 19-2).
Some dressings have nonstick surfaces to prevent
the dressing from sticking to the wound.
A special type of dressing, called an occlusive
dressing, does not allow air or fluids to pass
through. Plastic wrap and petroleum jelly-soaked
gauze are examples of this type of dressing.
Occlusive dressings are used for open abdominal
wounds. For more information on the use of an
occlusive dressing, refer to Chapter 21.
Application of Dressings
For most dressings, place pressure directly on the Fig. 19-3: To care for external bleeding, place pressure directly
wound with a sterile gauze pad. Place your fingers on the wound with your gloved fingers or hand over a dressing.
CRITICAL All open wounds need some type of covering to help control bleeding, absorb
FACTS drainage, and prevent contamination and infections. These coverings are commonly
referred to as dressings and bandages. There are many different types of both.
Chapter 19: Bleeding and Trauma | 449
Bandages
A bandage is any material used to wrap or cover
any part of the body. Bandages are used to hold
dressings in place, to apply pressure to control
bleeding, to help protect a wound from dirt and
infection, and to provide support to an injured limb
or body part. Many different types of bandages
are available commercially (Fig. 19-4). A bandage
applied snugly to create pressure on a wound or
injury is called a pressure bandage.
A common type of bandage is a commercial adhesive
Fig. 19-4: Bandages are used to hold dressings in place, apply
compress. Available in assorted sizes, an adhesive pressure, protect a wound from infection and provide support to
compress consists of a small pad of nonstick gauze an injured limb or body part.
(the dressing) on a strip of adhesive tape (the
bandage) applied directly to small injuries. Also
available is the bandage compress, a thick gauze
dressing attached to a gauze bandage. This bandage
can be tied in place. Because it is designed to help
control severe bleeding, the bandage compress
usually comes in a sterile package.
A roller bandage is usually made of gauze or
gauze-like material. Some gauze bandages are made
of a self-adhering material that easily conforms to
different body parts. Roller bandages are available
in assorted widths from ½ to 12 inches and lengths Fig. 19-5: An elastic roller bandage is designed to keep
from 5 to 10 yards. A roller bandage is generally continuous pressure on a body part.
wrapped around the body part, over a dressing,
using overlapping turns until the dressing is
completely covered. It can be tied or taped in place.
A folded strip of roller bandage may also be used
as a dressing or compress. In Chapter 22, you will
learn to use roller bandages to hold splints in place.
A special type of roller bandage is an elastic
bandage, sometimes called an elastic wrap.
Elastic bandages are designed to keep continuous
pressure on a body part (Fig. 19-5). When properly
applied, they can effectively control swelling or
support an injured limb. Elastic bandages are
available in assorted widths from 2 to 6 inches.
They are very effective in managing injuries to Fig. 19-6: Used as a sling, the triangular bandage can support
an injured shoulder, arm or hand.
muscles, bones and joints. Elastic bandages are
frequently used in athletic environments and should
be applied only by those who are trained and
proficient in their use.
Another commonly used bandage is the triangular
bandage. When it is folded, it can hold a dressing
or splint in place on most parts of the body. Used
as a sling, the triangular bandage can support an
injured shoulder, arm or hand (Fig. 19-6).
Application of Bandages
A pressure bandage will hold gauze pads in place Fig. 19-7: A pressure bandage can be applied to maintain direct
while maintaining direct pressure (Fig. 19-7). pressure.
450 | Emergency Medical Response
To apply a roller bandage, follow these general bleeding. If you are controlling bleeding from an
guidelines: open fracture, do not apply direct pressure over the
bones but instead pack sterile gauze around the
Secure the end of the bandage in place. area to control bleeding and prevent infection.
Wrap the bandage around the body part until
the dressing is completely covered and the If the dressing becomes saturated with blood
bandage extends several inches beyond the while you are applying pressure, do not remove the
dressing. Tie or tape the bandage in place original dressing or bandage. Instead, leave the
(Fig. 19-8, A–F). original and replace other dressings and bandages
Do not cover fingers or toes, if possible. with new dressings and reapply direct pressure.
By keeping these parts uncovered, you will be Then cover the dressings with a bandage to hold
able to tell if the bandage is too tight. If fingers them in place. Adding multiple dressings and
or toes become cold, numb or begin to turn bandages can reduce the overall effectiveness of
pale, ashen or blue, the bandage is too tight the dressings by spreading the pressure out over
and should be loosened slightly. a wider area. Keep the patient warm and position
them flat on their back. Care for other conditions,
If blood soaks through the bandage, do not
including shock.
remove the original dressing or bandage,
but remove excess blood-soaked bandages. Part of your care for severe bleeding is to always
Then apply an additional dressing and another assess and care for shock, since the risk of
bandage and reapply firm direct pressure. (hypovolemic) shock is high with significant
Elastic bandages can easily restrict blood flow if blood loss (see Chapter 18 for more information
not applied properly. Restricted blood flow is not on shock). Do not give food or drink if shock
only painful but also can cause tissue damage if is suspected.
not corrected. Fig. 19-9, A–D shows the proper
way to apply an elastic bandage. Nosebleeds
Nosebleeds are usually self-contained and can
most often be stopped easily. They can be caused
EXTERNAL BLEEDING by trauma or develop from a medical reason,
External bleeding is usually easy to control. Follow such as dryness or high blood pressure. In your
standard precautions when providing care. Wash assessment of the patient, you can expect to find
your hands before (if possible) and after providing pain or tenderness in the area and bleeding from
care, and wear disposable latex-free gloves. You the nose. The patient could also vomit swallowed
may use alcohol-based hand sanitizers if there is blood. For an unconscious patient, a nosebleed
no visible matter present and soap and water are can potentially block the airway.
not available. To care for a nosebleed:
Providing Care Ensure the conscious patient is sitting in an
upright position.
When treating a bleeding patient, apply a
sterile gauze dressing or trauma pad over the Tilt the patient’s head and upper body forward
slightly, if possible, to prevent swallowing or
wound and then apply direct pressure to the
choking on the blood.
wound with your gloved hand (see Skill Sheet 19-1).
If necessary, use your gloved hand to Pinch the patient’s nostrils together firmly for
begin applying direct pressure to the wound about 5 to 10 minutes to slow down the blood
while someone else obtains the necessary flow (Fig. 19-11).
material(s) (Fig. 19-10). If conscious and able, Tell the patient not to sniffle or blow their nose.
the patient may use their hand to apply pressure Do not pack the patient’s nose to stop the
while you obtain the necessary equipment or bleeding.
perform other, more urgent duties.
As with bleeding from external wounds, monitor the
For severe bleeding, apply strong, direct pressure patient for signs of shock if the bleeding does not
to the wound to counter the pressure from the stop. If you suspect a fractured skull, do not try to
beating heart. Use fingertip pressure (using the flat stop a nosebleed as this might increase pressure
part of fingers) first to control bleeding. If the wound on the brain. Instead, cover the nostrils loosely
is large and fingertip pressure does not work, use with sterile gauze and call for more advanced
hand pressure with gauze dressings to stop the medical personnel.
Chapter 19: Bleeding and Trauma | 451
A B
C D
E F
Fig. 19-8, A–F: To tie a bandage: (A) Begin by placing the end of the bandage on the dressing at a 45-degree angle. (B) Wrap the bandage one
full turn, and then fold the angled end of the bandage up, creating a “dog-ear.” (C) Continue wrapping the bandage, overlaying the “dog ear” to
anchor it and moving upward. (D) Once the dressing is covered, roll out the remaining length of bandage. (E) While holding the bandage, use the
index finger of the other hand to split the bandage in half, moving it down and underneath the limb. (F) Bring the two ends of the bandage up and
tie them in a bow or knot.
452 | Emergency Medical Response
A B
C D
Fig. 19-9, A–D: To apply an elastic bandage: (A) Start the elastic bandage at the point farthest from the heart. (B) Anchor the bandage.
(C) Wrap the bandage using overlapping turns. (D) Tape the end of the bandage in place.
Fig. 19-10: When treating a bleeding patient, apply a dressing Fig. 19-11: To care for a nosebleed, firmly pinch or have the
or trauma pad and use a gloved hand to apply direct pressure to patient pinch the nostrils together for about 5 to 10 minutes.
the wound.
Other Methods to Control Severe, not on an extremity or when a tourniquet is not
Life-Threatening Bleeding available or effective, a hemostatic dressing with
firm direct pressure may be considered, following
For a wound that is bleeding severely, if direct
the manufacturer’s instructions and local protocols.
pressure fails to control the bleeding or is
not possible, application of a manufactured
(commercial) tourniquet or a hemostatic dressing Tourniquets
by a properly trained responder can be considered. A tourniquet is a device placed around an
Manufactured tourniquets are preferred over arm or leg to constrict blood vessels and stop
makeshift or homemade devices. For wounds blood flow to a wound. In some life-threatening
Chapter 19: Bleeding and Trauma | 453
circumstances, you may need to use a tourniquet that you applied the tourniquet, and be sure to
to control bleeding as the first step instead of give the transporting personnel this information
maintaining direct pressure over several minutes. when they arrive. Once the tourniquet is applied,
Examples of situations where it may be necessary it should not be removed until the patient reaches
to use a tourniquet include: a healthcare facility. Skill Sheet 19-2 describes
step-by-step how to apply a commercially
Severe, life-threatening bleeding that cannot be manufactured tourniquet.
controlled using direct pressure.
A physical location that makes it impossible to If it is necessary to use a tourniquet and a
apply direct pressure to control the bleeding commercially manufactured tourniquet is not
(e.g., the injured patient or their limb is trapped available, make a tourniquet using a strip of soft
in a confined space). material that is 2 to 4 inches wide (such as a
triangular bandage that has been folded into a tie)
Multiple patients with life-threatening injuries
and a short, sturdy stick or other rigid object. Tie
who need care and there are limited resources
available. the stick or other rigid object into the material and
twist it to tighten the makeshift tourniquet.
A scene that is or becomes unsafe.
Tourniquets can be extremely painful. If you Hemostatic Dressings
must apply a tourniquet, make sure the patient A hemostatic dressing is a dressing treated
understands the reason for the tourniquet, and with an agent or chemical that speeds up clotting.
warn them that it may be painful. As is the case with tourniquets, hemostatic
dressings are used when severe, life-threatening
If you find yourself in a situation where you need bleeding exists and standard procedures (direct
to apply a tourniquet, follow the manufacturer’s pressure) for bleeding control fail or are not
instructions for applying it. Although tourniquets practical. Typically, hemostatic dressings are used
may have slightly different designs, all are applied on parts of the body where a tourniquet cannot
in generally the same way. First, place the be applied, such as the neck, torso and junctional
tourniquet around the wounded extremity about areas such as the abdomen and groin. Hemostatic
2 inches above the wound, avoiding the joint if dressings may also be used on extremities when a
possible. Secure the tourniquet tightly in place tourniquet is not available or is not effective.
according to the manufacturer’s instructions.
Twist the rod (windlass) to tighten the tourniquet Hemostatic dressings must be applied at the
until the bleeding stops, then secure the rod in site of the bleeding and be packed deep inside
place (Fig. 19-12, A–B). Note and record the time the wound along with direct pressure. Follow the
A B
Fig. 19-12, A–B: To apply a tourniquet: (A) Secure the tourniquet in place around the injured body part. (B) Tighten it by twisting the rod
and securing it into place. Note and record the time the tourniquet was applied.
CRITICAL Tourniquets can be extremely painful. If you must apply a tourniquet, make sure the
FACTS patient understands the reason for the tourniquet, and warn them that it may be
painful.
454 | Emergency Medical Response
Fig. 19-13: To be effective, hemostatic dressings require continuous direct pressure at the source
of the bleeding until the bleeding is controlled. Photo: courtesy of the Canadian Red Cross.
manufacturer’s instructions for proper application not be visible, it may lead to extensive concealed
of the hemostatic dressing according to local bleeding. It may also cause unexplained shock.
protocols. To be effective, hemostatic dressings
require continuous direct pressure at the source Internal bleeding can also occur along with external
of the bleeding until the bleeding is controlled bleeding. For example, if a patient is bleeding from
(Fig. 19-13). Any time a hemostatic dressing is a knife wound, the blade may have penetrated an
applied, the patient needs to be evaluated by organ, which then begins bleeding inside the body.
a healthcare provider. The patient may experience injuries to extremities,
causing pain, swelling or deformity. This may lead
Splints to serious internal blood loss from long bone
In an open wound to an extremity where the bone fractures. Internal bleeding is not always easy to
or joint is also injured, the bone ends or fragments recognize unless the patient is losing blood from
can be displaced and cause damage to soft the ears, mouth, vagina, rectum or possibly from
tissues and blood vessels, causing further the nose.
bleeding. Using a splint to immobilize the extremity
As with external bleeding, arterial bleeding is
can help prevent this problem. If the wound is over
typically the most severe. The strength of the
an open fracture (on the bones), do not apply direct
heartbeat will cause the blood to flow from the
pressure but instead pack sterile gauze around the
blood vessels into the interior of the body quickly
area to control bleeding and prevent infection.
and with great force.
INTERNAL BLEEDING Signs and Symptoms of
Causes Internal Bleeding
Internal bleeding is the escape of blood from Some signs and symptoms of internal bleeding
arteries, veins or capillaries into spaces in the body. include:
Internal bleeding can be caused by a variety of
injuries or conditions, including blunt force trauma. Discoloration of the skin around the area
(bruising) on the neck, chest, abdomen or side.
For example, the impact of the chest or head against
the steering wheel during a motor-vehicle collision Nausea, vomiting or coughing up blood.
can cause internal bleeding. It can also be caused Discolored, painful, tender, swollen or firm tissue
by a fracture, which may cause bones to pierce (e.g., the abdomen).
internal organs. Because this type of damage may Tenderness and guarding (protecting the area).
Chapter 19: Bleeding and Trauma | 455
CRITICAL Some signs and symptoms of internal bleeding include bruising on the neck, chest,
FACTS abdomen or side; nausea, vomiting or coughing up blood; patient guarding the area;
rapid pulse or breathing; skin that is cool or moist or looks pale, ashen or bluish;
excessive thirst; declining LOC and drop in blood pressure.
If a patient is bleeding internally, call for more advanced medical personnel, keep
the patient still and care for shock.
Signs and symptoms of shock may be present, severe bleeding. External bleeding is easily
including: recognized and should be cared for immediately.
Check and care for severe, life-threatening
Anxiety or restlessness. bleeding as you form your general impression
Rapid, weak pulse. and conduct the primary assessment. Severe
Rapid breathing. external bleeding is life threatening. Although
Skin that feels cool or moist or that looks pale, internal bleeding is less obvious, it also can be
ashen or bluish. life threatening. Recognize when a serious injury
has occurred and suspect internal bleeding.
Excessive thirst.
You may not identify internal bleeding until you
Declining level of consciousness (LOC).
perform the physical exam and patient history.
Drop in blood pressure. When you identify or suspect severe bleeding,
quickly transport or arrange for transport of
Providing Care the patient to a hospital. Continue to provide
If a patient is bleeding internally: care until more advanced medical personnel
take over.
Call for more advanced medical personnel
if serious internal bleeding is suspected. Do not wait for shock to develop before
providing care to someone who is injured or
Ensure the patient remains as still as possible,
suddenly ill, especially if there is blood loss or
to reduce the heart’s blood output.
if the normal function of the heart is interrupted.
Care for shock.
Care for life-threatening conditions, such as
When internal bleeding is from the capillary blood severe external bleeding, before caring for lesser
vessels, the result is bruising around the wound injuries. Remember that managing shock effectively
area and is not serious. To reduce discomfort for begins with recognizing a situation in which
the patient, you can apply a cold pack. shock may develop, and providing appropriate
care. Summon more advanced medical personnel
immediately if you notice signs and symptoms of
PUTTING IT ALL TOGETHER shock. Shock can often be reversed by advanced
One of the most important things you can do in medical care, but only if the patient is reached
any emergency is to recognize and control in time.
You Are the Emergency Medical Responder
You have called for more advanced medical personnel. Blood is spurting with each beat of the
patient’s heart. The bandage is soaked with blood and your partner notices that the patient is
turning pale and his LOC is changing. How would you respond? What other concerns do you
have and what additional steps should you take until EMS personnel arrive?
456 | Emergency Medical Response
Skill Sheet
Skill Sheet 19-1
Using Direct Pressure to
Control External Bleeding
NOTE: Always follow standard precautions when providing care.
STEP 1
Cover the wound with a sterile gauze pad and apply direct
pressure until the bleeding stops.
■■ If blood soaks through the dressing, leave the
original dressing in place, but remove any excess
dressings or bandages and apply a new one on
top. Then apply additional direct pressure (press
harder than you did before, if possible). It may take
several minutes for the bleeding to stop.
STEP 2
When the bleeding stops, check for circulation (feeling, warmth and color) beyond the injury.
STEP 3
Apply a roller bandage. Wrap the bandage around the
wound several times to hold the gauze pad(s) in place.
■■ Tie or tape the bandage to secure it.
■■ Check for circulation (feeling, warmth and color)
beyond the injury. If there is a change in feeling,
warmth or color (indicating that the bandage is
too tight), gently loosen it.
STEP 4
Remove your disposable latex-free gloves and wash your hands.
NOTE: If the bleeding does not stop with the application of direct pressure, call for more
advanced medical personnel if you have not already, and give care for shock if necessary.
Chapter 19: Bleeding and Trauma | 457
Skill Sheet
Skill Sheet 19-2
Using a Commercial Tourniquet with a Windlass
NOTE: Always follow the manufacturer’s instructions and local protocols when applying a tourniquet.
Always follow standard precautions when providing care.
After conducting a scene size-up, checking the patient and having someone else call for more
advanced medical personnel and then determining that standard first aid care for bleeding (direct
pressure) is not effective or appropriate for controlling the severe, life-threatening bleeding:
STEP 1
Place the tourniquet around the limb, approximately
2 inches above the wound. Avoid placing the tourniquet
over a joint.
STEP 2
Route the tag end of the strap through the buckle of the tourniquet, if necessary.
STEP 3
Pull the strap tightly and secure it in place.
STEP 4
Tighten the tourniquet by twisting the rod (windlass) until
the flow of bleeding stops and then secure the rod in
place. Do not cover the tourniquet with clothing.
STEP 5
Note and record the time that you applied the tourniquet,
and give this information to the transporting personnel
when they arrive to take over care.
458 | Emergency Medical Response
ENRICHMENT
Mechanisms of Injury—The Kinematics of Trauma
Vehicle Collisions
Motor-vehicle collisions are some of the most frequent scenes to which an emergency medical responder (EMR)
may be called. Collisions are categorized as head-on impact, rear impact, side impact, rotational impact and
rollover. Each collision category shows a predictable pattern of injury, which is influenced by the type of restraint
the occupant was using at the time of the collision.
A head-on collision is one in which a vehicle hits an object, such as a tree or a stopped vehicle, straight on.
When the car makes impact in a head-on collision, the bodies of the occupants will continue to move until they strike an
object such as a secured seat belt, an air bag, the steering wheel or the windshield. Additionally, the organs within the
body also continue to move forward until they strike an internal structure such as the sternum or skull. Injuries common
to head-on collisions include face, head, neck, chest and abdominal injuries. This is also true for rear-impact collisions.
In side-impact collisions, also known as broadside, lateral or t-bone collisions, the person on the impact
side of the crash sustains more injuries than do occupants on the opposite side. Due to the impact sustained
during a side-impact collision, the body moves one way and the head the other. This makes head and neck injuries
more common. Chest and pelvic injuries are also possible in this situation.
Rotational impact occurs off center, when the car strikes an object and rotates around it until the car either loses
speed or strikes another object. Injuries similar to head-on and side-impact collisions can be expected in these cases.
Rollovers see the occupants of the car changing positions as the car does (Fig. 19-14, A–D). In these cases,
predicting injury is impossible, as every object in the car becomes potentially lethal. If occupants are not wearing
seat belts, it is more likely that they may be thrown from the car, dramatically increasing the likelihood of death.
Common injuries in rollovers include soft tissue injuries, multiple broken bones and crushing injuries.
A B
C D
Fig. 19-14, A–D: In a rollover, unrestrained occupants of the car change positions as the car does.
Continued on next page
Chapter 19: Bleeding and Trauma | 459
ENRICHMENT
Mechanisms of Injury—The Kinematics of Trauma continued
When someone is struck by or falls against a blunt object—one with no sharp edges or points—the resulting
injuries are often closed wounds. This means that, although the soft tissues of skin, muscle, nerves and blood
vessels may be damaged, the skin is not broken and there is no visible bleeding. The patient may look unharmed,
but there may be serious, even fatal, injury to the internal organs and significant internal bleeding.
Proper use of restraints in a vehicle will help to lessen the likelihood of injury for the occupants. However,
injuries can still be sustained. Restraints vary based on the type of vehicle, and some can be more effective than
others in preventing injury.
Lap belts
� Prevent occupants from being thrown from a car.
� Do not prevent head, neck and chest injuries.
� Can cause internal injuries if not worn properly.
� Can cause injury to the diaphragm.
Lap and shoulder belts
� Prevent occupants from striking the steering wheel and dashboard.
� Upon severe impact can cause damage to the clavicle.
� Do not prevent head and neck injury.
Air bags
� Are located in the steering wheel, dashboard and/or side curtains.
� Must have high impact to deploy.
� Are fully effective only when occupants are wearing seat belts.
� Can cause burns, contusions (bruises) and other, more serious injuries.
� Protect the occupant only from the first collision in a multi-collision crash.
Head rests
� When properly adjusted, limit the effects of head, neck and spinal injuries.
Pediatric Considerations
Because an air bag could seriously injure or even kill a child, or even an adult of short stature,
these individuals are safest in the rear seat. A child or an infant in a rear-facing seat is close to the
dashboard and could easily be struck by the air bag with sufficient force to cause serious harm or
even death. Older children who have outgrown child seats are also at risk from a deploying air bag,
if not properly restrained.
Infants should always be transported in car seats. However, as with seat belts and air bags, car seats vary
based on type, and some can be more effective than others in preventing injury.
Infant car seats facing backward help prevent head and neck injuries.
The greatest danger is to the infant’s neck.
Seats vary, based on the age and size of the occupant.
In motorcycle crashes, there are four potential scenarios: head-on, angular, ejection and laying the bike down
(Fig. 19-15). The purpose of laying the bike down is to minimize impact in the case of an impending crash.
The rider may turn the motorcycle sideways and drag a leg along the ground to lose speed in order to get off
the bike. This can result in severe burns and abrasions, but lessens the likelihood of internal injuries.
Head-on impacts will usually result in the driver impacting the handlebars at the same speed the bike is
traveling. Multiple injuries can result.
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ENRICHMENT
Mechanisms of Injury—The Kinematics of Trauma continued
Fig. 19-15: In motorcycle crashes, there are four potential scenarios: head-on, angular, ejection and laying
the bike down (shown). Photo: courtesy of Captain Phil Kleinberg, EMT-P.
Angular impact can result in severe amputations, as the rider strikes an object at an angle. Ejection from the
bike causes the rider to fly over the handlebars, which can result in severe head, spinal and face injury, especially
if the rider is not wearing a helmet.
All-terrain vehicle (ATV) crashes commonly result in head, neck and extremity injuries similar to those seen in
motorcycle collisions. These vehicles are prone to crashes and rollovers.
Falls
A significant number of trauma-related injuries each year are caused by falls, particularly among older adults.
The severity of the injury depends on:
The distance of the fall.
Any interruptions during the fall.
Which body parts impact first.
The surface on which the patient lands.
The patient’s physical condition before the fall took place.
There are two types of falls. Feet-first falls cause energy to travel up the skeleton as the patient lands (Fig. 19-16).
When a patient’s knees are bent on landing, injury will be less severe. Spine, hip socket, femur, heel and ankle are
the most common sites for injury from these falls. If hands are outstretched to help “break” a fall, then wrists will
be also be impacted. Broken shoulders and clavicles are also common.
Headfirst falls begin with the arms and extend to the shoulders on impact. Therefore, spine and head injuries
are common. Chest, lower back and pelvis injuries often occur as the body is falling and the torso and legs are
thrown forward or backward.
Falls on the side of the head (as in skiing incidents) often do not show signs and symptoms until 1 to 2 hours
after the injury. Be sure to tell this to patients, so that they are aware of it. Strongly encourage patients to get
checked out by a healthcare provider before symptoms occur.
Continued on next page
Chapter 19: Bleeding and Trauma | 461
ENRICHMENT
Mechanisms of Injury—The Kinematics of Trauma continued
Penetrating Injuries
When an object is pushed through the surface and soft
tissue of the body, a penetrating injury occurs. There
are low-velocity and medium-high velocity penetrating
injuries. Low-velocity injuries occur most commonly with
the use of hand-powered weapons such as knives or
arrows. The severity of the injury can be determined by
the location of the injury and the length of the weapon.
The strength and force capacity of the attacker is also
a determining factor.
Medium-high velocity injuries are caused by guns.
Tissue damage can be much more widespread in a
patient with a gunshot wound than may be indicated by
the surface wound. Little external bleeding can still be
a result of a devastating internal injury.
Blast Injuries
Explosions can produce unique patterns of injury, often
inflicting multiple life-threatening injuries on several
patients simultaneously. Blast injuries are divided
into four categories: primary, secondary, tertiary and
miscellaneous.
Primary blast injury is caused by the direct effect
of blast overpressure on a patient’s tissue, resulting in Fig. 19-16: In a jump or fall from a height, the impact can cause
injury to air-filled structures such as the lungs, ears and injury to the spine, hip socket, femur, heel and ankle.
gastrointestinal tract. A primary blast injury damages
organs and tissue solely by the shock of the blast wave.
Secondary blast injury is caused when a patient is struck by flying objects and is responsible for the majority
of casualties in many explosions. Injuries most commonly include penetrating thoracic trauma, including
lacerations of the heart and major blood vessels, which is a common cause of death by secondary blast injuries.
Tertiary blast injuries are caused by individuals flying through the air and striking other objects, generally from
high-energy explosions. The patient is usually very close to the explosion source when injured this way.
Miscellaneous blast-related injuries, sometimes termed quaternary blast injuries, encompass all other injuries
a patient may experience caused by explosions, including burns, crush injuries and inhalation of toxic fumes or
substances. It is probable that wheezing associated with a blast injury is from one of the following:
Pulmonary contusion
Inhalation of toxic gases or dusts
Pulmonary edema from myocardial contusion
Adult respiratory distress syndrome (ARDS)
If possible, try to determine:
What material caused the explosion.
The patient’s location relative to the center of the explosion.
If there is evidence of radiation and/or chemicals.
462 | Emergency Medical Response
20 SOFT TISSUE
INJURIES
You Are the Emergency Medical Responder
You are on the medical emergency response team (MERT) responding to a call at a power
plant that at least one worker has suffered an electrical shock from a live junction box. Plant
workers thought that a colleague had turned off the power, but when the injured worker
reached inside and touched a wire, he received a shock and an electrical burn. The injured
worker lost consciousness momentarily. A second worker at the scene moved away from
his co-worker and called for help. When you arrive, the co-worker who placed the call
relates what happened. How should you respond? What are your immediate concerns?
KEY TERMS
Abrasion: The most common type of open wound; Epidermis: The outer layer of the skin; provides a
characterized by skin that has been rubbed or barrier to bacteria and other organisms that can
scraped away. cause infection.
Amputation: The complete removal or severing of an Full-thickness burn: A burn injury involving all layers
external body part. of skin and underlying tissues; skin may be brown
or charred, and underlying tissues may appear
Avulsion: An injury in which a portion of the skin, white; also referred to as a third-degree burn.
and sometimes other soft tissue, is partially or
completely torn away. Hypodermis: A deeper layer of skin located below
the epidermis and dermis; contains fat, blood
Burn: An injury to the skin or other body tissues vessels and connective tissues.
caused by heat, chemicals, electricity or radiation.
Laceration: A cut, usually from a sharp object,
Chemical burn: A burn caused by strong, caustic that can have either jagged or smooth edges.
chemicals damaging the skin.
Open wound: A wound resulting in a break in the
Closed wound: A wound in which soft tissue skin’s surface.
damage occurs beneath the skin and the skin is
not broken. Partial-thickness burn: A burn injury involving
the epidermis and dermis, characterized by red,
Compartment syndrome: Condition in which there wet skin and blisters; also referred to as a
is swelling and an increase in pressure within a second-degree burn.
limited space that presses on and compromises
blood vessels, nerves and tendons that run Puncture/penetration: A type of wound that results
through that limited space; usually involves the when the skin is pierced with a pointed object.
leg, forearm, arm, thigh, shoulder or buttock.
Radiation burn: A burn caused by exposure to
Critical burn: Any burn that is potentially life radiation, either nuclear (e.g., radiation therapy)
threatening, disabling or disfiguring; a burn or solar (e.g., radiation from the sun).
requiring advanced medical care.
Rule of Nines: A method for estimating the extent
Crush injury: An injury to a body part, often an of a burn; divides the body into 11 surface
extremity, caused by a high degree of pressure; areas, each of which comprises approximately
may result in serious damage to underlying tissues 9 percent of the body, plus the genitals, which
and cause bleeding, bruising, fracture, laceration are approximately 1 percent.
and compartment syndrome.
Soft tissues: Body structures that include the layers
Dermis: The deeper layer of the skin; contains of skin, fat and muscles.
the nerves, sweat glands, oil glands and
blood vessels. Superficial burn: A burn injury involving only the
top layer of skin, characterized by red, dry skin;
Electrical burn: A burn caused by contact with also referred to as a first-degree burn.
an electrical source, which allows an electrical
current to pass through the body. Wound: An injury to the soft tissues.
LEARNING OBJECTIVES
After reading this chapter, and completing the • Describe the emergency medical care for a patient
class activities, you will have the information with an injury from an embedded object.
needed to: • Describe the emergency medical care for a patient
• List the types of soft tissue injuries. with an open wound.
• Describe the emergency medical care for a patient • Describe the emergency medical care for a patient
with a soft tissue injury. with an amputation.
464 | Emergency Medical Response
LEARNING OBJECTIVES continued
• List the signs and symptoms of closed wounds. • Describe the kinds of injuries that might
• List the causes of a burn injury. occur from a thermal, electrical, chemical and
radiation burn.
• List conditions under which you would summon
more advanced medical personnel for a burn injury. • Describe how to care for thermal, chemical,
electrical and radiation burns.
• Describe the emergency medical care for burns.
INTRODUCTION Skin
An infant falls and bruises an arm while learning (epidermis)
to walk; a child needs stitches in the chin
after tumbling from the “monkey bars” on the
playground; a teenager gets a sunburn during
a weekend at the beach; and an adult cuts a
hand while working in a woodshop. What do Fat
these injuries have in common? They are all soft
tissue injuries.
In the course of growing up and in our daily
lives, soft tissue injuries occur often and in many Muscle
different ways. Fortunately, most soft tissue injuries
are minor, requiring little attention. Often, only an
adhesive bandage or a cold pack and rest are
needed. Some injuries, however, are more severe
and require immediate medical attention.
Burns are a special kind of soft tissue injury. Like
Fig. 20-1: Layers of skin, fat and muscle protect underlying
other types of soft tissue injury, burns can damage structures of the body.
the top layer of skin or the skin and the layers of
fat, muscle and bone beneath. In this chapter,
you will learn how to recognize and care for soft human body could not function. The skin provides
tissue injuries. a protective barrier for the body; it helps regulate
the body’s temperature and it receives information
about the environment through the nerves that
SKIN AND SOFT TISSUE run through it.
INJURIES The outer layer of skin, the epidermis, provides
Soft Tissues a barrier to bacteria and other organisms that can
The soft tissues include the layers of skin, fat and cause infection. The deeper layer, the dermis,
muscle that protect the underlying body structures contains the important structures of the nerves, the
(Fig. 20-1). sweat and oil glands, and the blood vessels. The
hypodermis—located beneath the epidermis and
In Chapter 4, you learned that the skin is the largest dermis—contains fat, blood vessels and connective
single organ in the body and that, without it, the tissues. Because the skin is well supplied with
CRITICAL The skin is the largest organ in the body. The outer layer, called the epidermis,
FACTS provides a barrier to bacteria and other organisms that can cause infection.
An injury to the soft tissues is called a wound. Soft tissue injuries are typically
classified as either closed wounds or open wounds.
Chapter 20: Soft Tissue Injuries | 465
blood vessels and nerves, most soft tissue injuries CLOSED WOUNDS
are likely to bleed and be painful.
Closed wounds occur beneath the surface of
Beneath the skin layers lies a layer of fat. This layer the skin. The simplest closed wound is a bruise,
helps insulate the body, to help maintain body also called a contusion (Fig. 20-2). Bruises result
temperature. The fat layer also stores energy. The when the body is subjected to blunt force, such as
amount of fat varies in different parts of the body when you bump your leg on a table or chair. Such
and in each person. a blow usually results in damage to soft tissue
layers and blood vessels beneath the skin, causing
The muscles lie beneath the fat layer and comprise internal bleeding.
the largest segment of the body’s soft tissues. Most
soft tissue injuries involve the outer layers of tissue. A much more serious closed wound can be caused
However, violent forces, such as those that cause by a violent force hitting the body. This type of force
deep burns or cause objects to penetrate the skin, can injure larger blood vessels and deeper layers of
can injure all the soft tissue layers. Muscle injuries muscle tissue, causing heavy bleeding beneath the
are discussed more thoroughly in Chapter 22, skin, which causes a localized tissue mass that can
along with other musculoskeletal injuries. be discolored by the internal bleeding. These injuries
are referred to as hematomas.
Types of Soft Tissue Injuries
Signs and Symptoms
An injury to the soft tissues is called a wound. of Closed Wounds
Soft tissue injuries are typically classified as either
closed wounds or open wounds. A wound is When blood and other fluids seep into the
considered closed when the soft tissue damage surrounding tissues, the area discolors (turns black
occurs beneath the surface of the skin, leaving and blue) and swells. The amount of discoloration
the outer layer intact; this often results in internal and swelling varies depending on the severity of
bleeding. A wound is considered open when there the injury. At first, the area may only appear red.
is a break in the skin’s outer layer; this usually Over time, more blood may leak into the area,
results in external bleeding. making the area appear dark red or purple. Violent
forces can cause more severe soft tissue injuries
Burns are a special kind of soft tissue injury. involving larger blood vessels, the deeper layers
A burn injury occurs when intense heat, certain of muscle tissue and even organs deep within the
chemicals, electricity or radiation contact the skin body. These injuries can result in profuse internal
or other body tissues. Burns are classified as bleeding. With deeper injuries, you may or may not
superficial, partial thickness or full thickness. see bruising immediately.
Fig. 20-2: Bruises result when the body is subjected to blunt force. Photo: courtesy of Ted Crites.
466 | Emergency Medical Response
Providing Care for Closed Wounds The force that caused the injury seems great
enough to cause serious damage.
Many closed wounds, such as bruises, do not
require special medical care. To care for a closed An injured extremity is blue or extremely pale.
wound, be sure to keep the injured area still. The patient’s abdomen is tender and
Applying cold can be effective early on in helping distended.
control both pain and swelling (Fig. 20-3). When The patient is vomiting blood or coughing
applying cold: up blood.
Make a cold pack by filling a sealable plastic The patient shows signs and symptoms
of shock.
bag with a mixture of ice and water, and then
apply it to the injured area for about 20 minutes. With all closed wounds, help the patient to rest
Place a thin towel as a barrier between the cold in the most comfortable position possible. If you
pack and the bare skin. If an ice-and-water suspect the patient may be in shock, have them lie
mixture is not available, use a bag of frozen flat on their back and care for shock. In addition,
vegetables or a chemical cold pack as an keep the patient from getting chilled or overheated.
alternative. Do not place ice directly on a wound. Be sure that a patient with an injured lower extremity
Remove the cold pack and wait 20 minutes does not bear weight on it until advised to do so by
before reapplying a new cold pack. a healthcare provider.
If the patient is not able to tolerate a 20-minute
application, limit application to 10 minutes.
Elevating the injured part may help to reduce OPEN WOUNDS
swelling; however, do not elevate the injured part In an open wound, the break in the skin can be
if doing so causes more pain or you suspect a as minor as a scrape of the surface layers or as
dislocation or fracture. severe as a deep penetration or even the loss of
a body part. The amount of bleeding depends on
Do not assume that all closed wounds are minor the location and severity of the injury as well as
injuries. Take the time to find out whether more other factors, including the patient’s use of certain
serious injuries could be present. With the cases medications such as blood thinners or aspirin.
that follow, the patient may be bleeding internally Any break in the skin provides an entry point for
and need emergency medical care. Call for more disease-producing microorganisms, or pathogens.
advanced medical care if:
There are six main types of open wounds,
The patient complains of severe pain or cannot including:
move a body part without pain.
Abrasions.
Amputations.
Avulsions.
Crush injuries.
Punctures/penetrations.
Lacerations.
Types of Open Wounds
Abrasions
An abrasion is the most common type of open
wound. It is characterized by skin that has been
rubbed or scraped away, such as when someone
falls and scrapes their hands or knees (Fig. 20-4).
Fig. 20-3: Applying cold to a closed wound can be effective in An abrasion is sometimes called a “rug burn,” “road
helping control pain and swelling. rash” or “strawberry.” Because the scraping of the
CRITICAL Burns are a soft tissue injury that has three classifications: superficial, partial
FACTS thickness and full thickness.
Chapter 20: Soft Tissue Injuries | 467
Fig. 20-4: An abrasion is characterized by skin that has been rubbed or scraped away.
outer skin layers exposes sensitive nerve endings, Although damage to the tissue is severe, bleeding
an abrasion is usually painful. Bleeding is easily may not be as profuse as you might expect. The
controlled and not severe, since only the capillaries blood vessels usually constrict and retract (pull
are affected. Because of the way the injury occurs, in) at the point of injury, slowing bleeding and
dirt and other matter can easily become embedded making it relatively easy to control with direct
in the skin, making it especially important to clean pressure. In the past, a completely severed
the wound. body part could not be successfully reattached.
With today’s technology, reattachment is often
Amputations successful, making it important to carefully
handle and send the severed part to the hospital
In some severe injuries, the force is so violent that
with the patient.
a body part, such as a finger, may be severed.
A complete severing of a part (usually involving a
bone or limb) is called an amputation (Fig. 20-5). Avulsions
An avulsion is an injury in which a portion of
the skin and sometimes other soft tissue is
partially or completely torn away (Fig. 20-6).
A partially avulsed piece of skin may remain
attached but hang like a flap. Bleeding can be
heavy because avulsions often involve deeper
soft tissue layers.
Crush Injuries
A crush injury is the result of a body part,
usually an extremity, being subjected to a high
degree of pressure, in most cases after being
compressed between two heavy objects
Fig. 20-5: An amputation is a complete severing of a part (Fig. 20-7). This type of injury may result in
of the body. serious damage to underlying tissues and cause
CRITICAL Open wounds are injuries that break the skin. These breaks can be as minor as a
FACTS scrape of the surface layers or as severe as a deep penetration or even the loss of
a body part. The six types of open wounds are abrasions, amputations, avulsions,
crush injuries, punctures/penetrations and lacerations.
468 | Emergency Medical Response
Fig. 20-6: In an avulsion, part of the skin and other soft tissue is torn away. Photo: courtesy of the Canadian Red Cross.
Punctures/Penetrations
A puncture/penetration wound results when
the skin is pierced with a pointed object, such as
a nail, piece of glass, splinter or knife (Fig. 20-8).
A bullet wound is also considered a puncture
wound. Because the skin usually closes around
the penetrating object, external bleeding is
generally not severe. However, internal bleeding
may be quite severe if the penetrating object
damages major blood vessels or internal organs.
An object that remains in the open wound is
called an embedded object. An object may also
Fig. 20-7: Crush injuries occur when a body part is subjected to pass completely through a body part, creating
a high degree of pressure. two open wounds—one at the entry point and
one at the exit point.
bleeding, bruising, fracture, laceration and Although puncture wounds generally do not
compartment syndrome. In a severe crush bleed profusely, they are potentially more
injury to the torso, internal organs may rupture. dangerous than wounds that bleed more, because
Crush injuries can be open or closed. they are more likely to become infected. Objects
penetrating the soft tissues carry microorganisms
Crush syndrome is common in people who are that cause infections. Of particular danger is the
trapped in collapsed structures due to, for example, microorganism that causes tetanus, a severe
an earthquake or act of terrorism. The injury does infection.
not happen at the time that the tissue is crushed,
but once the crushed muscle is released from
compression and the tissue is re-perfused with
Lacerations
blood. At that point, multiple adverse processes A laceration is a cut, usually from a sharp
occur, as the products of muscle breakdown object. The cut may have jagged or smooth
are released into the blood. The patient may edges (Fig. 20-9). Lacerations are commonly
suffer major shock and renal failure, and death caused by sharp-edged objects, such as knives,
may occur. scissors or broken glass. A laceration can also
Chapter 20: Soft Tissue Injuries | 469
Fig. 20-8: A puncture wound results when skin is pierced by a pointed object.
Fig. 20-9: A laceration is a cut in the skin. It may have either jagged or smooth edges.
470 | Emergency Medical Response
result when a blunt force splits the skin. Such Impaled Objects
splits occur in areas where bone lies directly An impaled object is one that has been embedded
under the skin’s surface, such as the jaw. Deep into an open wound (Fig. 20-10). There are two
lacerations can also affect the underlying layers situations in which it is appropriate to remove an
of fat and muscle, damaging both nerves and impaled object. The first is if the impalement is
blood vessels. Lacerations usually bleed freely and, through the cheek, with uncontrolled bleeding and
depending on the structures involved, can bleed interference with airway management. The second
profusely. Because the nerves may also be injured, is if the object impales the chest and interferes with
lacerations are not always immediately painful. CPR. When providing emergency care for an impaled
object, securing the object is highly important so that
Providing Care for Open Wounds it cannot move and cause further damage.
With any open wound, always follow standard Carefully secure the object manually, remove any
precautions to avoid contact with blood and OPIM. clothing from the area if possible and control
bleeding by applying direct pressure with sterile
Major Open Wounds dressings to the edges of the wound. Avoid
A major open wound involves serious tissue placing pressure on or moving the object. Once
damage and may bleed severely. As you learned
in Chapter 19, the main priority of care for a major
open wound is to control bleeding immediately
with direct pressure using sterile dressings and
pressure bandages and care for shock.
Minor Open Wounds
In minor open wounds, such as abrasions, damage
is only superficial and bleeding is normally minimal.
To care for a minor open wound, follow these
general guidelines:
Use a barrier between your hand and the
wound. If readily available, put on disposable
latex-free gloves and place a sterile dressing on
the wound.
Apply direct pressure for a few minutes to
control any bleeding.
Wash the wound thoroughly with soap and
water and gently dry it with clean gauze.
If possible, irrigate an abrasion for 5 minutes
with clean, warm, running tap water.
Cover the wound with a clean dressing and a
bandage (or with an adhesive bandage) to keep
the wound moist and prevent drying. Apply an
antibiotic ointment or wound gel to the dressing
or bandage first if the patient has no known
allergies or sensitivities to the medication. Do
not apply the ointment or gel directly to the
wound as doing so may contaminate the tube.
Wash your hands immediately after giving care, Fig. 20-10: An impaled object is one that has been embedded
even if you wore gloves. into the body.
CRITICAL With any open wound, always follow standard precautions to avoid contact with
FACTS blood and OPIM.
Chapter 20: Soft Tissue Injuries | 471
bleeding has stopped, apply a bulky dressing If the amputation is incomplete (i.e., an avulsion),
around the object, pack dressings around it and never remove the body part. Care for it as you
secure everything in place (Fig. 20-11). would any soft tissue injury, stabilizing the part.
If the body part is completely severed, find it, wrap
Amputations
it in sterile gauze, moistened in sterile saline if
In cases of amputation, first provide emergency available. Then place it in a plastic bag, seal the
care by controlling external bleeding. While it is bag, label it with the patient’s name and the time
important to care for the severed body part, it is and date it was placed in the bag. Keep the bag
vital to care for the patient first. Ask another cool by placing it in a larger bag or container of
responder to search for and provide care for the an ice and water slurry, not on ice alone and not
body part while you tend to the patient. on dry ice (Fig. 20-12). Transfer the bag to the
Fig. 20-11: To care for an impaled object, use bulky dressings to support the embedded object.
Use bandages over the dressing to control bleeding.
Fig. 20-12: Wrap a severed body part in sterile gauze, seal it in a plastic bag and put the bag in an
ice and water slurry.
472 | Emergency Medical Response
emergency medical services (EMS) personnel also tend to have more severe burns, especially if
transporting the patient to the hospital. they are not well nourished, have heart or kidney
problems, or are exposed to the burn source for
a prolonged period because they are unable to
BURNS escape.
Burns are another type of soft tissue injury, caused
primarily by heat. They can also occur when the
body is exposed to certain chemicals, electricity Classifying Burns
or radiation. Burns are classified in several ways, including
their depth, their extent, whether or not there is
When burns occur, they first affect the top respiratory involvement, the body part burned and
layer of skin, called the epidermis. If the burn the source (or cause): heat (thermal), chemical,
progresses, the dermis, or the second layer, electrical or radiation (such as from the sun).
can also be affected. Deep burns can damage
underlying tissues. Burns that break the skin can
Depth of Burn
cause infection, fluid loss and loss of temperature
control. They can also damage the respiratory Burns are classified by depth. The deeper the burn,
system and eyes. the more severe it is. The three classifications of
burns include superficial burns (formerly referred
The severity of a burn depends on the: to as first degree), partial-thickness burns (formerly
referred to as second degree) and full-thickness
Temperature of the source of the burn. burns (formerly referred to as third degree).
Length of exposure to the source.
Location of the burn. Superficial Burns
Size of the burn. A superficial burn involves only the top layer of
Patient’s age and medical condition. skin, the epidermis (Fig. 20-13). The skin is red
and dry, and the burn is usually painful. The area
In general, patients under 5 years of age and over may swell. Most sunburns are superficial burns.
age 60 have thinner skin and often burn more Superficial burns generally heal in 5 to 6 days
severely. People with chronic medical problems without permanent scarring.
Fig. 20-13: A superficial burn involves only the top layer of skin. Photo: courtesy of Alan Dimick, M.D., Professor of Surgery, Former
Director of UAB Burn Center.
Chapter 20: Soft Tissue Injuries | 473
Partial-Thickness Burns burns can be serious, requiring more advanced
A partial-thickness burn involves both the medical care. Scarring may occur from partial-
epidermis and the dermis (Fig. 20-14). These thickness burns.
injuries are also red and have blisters that may
open and weep clear fluid, making the skin appear Full-Thickness Burns
wet. The burned skin may look mottled (blotchy). A full-thickness burn destroys both layers of
These burns are usually painful, and the area skin as well as any or all of the underlying structures:
often swells. The body loses fluid, and the burn is fat, muscles, bones and nerves (Fig. 20-15). These
susceptible to infection. Although the burn usually burns may look brown or charred (black), with the
heals in 3 or 4 weeks, extensive partial-thickness tissues underneath sometimes appearing white.
Fig. 20-14: A partial-thickness burn involves the epidermis and the dermis. Photo: courtesy of Alan Dimick, M.D., Professor of Surgery,
Former Director of UAB Burn Center.
Fig. 20-15: A full-thickness burn destroys both layers of the skin in addition to any or all of the underlying structures, including fat,
muscles, bones and nerves. Photo: courtesy of Alan Dimick, M.D., Professor of Surgery, Former Director of UAB Burn Center.
474 | Emergency Medical Response
They can be either extremely painful or relatively Right thigh
painless if the burn destroys nerve endings in the Left thigh
skin. Full-thickness burns are often surrounded by
painful partial-thickness burns.
Right leg (below the knee)
Left leg (below the knee)
Full-thickness burns can be life threatening. Because
These body parts equal 99 percent, leaving the
the burns are open, the body loses fluid, and shock
genitals to make up the last one percent. The Rule
is likely to occur. These burns also make the body
of Nines is applied by adding up all the areas of
highly prone to infection. Scarring occurs and may be
the body that have partial- or full-thickness burns.
severe. Many burn sites eventually require skin grafts.
Partial areas are approximated.
Extent of Burn With pediatric patients, considerations must be
The extent of a burn is another important aspect of made for the fact that the head is a proportionally
the severity of the burn. It is commonly described larger contributor to body surface area and the upper
using the Rule of Nines. This method is used legs contribute less. The pediatric Lund-Browder
in the field to quickly determine if patients need diagram reflects this difference (Fig. 20-17).
to go to a specialty burn center for treatment. It The patient’s palm can be used to estimate the size
approximates the percentage of burned surface of a patchy burn. Assume that the patient’s palm
area of the patient. In an adult, the body surface represents approximately 1 percent of a body’s
is divided into the following 11 sections, each total surface area.
comprising approximately 9 percent of the body’s
skin coverage (Fig. 20-16): If you do not remember the Rule of Nines, simply
communicate to more advanced medical personnel
Head or the specialty burn center how the burn occurred,
Right arm the body parts involved and the approximate type
Left arm of burn. For example, “The patient was injured
Chest when an overheated car radiator exploded. The
patient has partial-thickness burns on the face,
Abdomen
neck, chest and arms.”
Upper back
Lower back
Respiratory Involvement
The respiratory system may also be damaged
when a patient is burned. If you note soot or burns
9 around the mouth, nose or the rest of the face,
this may be a sign that air passages or lungs have
18
front
18
18
9 9
back
18
1
9 front 9
18 18 18
back
1
14 14
Fig. 20-16: The Rule of Nines is used to estimate what Fig. 20-17: The Lund-Browder diagram is used to assess the
percentage of the body is affected by burns. severity of burns in pediatric patients.
Chapter 20: Soft Tissue Injuries | 475
Burns in any area where there is a significant joint
(e.g., hips and shoulders) are serious because of
potential loss of joint function.
Cause of Burn
It is also important to take into account the source
of the burn. Thermal burns include those caused
by an open flame; contact with a hot object, steam
or gas; or scalding by hot liquid. Burns can also be
caused by chemicals, electricity and radiation.
Expect that burns caused by flames or hot grease
will require medical attention, especially if the
Fig. 20-18: Soot burns around the mouth, nose or the rest of the
face may indicate air passages or lungs have been burned. patient is under 5 or over 60 years of age. Hot
grease is slow to cool and difficult to remove from
the skin. Burns that involve hot liquid or flames
been burned (Fig. 20-18). Respiratory damage contacting clothing will also be serious, since the
may include airway closure due to swelling of the clothing prolongs the heat contact with the skin.
face and throat. Consider a hoarse voice a sign of
respiratory involvement. Some synthetic fabrics melt and stick to the body.
The melted fabrics may take longer to cool than the
There may also be swelling of the larynx due to soft tissues. Although these burns may appear minor
inhalation of superheated air, which may also cause at first, they can continue to worsen for a short time.
fluid accumulation in the lungs. With more severe
inhalation of smoke and toxic gases, there may be
Severity of the Burn
respiratory arrest or compromise, or poisoning. Burns
around the chest can reduce the patient’s ability to It is important to be able to identify a critical burn.
expand the chest. This can cause trouble breathing. A critical burn requires the immediate attention of
more advanced medical personnel. Critical burns are
Circumferential burns are also of concern. potentially life threatening, disfiguring and/or disabling.
Circumferential burns refer to burns that circle an
entire body part. Circulatory compromise in that Knowing whether you should summon more
extremity can be the result of a circumferential burn advanced medical personnel for a burn injury can
to an extremity. A circumferential burn to the chest sometimes be difficult. It is not always easy or
is of critical concern because of expansion and possible to assess the severity of a burn immediately
contraction during respiration. after injury. Even superficial burns to large areas of
the body or to certain body parts can be critical. You
cannot judge severity by the pain the patient feels,
Body Part Burned because nerve endings may have been destroyed.
The particular part of the body burned also
determines the seriousness of the burn. Burns to Consult with medical control for a decision on
certain parts of the body are more critical than when to transport the patient. Call for more
to others. In particular, burns to the head, face, advanced medical personnel immediately for
eyes and ears may be associated with respiratory assistance in caring for the following:
problems and may be disfiguring. Burns to the
hands and feet are serious because of the potential Burns causing breathing difficulty
impact on the patient’s function. Burns to the Signs of burns around the mouth and nose
genitals or groin area are considered critical Burns covering more than one body part
because of the potential loss of function and Burns to the head, face, neck, hands, feet
because these areas are susceptible to infection. or genitals
CRITICAL Consult with medical control for a decision on when to transport the patient
FACTS involved in a burn incident. Advanced medical personnel must assist in the care
of serious burn injuries, such as those causing difficulty breathing, burns covering
more than one body part or to delicate body parts, any serious burns to a child or
older adult patient, and any burns from chemicals, explosions or electricity.
476 | Emergency Medical Response
Any partial-thickness or full-thickness burn to Partial-thickness burns. There are two kinds
a child or an older adult of signs and symptoms—superficial and deep:
Burns resulting from chemicals, explosions yy Superficial signs and symptoms: Painful,
or electricity red area that turns white to touch; mottling,
blisters, moist skin; hair is still present
Patients should be referred to a burn unit if they have: yy Deep signs and symptoms: May or may not
be painful (nerve endings may be destroyed);
Partial- or full-thickness burns that cover more than
may be moist or dry (sweat glands may be
10 percent of the body surface, for those patients
destroyed); may or may not turn white when
under the age of about 5 or over about 60.
area is touched; hair is usually gone
Partial- or full-thickness burns that cover more
Full-thickness burns. Painless, no sensation
than 2 percent of the body surface, for those in to touch, pearly white or charred, dry and may
other age groups. appear leathery
Partial- or full-thickness burns that involve the face,
hands, feet, genitalia, perineum or major joints. Providing Care for Thermal Burns
Full-thickness burns that cover more than 5 percent As you approach the patient, decide if the scene is
of the body surface, in patients of any age. safe. Look for fire, smoke, downed electrical wires
Electrical burns, including injury caused and warning signs for chemicals or radiation. If the
by lightning. scene is not safe and you have not been trained to
Chemical burns. manage it, summon specially trained personnel.
Inhalation injury. If the scene is safe, approach the patient cautiously.
Circumferential burns. If the source of the burn is still in contact with the
A burn injury and a pre-existing medical patient, take steps to remove and extinguish it.
condition that could make their care more Doing so may require you to smother the flames or
complicated or lengthy, or that could affect extinguish them with water or to remove smoldering
mortality (e.g., diabetes). clothing. For example, if the burn is caused by hot
Both burns and other injuries (e.g., fractures tar or plastic, cool the area with water but do not
or blast injury) where the burn injury poses the attempt to remove the tar or plastic.
greatest risk of morbidity or mortality.
Perform a primary assessment. Pay close attention
A burn injury (in a child) and the hospital lacks to the patient’s airway. Note soot or burns around the
qualified personnel or equipment. In this case, the mouth, nose and the rest of the face, which may be
child with burns should be transferred to a burn a sign that air passages or lungs have been burned.
center with the required personnel and equipment If you suspect a burned airway or burned lungs,
needed to look after a child with burns. continually monitor breathing and call for advanced
A burn injury (in a child) where there are special medical personnel immediately. Air passages may
circumstances (e.g., suspected child abuse or swell, impairing or stopping breathing. Administer
substance abuse) and where social/emotional supplemental oxygen if it is available.
and/or long-term rehabilitative support will
be needed. As you do a physical exam, look for additional signs
of burn injuries. Also look for other injuries, especially
if there was an explosion or electrical shock.
Thermal Burns
Signs and Symptoms of Thermal Burns If thermal burns are present, once you have removed
The signs and symptoms of thermal burns depend the patient from the source, follow these three basic
upon the extent of the burn. The signs and symptoms, care steps:
based on the degree of the burns, are as follows: 1. Cool the burned area.
Superficial burns. Painful, red area that turns white 2. Cover the burned area.
when touched; no blisters; moist-appearing skin 3. Minimize shock.
CRITICAL To care for a thermal burn, remove the patient from the source, cool and cover the
FACTS burned area, and take steps to minimize shock.
Chapter 20: Soft Tissue Injuries | 477
Cool the Burned Area extensive enough to require medical attention,
Even after the source of the burn has been care for the burned area as an open wound.
removed, soft tissue will continue to burn, causing Wash the area with soap and water. Cover
more damage. Therefore, it is essential to cool any the burn with a dressing and bandage. Apply
burned areas immediately with large amounts of antibiotic ointment or wound gel if your protocols
cool or cold running water for at least 10 minutes permit you to do so, one is available, and the
or until pain is relieved (Fig. 20-19, A). Do not patient has no known sensitivities or allergies
use ice or ice water. Ice or ice water can cause to the medication. Tell the patient to watch for
critical body heat loss and may make the burn signs of infection.
deeper. Flush the area using whatever resources
are available (e.g., a tub, shower or garden hose). Minimize Shock
You can apply soaked towels, sheets or other wet
Full-thickness burns and large partial-thickness
cloths to a burned face or other area that cannot
burns can cause shock as a result of pain and loss
be immersed. Be sure to keep these compresses
of body fluids. Have the patient lie down unless
cold by frequently resoaking them with cold water;
they are having trouble breathing. Administer
otherwise, they will not absorb the heat from the
supplemental oxygen based on local protocols
skin’s surface. Be careful to not cause hypothermia
and if it is safe to do so.
when cooling large burns or burns on small
children, who are more prone to hypothermia than
adults due to their greater skin surface area relative Risk of Hypothermia
to their weight. Patients who have sustained a burn have an
impaired ability to regulate the body’s temperature.
Allow adequate time for the burned area to cool.
Therefore, there is a tendency to chill. Keep the
If pain continues or if the edges of the burned area
patient warm to prevent hypothermia. Help the
are still warm to the touch when the cooling source
patient maintain normal body temperature by
is removed, continue cooling. When the burn is
protecting the patient from drafts. Remember that
cool, remove any remaining clothing from the area
cooling burns over a large area of the body also
by carefully removing or cutting material away. Do
risks inducing hypothermia in the burned patient.
not try to remove any clothing that is stuck to skin.
Be cautious and aware of this risk when cooling
Remove any jewelry only if doing so will not further
a burn that covers a large area.
injure the patient, as swelling may occur.
In some jurisdictions, you may be provided more Pediatric Considerations
specific directions for when and how to cool burns. Providing Care for Burns
Follow your local protocols. Children have a larger body surface area
relative to their weight than do adults. Body
Cover the Burned Area surface area is a major factor in determining
Burns often expose sensitive nerve endings. Cover how much water is lost through evaporation in
the burned area to keep out air and help reduce burn patients. Therefore, children with burns
pain (Fig. 20-19, B–C). Use dry, sterile dressings, lose more water through evaporation than
and loosely bandage them in place. The bandage do adult patients. This means that children
should not put pressure on the burn surface. If the usually tend to have greater fluid needs during
burn covers a large area of the body, cover it with resuscitation. Evaporative water loss leads to
clean, dry sheets or other clean cloths. greater heat loss, so children or infants with
burns are prone to hypothermia. Keep the
Covering the burn helps prevent infection. Do room temperature high.
not put ointments, butter, oil or other commercial
or home remedies on any burn that will receive When dealing with pediatric burn patients,
medical attention. These products seal in heat be aware of the possibility that the burns
and do not relieve pain. Other home remedies are the result of child abuse. Inflicted burns
can contaminate open skin areas, causing often leave characteristic patterns of injury
infection. Do not break blisters. Intact skin that cannot be concealed. A detailed history,
helps prevent infection. including previous trauma, presence of recent
illnesses and immunization records, will help
For small superficial burns or small burns with determine if your suspicions are correct.
open blisters that are not sufficiently severe or
478 | Emergency Medical Response
A
C
Fig. 20-19, A–C: To stop the burning of soft tissue: (A) Cool burned areas with large amounts of
cold water. (B–C) Cover and wrap it with sterile dressings when fully cooled.
Chapter 20: Soft Tissue Injuries | 479
Chemical Burns
Chemical burns are common in industrial
settings, but also occur in the home. Cleaning
solutions, household bleach, oven or drain
cleaners, toilet bowl cleaner, paint strippers,
and lawn or garden chemicals are common
sources of caustic chemicals that can eat away
or destroy tissue. Caustic chemicals cause
chemical burns.
Typically, burn injuries result from chemicals that
Fig. 20-20: Flush a chemical burn with large amounts of cool,
are strong acids or alkalis. These substances can running water.
quickly injure the skin. As with heat burns, the
stronger the chemical and the longer the contact,
advanced medical personnel arrive or for at least
the more severe the burn. The chemical will
20 minutes. Flush the affected eye from the nose
continue to burn as long as it is on the skin. You
outward and downward to prevent washing the
must remove the chemical from the skin as quickly
chemical into the unaffected eye.
as possible, and then call for more advanced
medical personnel immediately. If you suspect a Be aware that chemicals can be inhaled, potentially
chemical burn, also check to see whether the eyes damaging the airway or lungs. Call the national
are burned. Poison Help line at 800-222-1222 if you believe
chemicals have been inhaled and give that
Signs and Symptoms information to the call taker.
of Chemical Burns
Signs and symptoms of chemical burns include: Electrical Burns
Pain. The human body is a good conductor of
electricity. When someone comes into contact
Burning.
with an electrical source, such as a power
Numbness.
line, a malfunctioning household appliance
Change in level of consciousness (LOC). or lightning, electricity is conducted through
Respiratory distress. the body. Body parts resist electrical current;
Oral discomfort or swelling. some body parts, such as the bones, resist the
Eye discomfort. electrical current more strongly than others.
This resistance produces heat, which can
Change in vision.
cause electrical burns along the flow of the
current (Fig. 20-21).
Providing Care for Chemical Burns
Always brush dry or powdered chemicals off with Signs and Symptoms
a gloved hand or a cloth, if possible. If not, flush of Electrical Burns
them off with water. In some cases, a continuous The severity of an electrical burn depends on
flow of water will remove a dry substance before the type and amount of contact, the current’s
the water can activate it. Continue flushing path through the body and how long the contact
until more advanced medical personnel arrive lasted. Electrical burns are often deep; although
or for at least 20 minutes. If the substance is these wounds may look superficial, the tissues
a liquid, flush the burn continuously with large beneath may be severely damaged. Some electrical
amounts of cool, running water until more burns will be marked by entry and exit wounds
advanced medical personnel arrive or for at least indicating where the current has passed through
20 minutes (Fig. 20-20). Have the patient remove the body.
contaminated clothing and jewelry, if possible.
Take steps to minimize shock. The signs and symptoms of electrical injury
include:
Chemical burns to the eyes can be exceptionally
traumatic. Ensure more advanced medical Unconsciousness.
personnel have been called. If an eye is burned Dazed, confused behavior.
by a chemical, flush the affected eye until more Obvious burns on the skin’s surface.
480 | Emergency Medical Response
Fig. 20-21: Although electrical burns may look superficial, they are often deep, following the
current’s path through the body, and may severely damage underlying tissues.
Trouble breathing or no breathing. in addition to electrical burns. Be prepared to
Burns both where the current entered and perform CPR and use an AED. Anyone who suffers
where it exited the body, often on the hand an electrical shock needs an advanced medical
or foot. assessment to determine the extent of injury.
Providing Care for Electrical Burns Radiation Burns
Scene safety is of utmost importance. Once it is Radiation burns may occur from exposure
determined that the electrical current is secured to nuclear radiation, X-rays or as a side effect
and no longer passing through the patient, perform of radiation therapy. It can also be caused by
a primary assessment and care for any immediate tanning beds, or as the result of solar radiation
life-threatening conditions. During the physical from the sun. Solar burns are similar to heat
exam, look for two burn sites (entry and exit burns, often resulting in superficial and sometimes
wounds). Cool any electrical burns with cool or partial-thickness burns. Usually they are mild,
cold running water as you would a thermal burn; but they can be painful (Fig. 20-22). They may
then cover any burn injuries with a dry, sterile blister, involving more than one layer of skin.
dressing, and provide care to minimize shock. Care for sunburn as you would any other burn.
Look for painful, swollen and deformed extremities, Cool the burn and protect the burned area from
because the resistance to the electrical current
can cause severe muscle contractions, which may
produce musculoskeletal injuries.
With someone who has been struck by lightning,
look for and provide care for life-threatening
conditions such as respiratory or cardiac arrest.
The patient may also have fractures, including
spinal fracture, so do not move the patient
unless evacuation is required due to the scene
becoming unsafe. Caring for any immediate
life-threatening conditions takes priority over
caring for burns.
Fig. 20-22: Radiation burns, such as sunburns, are usually mild
Exposure to high- or even low-voltage electric but they can be painful and blister when involving more than one
current can cause dangerous cardiac arrhythmias layer of skin.
Chapter 20: Soft Tissue Injuries | 481
further damage by keeping it away from the source ensure the scene is safe. Approach the patient
of the burn. and check for life-threatening conditions and for
non-life-threatening conditions, if necessary.
People are rarely exposed to other types of radiation
unless working in special settings, such as certain Once the patient has been removed from the burn
medical, industrial or research sites. If you work source, follow the steps of burn care:
in such settings, you will be informed and will be
required to take precautions to prevent overexposure. Cool the burned area with water to minimize
additional tissue destruction.
PUTTING IT ALL TOGETHER Protect the burned area by covering it with
sterile dressings, clean sheets or other cloth.
Caring for wounds involves controlling bleeding To minimize shock, keep the patient from getting
and minimizing the risk of infection. Your primary chilled or overheated.
concern with minor wounds is to clean the wound
to prevent infection. For major wounds, control
Summon more advanced medical personnel for
any critical burn.
the bleeding quickly and summon more advanced
medical personnel. Always use a barrier such as In addition, always check for inhalation injury
disposable latex-free gloves, dressings or a clean if the person has a heat or chemical burn
folded cloth, to avoid contact with blood. Dressings involving the face. With electrical burns, check
and bandages, when correctly applied, help control carefully for other problems, such as difficulty
bleeding, reduce pain and minimize the risk of breathing, cardiac problems and painful, swollen,
infection. Apply pressure to help stop bleeding. deformed areas.
Burns damage the layers of the skin and Remember to take care with pediatric patients,
sometimes the internal structures, which can especially infants, as they are prone to
be life threatening. Heat, chemicals, electricity hypothermia. With electrical burns, check carefully
and radiation all cause burns. When caring for for additional conditions, such as difficulty
someone who has sustained a burn, always breathing, cardiac arrest and fractures.
You Are the Emergency Medical Responder
The safety officer quickly verifies that power has been shut off and it is safe to approach the
scene. You perform a primary assessment. The patient regains consciousness and complains
of pain in his hand and elbow. Your partner has called for more advanced medical personnel.
What types of injuries or conditions should you suspect and what emergency care should be
provided? Is calling for EMS personnel appropriate? Why or why not?
482 | Emergency Medical Response
21 INJURIES TO THE
CHEST, ABDOMEN
AND GENITALIA
You Are the Emergency Medical Responder
Your police unit responds to a call in a part of town plagued by violence. When you
arrive, you find the scene is empty except for a young woman lying on the sidewalk.
After sizing up the scene and approaching the young woman, you notice that she has
been shot and is bleeding profusely. How would you respond?
KEY TERMS
Chest tube: A tube surgically inserted into the chest Percussion: A technique of tapping on the surface
to drain blood, fluid or air, and to allow the lungs of the body and listening to the resulting sounds,
to expand. to learn about the condition of the area beneath.
Evisceration: A severe injury that causes the Peritoneum: The membrane that lines the
abdominal organs to protrude through the wound. abdominal cavity and covers most of the
abdominal organs.
Flail chest: A serious injury in which multiple rib
fractures result in a loose section of ribs that Pleural space: The space between the lungs and
does not move normally with the rest of the chest wall.
chest during breathing and often moves in the
opposite direction. Pneumothorax: Collapse of a lung due to pressure
on it caused by air in the chest cavity.
Hemopneumothorax: An accumulation of blood
and air between the lungs and chest wall. Subconjunctival hemorrhage: Broken blood
vessels in the eyes.
Hemothorax: An accumulation of blood between the
lungs and chest wall; caused by bleeding that may Subcutaneous emphysema: A rare condition in
be from the chest wall, lung tissue or major blood which air gets into tissues under the skin that
vessels in the thorax. covers the chest wall or neck; may occur as a
result of wounds to those areas.
Hyperresonance: Abnormal sounds during
percussion on the affected side of the chest. Sucking (open) chest wound: A chest wound
in which an object, such as a knife or bullet,
Hypotension: Abnormally low blood pressure. penetrates the chest wall and lung, allowing
air to pass freely in and out of the chest cavity;
Impaled object: An object that remains embedded breathing causes a sucking sound, hence
in an open wound; also referred to as an the term.
embedded object.
Tension pneumothorax: A life-threatening injury
Intercostal: Located between the ribs. in which the lung is completely collapsed and
air is trapped in the pleural space.
Jugular venous distension (JVD): Neck veins that
are swollen due to pressure from inside the vein. Thoracic: Relating to the thorax, or chest cavity.
Parenchyma: Tissue that is involved in the Traumatic asphyxia: Severe lack of oxygen due to
functioning of a structure or organ as opposed trauma, usually caused by a thoracic injury.
to its supporting structures.
LEARNING OBJECTIVES
After reading this chapter, and completing the • List different types of abdominal injuries.
class activities, you will have the information • List the signs and symptoms of abdominal
needed to: injuries.
• Describe general care steps for injuries to the • Explain assessment techniques for abdominal
chest, abdomen and pelvis. injuries.
• List the different types of chest injuries. • Describe how to care for closed and open
• List the signs and symptoms of chest injuries. abdominal injuries.
• Describe how to care for a sucking (open) • List the signs and symptoms of genital injuries.
chest wound. • Describe how to care for genital injuries.
• Describe how to care for an impaled or embedded
object in the chest.
484 | Emergency Medical Response
INTRODUCTION
Many injuries to the chest and abdomen involve
only soft tissues. Often these injuries, like those
that occur elsewhere on the body, are only minor
cuts, scrapes, burns and bruises. Occasionally,
a violent force or mechanism, known as trauma,
results in more severe injuries. These include Sternum
fractures and injuries to organs, which can
cause severe bleeding or impair breathing.
Ribs
Occupants who are not wearing seat belts during
motor-vehicle collisions often suffer fractures Diaphragm
and lacerations. Falls, athletic injuries and many
other forms of trauma may also cause such Spine
injuries. Injuries to the pelvis may be minor soft
tissue injuries or serious injuries to bone and
internal structures. Fig. 21-1: The thoracic cavity.
Because the chest, abdomen and pelvis contain
many organs important to life, injury to these areas The abdominal cavity is lined with a thick membrane
can be fatal if left untreated. A force capable of called the peritoneum, which supports the
causing severe injury in these areas may also organs, including the stomach, gallbladder, urinary
cause injury to the spine. bladder, intestines, liver, spleen, pancreas and
General care for these injuries includes: kidneys. It also contains important vascular
structures such as the abdominal aorta and inferior
Calling for more advanced medical personnel. vena cavae.
Limiting movement.
Genitalia are part of the reproductive systems of
Monitoring breathing and other vital signs. women and men. The male genitalia include the
Controlling bleeding. testicles, a duct system and the penis. The female
Minimizing shock. genitalia include the ovaries, fallopian tubes, uterus
and vagina (Fig. 21-3).
ANATOMY OF THE CHEST,
ABDOMEN AND GENITALIA CHEST INJURIES
The chest cavity, also called the thoracic cavity, Chest injuries are a leading cause of trauma deaths
is the second-largest body cavity and contains each year in the United States. Motor-vehicle
the heart and lungs (Fig. 21-1). The ribs, sternum collisions, direct blows and falls can all lead to
and upper portion of the spine (thoracic vertebrae) chest injuries (Fig. 21-4, A–C).
frame the wall of the thoracic cavity, also referred
to as the thoracic cage. The diaphragm, a large Chest wounds can be either open or closed.
muscular partition, separates the thoracic cavity Open chest wounds occur when an object, such
from the abdominal cavity. as a knife or bullet, penetrates the chest wall.
Open chest wounds also can be caused by
Below the diaphragm is the abdominal cavity. The fractured ribs that break through the skin. A chest
abdominal cavity contains the major organs of wound is considered closed if the skin is not
several of the body’s systems: the digestive system, broken. Closed chest wounds are generally
urinary system and endocrine system (Fig. 21-2). caused by a blunt object.
CRITICAL Because the chest, abdomen and pelvis contain many organs important to life, injury
FACTS to these areas can be fatal if left untreated. General care for these injuries includes
calling for advanced medical personnel, limiting movement in the patient, monitoring
breathing and other vital signs, controlling bleeding and taking steps to minimize
shock.
Chapter 21: Injuries to the Chest, Abdomen and Genitalia | 485
Stomach
Abdominal
Liver aorta
Gallbladder
Spleen
Right kidney
Left kidney
Intestines
Inferior vena
cavae Peritoneum
Pancreas
Urinary bladder
Fig. 21-2: The abdominal cavity.
FRONT VIEW
Ureter
Pelvis
Large intestine
Ovary
Fallopian
Bladder
tube
Femoral artery Uterus
Vas
deferens Vagina
Urethra
Scrotum
Testis
Female
Male
Fig. 21-3: Genitalia are part of the reproductive systems of women and men.
Types of Chest Injuries Blunt Trauma
Certain types of chest injuries may be life Blunt trauma is injury caused by the force of an object
threatening, and others merely cause discomfort. that impacts with, but does not penetrate, the body.
You will likely be able to recognize severe injuries. Signs and symptoms include severe shortness of
It is important to summon more advanced medical breath, chest pain and rapid, possibly irregular pulse.
personnel in those situations. The possibility of blunt trauma should be considered
486 | Emergency Medical Response
in patients who sustain a blow to the abdomen or
chest and show signs of respiratory distress.
Often, associated injuries will occur with blunt
trauma, including major trauma to the spleen, liver or
large blood vessels. Therefore, it is not unusual for
patients with these injuries to go into hypovolemic
shock, a type of shock in which there is multiple
organ failure due to major fluid loss—usually blood.
Traumatic Asphyxia
Traumatic asphyxia, or severe lack of oxygen
due to trauma, can result from chest injury. These
injuries often are caused by a strong crushing
mechanism or by situations in which patients have
been pinned under a very heavy object.
A
Signs and symptoms of traumatic asphyxia include:
Shock.
Distended neck veins.
Bluish discoloration of the head, tongue, lips,
neck and shoulders (cyanosis).
Broken blood vessels in the eyes
(subconjunctival hemorrhage).
Black eyes.
Pinpoint-sized red dots (petechiae) on the head
and neck.
Rounded, “moon-like” facial appearance.
Bleeding from the nose or ear.
Coughing up or vomiting blood.
Loss of consciousness, seizures or blindness.
Traumatic asphyxia is a very serious emergency that
B requires immediate intervention. If it is suspected,
call for more advanced emergency medical services
(EMS) personnel immediately. Assess the patient
for associated chest and abdominal injuries. Elevate
the patient’s head to approximately 30° to decrease
pressure to the head. Establish and maintain
adequate airway and breathing, and administer
supplemental oxygen, based on local protocols.
Fractured Ribs
Rib fractures are usually caused by a forceful blow
to the chest. Although painful, a simple rib fracture
is rarely life threatening. The patient will usually
attempt to ease the pain by leaning toward the side
of the fracture and pressing a hand or arm over the
injured area, thereby creating an anatomical splint
(Fig. 21-5). When ribs are fractured, suspect the
C possibility of internal injuries.
Fig. 21-4, A–C: (A) Motor-vehicle collisions, (B) direct blows
and (C) falls can lead to chest injuries, which are a leading cause The first priority with fractured ribs is adequate
of trauma deaths in the U.S. each year. breathing. A patient with a fractured rib often
Chapter 21: Injuries to the Chest, Abdomen and Genitalia | 487
CRITICAL Certain types of chest injuries may be life threatening, and others merely cause
FACTS discomfort. You will likely be able to recognize the difference.
Blunt trauma is injury caused by the force of an object that impacts with, but does
not penetrate, the body.
Traumatic asphyxia, or severe lack of oxygen due to trauma, can result from chest
injury. These injuries often are caused by a strong crushing mechanism or by
situations in which patients have been pinned under a very heavy object.
Fig. 21-5: Patients with rib injuries usually attempt to ease the Fig. 21-6: Give a patient with fractured ribs or flail chest a pillow
pain by creating an anatomical splint with their hand or arm and or rolled blanket to hold against the injury to immobilize the
leaning toward the side of the injury. injured area. Use a sling and binder to hold the patient’s arm
against the injured side of the chest.
has shallow breathing because normal or deep Air in the tissues under the skin (subcutaneous
breathing is painful. Give the patient a rolled emphysema).
blanket or pillow to hold against the fractured Bruising or piercing of the lung and injuries to
ribs to immobilize the injured area (Fig. 21-6). Use a the spleen or liver.
sling and binder to hold the patient’s arm against
the injured side of the chest. Monitor breathing.
Lacerated blood vessels between the ribs.
Possible complications of fractured ribs include: Flail Chest
In situations involving severe blows or crushing
Collapse of a lung due to air in the chest cavity injuries, multiple ribs can fracture in multiple
pressing on the lung (pneumothorax). places. These fractures can produce a loose
Accumulation of blood between the lungs and section of ribs that does not move normally with
chest wall (hemothorax).
CRITICAL Rib fractures are usually caused by a forceful blow to the chest.
FACTS
A flail chest injury is a serious, life-threatening rib fracture. It results from a severe
blow or crushing injury in which multiple ribs fracture in multiple places, causing
loose sections of ribs that move abnormally in the chest.
488 | Emergency Medical Response
Fig. 21-7: Severe blows or crushing injuries can cause flail chest, in which multiple ribs fracture in multiple places, creating a loose
section of ribs.
the rest of the chest during breathing. Usually, the trauma, it may result when a fractured rib penetrates
loose section will move in the opposite direction the lung, causing air to leak. It can also occur when
from the rest of the chest. This injury is called a air enters the chest cavity because of a sucking
flail chest, which is considered a serious rib (open) chest wound. Pneumothorax reduces lung
fracture and can be life threatening (Fig. 21-7). pressure and leads to respiratory distress.
When a flail chest involves the breastbone, the
breastbone is separated from the rest of the ribs. Patients may report pain while breathing, and pain
at the site of the rib fractures. Decreased breath
In flail chest, the lung tissues may be bruised, sounds will be present upon examination, and many
leading to inadequate oxygenation. There is also patients with traumatic pneumothorax also have
a risk of the ribs puncturing a lung. If you suspect some element of severe bleeding (hemorrhage),
a fractured rib or ribs, have the patient rest in a causing a hemopneumothorax. Patients with
position that will make breathing easier. Binding the pneumothorax will require a chest tube in the
patient’s arm to the chest on the injured side will hospital setting to fully re-expand the lung.
help support the injured area and make breathing
more comfortable. You can use an object such Hemothorax
as a pillow or rolled blanket to help support and Hemothorax is an accumulation of blood between
immobilize the injured area. Serious fractures often the lungs and chest wall (pleural space) that
cause severe bleeding and trouble breathing, and
creates pressure on the heart and lungs and
shock is likely to develop. Administer supplemental
prevents the lungs from expanding, resulting in
oxygen based on local protocols, and continue to
the same symptoms as those which occur in
monitor the patient’s vital signs.
pneumothorax (Fig. 21-8, B). The bleeding that
leads to hemothorax may be from the chest wall,
Pneumothorax the lung’s functional tissue (parenchyma) or
Pneumothorax is the collapse of a lung due major blood vessels in the thorax. It may occur
to air in the chest cavity pressing on the lung following blunt or penetrating injury to the chest,
and preventing it from expanding (Fig. 21-8, A). and often occurs together with pneumothorax.
Pneumothorax can occur in two ways. In blunt chest
CRITICAL Pneumothorax is the collapse of a lung due to air in the chest cavity pressing on the
FACTS lung and preventing it from expanding.
Hemothorax is an accumulation of blood between the lungs and chest wall
(pleural space), which creates pressure on the heart and lungs and prevents
the lungs from expanding.
Chapter 21: Injuries to the Chest, Abdomen and Genitalia | 489
Again, patients will complain of pain and
shortness of breath, and the condition may cause
shock. During patient assessment, if trained to
do so, you likely will note a decrease in breath
sounds when listening and dullness when tapping
(percussion) over the affected area. A massive
hemothorax will also cause abnormal or unstable
blood pressure.
Tension Pneumothorax
Tension pneumothorax is a serious, life-threatening
injury in which there is complete collapse of the
lung. Air enters the space around the lungs and
remains trapped there (Fig. 21-8, C). It is caused A Pneumothorax
by the same traumas as those that produce a simple
pneumothorax. Tension pneumothorax causes air
to continue leaking from an underlying injury to
the functional lung tissue (pulmonary parenchymal
injury), which increases pressure within the affected
side of the chest cavity.
Patients experiencing a tension pneumothorax are
typically in respiratory distress with diminished
or absent breath sounds and abnormal sounds
(hyperresonance) during percussion on the
affected side of the chest. The trachea shifts
away from the side of the injury (a very late sign
of tension pneumothorax that may not be seen
in the out-of-hospital setting) and the neck veins
become swollen, which is known as jugular B Hemothorax
venous distension (JVD). The patient will
show signs of unstable blood pressure, such as
abnormally low blood pressure (hypotension),
which can quickly develop into complete
cardiovascular collapse.
Extreme pressure in the chest cavity prevents
blood from returning to the heart, and the blood is
no longer pumped out. Death can occur quickly.
Immediate care provided by advanced medical
personnel for this life-threatening condition
includes decompression of the affected lung by
inserting a large-bore needle through the second
or third intercostal space, along an imaginary
line that passes through the midpoint of the
clavicle (midclavicular line), or through the fourth
or fifth intercostal space on the lateral chest wall.
C Tension Pneumothorax
Typically, a chest tube is then inserted in the Fig. 21-8, A–C: In the term hemothorax, “hemo” refers to blood. In
pneumothorax and tension pneumothorax, “pneumo” refers to air.
hospital setting.
CRITICAL Tension pneumothorax is a serious, life-threatening injury in which there is
FACTS complete collapse of the lung. Air enters the space around the lungs and
remains trapped there.
490 | Emergency Medical Response
Signs and Symptoms cavity and the patient cannot breathe normally.
of Chest Injuries With each breath the patient takes, you may hear
a sucking sound coming from the wound. This
You should know the signs and symptoms of
is the primary sign of a penetrating chest injury,
serious chest injury. These may occur with both
called a sucking (open) chest wound.
open and closed wounds. They include:
Without proper care, the patient’s condition will
Shortness of breath and difficulty breathing. worsen quickly. The affected lung or lungs will fail to
Pain during breathing. function, and breathing will become more difficult.
Pain at the site of the injury that increases with Your main concern is the breathing problem. To
deep breathing or movement. care for a sucking (open) chest wound, ensure that
Obvious deformity, such as that caused by advanced medical personnel have been summoned.
a fracture. Control any bleeding with a sterile gauze dressing
but do not let the wound become occluded by
Flushed, pale, ashen or bluish discoloration
changing the dressings frequently.
of the skin.
Coughing up blood. Most open chest wounds do not bleed heavily so
Distended (protruding) neck veins. you may be able to leave the wound uncovered and
exposed to the air, based on local protocols.
Drop in blood pressure.
Because of the risk of creating a tension
pneumothorax, most open chest wounds should be
Providing Care left uncovered and not be sealed unless advanced
Providing Care for a Sucking (Open) medical personnel are on scene to recognize and
Chest Wound treat a tension pneumothorax should one develop.
Puncture wounds to the chest range from minor to Some local protocols call for open chest wounds
life threatening. A forceful puncture may penetrate to be sealed with an occlusive dressing, one that
the rib cage and allow air to enter the chest does not allow air to pass through it.
through the wound. This prevents the lungs from The most effective occlusive dressing is called a
functioning normally (Fig. 21-9). vented chest seal (Fig. 21-10). Other occlusive
Puncture wounds cause varying degrees of internal dressings can be taped in place on all sides except
or external bleeding. If the injury penetrates the rib for one side that should remain loose. (For more
cage, air can pass freely in and out of the chest information on occlusive dressings, see Chapter 19.)
Taping the dressing this way keeps air from entering
the wound during inhalation but allows it to escape
during exhalation. If none of these materials is
available, a folded cloth or, as a last resort, your
gloved hand, may be used. Administer supplemental
oxygen, based on local protocols, and take steps to
minimize shock. If no spinal injury is suspected,
have the patient sit or lie in a comfortable position.
Fig. 21-9: If a puncture wound penetrates the rib cage, air can
pass freely in and out of the chest cavity and the patient cannot
breathe normally. Fig. 21-10: A vented chest seal.
Chapter 21: Injuries to the Chest, Abdomen and Genitalia | 491
Providing Care for Impaled Objects protect this organ. However, it is delicate and can
in the Chest be torn by blows from blunt objects or penetrated
An impaled object, or embedded object, is by a fractured rib. The resulting bleeding can be
one that remains in an open wound. In the case severe and quickly be fatal. The liver, when injured,
of an impaled object in the chest, it is extremely can also leak bile into the abdomen, which can
important not to remove the object, unless it cause severe infection.
interferes with chest compressions. Instead, the The spleen is located in the upper left quadrant of
object must be stabilized to keep it from moving. the abdomen, behind the stomach, and is protected
This can be accomplished by using a bulky somewhat by the lower left ribs. Like the liver, this
dressing or gauze around the object. This will organ is easily damaged. The spleen may rupture
also assist in controlling bleeding. when a blunt object strikes the abdomen forcefully.
Emergency care for an impaled object includes the Since the spleen stores blood, a spleen injury can
following steps: cause a severe loss of blood in a short time and
can be life threatening.
Stabilize the object to prevent further damage.
The stomach is one of the main digestive organs.
Remove clothing to expose the wound.
The upper part of the stomach changes shape
Control bleeding by applying direct pressure to depending on its contents, the stage of digestion,
the edges of the wound (but avoid placing direct and the size and strength of the stomach muscles.
pressure on the object). Many blood vessels and nerves line the stomach.
Use a sterile bulky dressing to help hold the It can bleed severely when injured, and food
object in place. Carefully pack the dressing contents may empty into the abdomen and
around the object. possibly cause infection.
Secure the sterile bulky dressing in place with
gauze, a cravat or tape.
Acute Abdomen
Abdominal pain is common and often not serious.
ABDOMINAL INJURIES However, acute and severe abdominal pain,
The abdomen is the area immediately below the referred to as acute abdomen, is usually a symptom
chest and above the pelvis. It is easily injured of intra-abdominal disease such as appendicitis
because it is not surrounded by bones, although it or peritonitis, but it may also be a symptom of
is protected at the back by the spine and ribs. The abdominal trauma.
upper abdomen is only partially protected in front
by the lower ribs. The muscles of the back and
Signs and Symptoms of an
abdomen also help protect the internal organs, many
of which are vital. Certain organs are easily injured
Abdominal Injury
or tend to bleed profusely when injured, such as the The signs and symptoms of serious abdominal
liver, spleen and stomach. injury include:
The liver is rich in blood. Located in the upper right Severe abdominal pain.
quadrant of the abdomen, the lower ribs somewhat Bruising.
CRITICAL With an impaled object injury to the chest, do not remove the object unless you need
FACTS to do chest compressions. Stabilize it with bulky dressing or gauze to prevent further
damage, and control bleeding by applying direct pressure to the edges of the wound.
Signs and symptoms of serious chest injury are similar in both open and closed
wounds. They include trouble breathing, including shortness of breath and pain
when breathing (especially deep breathing); pain at the site of the injury; obvious
deformity; pale or bluish skin; coughing up blood; protruding neck veins; and a
drop in blood pressure.
Puncture wounds to the chest range from minor to life threatening. A forceful
puncture may penetrate the rib cage and allow air to enter the chest through the
wound. This prevents the lungs from functioning normally.
492 | Emergency Medical Response
External bleeding. If the patient has a decreased mental status, it
Nausea and vomiting (sometimes vomit is important to note grimacing or signs of pain
containing blood). as you palpate. Keep in mind that the patient
may be contracting stomach muscles to avoid
Pale or ashen, cool, moist skin.
pain, or the contractions may be the result of
Weakness.
muscle spasms.
Thirst.
Assess both the upper and lower extremities
Pain, tenderness or a tight, swollen feeling in the for injury and a pulse, as abdominal aortic injury
abdomen. may cause the pulses of the lower extremities to
Organs possibly protruding from the abdomen. be weaker than the upper. If no foot pulses are
found, check the pulses at the back of the knee
Assessment Techniques for or thigh. These should be equal to or stronger
Abdominal Injury than the radial pulse, even in the case of shock.
Several steps must be taken when assessing a Assess motor and sensory function.
patient with a potential abdominal injury: Log roll the patient and inspect for signs of
trauma on their back.
First, establish spinal motion restriction if a
Assess baseline vital signs, especially
spinal injury is suspected.
for indications of blood loss and shock.
Check the patient’s position. Knees flexed toward Symptoms such as low blood pressure, rapid
the chest are a good indication the patient has heartbeat or pale, cool, moist skin are all
suffered an abdominal injury (Fig. 21-11). indications of shock.
Inspect the abdomen for contusions, lacerations,
Ensure that the airway is open and the patient is
abrasions and punctures. able to breathe adequately. If inspection of the
Look for signs of potential internal bleeding, airway shows signs of bloody vomitus, suctioning
including a distended abdomen as well as may be required. If the patient is not breathing
discoloration and bruising around the navel adequately, begin positive pressure ventilation with
and sides. supplemental oxygen based on local protocols.
Inspect the patient for internal organs protruding
from an open abdominal wound (abdominal
evisceration or disembowelment). Providing Care for Abdominal Injury
Palpate the four quadrants of the abdomen from Like a chest injury, an injury to the abdomen is
the farthest point away from the pain, noting either open or closed. Even with a closed wound,
tenderness or masses. the rupture of an organ can cause serious internal
Fig. 21-11: Patients who have suffered abdominal injuries often guard the injury by flexing their
knees toward their chests.
Chapter 21: Injuries to the Chest, Abdomen and Genitalia | 493
CRITICAL Signs and symptoms of serious abdominal injury may include severe pain, tenderness
FACTS or swollen feeling in the abdominal area; bruising; external bleeding; nausea and
vomiting; pale or ashen, cool, moist skin; weakness; thirst; and protruding organs.
To care for a closed abdominal injury, carefully position the patient on the back,
avoid applying direct pressure, bend their knees slightly, administer supplemental
oxygen based on local protocols, take steps to minimize shock and summon more
advanced medical personnel.
bleeding that can quickly result in shock. Injuries Administer supplemental oxygen based on local
to the abdomen can be extremely painful. Serious protocols.
reactions can occur if organs leak blood or other Take steps to minimize shock.
contents into the abdominal cavity.
Summon more advanced medical personnel.
To care for a closed abdominal injury:
Providing Care for Eviscerations
Carefully position the patient on their back.
A severe open injury may result in evisceration,
Avoid applying direct pressure.
a situation in which abdominal organs protrude
Bend the patient’s knees slightly. Doing so
through the wound (Fig. 21-12, A). To care for an
allows the muscles of the abdomen to relax.
open wound in the abdomen, follow these steps
Place rolled-up blankets or pillows under the
(Fig. 21-12, B–D):
patient’s knees. If moving the patient’s legs
causes pain, or you suspect spinal injury, leave Summon more advanced medical personnel.
the legs straight. Carefully position the patient on the back.
A B
C D
Fig. 21-12, A–D: (A) Severe injuries to the abdominal cavity can result in protruding organs. (B) Carefully remove clothing from around
the wound. (C) Apply a large, moist, sterile dressing over the wound and cover it with plastic wrap. (D) Place a folded towel over the
dressing to maintain warmth.
494 | Emergency Medical Response
CRITICAL A severe open injury may result in evisceration, a situation in which abdominal
FACTS organs protrude through the wound. To care for an evisceration: summon more
advanced medical personnel; position the patient on their back; remove clothing
from around the wound; apply moist, sterile or clean dressings loosely over the
wound; cover the dressings loosely with plastic wrap, if available, then cover
lightly with a folded towel; keep the patient from getting chilled or overheated;
and administer supplemental oxygen based on local protocols.
Avoid applying direct pressure. as an avulsion or laceration. Regardless, genital
Avoid pushing the organs back in. injuries are extremely painful.
Remove clothing from around the wound. The female organs, like those of the male, can
Apply moist sterile or clean dressings loosely cause extreme pain when injured. However, these
over the wound. types of injuries are rare, as the female genitals are
Cover the dressings loosely with plastic wrap, smaller and much more protected. Straddle injury
if available. and sexual assault are the most common situations
Cover the dressings lightly with a folded towel to in which the female genitals can be injured, as well
maintain warmth. as childbirth. Injuries can cause severe bleeding
and pain due to the large amount of blood vessels
Keep the patient from getting chilled or overheated.
in this area. Despite excessive bleeding, these
Administer supplemental oxygen based on
injuries are rarely life threatening.
local protocols.
Signs and Symptoms
Providing Care for Impaled of Genital Injuries
Objects in the Abdomen Signs and symptoms of genital injury are similar
If the patient has been impaled by an object in the to those for an abdominal injury. They include:
abdomen, it is important not to remove the object.
Instead, dress the wound around the object to Severe pain.
control the bleeding. Stabilize the object with bulky Bruising.
dressings to prevent movement. External bleeding.
Nausea.
GENITAL INJURIES Vomiting (sometimes containing blood).
Assessing and treating a patient with a genital Weakness.
injury requires a calm and professional approach, Thirst.
as it can be embarrassing not only for the patient, Pain, tenderness or a tight feeling in the area.
but also for you. Using a sensitive approach to
the patient’s situation, such as clearing onlookers
Protruding organs.
from the scene, supplying a drape for privacy and Rigid abdominal muscles.
reassuring the patient, will help the process be less Other signs of shock.
embarrassing. If possible, someone of the gender
of the patient’s choosing should treat them. Providing Care for Genital Injuries
Care for a closed wound to the male genitals as
Injuries to the penis usually occur as a result of
you would for any closed wound. Wrap the penis
an accident or assault. They can be either closed
in a soft, sterile dressing moistened with saline
wounds, such as a bruise, or open wounds, such
CRITICAL Signs and symptoms of genital injury are the same as those for an abdominal injury.
FACTS
To care for injuries to the male genital region, remember never to remove an impaled
object. Closed wounds to this area should be treated as any other closed wound
injury. For open wounds, apply sterile dressing and direct pressure, either with your
gloved hand or allow the patient to do it.
Chapter 21: Injuries to the Chest, Abdomen and Genitalia | 495
CRITICAL To provide care for injury to the female genitals, control bleeding with pressure
FACTS using compresses moistened with saline. Use a diaper-like dressing for the wound
and stabilize any impaled objects with a bandage. Use cold packs over the dressing
to reduce swelling and ease pain.
solution, and apply a cold pack to reduce pain to reduce swelling and ease pain. Never place
and swelling. As with any injury, never remove an anything in the vagina, including dressing. Treat
impaled object. Stabilize the object and bandage the patient for shock as required.
it in place for transport.
Remember your training regarding a crime scene
If the injury is an open wound, apply a sterile if you suspect a patient has been a victim of sexual
dressing and direct pressure with your gloved hand assault. Take care to provide the patient with privacy
or the patient’s hand, or use a protective barrier by clearing the area of onlookers and draping a
to avoid contact. In the case where the penis is sheet or blanket over the patient. Do not touch the
partially or completely amputated, apply a sterile genitals; discreetly ask if the patient has suffered any
pressure dressing to help stop bleeding, which other injuries, such as to the head. If bleeding is life
may be significant. Aggressive direct pressure may threatening, this will take priority over maintaining the
also be needed if bleeding is excessive. As with an integrity of the crime scene. Do not allow the patient
avulsion, if the penis is found, follow the procedure to bathe or douche, and discourage the patient from
for preserving and transporting body parts. If any washing their hair or cleaning under their fingernails.
parts are avulsed or completely amputated, wrap Unless injuries are life threatening, do not clean or
them in sterile gauze, moistened in sterile saline if touch any wounds. Handle the patient’s clothing
available. Then place them in a plastic bag, labeled as little as possible, placing them in paper bags
with the patient’s name and the time and date separately from any other items. If there is blood on
they were placed in the bag. Keep the bag cool the items, do not use plastic bags and be sure to
by placing it in a larger bag or container of ice and follow local protocols.
water slurry, not on ice alone and not on dry ice.
Transfer the bag to the EMS personnel transporting PUTTING IT ALL TOGETHER
the patient to the hospital.
Injuries to the chest, abdomen or genitalia can
It is also possible for injuries to affect the scrotum be serious. They can damage soft tissues, bones
and testicles. A blow to this area can rupture and internal organs. Although many injuries are
the scrotum and can cause pooling of blood, immediately obvious, some may be detected only
which is extremely painful. A ruptured testicle as the patient’s condition worsens over time.
requires surgery. Apply a cold pack to the area Watch for signs and symptoms of serious injuries
to reduce swelling and pain, and if the scrotal that require immediate medical attention.
skin has become avulsed, try to find it. Wrap
the skin in sterile dressing and transport with Care for any life-threatening condition and then
the patient. The scrotum should be dressed give any additional care needed for specific injuries.
with gauze sterilized and moistened with saline. Always call for more advanced medical personnel as
Apply pressure to control bleeding. soon as possible. Have the patient remain as still as
possible. For open wounds to the chest, abdomen
To provide care for injury to the female genitals, or genitalia, control bleeding. If you suspect a
control bleeding with pressure using compresses fracture, immobilize the injured part. Use occlusive
moistened with saline. Use a diaper-like dressing dressings for open abdominal wounds when these
for the wound and stabilize any impaled objects materials are available. Your actions can make the
with a bandage. Use cold packs over the dressing difference in the patient’s chances of survival.
You Are the Emergency Medical Responder
As you begin your assessment, you notice that the young woman has multiple gunshot
wounds to her chest and abdomen. How should you care for this patient?
496 | Emergency Medical Response
22 INJURIES TO
MUSCLES, BONES
AND JOINTS
You Are the Emergency Medical Responder
You arrive on the scene of a minor motor-vehicle collision. Local law enforcement have
secured the scene. As you approach, you find the driver sitting on the ground against
her vehicle complaining of knee pain. How would you respond?
KEY TERMS
Air splint: A hollow, inflatable splint for immobilizing Ligament: A fibrous band that holds bones together
a part of the body. at a joint.
Anatomic splint: A splint formed by supporting Muscle: A tissue that contracts and relaxes to
an injured part of the body with an uninjured, create movement.
neighboring body part; for example, splinting
one finger against another; also called a Open fracture: A type of fracture in which there is
self-splint. an open wound in the skin over the fracture.
Angulation: An angular deformity in a fractured Rigid splint: A splint made of rigid material such as
bone. wood, aluminum or plastic.
Binder: A cloth wrapped around a patient to securely Self-splint: A splint formed by supporting one
hold the arm against the patient’s chest to add part of the body with another; also called an
stability; also called a swathe. anatomic splint.
Bone: A dense, hard tissue that forms the skeleton. Smooth muscles: Muscles responsible for
contraction of hollow organs such as blood
Cardiac muscle: A specialized type of muscle found vessels or the gastrointestinal tract.
in the heart.
Soft splint: A splint made of soft material such as
Circumferential splint: A type of splint that towels, pillows, slings, swathes and cravats.
surrounds or encircles an injured body part.
Splint: A device used to immobilize body parts.
Closed fracture: A type of fracture in which the skin
over the broken bone is intact. Sprain: The partial or complete tearing or stretching
of ligaments and other soft tissue structures at
Cravat: A folded triangular bandage used to hold a joint.
splints in place.
Strain: The excessive stretching and tearing of
Crepitus: A grating or popping sound under the muscles or tendons; a pulled or torn muscle.
skin that can be due to a number of causes,
including two pieces of bone rubbing against Swathe: A cloth wrapped around a patient to
each other. securely hold the arm against the patient’s chest,
to add stability; also called a binder.
Direct force: A force that causes injury at the point
of impact. Tendon: A fibrous band that attaches muscle
to bone.
Dislocation: The displacement of a bone from its
normal position at a joint. Traction splint: A splint with a mechanical device
that applies traction to realign the bones.
Extremity: A limb of the body; upper extremity is the
arm; lower extremity is the leg. Twisting force: A force that causes injury when one
part of the body remains still while the rest of the
Fracture: A break or disruption in bone tissue. body is twisted or turns away from it.
Immobilize: To use a splint or other method to keep Vacuum splint: A splint that can be molded to the
an injured body part from moving. shape of the injured area by extracting air from
the splint.
Indirect force: A force that transmits energy through
the body, causing injury at a distance from the Voluntary muscles: Muscles that attach to bones;
point of impact. also called skeletal muscles.
Joint: A structure where two or more bones
are joined.
498 | Emergency Medical Response
LEARNING OBJECTIVES
After reading this chapter, and completing the class • List the signs and symptoms of muscle, bone and
activities, you will have the information needed to: joint injuries.
• List the three mechanisms of muscle, bone and • Describe general care for muscle, bone and joint
joint injuries. injuries.
• Describe different types of musculoskeletal • List general guidelines for splinting.
injuries. • List the purposes of immobilizing an injury.
• Describe how to assess for muscle, bone and
joint injuries.
SKILL OBJECTIVES
After reading this chapter, and completing the class • Demonstrate how to immobilize muscle, bone and
activities, you should be able to: joint injuries.
INTRODUCTION MUSCULOSKELETAL SYSTEM
Although musculoskeletal injuries are almost The musculoskeletal system is a combination of
always painful, they are rarely life threatening. two body systems—the muscular and skeletal
However, when not recognized and taken care systems. It consists of the bones, muscles, tendons
of properly, they can have serious consequences and ligaments. The skeletal system creates a
and even result in permanent disability or death. structural framework for the body and is composed
Broken bones, dislocated joints, strained muscles of approximately 206 bones of varying shapes and
and similar injuries are common, and most people sizes. Six sections comprise the skeleton: the skull,
will experience one or more of these during their spine, thorax, pelvis, upper extremities and lower
lifetime. Injuries to muscles, bones and joints range extremities.
from simple, minor problems such as a sprained
There are three types of muscles: the voluntary
finger, to serious situations such as a fractured
muscles, smooth muscles of the walls of organs,
pelvis.
and cardiac muscles of the heart. Voluntary
In this chapter, you will learn how to recognize muscles, also called skeletal muscles, are the
and care for muscle, bone and joint injuries. major muscles that make up the body and enable
Developing a better understanding of the structure movement (Fig. 22-1). Ligaments and tendons join
and function of the body’s framework will help structures of the musculoskeletal system together.
you assess musculoskeletal injuries and give Ligaments hold the bones at a joint together
appropriate care. and tendons connect muscle to bone. All joints
CRITICAL The musculoskeletal system is a combination of two body systems—the muscular
FACTS and skeletal systems. It consists of the bones, muscles, and tendons and ligaments.
There are three types of muscles: the voluntary muscles, smooth muscles of the
walls of organs and cardiac muscles of the heart.
Muscles, bones and joints are injured when force is applied to them. The three
basic mechanisms of injury (MOIs) are direct force, indirect force and twisting force.
Chapter 22: Injuries to Muscles, Bones and Joints | 499
FRONT VIEW BACK VIEW
Face muscles
Neck
Neck
muscles
muscles
Deltoid Deltoid
Chest
Biceps muscles Back
muscles Triceps
Extensors
Extensors Abdominal of wrist
of wrist muscles and
and fingers
Gluteus
fingers
maximus
Hamstring
Quadriceps Groin
muscles
muscles muscles
Extensors Calf
of foot muscles
and toes
Achilles
tendon
Fig. 22-1: The major muscles of the body.
have a normal range of movement—an area in Indirect force transmits energy through the
which they can move freely without too much body and causes injury at some distance from
stress or strain. When joints are forced beyond the original point of impact (Fig. 22-2, B). For
this range, ligaments can stretch and tear. example, the patient might have a fall from a
Muscles and tendons can also become stretched galloping horse, and stretch out the arms while
or torn when placed under a lot of stress or landing so that the hands hit the ground first.
worked too hard. The collarbone is broken when the force is
transmitted up the arm to the shoulder.
Twisting force, or rotating force, causes injury
INJURIES TO MUSCLES, BONES when one part of the body remains still while the
AND JOINTS rest of the body is twisted or turned away from
it (Fig. 22-2, C). For example, a patient may be
Causes of Injury
skiing and fall to the side, causing a leg to twist
Muscles, bones and joints are injured when force is while still in a ski boot that is pointing downhill.
applied to them. Knowing the specific mechanism,
or cause, of injury can give you important clues
about which parts of the body may be injured, what Types of Injuries
other hidden injuries may exist along with the more The four basic types of injuries to muscles, bones
obvious ones and how serious the injuries may be. and joints are fractures, dislocations, strains and
sprains.
There are three basic mechanisms of injury (MOIs):
Direct force causes injury at the point of Fractures
impact (Fig. 22-2, A). For example, the patient A fracture is a break or damage to a bone.
may have been hit by a loose pitch during a Fractures can involve bones that are broken all the
baseball game, fracturing the bone in the ankle. way through, chipped or cracked (Fig. 22-3). A fall,
500 | Emergency Medical Response
Cracked
bone
Broken
bone
Direct force Chipped
bone
Fig. 22-3: Fractures include chipped or cracked bones and
bones broken all the way through.
a blow or sometimes even a twisting movement can
cause a fracture. Some fractures are obvious, but
others may not be easy to detect without an X-ray.
While most isolated fractures are not considered
critical or life threatening, if the femur or pelvis is
fractured, the patient is at serious risk of excessive
B blood loss, shock and death. These two bones
contain many blood vessels, and any injury tends
Indirect force to cause heavy bleeding. Fracture to the spine can
also result in damage to the spinal cord.
There are two kinds of fractures:
Closed fractures: The skin over the broken
bone is intact (Fig. 22-4, A).
Open fractures: There is an open wound in
the skin over the fracture. In some cases, the
broken bone actually protrudes from the skin
or is visible through the wound (Fig. 22-4, B).
While closed fractures are more common, open
C fractures are more dangerous because they carry
Fig. 22-2, A–C: The three basic
Twisting MOIs are (A) direct
force a risk of infection and severe bleeding. In general,
force, (B) indirect force and (C) twisting force. fractures are life threatening only if they involve
CRITICAL The four basic types of injuries to muscles, bones and joints are fractures,
FACTS dislocations, strains and sprains.
Chapter 22: Injuries to Muscles, Bones and Joints | 501
A B
Fig. 22-5: A dislocation is the movement of a bone at a joint away
Fig. 22-4, A–B: (A) Closed fracture. (B) Open fracture. from its normal position.
breaks in large bones such as the femur, sever an bleeding and damaged nerves, so it is important to
artery or affect breathing. Since you cannot always check for those injuries as well. A dislocation can
tell if a person has a fracture, you should consider be extremely painful.
the MOI. A fall from a height or a motor-vehicle crash
could signal a possible fracture. When in doubt, Sprains
suspect a fracture and provide care accordingly. A sprain is the partial or complete tearing or
stretching of ligaments and other tissues at a joint
Dislocations (Fig. 22-6, A). If the bones that meet at a joint are
Dislocations are usually more obvious than forced beyond their usual range of movement, the
fractures. A dislocation is the displacement of ligaments can be stretched or torn even though
a bone at a joint away from its normal position the bones are not actually dislocated. The greater
(Fig. 22-5). The bones in the human body are the number of ligaments torn, the more severe
linked together at joints. When the bones that is the injury. Severe sprains, caused by a great deal
normally meet at a particular joint have been of force being applied, can also involve fractured or
displaced or separated from each other, and dislocated bones. Milder sprains are caused when
the ligaments or tendons have been stretched, the only injury is stretched ligaments.
displaced or torn, this is called a dislocation.
Patients generally find that the pain of these mild
Some joints, such as the shoulder and fingers, sprains is quickly resolved and they return to
dislocate more easily because they are relatively their normal activities. However, this often leads
exposed and not as well protected by ligaments. to re-injury of the joint that was sprained. Proper
Other joints, such as the elbow, are less likely to care should always be given once ligaments have
become dislocated, but are just as serious as any been stretched or torn, even if the injury is mild.
joint dislocation. In general, dislocation requires Otherwise, the joint may become less stable and
a severe force. However, if a joint has become the partially healed, less stable joint will be much
dislocated once and the ligaments holding the more susceptible to re-injury. The joints most easily
bones in place were damaged, subsequent injured are at the ankle, knee, wrist and fingers.
dislocations are then more likely to occur. In some
cases, dislocation can become chronic so that
Strains
relatively minor movements can cause joint instability.
A strain is the excessive stretching and tearing
A force strong enough to cause an initial of muscles or tendons, sometimes called a pulled
dislocation can also cause a fractured bone, muscle or a tear (Fig. 22-6, B). Tendons are
502 | Emergency Medical Response
A B
Fig. 22-6, A–B: (A) A sprain is the partial or complete tearing or stretching of ligaments and other tissues at a joint. (B) A strain is the
excessive stretching and tearing of muscles or tendons.
stronger than muscles and more resistant to injury, bleeding, internal injuries and shock. Fractures
so damage more often happen in muscles or at can cause severe pain and there may be so much
the attachment between the muscle and tendon. focus on this that the patient will not mention other
Strains can result from overexertion, such as lifting problems such as abdominal pain, which may
something too heavy, or from working a muscle actually indicate more serious injuries.
for too long. They can also result from sudden or
uncoordinated movements. Strains most often Some common signs and symptoms associated
involve the muscles in the neck, back, thigh or calf. with musculoskeletal injuries include:
Like sprains, strains are often neglected and this A snapping sound. If a bone has fractured, the
may lead to re-injury. The muscles need time and patient may report hearing or feeling the bone
rest to repair the damage. Repeated strains of the snap or break.
neck and back are common causes of workers Deformity or angulation (Fig. 22-7). If you
being absent from work. suspect injury in one arm or leg but not the other,
compare the two arms or two legs to see if the
injured limb is bent at an abnormal angle, or has
Assessing Signs and Symptoms of changed in shape compared to the uninjured one.
Injuries to Muscles, Bones and Joints Other fractured bones may show indentations,
Injuries to the musculoskeletal system are identified and a dislocated joint often shows an indentation
during the physical examination. Because these where the bones would normally meet.
injuries often appear to be similar, it may be
difficult for you to determine exactly what type of
injury has occurred. As you complete the physical
examination, think about how the body normally
looks and feels. Check for deformity; compare the
injured side to the uninjured side.
Ask how the injury happened. The cause of the
trauma may alert you to the possibility that the
muscles, bones and joints have been injured. As
the patient or bystanders explain how the injury
occurred, listen for clues, such as a fall from a
height or a serious motor-vehicle crash. Also ask
the patient if any areas are painful. Then carefully
examine the entire body, starting with the head.
Keep in mind as you assess the patient that if
there was sufficient force present to fracture a
bone or dislocate a joint, that force may also cause Fig. 22-7: Serious bone or joint injuries may appear deformed.
Chapter 22: Injuries to Muscles, Bones and Joints | 503
Pain and tenderness. The pain of a fractured Ensure that the patient is breathing effectively,
bone or dislocated joint is often severe. and administer supplemental oxygen based on
Crepitus. There may be a grating sound or local protocols.
feeling when attempting to move the fractured If a spinal injury is suspected, maintain spinal
bone, caused by the two pieces of bone rubbing motion restriction and keep the patient flat.
against each other. Avoid any movements or changes in position
Swelling. Swelling may be present and may that cause pain. The patient will usually find the
obscure some indentations. most comfortable position. Keep the injured area
Restricted movement. The patient may be immobile in that position (Fig. 22-8).
unable to move the affected area, due to pain or Remove any jewelry or restrictive clothing in the
because of a dislocated joint. affected area so that swelling does not cause
Visible break. In an open fracture, the broken more pain or injury.
ends of the bones may be visible. Clean and bandage any open wounds before
Bruising or discoloration. Internal bleeding may splinting.
cause bruising as blood pools under the skin. Follow the steps on Skill Sheets 22-1 to 22-4
Loss of circulation or sensation. There may be a to immobilize the injured joint or bones with
loss of circulation or sensation in an extremity splints only if you must transport the patient
(the shoulders to the fingers; the hips to the toes). to definitive medical care and you can do so
without causing more pain.
It is often impossible to determine whether a
patient has experienced a fracture, dislocation,
Check for circulation and sensation to the limb.
Feel for the patient’s distal pulse, skin temperature,
sprain or strain at the initial examination. X-rays and and ability to move and detect touch in the injured
other tests by a healthcare provider will determine parts, before and after splinting.
the precise nature of the injuries. Fortunately, it
is not necessary to know whether the swelling of Call for more advanced medical personnel if:
an ankle, for example, is caused by a fracture or a
sprain to provide appropriate care. You suspect a fracture to an area proximal to the
wrist or ankle.
Providing Care for Injuries to The injury involves severe bleeding.
Muscles, Bones and Joints The injury impairs breathing.
A gentle, reassuring approach is important in The injury involves the head, neck or spine.
caring for patients with muscle, bone and joint You see or suspect multiple injuries.
injuries. The patient is likely to be experiencing The general care for all musculoskeletal injuries is
severe pain and may be frightened. Avoid moving similar: rest, immobilize, cold and elevate, or “RICE.”
the injured parts of the patient’s body as much as
possible, as this is likely to increase the pain and Rest
may cause further injury. Keep the injured area Avoid any movements or activities that cause pain.
stable in the position found until more advanced Help the patient find the most comfortable position.
medical personnel take over. If you suspect head, neck or spinal injuries, leave
For any muscle, bone or joint injury, follow these the patient lying flat.
general guidelines when providing care:
Immobilize
Follow standard precautions. Stabilize the injured area in the position it was
Control bleeding if present. found. In most cases, it will not be necessary to
CRITICAL Signs and symptoms of musculoskeletal injuries include a snapping sound,
FACTS deformity/angulation, pain and tenderness, crepitus, swelling, restricted movement,
bruising, and loss of circulation or sensation.
Call for more advanced medical personnel if you suspect a fracture to an area
proximal to the wrist or ankle; if the injury involves severe bleeding or impairs
breathing, involves the head, neck or spine; or if you see or suspect multiple injuries.
504 | Emergency Medical Response
Fig. 22-8: When caring for a musculoskeletal injury, have the patient rest in a comfortable position
and avoid moving the injured body part, then immobilize, cool and elevate the injured area.
apply a splint. For example, the ground can provide SPLINTING
support to an injured leg, ankle or foot, or the
When an injury to bones, muscles or joints is
patient may cradle an injured elbow or arm in a
suspected, immobilizing the affected body part
position of comfort.
is an important step in treatment. Preventing
the bones, joints and ligaments from moving
Cold helps to reduce the risk of further injury,
Apply a cold pack for periods of 20 minutes. If 20 and minimizes the risks of some possible
minutes cannot be tolerated, apply a cold pack for complications such as:
periods of 10 minutes. If continued cold is needed,
remove the pack for 20 minutes, and then replace it. Broken bone ends injuring blood vessels, nerves
or muscles as they move. This can cause loss
Cold helps reduce swelling and eases pain and of sensation in the affected area or increase the
discomfort. Commercial cold packs can be stored bleeding.
in a kit until ready to use, or you can make a cold
pack by placing ice (crushed or cubed) with water Broken bone ends breaking through the skin.
in a plastic bag and wrapping it with a towel or Blood vessels being compressed by broken or
cloth. Place a thin layer of gauze or cloth between dislocated bones, thus reducing blood flow.
the source of cold and the skin to prevent injury to Paralysis caused by damage to the spine.
the skin. Do not apply a cold pack directly over an The purposes of immobilizing an injury are to:
open fracture, because doing so would require you
to put pressure on the open fracture site and could Lessen pain.
cause discomfort to the patient. Instead, place cold Prevent further damage to soft tissues.
packs around the site. Do not apply heat, as there
is no evidence that applying heat helps. Reduce the risk of severe bleeding.
Reduce the possibility of loss of circulation to
the injured part.
Elevate
Elevating the injured area above the level of the
Prevent closed extremity injuries from becoming
open extremity injuries.
heart helps slow the flow of blood, helping to
reduce swelling. Elevation is particularly effective in A tool or device used to immobilize an injury is
controlling swelling in extremity injuries. However, called a splint. There are many commercially
never attempt to elevate a seriously injured area of a manufactured types of splints, but if necessary
limb unless it has been adequately immobilized. Also, one can be improvised from items available at
only elevate it if it does not cause additional pain. the scene.
Chapter 22: Injuries to Muscles, Bones and Joints | 505
CRITICAL Immobilizing an injury is important. It lessens pain, prevents further damage to
FACTS soft tissues, reduces the risk of severe bleeding, reduces the possibility of loss
of circulation to the injured part and prevents closed injuries from becoming open
injuries.
Rules for Splinting If a fracture is suspected, immobilize
the joints above and below the injury
No matter where the splint will be applied, or
(Fig. 22-9, A). For example, if a bone in the
what the injury is, there are some general rules
lower leg is broken, you would immobilize the
for splinting:
ankle and the knee. If a joint injury is suspected,
immobilize the bone above and below the injury
Splinting should only be performed if you have
(Fig. 22-9, B).
to move or transport the patient to receive
medical care and you can do so without causing Cut off or remove any clothing around the injury
more pain. site. If the patient is wearing a watch or jewelry
near the injury, these should also be removed.
Assess the patient’s distal pulse, skin
Swelling may occur beyond the actual injury site.
temperature, ability to move and ability to feel
the body part that is on the other side of the If an elbow is injured, for example, any bracelets,
injury from the heart. For example, if the elbow watches or rings on the wrist and hand should
has been injured, check pulse, skin temperature, be removed.
mobility and sensation at the wrist. If a leg Cover any bleeding or open wounds, including
bone is injured, check at the ankle. Continue open fractures, with sterile dressings, and
to assess these three signs every 15 minutes carefully bandage with minimal pressure.
after the splint has been applied. This will let you Do not try to push protruding bones back below
know if the splint, or swelling under the splint, the skin.
has impaired circulation to the affected area.
A B
Fig. 22-9, A–B: (A) If a fracture is suspected, immobilize the joints above and below the injury. (B) If a joint injury is suspected, immobilize
the bones above and below the injury.
506 | Emergency Medical Response
Do not attempt to straighten any angulated fracture; binder—wrapping the cloth around the patient
always splint the limb in the position found. and the arm to hold the arm securely against the
Do not allow the patient to bear weight on an side of the patient’s chest. With both the sling and
injured lower extremity. binder in place, the arm will not be able to move,
the weight of the arm will be supported and the
Pad the splints you are using so that they will be
patient’s pain should be significantly reduced
more comfortable and conform to the shape of
the injured body part. (Fig. 22-11).
Secure the splint in place with folded triangular
bandages, roller bandages or other wide strips Rigid Splints
of cloth. A rigid splint is one that is made of a rigid material
such as wood, aluminum, plastic, cardboard
Elevate the splinted part, if possible.
or composite materials (Fig. 22-12). Some are
specially shaped to be used for a particular body
Types of Splints
part, such as an arm or a finger. Some are designed
Whether commercially made or improvised, there to be pliable so they can be shaped to the body
are six general types of splints: soft, rigid, traction, part. They may come with padding or require
circumferential, vacuum, and anatomic or self-splint. padding to be added at the time of use.
Soft Splints
Soft splints include folded blankets, towels,
pillows, slings, swathes (also called binders) and
cravats (Fig. 22-10). Many improvised splints are
made from soft materials such as bed pillows or
blankets, and they can be effective if secured
properly. A swathe is a cloth wrapped around
a patient to securely hold the arm against the
patient’s chest, to add stability. Cravats are folded
triangular bandages used to hold splints in place.
A sling is a type of soft splint made from a
triangular bandage. It can provide stability when
the shoulder, elbow or upper arm has been injured.
The sling will support the weight of the arm. To
immobilize the injury, you should then apply a Fig. 22-11: A sling made from a triangular bandage can provide
stability to an injury to the shoulder, elbow or upper arm, while a
binder wrapping the injured body part to the chest can be used
to immobilize.
Fig. 22-10: Soft splints use soft, pliable materials, such as folded
blankets or towels, to immobilize an injury. Fig. 22-12: Commercially manufactured rigid splints.
CRITICAL Splints can be commercially made or improvised with items you have on hand.
FACTS There are six different types of splints: soft, rigid, traction, circumferential, vacuum
and anatomic (self-splint).
Chapter 22: Injuries to Muscles, Bones and Joints | 507
If commercial splinting materials are not available, Circumferential Splints
improvised rigid splints can be created from A circumferential splint surrounds or encircles
cardboard boxes, rolled-up magazines, an athlete’s the injured body part. One example is a commercial
shin guards or other items available at the scene. air splint, which begins as a soft, pliable splint that
Look for an item that is light but rigid, and strong can be positioned around the injured area. It is then
enough to resist breaking. It should be long enough filled with air and becomes rigid and applies pressure
to prevent movement on either side of the injury, to the injured area. Air splints have the potential
and wide enough that it will cover the entire injured to interfere with circulation, making it difficult to
area. You should also be able to pad it effectively check the patient’s pulse or temperature. They can,
to protect the skin and any wounds. however, be helpful in reducing bleeding. Air splints
should only be used under medical direction.
Traction Splints
A traction splint contains a mechanical device Vacuum Splints
that is attached to the body part above and below A vacuum splint starts out soft and pliable so
the injury and provides a steady counter-pull that it can be shaped to fit the area that has been
(Fig. 22-13). This is not the same as applying injured. Once it is in place, the air can be sucked
manual traction to realign the bones, and these out, creating a vacuum inside and making the splint
splints are not intended to reposition fractured rigid and immobilizing.
bones. Instead, they reduce pain and blood loss
by immobilizing bones that might otherwise move
in the direction opposite to the splint’s pull. Each
Anatomic or Self-Splints
brand or type of traction splint will have instructions In many cases, the patient’s own body can act
about correct use. as a splint. This is called an anatomic splint or
self-splint. For example, if the right leg is broken,
the left leg can be used as a splint (Fig. 22-14).
The legs are fastened together using cravats or
roller bandages. Any gaps between the legs are
filled with padding.
Splinting Upper Extremities
The upper extremities are the arms and hands. The
bones in the upper extremities are the collarbone,
Fig. 22-13: A traction splint. scapula, humerus, radius and ulna, as well as the
Fig. 22-14: In an anatomic splint, the patient’s own body is used to immobilize an injured body part.
Photo: courtesy of the Canadian Red Cross.
508 | Emergency Medical Response
bones in the hand, wrist and fingers. The upper Splinting the Upper Arm
extremities are the most commonly injured parts The humerus is a strong bone, so if it is broken
of the body. Since people who are falling or about (most often near the shoulder or partway towards the
to crash instinctively try to protect themselves by elbow), check for other injuries, as considerable force
throwing out their arms and hands, these areas probably was involved. This injury can be splinted
receive the force of the impact. Often, the result is with a padded rigid splint on the outside of the arm.
a fracture, sprain or dislocation. If the elbow can be comfortably bent, you can then
use a sling and binder. If the elbow cannot be bent
Splinting the Collarbone without causing more pain, or if the rigid splint you
When the collarbone is broken, the patient’s are using is longer than the upper arm, keep the arm
shoulder may look lower than the uninjured side. straight at the patient’s side and wrap the bandages
You may see obvious deformity in the collarbone. It or binders around the arm and chest (Fig. 22-16).
is best splinted with a sling, to reduce the pull from
the arm’s weight, and a binder to immobilize the Splinting the Elbow
arm against the chest. Do not attempt to straighten or bend the elbow
or change its position. If the elbow is bent, even
Splinting the Shoulder if it is deformed, splint with a sling and binder
A dislocated shoulder will appear deformed and a (Fig. 22-17). You may use a flat pillow or towel
hollow may be visible in the upper arm below the wrapped around the injured area and then
shoulder. This injury is extremely painful. There is secured to the chest. If the elbow is straight,
a risk that nerves and arteries near the shoulder use rigid splints along the length of both sides
can be damaged by movement, so be cautious as of the arm, from fingertips to underarm.
you apply any splints. A sling and binder should
be used, with some padding between the arm and Splinting the Forearm and Wrist
the chest to maintain a reasonably comfortable A rigid splint extending from the elbow to the
position (Fig. 22-15). fingertips should be applied first. Then a sling and
Fig. 22-15: Splint for a shoulder injury. Fig. 22-16: Splint for an upper arm injury.
Chapter 22: Injuries to Muscles, Bones and Joints | 509
Fig. 22-17: Splint for an elbow injury. Fig. 22-18: Splint for a forearm injury.
binder can be applied to support the arm against
the chest (Fig. 22-18). If there is no open wound,
a circumferential air splint, extending from elbow
to past the fingertips, can be applied instead of
the rigid splinting.
Splinting the Hands and Fingers
If a single finger has a broken bone, you may be able
to create a self-splint or anatomic splint by taping the
injured finger to the one beside it. A tongue depressor
or similar-sized piece of cardboard can also work as a Fig. 22-19: Splint for a finger injury.
rigid splint, taped to the finger (Fig. 22-19).
When several fingers have broken bones or the back Assess the patient for shock and internal blood
of the hand is involved in the injury, you will need to loss. To immobilize a pelvic fracture, a pelvic
splint the entire hand. To immobilize the hand, place a binder can be used, following the manufacturer’s
small ball, or a rolled-up bandage or face cloth, inside instructions and if you are trained to apply one
the palm of the person’s hand, with the fingers curled (Fig. 22-20). If a pelvic binder is not available,
naturally around it. Then wrap the entire hand, and one can be improvised using a sheet that is
splint the lower arm and wrist with a rigid splint or arm repeatedly folded lengthwise to create a thick,
board. A sling can be added to help support the arm. 8-inch-wide strip. Slide this strip under the small
of the patient’s back and pull it through until equal
lengths appear on each side of the patient’s body.
Splinting Lower Extremities Using the extended ends of the fabric, slide the
Splinting the Pelvis strip of fabric down so that it is behind the injured
Injuries to the pelvis are potentially life threatening pelvis, and cross the ends in front of the pelvis.
because of the risk of heavy bleeding in this area. Twist the ends together so that the fabric is tightly
510 | Emergency Medical Response
Fig. 22-20: Splint for a pelvis injury.
secured around the pelvis. Tuck the leftover
fabric ends under the patient or tie them in a knot.
Alternatively, the patient can be lowered onto an
ambulance stretcher with the pelvic sheet and/or a Pelvis
long backboard in place, using a scoop stretcher,
based on local protocols.
Use a blanket or pillow for padding between the
patient’s legs, and add padding on both sides of
the patient’s hips. Minimize movement of the pelvis
and legs. Hip
Splinting the Hip
The hip is the joint where the thigh bone, or femur,
fits into the pelvis (Fig. 22-21). Like the pelvis, the
femur has significant blood vessels, and any injury
in this area can cause dangerous bleeding, which
can be difficult to detect. Look for swelling in the Femur
thigh area. Assess and treat for bleeding and
shock before beginning to splint. To immobilize the
hip you will need to splint the patient’s entire body Fig. 22-21: The hip joint.
on a long backboard.
Splinting the Femur If a traction splint cannot be applied, you can use
As mentioned previously, injuries to the femur can two long rigid splints instead, with padding to
be very serious because of the risk of bleeding, fill any gaps between the splint and the patient’s
which may be internal and not noticed. A broken body (Fig. 22-23). One splint or board must
femur causes a great deal of pain and significant start at the patient’s groin area and extend past
swelling; the deformity of the thigh is usually the bottom of the patient’s foot, on the inside
quite noticeable, and the muscle often contracts of the affected leg. The other should go from
(shortens) with this type of break (Fig. 22-22). The the patient’s armpit to below the bottom of the
leg may also be turned inward or outward. Use a patient’s foot. Wrap the boards tightly, using
traction splint if one is available and you have the cravats at the chest, hips, knees and ankles to
training to apply this type of splint correctly. immobilize the body.
Chapter 22: Injuries to Muscles, Bones and Joints | 511
Fig. 22-22: The deformity of the thigh from a broken femur is usually quite noticeable.
Fig. 22-23: Splint for a femur injury. Fig. 22-24: Splint for a tibia or fibula injury.
Splinting the Knee a weight-bearing bone and fractures of this bone
Knees may be injured in either a bent or straight may not be as easily detected. Injuries to either bone
position. Do not attempt to change the position of the are splinted in the same way, using a circumferential
knee. If it is straight, use two padded rigid splints, one air splint, extending from above the knee to below
on the outside and one on the inside of the leg. The the foot. Or you can use two padded rigid splints,
inside splint should start at the groin and extend past one on the inside running from the groin to below
the bottom of the foot. The outside splint should start the foot, and the other on the outside running from
at the hip and also extend past the foot. Use cravats the hip to below the foot (Fig. 22-24).
to keep the splints in place. If the knee is bent, use
a pillow or folded blanket under the knee to maintain Splinting the Ankle and Foot
the bent position. Then use short, padded rigid splints
Injuries to the foot or ankle are often caused by
running along either side of the knee to immobilize the
heavy objects falling on the foot, or when a falling
upper and lower leg in relationship to the knee.
person lands on the feet. Twisting forces during
a fall or while running can also cause an ankle
Splinting the Tibia and Fibula injury. Whether the injury is a break or a sprain,
(Lower Leg Bones) both should be splinted in the same way, by
The tibia (shinbone) and fibula are the two bones immobilizing the entire foot and ankle (Fig. 22-25).
that extend from the knee to the ankle. The tibia A circumferential air splint is a good choice, but a
is covered by only a thin layer of skin, so open pillow or thick blanket wrapped around the foot and
fractures of this bone are common. The fibula is not ankle and secured in place will also work.
512 | Emergency Medical Response
Assess for severe, life-threatening bleeding and
take steps to control bleeding if necessary. Ensure
that the patient is breathing effectively and provide
supplemental oxygen based on local protocols. If
a spinal injury is suspected, maintain spinal motion
restriction and keep the patient flat. Avoid any
movements or changes in position that cause pain.
Help the patient find the most comfortable position.
Remove any jewelry or restrictive clothing in the
affected area.
Clean and bandage any open wounds before
splinting. Follow guidelines to immobilize the
Fig. 22-25: Splint for an ankle or a foot injury. injured joint or bones with splints. Check the
patient’s pulse and ability to move and detect
touch in the injured parts before and after splinting.
Apply a cold pack to reduce swelling and ease
PUTTING IT ALL TOGETHER pain and discomfort. If there is no spinal injury and
Injuries to bones, muscles and joints are generally the limb has been securely immobilized, elevate it
caused by significant force, so careful assessment so that it is above the level of the patient’s heart.
should be done to identify or rule out other injuries.
Injuries can include fractures to bones; dislocations In most cases, splinting the injured area will help
of joints; and strains and sprains involving muscles, prevent further damage, reduce bleeding and
ligaments and tendons. It is not always easy to reduce pain. A variety of commercial splints are
identify the type of injury present. available for this purpose; many splints can be
improvised if commercial products are not available.
Injuries to the pelvis or femur are potentially critical After splinting, check every 15 minutes to see that
because of the major blood vessels running the patient’s pulse, ability to move, skin temperature,
through these parts of the body. Assess the patient color and ability to detect touch in the part of the
for bleeding and shock. body past the injured area are still stable.
You Are the Emergency Medical Responder
After approaching the driver, you find out that she slammed her knee into the dashboard and
cannot put weight on the right leg without significant pain. The ambulance has not yet arrived
on scene. How should you respond? What actions should you take?
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Skill Sheet
Skill Sheet 22-1
Applying a Rigid Splint
To apply a rigid splint:
STEP 1
Follow standard precautions and obtain consent.
STEP 2
Support the injured body part above and below
the site of the injury.
STEP 3
Check for circulation and sensation beyond the
injured area.
STEP 4
Place an appropriately sized rigid splint (e.g.,
padded board) under the injured body part.
NOTE: Place padding, such as a roller gauze,
under the palm of the hand to keep it in a
normal position.
▼ (Continued)
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Skill Sheet
Skill Sheet 22-1
Applying a Rigid Splint Continued
STEP 5
Tie several folded triangular bandages above
and below the injured body part.
STEP 6
Recheck for circulation and sensation beyond
the injured area.
NOTE: If a rigid splint is used on an injured
forearm, immobilize the wrist and elbow. Bind
the arm to the chest using folded triangular
bandages or apply a sling. If splinting an injured
joint, immobilize the bones on either side of
the joint.
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Skill Sheet
Skill Sheet 22-2
Applying a Sling and Binder
To apply a sling and binder:
STEP 1
Follow standard precautions and obtain consent.
STEP 2
Support the injured body part above and below
the site of the injury.
STEP 3
Check for circulation and sensation beyond the
injured area.
STEP 4
Place a triangular bandage under the injured arm
and over the uninjured shoulder to form a sling.
▼ (Continued)
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Skill Sheet
Skill Sheet 22-2
Applying a Sling and Binder Continued
STEP 5
Tie the ends of the sling at the side of the neck.
STEP 6
Bind the injured body part to the chest with a
folded triangular bandage.
STEP 7
Recheck for circulation and sensation beyond
the injured area.
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Skill Sheet
Skill Sheet 22-3
Applying an Anatomic Splint
After checking the scene and the injured patient:
STEP 1
Follow standard precautions and obtain consent.
STEP 2
Support the injured part.
■■ Support both above and below the site
of the injury.
STEP 3
Check for circulation.
■■ Check for feeling, warmth and color
beyond the injury.
STEP 4
Position the bandages.
■■ Place several folded triangular bandages
above and below the injured body part.
▼ (Continued)
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Skill Sheet
Skill Sheet 22-3
Applying an Anatomic Splint Continued
STEP 5
Align body parts.
■■ Place the uninjured body part next to the
injured body part.
STEP 6
Place padding between the body parts and fill
any voids. Tie the bandages securely around
both legs.
Photo: courtesy of the Canadian Red Cross.
STEP 7
Recheck for circulation.
■■ Recheck for feeling, warmth and color.
TIP: If you are not able to check warmth and
color because a sock or shoe is in place, check
for feeling.
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Skill Sheet
Skill Sheet 22-4
Applying a Soft Splint
To apply a soft splint:
STEP 1
Follow standard precautions and obtain consent.
STEP 2
Support the injured body part above and below
the site of the injury.
STEP 3
Check for circulation and sensation beyond the
injured area.
STEP 4
Place several folded triangular bandages above
and below the injured body part.
▼ (Continued)
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Skill Sheet
Skill Sheet 22-4
Applying a Soft Splint Continued
STEP 5
Gently wrap a soft object (e.g., a folded blanket
or pillow) around the injured body part.
STEP 6
Tie triangular bandages securely with knots.
STEP 7
Recheck for circulation and sensation beyond
the injured area.
NOTE: If you are not able to fully check circulation
because a sock or shoe is in place, check for
sensation.
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Agricultural and Industrial Emergencies
Because of the heavy equipment involved, some of the most serious injuries occur on agricultural and industrial
sites. You can expect to see crush injuries, avulsions, amputations, and other major open and closed soft tissue
and musculoskeletal injuries.
Scene Size-Up and Safety
As always, size up the scene of an agricultural or industrial emergency before entering. Never enter a scene if
there is any risk to your safety. Look out for toxic chemicals, fires or fire hazards, unstable or running machinery,
and unsecured livestock. If necessary, call specialized personnel, such as the fire department or a hazardous
material (HAZMAT) removal team, to stabilize the scene before entering (Fig. 22-26).
Be sure to observe lockout/tagout procedures. Lockout/tagout refers to a set of procedures and practices
that safeguard against the unexpected startup of machinery and equipment, or the possible release of hazardous
energy when machinery is being maintained. The individual using the machinery turns off and disconnects it from
its energy source before performing maintenance, and an authorized employee either locks or tags the energy-
isolating device to prevent inadvertent release of energy. Machinery that is on and/or that might be leaking fuel or
hydraulic fluid should not be approached. An agricultural storage area should not be entered alone.
Working in confined spaces is another safety concern. A confined space is one with restricted openings for
entry and exit, poor ventilation with possible air contaminants, and physical hazards related to engulfment (being
surrounded and overwhelmed by a substance such as soil or grain) or collapse. Such scenes might include pits,
tunnels, storage tanks, sewers, ventilation and exhaust ducts, underground utility vaults and pipelines.
A responder who is required to enter a confined space should follow these guidelines:
An emergency rescue involving entry into a confined space must never be attempted without training in safe
confined space entry and rescue procedures.
Assume a confined space is hazardous.
A person qualified to do so must ensure that structures are safe from collapse prior to anyone entering the
confined space.
An attendant must be present immediately outside the space to provide help to the responder inside, and there
must be a plan for emergency rescue.
There must be a safe method of communication between the responder inside the space and the attendant.
Appropriate PPE must be worn by the responder entering. Exact equipment is determined by the specific
hazards encountered in the confined space (e.g., eye/face and head and foot protection, respiratory protection,
safety belts, lifelines and harnesses).
Once a confined space has been identified, warning signs should be posted and, when possible, the entry
physically blocked.
The conditions must be tested prior to entry and continuously monitored during entry. Testing must be
performed by someone who is properly trained and has the appropriate equipment; one’s senses should
never be trusted to determine if the air in a confined space is safe. Many toxic gases and vapors cannot be
seen or smelled. This is also not a reliable way to determine if sufficient oxygen is present.
Adequate air conditions must be maintained in the confined space, through proper ventilation.
If safe atmospheric conditions cannot be maintained, the absolute necessity of entering should be evaluated.
If it is necessary to enter, an appropriate respirator must be worn, and this equipment must be evaluated by
someone with the proper training to do so.
Properly trained workers must control utilities prior to entry into confined spaces, including, for example,
electrical services, gas, propane, water, sanitary systems, communications and any secondary service
systems.
If an unsafe condition develops, the space should be exited immediately.
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Agricultural and Industrial Emergencies continued
Fig. 22-26: Emergencies occurring on industrial sites often involve heavy, powerful, mechanized
equipment, and injuries are often compounded by exposure to gases, fumes and chemicals.
Photo: courtesy of David Denniston, Director, National FARMEDIC Training Program.
Agricultural Emergencies
On an agricultural site, the combination of long hours, powerful mechanized equipment that may or may not be
properly maintained and remote locations can be deadly. Expect severe trauma, patients left unfound for hours
and a high incidence of spinal injury.
Typical Injuries
On an agricultural site, injuries most often involve the hands and arms, which can get caught in machinery.
The most common injuries include:
Abrasions.
Amputations.
Animal bites.
Avulsions.
Burns.
Concussions.
Contusions.
Eye injuries.
Fractures.
Lacerations.
Punctures.
Sprains.
Strains.
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Agricultural and Industrial Emergencies continued
Working with the Equipment
Injuries associated with different types of machinery each involve a different approach. It is important to have a
basic understanding of how each piece of equipment works and how it can cause harm in order to avoid injuries
to yourself or further injury to the patient.
Before trying to extricate a patient from agricultural equipment, the equipment must be stabilized and shut
down. If necessary, call a specialized crew to do this.
As a general principle, agricultural equipment can be stabilized by blocking or chocking the wheels, putting
on the parking brake or tying the equipment to another vehicle. The equipment should be shut down by entering
the cab to access the main controls. The engine should be slowed down with the throttle and then the machine
switched off using the ignition key. Some diesel-powered machines are shut down via an air shut-off lever rather
than an ignition key.
The engine can also be shut off by shutting the fuel line. This is done using the shut-off valve at the bottom of
the fuel tank or using vice-grip pliers. If a diesel engine cannot be shut down and the patient is in a life-threatening
situation, a 20-pound CO2 fire extinguisher can be emptied into the air intake. This will shut down the engine but
will also cause considerable damage.
Never touch a control on a piece of agricultural machinery unless you are sure you know what it does.
Tractors
Be aware that tractors can be fueled by diesel, gasoline or propane, and that fuel leaks, fires and explosions are a
real possibility. Tractors often cause injuries by rolling over onto the rider. Do not approach the site until the tractor
has been stabilized.
A patient trapped by a tractor can be freed by digging a trench underneath the patient’s body or by cutting off
a piece of the machine, such as the steering wheel. In some cases, however, the tractor may need to be lifted off
the patient by a specialized team.
Combines
Some common trouble spots on a combine include the auger, which is the rotating part of the screw conveyor;
the heads, with their oscillating cutting bars; the reels, steel tines that can impale someone; and the snapping
rollers, which can cause crush injuries (Fig. 22-27).
Fig. 22-27: Combine parts such as the auger, heads, reels and snapping rollers can cause serious
injuries. Photo: courtesy of Michelle Lala Clark.
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Agricultural and Industrial Emergencies continued
The reverse feature should never be used in an attempt to extricate a patient from a combine. The safest
approach is to keep the machinery from moving, so pry bars and other tools should be used to jam the
moving parts into place before beginning extrication. The hydraulic system must be locked. Usually a bar
near the hydraulic cylinder will lock the header. If possible, the combine header should be divided from the
drive mechanism. An acetylene torch can be used to cut pieces of the combine to free a patient, but the
combine and surrounding soil should first be washed down and the inside of the combine flushed, to reduce
the risk of fire.
If a patient is trapped in the auger, the auger may need to be first cut free, and it should be transported with
the patient. First, a large pipe wrench should be wedged on the shaft to prevent it from reversing, and then the
auger drive disconnected. No attempt should be made to extricate a patient in the field if the auger has caused
an avulsion.
On older equipment, rescue tools can be used to spread snapping rollers, but this approach will not work on
newer equipment.
Hay Balers
To free a patient caught in a hay baler, the tines may need to be disassembled by unscrewing the bolts holding
it together. The drive belts that drive the cross auger or raise the auger may need to be disassembled with
rescue tools. To prevent reverse motion, a pipe wrench can be used to hold on to the input shaft as the auger
is cut free. To release a patient from the smooth rollers, the mounting bolts at each end should be removed,
to remove the bearings.
An acetylene torch should never be used to take apart a hay baler, as the combustible dust inside the baler
may ignite.
Other Areas
In addition to the fields, agricultural emergencies may occur in silos, manure storage devices and places where
livestock are held. Each of these areas carries its own hazards.
Silos
The major hazard in a silo is the gas formed during fermentation of stored crops, which, when inhaled, can kill
within minutes (Fig. 22-28). Keep in mind that “silo gas” can leak out to the surrounding area. Signs of this
gas include a bleach-like smell, the presence of dead birds and insects, a yellowish or reddish vapor, and
sick livestock nearby. A self-contained breathing apparatus (SCBA) must be worn to rescue a patient in the
presence of silo gas. Administer supplemental oxygen to the patient, based on local protocols, and transport
them as soon as possible.
Manure Storage
Manure is often flushed from livestock facilities into a holding pond or a closed structure. The hazards include
toxic fumes and risk of drowning. To rescue a patient in a manure storage area, you must wear an SCBA and
lifeline. Treat an immersed patient as you would a victim of drowning. If the patient is breathing, connect the
patient to an SCBA. Also administer supplemental oxygen, based on local protocols. Before transporting the
patient, remove any contaminated clothing and flush the patient’s body with water. Do not bring any contaminated
materials into the transport vehicle. Anyone and everything that came into contact with manure will require
decontamination.
CRITICAL If the patient is breathing after a manure storage incident, connect the patient to an
FACTS SCBA.
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Agricultural and Industrial Emergencies continued
Fig. 22-28: The gas formed during fermentation of crops stored in a silo can kill within minutes
when inhaled. Photo: © Shutterstock.com/Jorg Hackemann.
Livestock
Never enter an area with unsecured livestock. Treat injuries inflicted by livestock as you would any similar injury,
but be sure to flush animal feces from any wound.
Chemicals Used in Farming
Many types of chemicals, particularly pesticides and fertilizers, are used in farming. Use protective clothing before
entering a scene that may contain pesticides or other chemicals. If necessary, call a HAZMAT removal team. If
you know what pesticide was involved in a particular emergency, check the label for instructions and precautions,
and take the label with you to the hospital. Before transporting a patient, remove all clothing and flush the patient’s
body with water.
Industrial Emergencies
The hazards of industrial emergencies often mimic those of agricultural emergencies and include exposure to
gases, fumes or other chemicals and to unstable machinery. The specific hazards depend on the site.
Scene Size-Up and Safety
Once again, it is important to size up the scene and not enter it until it has been secured. Keep in mind
that even small industrial sites, such as newspaper printers and garages, may present significant hazards.
These may include dangerous equipment and machinery, hazardous materials, a risk of explosion or fire, and
confined spaces.
When responding to the scene of an industrial emergency, determine whether there are hazardous materials
present at the scene before entering. Communicate with staff about potential hazards, especially if you are
unfamiliar with the operations. Determine if more than one patient is ill or has been injured, and if so, how many.
Also determine the type of environment in which the emergency occurred: was it on the main level, in an elevated
location or in a confined space?
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Once you have performed the scene size-up, communicate with safety or management personnel at the site,
prior to entering the scene. Call for any specialized teams that may be needed, for example, to manage hazardous
materials. Find out if the site has an emergency plan and whether or not that plan has already been activated.
Also initiate the incident command system. Always ensure your safety and that of others in the area before entering
the scene.
Safety Equipment and Guidelines
Before attempting a rescue in an industrial site, locate and speak to the industrial safety or management
personnel. They can guide you through the emergency protocols that should be in place at every industrial site.
Equipment
Hazardous equipment that you may find at industrial sites includes all types of dangerous chemicals and
machinery. Chemicals can cause toxic inhalations or absorptions, as well as burns. Be sure to use proper
protective gear any time you approach a scene that is suspected of being contaminated with toxic chemicals.
Dangerous types of machinery include presses, hoists, conveyors and crushing devices. As with agricultural
emergencies, never approach any equipment that has not been stabilized and shut down. Enlist the help of the
safety or management personnel to properly stabilize and shut down machinery.
Dangerous Locations
Dangerous locations on industrial sites include trenches and confined spaces, especially if there are toxic
chemicals that can collect there, and elevated locations. A confined space should not be entered until the need
for an SCBA has been determined and the possible risk of collapse has been evaluated by a person trained to
do so. Sick or injured people in elevated (aboveground) locations may require rescue by specialized high-angle
rescue teams.
Chemicals
A wide range of industrial chemicals is used across various industries and may be found in a gas, aerosol,
liquid or solid state. These chemicals can be hazardous either because of the chemicals they contain (e.g.,
carcinogens, reproductive hazards, corrosives, or agents that affect the lungs or blood) or because of their
physical properties (e.g., flammable, combustible, explosive or reactive). Large quantities of these chemicals are
present throughout the United States and may pose a risk because of exposure through either routine use or
through acts of terrorism. If these hazardous chemicals are released, they could have extremely serious effects
on exposed individuals.
In any of their states (gas, aerosol, liquid or solid), these toxic industrial chemicals could enter the body
by being inhaled, absorbed through the skin or ingested. The time it takes for these substances to have an
effect depends mainly on the route they use to enter the body. Generally, poisoning occurs more quickly if the
chemical enters the body through the lungs. Safety Data Sheets (SDS) or chemical information cards will provide
information on the effects of each chemical on humans and the symptoms of exposure.
If you or someone you are helping is exposed to a toxic industrial chemical, get yourself and the patient away
from the area as quickly as you can. Avoid passing through the contaminated area, if possible. Employers should
have an effective plan in place to assist employees in reaching shelter safely. They may be required to “shelter-
in-place” if they cannot get out of a building or if the nearest place with clean air is indoors. Health and safety
plans should take into account the possible impact of a release of toxic industrial chemicals. Plans should include
guidelines such as monitoring, detection, awareness training, PPE, decontamination and medical surveillance of
acutely exposed workers.
Responders may have available to them a wide variety of direct reading instruments, as well as procedures for
analytical sampling and analysis, to detect toxic industrial chemicals.
Continued on next page
Chapter 22: Injuries to Muscles, Bones and Joints | 527
ENRICHMENT
Agricultural and Industrial Emergencies continued
During or after a toxic chemical release, and if the duration of the chemical release or airborne concentration
of chemicals is unknown, Occupational Safety and Health Administration (OSHA) PPE Level B protection should
be considered a minimum. Level B requires the highest level of respiratory protection but a lower level of skin
protection. Required equipment would include an SCBA, hooded chemical-resistant clothing, special gloves,
boots with covers and a hard hat.
528 | Emergency Medical Response
23
INJURIES TO
THE HEAD,
NECK AND
SPINE
You Are the Emergency
Medical Responder
You are the emergency medical
responder (EMR) with an ambulance
crew responding at the scene of
a motorcycle crash. As you round
a curve and approach the scene,
you begin your size-up and see
that the motorcycle driver is lying
on the road, not moving, and two
bystanders appear to be rendering
assistance. The motorcycle is a
considerable distance from where
the driver is located. The motorcyclist
is wearing a helmet. As you begin
your primary assessment, how
should you adjust your methods?
What types of injuries should you
suspect?
KEY TERMS
Cerebrospinal fluid: A clear fluid that flows within Spinal cord: A cylindrical structure extending from
the ventricles of the brain, and around the brain the base of the skull to the lower back, consisting
and spinal cord. mainly of nerve cells and protected by the
spinal column.
Cervical collar: A commercially produced rigid
device that is positioned around the neck to Spinal motion restriction (SMR): A collective
limit movement of the head and neck; also called term that includes all methods and techniques
a C-collar. used to limit the movement of the spinal column
of a patient with a suspected spinal injury.
Concussion: A temporary loss of brain function
caused by a blow to the head; considered a Traumatic brain injury (TBI): An injury to the brain
traumatic brain injury (TBI). resulting from an external force such as a blow to
the head or a penetrating injury to the brain; TBIs
Manual stabilization: A technique used to achieve are associated with temporary and/or permanent
spinal motion restriction by manually supporting impairment to brain function, including physical,
the patient’s head and neck in the position found emotional and cognitive functioning; a concussion
without the use of any equipment. is a common type of TBI.
Spinal column: The series of vertebrae extending
from the base of the skull to the tip of the tailbone
(coccyx); also referred to as the spine.
LEARNING OBJECTIVES
After reading this chapter, and completing the class • Describe care for specific head injuries.
activities, you will have the information needed to: • Describe the method of determining if a responsive
• Relate the mechanism of injury to potential injuries patient may have a spinal injury.
of the head, neck and spine. • Explain the importance of minimizing the
• List signs and symptoms of head, neck and movement of a victim with a possible head,
spinal injuries. neck or spinal injury.
• Describe general care for head, neck and • Discuss various ways of preventing head, neck and
spinal injuries. spinal injuries.
SKILL OBJECTIVES
After reading this chapter, and completing the class • Demonstrate how to immobilize a head, neck or
activities, you should be able to: spinal injury to move a patient from the scene to a
stretcher (Enrichment skill).
• Perform the proper care for specific head injuries.
• Demonstrate manual stabilization of the head,
neck and spine.
INTRODUCTION all injury deaths and approximately 2.5 million
emergency department visits a year in the United
Although injuries to the head, neck and spine States. Falls are the leading cause of TBI and
account for only a small percentage of all injuries, other head, neck and spinal injuries, with a
they are the cause of a significant number of large percentage occurring in children up to
fatalities annually. Traumatic brain injury 14 years of age and adults over the age of 65.
(TBI) alone accounts for about 30 percent of
530 | Emergency Medical Response
Causes of Head, Neck and Spinal Injuries
Cranial cavity
Forehead
Falls, Sports Injuries,
Recreational Accidents, Violence
and Other Causes Motor-Vehicle Collisions
55% 45%
Nose
Cheek
Fig. 23-1: Falls, being struck by an object and motor-vehicle
collisions are the leading causes of TBI.
Jaw
Being struck by an object is the second leading
cause of TBI, followed by motor-vehicle collisions.
Other causes of head, neck and spinal injuries Fig. 23-2: The head.
include sports-related mishaps, incidents related
to recreational activities and violent acts such as
assault (Fig. 23-1). INJURIES TO THE HEAD
Head Injuries
Survivors of serious head, neck and spinal
injuries have a wide range of physical and mental The head is easily injured because it lacks the
impairments, including paralysis, speech and padding of muscle and fat that are found in other
memory problems, and behavioral disorders. areas of the body. The most common cause of death
in patients with head injuries is a lack of oxygen to the
Fortunately, prompt, appropriate care can brain. Also, swelling of the brain tissues or bleeding
help minimize the damage from most head, within the brain can cause increased pressure inside
neck and spinal injuries. In this chapter, you will the skull that, in turn, can cause damage to the brain.
learn how to recognize when a head, neck or A brain injury may lead to altered consciousness with
spinal injury may be serious. You will also learn airway and breathing problems. The two types of
how to provide appropriate care to minimize head injury are open and closed.
these injuries.
Open Head Injuries
Open head injuries involve a break in the skull or
ANATOMY OF THE HEAD, occur when an object penetrates the skull. There
THE NECK AND THE SPINE is direct damage to the skull, and brain damage
The head contains special sense organs may be involved. Head injuries bleed profusely, and
(e.g., eyes, nose and ears), the brain, mouth a patient may lose blood quickly. With open head
and related structures. The head is formed by injuries, it is important that you:
the skull and the face. The four flat bones of the
skull are fused together to form a hollow shell. Control bleeding promptly with dressings, direct
pressure and a pressure bandage, while limiting
This shell, known as the cranial cavity, contains
spinal movement (see Skill Sheet 23-1).
the brain. The face is on the front of the skull. The
bones of the face include the bones of the cheek, Do not apply direct pressure over where there is
forehead, nose and jaw (Fig. 23-2). an obvious skull fracture or depression.
Do not remove any penetrating object; instead
The neck contains the esophagus, larynx and part stabilize it with thick dressings.
of the trachea. It also contains major blood vessels,
muscles and tendons, and the cervical bones of
Closed Head Injuries
the spine.
Closed head injuries occur when the brain is struck
The back is made up of soft tissue, bones, against the skull but the skull remains intact. They
cartilage, nerves, muscles, tendons and ligaments. can also occur from impact with a blunt object.
It supports the skull, shoulder bones, ribs and This type of injury may be more challenging to
pelvis, and protects the spinal cord and other detect as there may not be any visible damage
vital organs. to the skull although, in some cases, swelling
Chapter 23: Injuries to the Head, Neck and Spine | 531
or a depression is evident. In addition to the Concussion
general signs of head injury, there may be a A concussion is a common type of traumatic
softness or depression on the skull and blood, or brain injury that involves a temporary loss of
cerebrospinal fluid may be leaking from the brain function. Concussions are particularly
nose or ears. If you suspect a closed head injury, common sports-related injuries, but they can
do not control bleeding using direct pressure, as occur whenever a person experiences a bump,
this could cause further injury by pushing bone blow or jolt to the head or body that results in
fragments into the brain. Because of the rigid rapid movement of the head. A patient who
nature of the skull, if swelling or bleeding in the has had one concussion is at increased risk for
brain occurs, brain damage may occur depending subsequent concussions.
on the nature and force of the injury.
A concussion can result from even a seemingly
Skull Fractures minor bump, blow or jolt and may be tricky to
recognize. Many patients who experience a
You should suspect a skull fracture any time there
concussion do not lose consciousness, or they
has been significant trauma to the head, even if
may only lose consciousness very briefly. Your
the patient has suffered a closed head injury. Skull
best clues that a patient may have a concussion
fractures may be accompanied by brain damage,
are often changes in their behavior noted after they
caused by bleeding or swelling within the brain,
have experienced a bump, blow or jolt. For example,
which is a life-threatening condition. If the patient
the patient may seem confused, dazed or stunned;
is showing any of the signs of head injury, a skull
lose the ability to remember or follow simple
fracture may be present and brain injury is possible.
instructions; or ask repeatedly what happened. The
A patient with a skull injury should be seen by a
patient may complain of a headache, feel nauseated
more advanced medical professional immediately.
or vomit, have blurred or double vision, complain
The signs and symptoms of a skull fracture with of dizziness, or be especially sensitive to light or
brain injury include: noise. Many patients who have experienced a
concussion say that the concussion caused them
Damage to the skull, including deformity to the to feel “sluggish,” “groggy” or just “not right.” Signs
skull or face. and symptoms of a concussion (Table 23-1) usually
Pain or swelling at the site of injury. are apparent soon after the injury, although some
Blood or other fluids leaking from the mouth, can appear hours or days later. For example, the
nose, ears or scalp wound. patient may sleep more or less than usual. Children
may show changes in playing or eating habits. The
Unequal facial movements; drooping, unequal or
effects of the concussion can last for several days,
unresponsive pupils; or vision problems in one
or both eyes. weeks or longer.
Bruising around the eyes (“raccoon eyes”) If you think that a patient has sustained a
(Fig. 23-3, A). concussion, advise them to stop the activity they
Bruising behind the ear (“Battle’s sign”) were engaged in when the incident occurred.
(Fig. 23-3, B). The patient should follow up with a healthcare
CRITICAL The head is easily injured because it lacks the padding of muscle and fat that are
FACTS found in other areas of the body.
Open head injuries involve a break in the skull or occur when an object penetrates
the skull. There is direct damage to the skull, and brain damage may be involved.
Closed head injuries occur when the brain is struck against the skull but the skull
remains intact. They can also occur from impact with a blunt object.
You should suspect a skull fracture any time there has been significant trauma
to the head, even if the patient has suffered a closed head injury.
A concussion is a temporary loss of brain function caused by a blow to the head.
It is considered a brain injury, although there may be no detectable damage to
the brain.
532 | Emergency Medical Response
A
B
Fig. 23-3, A–B: (A) Bruising around the eyes or (B) behind the ear indicates a skull fracture with a
possible brain injury.
provider for a full evaluation. A healthcare provider considered a penetrating wound. Penetrating
is best able to evaluate the severity of the injury wounds can cause long-term damage.
and make recommendations about when the
patient can return to normal activities. And, while Do not try to remove an object that is impaled in the
rare, permanent brain injury and death are potential skull. Stabilize the object and the wound site with
consequences of failing to identify and respond bulky dressings, and then dress the surrounding
to a concussion in a timely manner. area with sterile gauze. If you suspect an object
has penetrated the skull, but it is not visible, cover
the area lightly with sterile dressings. Never apply
Penetrating Wounds firm, direct pressure to a head injury that shows
If an object such as a bullet, knife or nail passes bone fragments, exposed brain tissue or where a
through the skull and lodges in the brain, it is depression is visible. Do not stop the flow of blood
Chapter 23: Injuries to the Head, Neck and Spine | 533
Table 23-1:
Signs and Symptoms of a Concussion
THINKING AND
PHYSICAL EMOTIONAL BEHAVIORAL
REMEMBERING
••Difficulty thinking clearly ••Headache ••Irritability ••Changes in sleeping
•• Difficulty remembering events ••Blurry vision ••Sadness habits (sleeping
that occurred just prior to the ••Nausea or vomiting ••Heightened more or less than
incident and just after the incident emotions usual, difficulty
••Dizziness
••Difficulty remembering new falling asleep)
••Sensitivity to noise ••Nervousness or
information anxiety ••Changes in playing
or light
••Difficulty concentrating and eating habits
••Balance problems (in children)
••Feeling mentally “foggy” ••Feeling sluggish
••Difficulty processing information (lack of energy)
or cerebrospinal fluid draining from the ears or nose. wound. Attempt to control bleeding with pressure
Apply loose gauze dressings. Keep the patient still on the area around the wound (Fig. 23-4). Examine
and minimize movement of the head and neck. the injured area carefully because the patient’s hair
may hide part of the wound. If you are unsure of the
extent of the scalp injury, summon more advanced
Scalp Injuries medical personnel who will be better able to evaluate
Scalp bleeding can be minor or severe. A scalp the injury. Severe bleeding from the scalp can cause
injury may bleed more than expected due to the large shock in young children and infants.
number of blood vessels in the scalp. The bleeding
is usually easily controlled with direct pressure. Once bleeding is controlled, apply several
Because the skull may be injured, be careful to press dressings and hold them in place with a gloved
gently at first. If you feel a depression, a spongy area hand. Secure the dressings with a roller bandage.
or bone fragments, do not put direct pressure on the Use a pressure bandage if necessary.
Fig. 23-4: Control bleeding from a scalp injury by applying pressure around the wound. Avoid direct
pressure.
534 | Emergency Medical Response
Signs and Symptoms of Head
and Brain Injury
Some of the typical signs and symptoms of head
and brain injury include the following:
Damage to the skull, including deformity to the
skull or face
Pain or swelling at the site of the injury
Irregular breathing
A sudden, debilitating headache
A
Nausea or vomiting
Incontinence (involuntary urination or defecation)
High blood pressure and slowed pulse
Paralysis or droopiness, often on one side of the
body; rigidity of limbs
Loss of balance
Asymmetrical facial movements
Confusion, unresponsiveness or other type
of altered mental state
Facial bruising, including “raccoon eyes”
(visible bruising around the eyes)
External bleeding of the head
B
Unusual bumps or depressions on the head
Blood or other fluids draining from the ears,
mouth or nose
Bruising behind the ears (“Battle’s sign”)
Unequal pupil size and unresponsive pupils;
disturbance of vision in one eye or both
Speech problems
Seizures
Providing Care
Your first step should be to summon more advanced
medical care. Making sure to follow standard C
precautions to prevent disease transmission, Fig. 23-5, A–C: After summoning more advanced medical care,
provide the following care while waiting for more care for a suspected head and neck injury by maintaining manual
advanced medical personnel to arrive: stabilization, keeping the head in the position found.
Establish manual stabilization of the head Do not attempt to remove any penetrating
and neck (Fig. 23-5, A–C), perform a primary object; instead stabilize it with a bulky dressing.
assessment and maintain manual stabilization
while at the scene.
Maintain manual stabilization until other
emergency medical services (EMS) responders
Maintain an open airway. Monitor the airway, relieve you. If you are trained to do so and
suction if needed and administer supplemental protocols allow, apply a cervical collar (also
oxygen, based on local protocols. called a C-collar). (For more information on
Control any bleeding and apply dressings to backboards, refer to Chapter 5.)
any open wounds. Monitor the patient’s vital signs and mental
Do not apply direct pressure if there are any status closely, and watch for any changes in the
signs of an obvious skull fracture. patient’s status.
If there is leaking of cerebrospinal fluid from Try to calm and reassure the patient. Encourage
the ears or a wound in the scalp, cover the the patient to engage in conversation with you;
area loosely with a sterile gauze dressing. it may prevent loss of consciousness.
Chapter 23: Injuries to the Head, Neck and Spine | 535
Nosebleed Eye Injuries
Nose injuries often result from a blow by a blunt Injuries to the eye can involve the eyeball, the bone
object. A broken nose may be deformed and and the soft tissue surrounding the eye. Blunt
will swell. Nosebleeds can also be caused by objects, like a fist or a baseball, may injure the
dryness and high blood pressure. Nosebleeds eye and surrounding area, or a smaller object may
can be painful or the nose may be tender, there penetrate the eyeball. Care for open and closed
can be bleeding only from the nose or the patient wounds around the eye as you would for any other
could vomit swallowed blood. If the patient is soft tissue injury.
unresponsive, the airway can become blocked by
blood. Care for soft tissue injuries to the nose as Injuries to the eyeball itself require different
you would other soft tissue injuries. Apply cold care. Injuries that penetrate the eyeball or cause
packs to reduce swelling and take special care to the eye to be removed from its socket are very
maintain an open airway. You can usually control serious and can cause blindness. Never put
bleeding by having the patient sit with the head direct pressure on the eyeball. Remember
slightly forward while pinching the nostrils together that all eye injuries should be examined by a
for about 10 minutes (Fig. 23-6). healthcare provider. It is not necessary to cover
both the injured and the uninjured eyes, because
Advanced medical care is needed if the bleeding sympathetic or involuntary eye movement occurs
does not stop, recurs or the patient has a history of even when both eyes are covered and not exposed
high blood pressure. Tell the patient not to sniffle or to outside stimuli. Covering both eyes can also
blow their nose. If the patient loses consciousness, cause fear and increase anxiety, especially in
place the patient in a side-lying recovery position to children, and pose a safety risk to the patient,
allow the blood to drain away from the airway. but follow local protocols or, if in doubt, contact
medical control.
Children may have objects in the nose. Do not
attempt removal, as special lighting and instruments
are required. Reassure the child and parent, and Assessment
call for more advanced medical personnel. To assess what type of care the patient will need,
first determine when the injury occurred, whether
one or both eyes were injured, and when the
patient first noticed the symptoms. Then, using
a small penlight, follow these guidelines:
Check the eye sockets and eyelids for bruising,
lacerations, swelling or deformity.
Check the whites of the eyes for foreign objects,
discoloration or discharge.
Check that the eyes can move in all directions,
and that the pupils react equally to light. Ensure
that there is no pain when the eyes move.
Check that the pupils are equal in size.
Fig. 23-6: Control a nosebleed by having the patient sit with the Check that there are no lacerations or foreign
head slightly forward, pinching the nostrils together. objects in the eyeballs.
CRITICAL There are numerous signs and symptoms of head or brain injury, including irregular
FACTS breathing, high blood pressure and slowed pulse, loss of balance, external bleeding
of the head, bruising behind the ears and seizures—among others.
To provide care for a head injury, maintain an open airway and manual stabilization
until other emergency medical services (EMS) responders relieve you.
Nose injuries often result from a blow by a blunt object. A broken nose may be
deformed and will swell. Nosebleeds can also be caused by dryness and high
blood pressure.
536 | Emergency Medical Response
Foreign Bodies eyes with clean water for at least 15 minutes.
Foreign bodies that get in the eye, such as dirt or If only one eye is affected, make sure you do
slivers of wood or metal, are irritating, painful and not let the water run into the unaffected eye. If
can cause significant damage to the cornea. It is water is not available, you can use sterile saline.
important to tell the patient not to rub the eyes. Continue care while transporting the patient,
Never touch the eye and always follow standard if you can.
precautions when caring for the patient.
Impaled Objects
If you determine there is a foreign body in the eye,
Do not attempt to remove an object that is
try to remove it by telling the patient to blink several
impaled in the eye. Keep the patient in a face-up
times. If the object is visible on the lower eyelid,
position and enlist someone to help stabilize the
pull the eyelid down and try to remove the object
patient’s head. Stabilize the object by encircling
with the corner of a sterile gauze pad. Be careful
the eye with a gauze dressing or soft sterile
not to touch the eyeball.
cloth, being careful not to apply any pressure
Next, gently flush the eye with irrigation/saline to the area. Position bulky dressings around
solution or water (Fig. 23-7). After irrigating, if the the impaled object, such as roller gauze, and
object is visible on the upper eyelid, gently roll the then cover it with a shield such as a paper cup
upper eyelid back over a cotton swab and attempt (Fig. 23-8, A–B). Do not use Styrofoam®-type
to remove the object with the corner of a sterile materials, as small particles can break off and
gauze pad, being careful not to touch the eyeball get into the eye.
(Skill Sheet 23-2). If the object remains, the patient
The shield should not touch the object. Bandage
should receive advanced medical care. Cover the
the shield and dressing in place with a self-
injured eye with an eye pad/shield.
adhering bandage and roller bandage covering
the patient’s injured eye, to keep the object
Chemical Exposure to the Eye stable and minimize movement (Skill Sheet 23-3).
If chemicals have been in contact with the Comfort and reassure the patient. Do not leave the
patient’s eyes, irrigate the affected eye or patient unattended.
Fig. 23-7: Gently flush an eye with a foreign object or one that has undergone chemical exposure with water.
CRITICAL Do not attempt to remove an object that is impaled in the eye. Keep the patient in a
FACTS supine position and enlist someone to help stabilize the patient’s head.
Chapter 23: Injuries to the Head, Neck and Spine | 537
A
B
Fig. 23-8, A–B: To care for an impaled object in the eye, do not attempt to remove the object.
Instead, (A) stabilize the object with a shield such as a paper cup and (B) bandage the cup in place.
Oral Injuries Pain in areas around the ears.
Patients with facial injuries may have injuries to their
teeth or jaws. Situations that fracture or dislocate
Difficulty or pain when speaking.
the jaw can also cause head, neck or spinal If the patient is bleeding from the mouth, and
injuries. Maintaining an open and clear airway and a head, neck or spinal injury is not suspected,
restricting spinal motion should be priorities. place the patient in a seated position with the
head tilted slightly forward or on their side in a
The signs and symptoms of oral injuries include: recovery position to allow any blood to drain from
the mouth.
Teeth that do not meet or are uneven, loose
or missing. If the injury has penetrated the lip, place a rolled
A patient who is unable to open or close dressing between the lip and the gum and
the mouth. another dressing on the outer surface of the lip.
Saliva mixed with blood. If the tongue is bleeding, apply a dressing and
538 | Emergency Medical Response
show the severity of these injuries, you should
always care for them as if they are serious.
Mechanism of Injury
Consider the possibility of a serious neck or spinal
injury in a number of situations. These may include:
Any injury caused by entry into shallow water.
Injury as a result of a fall greater than a
standing height.
An injury involving a diving board, water slide or
entering water from a significant height, such as
Fig. 23-9: For a knocked-out tooth, control bleeding an embankment, cliff or tower.
by placing a rolled gauze pad into the space left by the
missing tooth and have the patient gently bite down to Any injury, such as from a car or other vehicle
maintain pressure. collision, involving severe blunt force to the
person’s head or trunk.
A motor-vehicle, motorized cycle or bicycle
direct pressure. A cold pack may alleviate pain collision involving a pedestrian or driver or
and swelling. passengers not wearing safety belts, or
one that results in a broken windshield or
If a tooth is knocked out, control the bleeding
a deformed steering wheel.
by placing a rolled gauze pad into the space left
by the missing tooth and have the patient gently Injury as the result of a hanging.
bite down to maintain pressure (Fig. 23-9). Try Any unresponsive trauma patient.
to locate and save the tooth, because a dentist Injury involving a penetrating trauma to the head,
or other healthcare provider may be able to neck or torso.
reimplant it. Place the tooth in Hanks’ Balanced Any person thrown from a motor vehicle.
Salt solution (e.g., Save-A-Tooth®), if available.
If you do not have Hanks’ Balanced Salt solution,
Any injury in which a patient’s industrial hard
hat or helmet is broken, including a motorcycle,
place the tooth in egg white, coconut water or bicycle, football or other sports helmet.
whole milk. If these are not available, place the
tooth in the injured patient’s saliva. Be careful A person who has other painful injuries,
especially of the head and neck.
to pick up the tooth only by the crown (the part
of the tooth that is normally visible above the A person complaining of neck or back pain or
gum line) rather than by the root. The patient tenderness, tingling in the extremities or weakness.
should seek dental or emergency care as soon An injured person who appears to be frail.
as possible after the injury. The sooner the tooth A person who is not fully alert or appears to
is reimplanted, the better the chance that it will be intoxicated.
survive. Ideally, reimplantation should take place Someone with an obvious head or neck injury.
within 30 minutes.
Sensory deficit or muscle weakness involving
Leave intact dentures in position to support the the torso or upper extremities.
mouth structure. Remove broken dentures and Children less than 3 years of age with evidence
send them with the patient to assist the oral of head or neck trauma.
surgeon with jaw alignment.
Lacerations of the Neck
The carotid artery and jugular vein are both located
INJURIES TO THE NECK in the neck, and injuries to one or both will produce
AND SPINE serious, possibly fatal bleeding (Fig. 23-10).
Injuries to the neck or spine can damage both An open wound in the neck may result in an air
bone and soft tissue, including the spinal cord. embolism, which is caused by air being sucked into
It is difficult to determine the extent of damage in the wound. A fractured larynx or collapsed trachea
neck or spinal injuries. Since generally only X-rays, is also a common neck injury. If the laceration is
computerized tomography (CT or CAT) scans or caused by an object impaled in the neck, do not
magnetic resonance imaging (MRI) scans can attempt to remove it.
Chapter 23: Injuries to the Head, Neck and Spine | 539
Numbness, weakness, tingling, or loss of feeling
or movement in the extremities.
Partial or complete loss of movement or feeling
below the suspected level of injury.
Difficulty breathing or shallow breathing.
Loss of bladder and/or bowel control.
If the patient can walk, move and has feeling in the
arms and legs, it does not necessarily rule out the
possibility of injury to the bones of the spine or to
the spinal cord.
Providing Care
If you suspect a patient has a neck or spinal injury,
restrict spinal motion and control any bleeding.
Do not move the patient or ask the patient to move
to try to find a pain response. It is essential when
Fig. 23-10: Injuries to the carotid artery or jugular vein will
treating neck injuries to maintain an open airway.
produce serious, possibly fatal, bleeding. If the patient is wearing a helmet, do not remove
it unless you have been trained to do so and have
the appropriate resources, or unless it is necessary
Signs and Symptoms of Neck to access and assess the patient’s airway.
and Spinal Injuries Because movement of an injured neck or spine can
The signs and symptoms of neck injuries irreversibly damage the spinal cord, keep the patient
may include: still. To restrict spinal motion initially, use manual
stabilization with your hands or knees. Perform a
Obvious lacerations, swelling or bruising. primary assessment on the scene while maintaining
Objects impaled in the neck. spinal motion restriction (SMR). Assess the patient’s
pulse, movement and feeling in the extremities.
Profuse external bleeding.
Impaired breathing as a result of the injury. Approach patients from the front so they can see
Difficulty speaking or complete loss of voice. you without turning their heads, and tell patients
A crackling sound when the patient is speaking to respond verbally to your questions. Ask the
or breathing, due to air escaping from an injured responsive patient the following questions, while
trachea or larynx. maintaining SMR, to further assess the situation:
An obstructed airway caused by swelling of
Does your neck or back hurt?
the throat.
What happened?
The signs and symptoms of spinal injuries Where does it hurt?
may include: Can you move your hands and feet?
Pain or pressure in the back, independent of Can you feel where I am touching?
movement or palpation. For an unresponsive patient, maintain an open
Tenderness in the area of the injury. airway using the jaw-thrust (without head extension)
Pain associated with moving. maneuver and assist ventilation if needed. You
CRITICAL Injuries to the neck or spine can damage both bone and soft tissue, including the
FACTS spinal cord. It is difficult to determine the extent of damage in neck or spinal injuries.
Always care for these types of injuries as if they are serious.
You should suspect possible serious neck or spinal injury in many situations,
including but not limited to diving board mishaps, motor-vehicle crashes where a
person has been thrown from the vehicle, and situations where hard hats or helmets
have been broken.
540 | Emergency Medical Response
should not attempt to align the head and neck do not try to remove it. If the patient is breathing
with the body unless you cannot maintain an open and the airway is clear, maintain SMR with the
airway, you need to remove a helmet or you need to helmet in place. Consider the need to pad under
assist with the application of a C-collar. the shoulders to maintain the airway in a neutral
position. Additionally, both the helmet and the
Administer supplemental oxygen based on local shoulder pads, if worn, should be removed to
protocols. While obtaining further information, maintain the patient in a neutral position.
maintain SMR of the head and neck in the position
in which they were found. Obtain any further Some helmets are closed in front with face
information from others at the scene to determine protectors. If the protector cannot be lifted out
the mechanism of injury and the patient’s mental of the way, it is preferable that it be cut off rather
status before your arrival. than the helmet removed.
Keeping the head, neck and spine from moving Situations that may require removing the helmet
(spinal motion restriction) helps prevent include those in which:
further damage to the spinal column. If a second
responder is available, that person can provide You cannot access or assess the patient’s
care for any other conditions while you keep the airway and breathing.
head and neck stable. The airway is impeded and cannot be opened
with the helmet on.
Assist more advanced medical personnel upon
arrival by maintaining SMR. More advanced
The patient is in cardiac arrest.
medical personnel will then apply a cervical collar You cannot immobilize the spine.
to further assess the patient to determine the If a helmet is loose, this does not necessarily mean
best way to prepare them for transport. If you you must remove it. Try to stabilize the helmet
must move the patient, secure the patient to a by adding padding between the helmet and the
backboard or other extrication device prior to patient’s head.
moving them. Backboards should be used only for
extricating the patient from the scene and moving
them to the ambulance, as evidence has shown Preventing Head, Neck
that backboards are not beneficial for spinal cord and Spinal Injuries
injuries and can cause harm. Always follow local While some injuries are unavoidable, many others
protocols when considering care for a suspected are preventable by being aware of potential
spinal injury. dangers in the environment and taking appropriate
safety measures. To prevent head, neck and spinal
Helmet Removal injuries, take the following steps:
When you encounter a patient who has sustained Know your risk. Be aware of your surroundings
injuries while wearing a helmet, you must assess and wear appropriate safety equipment and
whether it is necessary to remove the helmet. protective devices such as padding, footwear,
As always, assess breathing and pulse and helmets and eye protection.
determine your course of action.
Do not dive into a body of water if you are
Since properly fitted helmets fit snugly to the unsure of the depth.
head, it is difficult to remove one without moving Wear your seat belt in a motor vehicle. Insist
the patient’s head and neck. Removing a helmet that passengers wear seat belts and always
requires a minimum of two responders. When transport children in approved child safety seats
providing care to a patient with a helmet, you in the back of the vehicle, according to state and
should only remove it if it is impeding your care, local regulations.
you are unable to access and assess the airway, To prevent head and neck injuries in rear-end
or if the patient is in cardiac arrest. Otherwise, collisions, properly adjust your motor vehicle’s
CRITICAL Backboards should be used only for extricating the patient from the scene and
FACTS moving them to the ambulance, as evidence has shown that backboards are not
beneficial for spinal cord injuries and can cause harm.
Chapter 23: Injuries to the Head, Neck and Spine | 541
headrest. The top of the headrest should be as must consider its cause. Often the cause is the
high as the top of your head and no more than best indicator of whether an injury to the head,
4 inches from the back of your head. neck or spine should be considered serious.
To prevent falls, safety-proof your home and You must also carefully assess the signs and
workplace. Ensure that hallways and stairways symptoms. If you have any doubts about the
are well lit and stairways have handrails. seriousness of an injury, summon more advanced
medical personnel.
Always use a stepstool or a stepladder to
reach objects out of reach. Do not attempt Like injuries elsewhere on the body, injuries to
to pull heavy objects that are out of reach over the head, neck and spine often involve both soft
your head. tissues and bones. Control bleeding as necessary,
Use good lifting techniques when lifting and usually with direct pressure on the wound. With
carrying heavy objects. scalp injuries, however, be careful not to apply
Use nonslip treads or carpet on stairways, and pressure to a possible skull fracture. With eye
secure any area rugs with double-sided tape. injuries, remember not to apply pressure on the
Use nonslip mats in the bathtub, or install eyeball.
handrails.
If you suspect that the patient may have a serious
Know your risk for osteoporosis, a bone disease head, neck or spinal injury, minimize movement of
responsible for many spine, hip, wrist and the injured area when providing care. Minimizing
other fractures. Make sure you have enough movement is best accomplished by providing
calcium in your diet, and engage in weight- spinal motion restriction using manual stabilization
bearing exercises like walking or weight training (Skill Sheet 23-4). Apply a cervical collar and
to increase bone density and stimulate new secure the patient to a backboard or other
bone formation. extrication device if you must move the patient from
the scene to the ambulance, you are trained to do
PUTTING IT ALL TOGETHER so and local protocols allow.
In this chapter, you learned how to recognize and Many injuries are preventable if simple safety
care for serious head, neck and spinal injuries. precautions are followed. Know your risks and
To decide whether an injury is serious, you mitigate your danger of injury.
You Are the Emergency Medical Responder
As you assess the patient, you find that you cannot determine the status of the airway or
breathing because of the patient’s helmet. What injuries should you suspect? What can you
do to access and assess the airway?
542 | Emergency Medical Response
Skill Sheet
Skill Sheet 23-1
Controlling Bleeding from an
Open Head Wound
NOTE: Always follow standard precautions when providing care, and summon more advanced medical
personnel if necessary.
STEP 1
Apply direct pressure.
■■ Place a sterile dressing or clean cloth over
the wound and press gently against the
wound with your hand.
■■ Do not put direct pressure on the wound if
you feel a depression, spongy area or bone
fragments.
■■ Press gently on the area around the wound.
STEP 2
Elevate the body part.
■■ Elevate the head and shoulders unless you suspect an injury to the spine.
STEP 3
Apply a pressure bandage.
■■ Using a roller bandage, cover the dressing
completely, using overlapping turns.
■■ Tie or tape the bandage in place.
■■ If blood soaks through the bandage, leave
the original dressing in place but remove
and replace any additional dressings and
bandages over the wound.
▼ (Continued)
Chapter 23: Injuries to the Head, Neck and Spine | 543
Skill Sheet
Skill Sheet 23-1
Controlling Bleeding from an
Open Head Wound Continued
STEP 4
If bleeding stops:
■■ Determine if further care is needed.
STEP 5
If bleeding does not stop:
■■ Summon more advanced medical personnel.
544 | Emergency Medical Response
Skill Sheet
Skill Sheet 23-2
Caring for Foreign Bodies in the Eye
NOTE: Tell the patient not to rub the eyes. Never touch the eye and always follow standard precautions
when providing care.
STEP 1
Remove the foreign object from the eye.
■■ Tell the patient to blink several times.
■■ If the object is visible on the lower eyelid,
pull the eyelid down and try to remove the
object with the corner of a sterile gauze
pad.
NOTE: Be careful not to touch the eyeball.
STEP 2
Gently flush the eye with water or irrigation/
saline solution.
STEP 3
If the object is visible on the upper eyelid, gently
roll the upper eyelid back over a cotton swab and
attempt to remove the object with the corner of a
sterile gauze pad, being careful not to touch the
eyeball.
NOTE: If the object remains, the patient should
receive advanced medical care. Cover the injured
eye with an eye pad/shield.
Chapter 23: Injuries to the Head, Neck and Spine | 545
Skill Sheet
Skill Sheet 23-3
Bandaging an Eye with an Injury
from an Impaled Object
NOTE: Do not attempt to remove an object that is impaled in the eye. Keep the patient in a face-up
position and enlist someone to help stabilize the patient’s head. Always follow standard precautions
when providing care.
STEP 1
Stabilize the object by encircling the eye with a gauze dressing or soft sterile cloth.
■■ Do not apply any pressure to the area.
STEP 2
Position bulky dressings around the impaled object,
such as roller gauze, and then cover it with a shield
such as a paper cup.
■■ The shield should not touch the object.
NOTE: Do not use Styrofoam®-type materials, as
small particles can break off and get into the eye.
STEP 3
Bandage the shield and dressing in place with a
self-adhering bandage and roller bandage covering
the patient’s injured eye to keep the object stable
and minimize movement.
STEP 4
Comfort and reassure the patient.
NOTE: Do not leave the patient unattended.
546 | Emergency Medical Response
Skill Sheet
Skill Sheet 23-4
Spinal Motion Restriction Using
Manual Stabilization
NOTE: Call for more advanced medical personnel for a head, neck or spinal injury, while minimizing
movement of the head, neck and spine. Always follow standard precautions when providing care.
STEP 1
Minimize movement by placing your hands on both sides of the patient’s head.
STEP 2
Support the head in the position found.
NOTE: Do not align the head and neck with the spine if the head is sharply turned to one side,
there is pain on movement or if you feel any resistance when attempting to align the head and
neck with the spine. Instead, gently maintain the head and neck in the position found.
STEP 3
Maintain an open airway. Control any external bleeding and keep the patient from getting
chilled or overheated.
NOTE: Gently position the patient’s head in line with the body; if you cannot maintain an open
airway, you need to remove a helmet or you need to apply a C-collar.
Chapter 23: Injuries to the Head, Neck and Spine | 547
ENRICHMENT
Removing Helmets and Other Equipment
If you determine that it is necessary to remove a helmet from a patient to provide care, you must do so correctly to
avoid causing further harm to the patient.
Helmets fall into multiple categories including sports helmets and motorcycle helmets. Sports helmets
usually have an opening in front, which allows for easier access to the airway. You can usually remove the
face mask on a football helmet by cutting the plastic clips with pruning shears or using a screwdriver to
unscrew the clips. Avoid trying to unsnap or manipulate the clips as it may cause unnecessary movement of
the head and neck. It is more difficult to access the airway with a motorcycle helmet in place, as they usually
cover the full face and the airway.
The steps for a non-athletic helmet removal require two responders and are as follows:
1. If the patient is wearing glasses, remove them first before attempting helmet removal.
2. The first responder applies stabilization by holding both sides of the helmet, with fingers on the patient’s lower
jaw (Fig. 23-11, A). This will prevent the helmet from moving around if the strap is loose.
3. The second responder loosens the strap at the D-rings while the first responder maintains manual stabilization
(Fig. 23-11, B).
4. The second responder then places one hand on the patient’s mandible at an angle, with the thumb on one
side, and the long and index fingers on the other. With the other hand, the second responder holds the back
of the patient’s head (occipital region).
5. The first responder then removes the helmet halfway, making sure to clear the ears, while the second
responder readjusts hand position under the patient’s head. The first responder then removes the helmet the
rest of the way, making sure to tilt backward to avoid hitting the nose (Fig. 23-11, C).
6. The second responder maintains manual stabilization throughout, from below, preventing head tilt. After the
helmet has been removed, the first responder replaces the hands over the ears, taking over responsibility
for stabilization (Fig. 23-11, D).
7. The first responder maintains manual stabilization from above until a cervical collar can be applied
(Fig. 23-11, E).
For an emergency medical responder (EMR), the removal of athletic equipment, such as football helmets, is
usually more challenging than the removal of a motorcycle helmet. Unlike a motorcycle helmet, removal of a
football, hockey or lacrosse helmet alone without removal of the athlete’s shoulder pads increases the risk of
cervical movement and further spinal injury. If an athlete is suspected of having a spinal injury, the helmet should
only be removed when:
The face mask cannot be removed after a reasonable period of time to gain access to the airway.
The design of the helmet and chin strap, even in the absence of the face mask, does not allow for a controlled
airway or adequate ventilation.
The design of the helmet and chin straps do not hold the head securely in place (immobilization of the helmet
does not also immobilize the head).
The helmet prevents extrication of the patient for transport in an appropriate position.
The face mask should be removed after an athlete is suspected of having a spinal injury, even if the patient is
still conscious. A face mask is held in place using four loop-straps, two on the top and one on either side. Each
of these loop-straps must be removed by one EMR while a second responder minimizes neck movement and
maintains the neck in a neutral position (Fig. 23-12, A). The loop-straps can be removed using a variety of tools
such as a screwdriver, pruner shear and several other commercial devices designed specifically for this task
(Fig. 23-12, B). However, this is a skilled task, requiring practice. The two side loop-straps are removed first,
followed by the two top loop-straps (Fig. 23-12, C). Never use items such as razor blades, scalpels, or emergency
medical technician (EMT) or trauma shears to remove the loop-straps, as these items increase the risk of injury to
the athlete and the EMR and may delay removal of the face mask.
548 | Emergency Medical Response
ENRICHMENT
Removing Helmets and Other Equipment continued
A B
C D
E
Fig. 23-11, A–E: Remove a helmet only if it is impeding care or blocking access to the airway or if the patient is in cardiac arrest.
To remove a helmet and shoulder pads, one EMR must provide manual stabilization while a second EMR
cuts away the chin strap, shoulder pad straps and jersey. This is followed by removal of the internal cheek
pads (using a tongue depressor) and deflating the helmet’s air bladder system, if necessary (using a syringe or
air pump), while another trained responder stabilizes the chin and back of the neck. Two to four other trained
responders are placed at strategic locations along the body to support the shoulders, upper torso and other
locations based on the size of the athlete. The athlete is lifted and the helmet is slid off the head by rotating the
helmet in an anterior direction. Do not attempt to spread the helmet by the ear holes, as this will only tighten the
Continued on next page
Chapter 23: Injuries to the Head, Neck and Spine | 549
ENRICHMENT
ENRICHMENT
Removing Helmets and Other Equipment continued
A B
C
Fig. 23-12, A–C: To remove a face mask: (A) One EMR should minimize neck movement, maintaining a neutral position for the neck.
(B) A second EMR removes the loop-straps. (C) Once the loop-straps are removed, the face mask can be removed.
helmet on the head causing further spinal movement and possible injury. Once the helmet is off, the shoulder
pads are immediately removed by spreading apart the front panels and pulling them around the head. Remove
any clothing or equipment under the shoulder pads. Lower the athlete back to the ground.
Removal of protective equipment such as a football helmet and shoulder pads is a skilled technique, requiring
hours of practice. It often requires a minimum of five responders trained in this skill. If this type of situation is
encountered during an athletic event, look to the certified athletic trainer to assist in removal of the face mask,
helmet and shoulder pads, as the necessary tools will be included in athletic emergency kits. Prior planning
and interdisciplinary practice among the EMR, certified athletic trainer and emergency department personnel is
recommended prior to the beginning of the athletic season, particularly for football.
550 | Emergency Medical Response
ENRICHMENT
Cervical Collars and Backboarding
A cervical collar (also called a C-collar) is a rigid device positioned around the neck to limit movement of the
head and neck (Fig. 23-13). Once you have spinal motion restriction (SMR), a rigid C-collar should be applied
if local protocols and medical direction permit. This collar helps minimize movement of the head and neck
and keeps the head in line with the body. Applying a C-collar requires two responders. While one responder
maintains SMR, another carefully applies an appropriately sized C-collar. An appropriately sized collar is one
that fits securely, with the patient’s chin resting in the proper position and the head maintained in line with the
body (Fig. 23-14). Some C-collars come with specific manufacturer’s instructions for proper sizing. Do not
apply a C-collar in a circumstance in which you would not want to align the head with the body.
Once a C-collar has been applied and SMR is maintained, the patient’s entire body should be immobilized
for extrication (see Skill Sheet 23-5). This can be done using the following equipment:
A backboard
Head immobilizer
Straps
If you do not have a backboard or other extrication device available, support the patient in the position in
which the patient was found until more advanced medical personnel arrive. Once a C-collar is in place, the
patient is positioned on a backboard or other device, such as a scoop stretcher. This is done by “log rolling”
Fig. 23-13: Cervical collars (C-collars).
Fig. 23-14: A C-collar should fit securely, with the patient’s chin resting in the proper position.
Continued on next page
Chapter 23: Injuries to the Head, Neck and Spine | 551
ENRICHMENT
ENRICHMENT
Cervical Collars and Backboarding continued
the patient onto the board. This technique keeps the head in line with the body. It requires a minimum of
three responders: one to support the head and maintain SMR, and two others to position the backboard
and roll the patient’s body. However, it is highly preferable to have at least four responders available to perform
this technique. One responder can provide SMR and the others can log roll the patient and position the
backboard.
Once the patient is on the board, use several straps to secure the patient’s body to the backboard. There are
several ways to apply the straps used to secure the patient onto the board. A common way is to secure the chest
by crisscrossing the straps. Regardless of which method is used, the straps should be snug but not so tight as to
restrict movement of the chest during breathing. With the remaining straps, secure the patient’s hips, thighs and
legs. Secure the hands in front of the body.
Once the patient’s body is secured to the backboard, secure the patient’s head. If the patient’s head does
not appear to be resting in line with the body, you may need to place a small amount of padding, such as a
small folded towel, to support the head. Normally, approximately 1 inch of padding is all that is needed to keep
the head in line with the body and at the same time provide comfort for the patient. Next, use a commercially
made head-immobilization device. Many of these devices use Velcro® straps to secure the head. You should
follow the manufacturer’s instructions when using these devices. Based on local protocols, patients may be
removed from the backboard once they are placed on the ambulance stretcher. Remember that the purpose
of the backboard is for extricating the patient from the scene and moving them to the ambulance. It is not for
transportation to the hospital.
552 | Emergency Medical Response
Skill Sheet
Skill Sheet 23-5
Immobilizing a Head, Neck or Spinal Injury
NOTE: Call for more advanced medical personnel for a head, neck or spinal injury, while minimizing
movement of the head, neck and spine. Always follow standard precautions when providing care.
STEP 1
Apply spinal motion restriction.
■■ Place your hands on both sides of the patient’s head.
■■ Gently position the head in line with the body,
if necessary.
■■ Support the head in that position.
NOTE: Do not align the head and neck with the spine if the head is sharply turned to one side,
there is pain on movement or if you feel any resistance when attempting to align the head and
neck with the spine. Instead, gently maintain the head and neck in the position found.
STEP 2
Apply a cervical collar (C-collar).
■■ One responder maintains spinal motion restriction.
■■ A second responder applies appropriately
sized C-collar (correct size as determined by
manufacturer’s instructions).
STEP 3
Log roll the patient onto a backboard.
■■ One responder maintains spinal motion restriction of the head.
■■ Additional responders support patient’s shoulders, hips and legs.
■■ Roll the patient in unison, keeping the patient’s head and spine in alignment until the
patient is resting on their side.
■■ Position the backboard.
■■ Log roll the patient onto the backboard.
▼ (Continued)
Chapter 23: Injuries to the Head, Neck and Spine | 553
Skill Sheet
Skill Sheet 23-5
Immobilizing a Head, Neck or Spinal Injury Continued
STEP 4
Secure the patient’s body.
■■ Secure the patient’s chest.
■■ Secure the patient’s arms, hips, thighs and
legs with the remaining straps.
■■ If necessary, secure the patient’s hands in
front of the body.
STEP 5
Secure the patient’s head.
■■ Place padding beneath the head if it is
not resting in line with the body.
■■ If a commercial head immobilizer is not
available, place a folded or rolled blanket
around the head and neck.
■■ Secure the forehead.
554 | Emergency Medical Response
UNIT 7
Special Populations
24 Childbirth���������������������������������������������������������������������� 556
25 Pediatrics ���������������������������������������������������������������������579
26 Older Adults and Patients with Special
Healthcare or Functional Needs�������������������������� 599
24 You Are the Emergency
Medical Responder
You are the lifeguard at a local pool and
are working as the emergency medical
responder (EMR) at that facility for the day.
A young woman runs over to you and tells
you that she thinks her older sister is in
labor. How should you respond?
CHILDBIRTH
KEY TERMS
Abruptio placentae: Placental abruption; a life- Ectopic pregnancy: A pregnancy outside of the
threatening emergency that occurs when the uterus; most often occurs in the fallopian tubes.
placenta detaches from the uterus.
Embryo: The term used to describe the early stage of
Amniotic fluid: The fluid in the amniotic sac; bathes development in the uterus, from fertilization to the
and protects the fetus. beginning of the third month.
Amniotic sac: “Bag of waters”; sac that encloses Fetal monitoring: A variety of tests used to measure
the fetus during pregnancy and bursts during the fetal stress, either internally or externally.
birthing process.
Fetus: The term used to describe the stage of
APGAR score: A mnemonic that describes development in the uterus after the embryo stage,
five measures used to assess the newborn: beginning at the start of the third month.
Appearance, Pulse, Grimace, Activity and
Respiration. Hemorrhagic shock: Shock due to excessive
blood loss.
Birth canal: The passageway from the uterus to the
outside of the body through which a baby passes Implantation: The attachment of the fertilized egg to
during birth. the lining of the uterus, 6 or 7 days after conception.
Bloody show: Thick discharge from the vagina that Labor: The birth process, beginning with the
occurs during labor as the mucous plug (mucus contraction of the uterus and dilation of the cervix,
with pink or light red streaks) is expelled; often and ending with the stabilization and recovery of
signifies the onset of labor. the mother.
Braxton Hicks contractions: False labor; irregular Meconium aspiration: Aspiration of the first bowel
contractions of the uterus that do not intensify movement of the newborn; can be a sign of fetal stress
or become more frequent as genuine labor and can lead to meconium aspiration syndrome.
contractions do.
Miscarriage: A spontaneous end to pregnancy
Breech birth: The delivery of a baby’s feet or before the 20th week; usually because of birth
buttocks first. defects in the fetus or placenta; also called a
spontaneous abortion.
Bulb syringe: Small nasal syringe to remove
secretions from the newborn’s mouth and nose. Mucous plug: A collection of mucus that blocks the
opening into the cervix and is expelled, usually
Cervix: The lower, narrow part of the uterus (womb) toward the end of the pregnancy, when the cervix
that forms a canal that opens into the vagina, begins to dilate.
which leads to the outside of the body; upper part
of the birth canal. Multiple birth: Two or more births in the same
pregnancy.
Cesarean section: C-section; delivery of a baby
through an incision in the mother’s belly and uterus. Obstetric pack: A first aid kit containing items
especially helpful in emergency delivery and
Contraction: During labor, the rhythmic tightening initial care after birth; items can include personal
and relaxing of muscles of the uterus. protective equipment, towels, clamps, ties, sterile
scissors and bulb syringes.
Crowning: The phase during labor when the baby’s
head is visible at the opening of the vagina. Placenta: An organ attached to the uterus and
unborn baby through which nutrients are delivered;
Dilation: During the first stage of labor, refers to the expelled after the baby is delivered.
opening of the cervix to allow the baby to be born.
Placenta previa: Placental implantation that occurs
Dropping: “Engagement” or “lightening”; when the lower on the uterine wall, touching or covering the
baby drops into a lower position and is engaged cervix; can be dangerous if it is still covering part
in the mother’s pelvis; usually takes place a few of the cervix at the time of delivery.
weeks before labor begins.
Preeclampsia: A type of toxemia that occurs during
Eclampsia: A complication during pregnancy in pregnancy; a condition characterized by high
which the patient has convulsions or seizures blood pressure and excess protein in the urine
associated with high blood pressure. after the 20th week of pregnancy.
(Continued)
Chapter 24: Childbirth | 557
KEY TERMS continued
Premature birth: Birth that occurs before the end of Trimester: A three-month period; there are three
the 37th week of pregnancy. trimesters in a normal pregnancy.
Prolapsed cord: A complication of childbirth in Umbilical cord: A flexible structure that attaches the
which a loop of the umbilical cord protrudes placenta to the fetus, allowing for the passage of
through the vagina before delivery of the baby. blood, nutrients and waste.
Stabilization: The final stage of labor in which Uterus: A pear-shaped organ in a woman’s pelvis in
the mother begins to recover and stabilize after which an embryo forms and develops into a baby;
giving birth. also called the womb.
Stillbirth: Fetal death; death of a fetus at 20 or more Vagina: Tract leading from the uterus to the outside
weeks of gestation. of the body; often referred to during labor as the
birth canal.
Toxemia: An abnormal condition associated with the
presence of toxic substances in the blood.
LEARNING OBJECTIVES
After reading this chapter, and completing the class • Describe how to assess a newborn.
activities, you will have the information needed to: • Describe how to control bleeding after birth.
• Describe each trimester of pregnancy. • Describe how to care for the newborn and mother.
• Describe the four stages of labor. • List complications during pregnancy.
• Describe how to help the mother with labor and • Describe complications during delivery.
normal delivery.
INTRODUCTION By following a few simple steps, you can
effectively assist in the birth process. This chapter
Someday, you may be faced with a situation requiring will help you better understand the birthing
you to assist with childbirth. If you have never seen process, how to assist with the delivery of a
or experienced childbirth, your expectations probably baby, how to provide care for both the mother
consist of what others have told you. and newborn, how to recognize complications
Terms such as exhausting, stressful, exciting, and what complications could require more
fulfilling, painful and scary are sometimes used to advanced care.
describe a planned childbirth, one that occurs in
the hospital or at home under the supervision of a
healthcare provider. If you find yourself assisting ANATOMY AND PHYSIOLOGY
with the delivery of a baby, however, it is probably OF PREGNANCY
not happening in a planned situation. Therefore, your
feelings, as well as those of the expectant mother, The developing fetus is contained in the uterus
may be intensified by fear of the unexpected or the and surrounded by amniotic fluid. The uterus
possibility that something might go wrong. is made up of a special arrangement of smooth
muscle and blood vessels that allow it to enlarge
Take comfort in knowing that things rarely go significantly during pregnancy and to forcibly
wrong. Childbirth is a natural process. Thousands contract during labor and delivery. The ability
of children all over the world are born each day, of the uterus to produce strong contractions
without complications, in areas where no medical helps pass the baby from the uterus into the
assistance is available during childbirth. birth canal. Strong contractions also help
558 | Emergency Medical Response
the uterus constrict blood vessels, thus preventing NORMAL PREGNANCY
hemorrhage, and help the uterus return to its
The duration of a full-term pregnancy spans a
previous size.
9-month period, or 38 weeks from the time in
The cervix (or neck of the uterus) is the lower, which the embryo becomes implanted into the
narrow part of the uterus that forms a canal that woman’s uterus. The due date is usually calculated
opens into the vagina, which contains a mucous as 40 weeks from the woman’s last menstrual
plug up to the time of labor. The mucous plug period (Fig. 24-1). Pregnancy is broken down
seals the uterine opening and prevents any into 3 trimesters, each lasting approximately
contamination. Once labor begins and the cervix 3 months.
begins to dilate (widen), the mucous plug is
expelled. The fetus is pushed through the cervix First Trimester
and vagina.
Implantation and rapid development of the
The placenta, or “organ of pregnancy,” begins embryo occur during the first trimester of
to develop inside the uterus after the egg pregnancy. Usually implantation takes place
attaches itself to the uterine wall. It is rich in with no noticeable symptoms, although slight
blood vessels, and its purpose is to deliver bleeding may occur in some women. The gradual
oxygen and nourishment to the fetus from the appearance of morning sickness is common during
mother, and remove carbon dioxide and waste the first trimester. Morning sickness occurs in 70
products. percent of pregnant women and usually disappears
Placenta
Umbilical
cord
Fetus
Uterus
Cervix
Vagina
Fig. 24-1: Mother and fetus at 40 weeks.
CRITICAL The duration of a full-term pregnancy spans a 9-month period, or 38 weeks from
FACTS the time in which the embryo becomes implanted into the woman’s uterus. The due
date is usually calculated as 40 weeks from the woman’s last menstrual period.
Pregnancy is broken down into 3 trimesters, each lasting approximately 3 months.
Chapter 24: Childbirth | 559
by the second trimester. Also, the first trimester BIRTH AND LABOR PROCESS
is generally the time in which a miscarriage, also
Pregnancy culminates in the birth process, or
called a spontaneous abortion, might occur.
labor, during which the baby is delivered. Labor
As the embryo grows, its organs and body parts begins with rhythmic contractions of the uterus.
develop. After about 8 weeks, the embryo is called This may follow or be accompanied by rupture of
a fetus. To continue developing properly, the fetus the amniotic sac (the “water breaking”) and a
must receive nutrients, which it receives from gush of clear fluid. As contractions continue, they
the mother through the placenta. The placenta is dilate the cervix. When the cervix is sufficiently
attached to the fetus by a flexible structure called dilated, it allows the baby to travel from the uterus
the umbilical cord. through the birth canal and into the outside world.
For first-time mothers, this process normally takes
between 12 and 24 hours. Subsequent deliveries
Second Trimester usually require less time. The labor process has
Pregnant women commonly experience a feeling of four distinct stages. The length and intensity of
re-energization during the second trimester. This is each stage vary.
also when a woman will begin to “show,” putting
on more weight with the growth of the fetus. The
mother can now detect “quickening,” or movement First Stage: Dilation
of the fetus. The fetus has begun to produce insulin In the first stage of labor, the mother’s body
and is urinating, and the placenta is fully developed. prepares for the birth. This stage covers the time
Teeth are visible inside the gums, and it is now from the first contraction until the cervix is fully
possible to determine if the fetus is male or female. dilated. A contraction is a rhythmic tightening and
relaxing of the muscles in the uterus. Like a wave, it
begins gently, rises to a peak of intensity and then
Third Trimester
subsides. A break occurs between contractions,
The mother gains the most weight during the and a contraction usually lasts about 30 to
third trimester, when the fetus grows most rapidly. 60 seconds. Contractions cause dilation, the
An expanding abdomen sometimes causes the process that allows the mother’s cervix to expand
mother’s navel to become convex. Growth of enough for the baby to pass through during the
the baby can cause discomfort for the mother, birth (Fig. 24-2, A).
including weak bladder control and backache. The
size and movement of the baby may also cause During this stage of labor, the mucous plug may
pain or discomfort when pressure is applied to emerge. The release of the mucous plug, referred
the woman’s ribs and spine. The baby moves into to as the bloody show, may also have occurred
a head-down position in preparation for birth, prior to labor. Before or during labor the amniotic
which is known as dropping. Babies born during sac will break, releasing the amniotic fluid. When
the third trimester, but prior to full term, have a this happens, people often say the woman’s “water
good chance of surviving, due to ever-advancing has broken.” As the time for delivery approaches,
technology and improved intensive care practices. the contractions occur closer together, last longer
CRITICAL Implantation and rapid development of the embryo occur during the first trimester
FACTS of pregnancy.
Pregnant women commonly experience a feeling of re-energization during the
second trimester. This is also when a woman will begin to “show,” putting on more
weight with the growth of the fetus.
The mother gains the most weight during the third trimester, when the fetus grows most
rapidly. An expanding abdomen sometimes causes the mother’s navel to become convex.
Pregnancy culminates in the birth process, or labor, during which the baby is
delivered. Labor begins with rhythmic contractions of the uterus. This may follow or be
accompanied by rupture of the amniotic sac (“water breaking”) and a gush of clear fluid.
The labor process has four distinct stages. The length and intensity of each stage vary.
560 | Emergency Medical Response
and feel stronger. Normally, when contractions
are less than 3 minutes apart, delivery is near. The
woman may be in considerable discomfort at this
time. This stage is the longest, and may last for
18 hours or more, especially for a first delivery. For
a woman who has already gone through labor, this
stage may last only a few hours.
Second Stage: Expulsion
The second stage of labor begins when the cervix
is completely dilated, and includes the baby’s A
movement through the birth canal and delivery First Stage: Dilation
(Fig. 24-2, B). During this stage of labor, the
mother will experience enormous pressure, similar
to the feeling she has to have a bowel movement.
This sensation is an indication that it is time for
her to push or “bear down,” to help ease the baby
through the birth canal. Considerable blood may
come from the vagina at this time. Contractions
are more frequent during this stage, and may last
between 45 and 90 seconds each. In a normal
delivery, the baby’s head becomes visible as it
emerges from the vagina. When the top of the B
head begins to emerge, called crowning, birth is Second Stage: Expulsion
imminent and you must be prepared to receive the
baby (Fig. 24-3).
Third Stage: Placental Delivery
Once the baby’s body emerges, the third stage
of labor begins. During this stage, the placenta
usually separates from the wall of the uterus and
exits from the birth canal (Fig. 24-2, C). This
process normally occurs within 30 minutes of the
delivery of the baby. C
Third
Fig. 24-2, A–C: TheStage:
stagesPlacental Delivery
of labor include (A) dilation,
(B) expulsion and (C) placental delivery.
Fourth Stage: Stabilization
The final stage of labor involves the initial recovery
and stabilization of the mother after childbirth.
Normally, this stage lasts approximately 1 hour.
During this time, the uterus contracts to control
bleeding, and the mother begins to recover from
the physical and emotional stress that occurred
during childbirth.
Assessing Labor
If you are called to assist a pregnant woman, you
will need to determine whether she actually is in
labor. The woman may be experiencing Braxton
Hicks contractions, or false labor contractions.
During false labor, the contractions do not get
closer together, do not increase in how long
they last and do not feel stronger as time goes Fig. 24-3: When crowning begins, birth is imminent.
Chapter 24: Childbirth | 561
on—as they would with true labor. Also, false Calm the mother and make her feel confident you
labor contractions tend to be sporadic; true labor are there to keep her and the baby safe. Continue
has regular intervals of contractions and they are with the following questions:
accompanied by the water breaking. But because
there is no real, safe way to determine if the labor is Is there a chance of a multiple birth? Labor
false, transporting the woman to a medical facility does not usually last as long in a multiple birth
is a prudent decision. situation. Also, if you know it is a multiple birth,
you can prepare what you will need to help in
If the woman is in labor, you should determine how the delivery of more than one baby. Additional
far along she is in the pregnancy, including when information on multiple births is presented later
the baby is due, and whether she expects any in this chapter.
complications. You can determine these factors
by asking a few key questions and making some
Is this a first pregnancy? The first stage of labor
normally takes longer with first pregnancies than
quick observations. with subsequent ones, but not always.
To determine if the birth is imminent, ask the Is there a bloody discharge? A pink or light
woman her due date. Time the contractions red, thick discharge from the vagina is the
to determine how far apart they are. Take the mucous plug that falls from the cervix as it
following steps: begins to dilate, which also signals the onset of
labor. This discharge is also referred to as the
1. Feel the mother’s abdomen with a gloved hand bloody show.
for involuntary tightening and relaxing of the
uterine muscles (Fig. 24-4). Has the amniotic sac ruptured? When this
happens, fluid flows from the vagina in a sudden
2. Time the length of the movements in seconds gush or a trickle. Some women think they have
from the time the abdomen tightens to the time lost control of their bladder. The breaking of
it relaxes. the sac usually signals the beginning of labor.
3. Time the start of one contraction to the start of People often describe the rupture of the sac as
the next in minutes. “the water breaking.”
If the contractions are 5 minutes apart or longer, Does she have an urge to bear down? If the
the woman should be transported to a medical expectant mother expresses a strong urge to
facility if possible. If the contractions are 2 minutes push, labor is far along.
apart or less, you will not have time to transport the Is the baby crowning? If the baby’s head is
woman because the birth is imminent. visible, the baby is about to be born.
Fig. 24-4: To assess labor, feel the mother’s abdomen for tightening and relaxing of the uterine
muscles, known as contractions, and time how long they are and how far apart they are.
562 | Emergency Medical Response
PREPARING FOR DELIVERY to pain, anxiety or blood loss. Heart rate may be
increased, peripheral pulses may be weak or absent,
The realization that you are about to assist with skin may be cool and clammy, and shock is possible
childbirth can be as intimidating as it is exciting. where there has been excessive bleeding. The
Childbirth involves a discharge of watery, woman’s vital signs may show normal blood pressure;
sometimes bloody fluid and other body fluids or however, blood pressure will decrease in case of
substances, such as urine or feces, at stages one shock and increase in the case of preeclampsia. Your
and two of labor, in addition to what appears to be physical exam will include evaluating the contractions,
a rather large loss of blood after stage two. Fluid inspecting for crowning and preparing for delivery.
discharge sometimes creates splashes, and it is
important for the emergency medical responder If the woman is conscious and seems to be
(EMR) to follow standard precautions using experiencing normal symptoms of labor, find out
appropriate personal protective equipment (PPE) any other pertinent medical history.
(see Chapter 6). An obstetric pack is a first aid
kit containing items especially helpful in emergency Explain to the expectant mother that the baby
delivery and can include items such as PPE, towels, is about to be born. Be calm and reassuring. A
clamps, ties, sterile scissors and bulb syringes woman having her first child often feels fear and
(Fig. 24-5). Try not to be alarmed at the loss of apprehension about the pain and the condition of
blood. It is a normal part of the birth process. Only the baby. Labor pain ranges from discomfort similar
bleeding that cannot be controlled after the baby to menstrual cramps to intense pressure or pain.
is born is a problem. Take a deep breath and try to Many women experience something in between.
relax. Remember that you are only assisting in the Factors that can increase pain and discomfort
process; the expectant mother is doing all the work. during the first stage of labor include:
Irregular breathing.
Helping the Mother with Labor Tensing up because of fear.
and Delivery Not knowing what to expect.
As part of your primary assessment, check the Feeling alone and unsupported.
woman’s breathing and pulse. Check for a potentially
You can help the expectant mother cope with the
closed airway. Breathing rate may be increased due
discomfort and pain of labor. By staying calm, firm
and confident, and offering encouragement, you can
help reduce her fear and apprehension. Reducing
fear will aid in reducing her pain and discomfort.
Begin by reassuring her that you are there to
help. Explain what to expect as labor progresses.
Suggest specific physical activities that she can do
to relax, such as regulating her breathing. Ask her
to breathe slowly and deeply, in through the nose
and out through the mouth. Ask her to focus on one
object in the room while regulating her breathing.
Breathing slowly and deeply in through the nose
and out through the mouth during labor can help
the expectant mother in several ways because it:
Aids muscle relaxation.
Offers a distraction from the pain of strong
contractions as labor progresses.
Ensures adequate oxygen delivery to both the
Fig. 24-5: Obstetric pack. mother and the baby during labor.
CRITICAL If you find yourself helping the mother with labor and delivery, check the woman’s
FACTS breathing and pulse as part of your primary assessment. Check for a potentially
closed airway. Breathing rate may be increased due to pain, anxiety or blood loss.
Chapter 24: Childbirth | 563
Taking childbirth classes, usually offered at local
hospitals, may help you become more competent in
techniques to help an expectant mother relax.
Expect delivery to be imminent when you observe
the following signs and symptoms:
Intense contractions are 2 minutes apart or less
and last 60 to 90 seconds.
The woman’s abdomen is very tight and hard.
The mother reports feeling the infant’s head
moving down the birth canal or has a sensation
like an urge to defecate.
Crowning occurs (the infant’s head appears at
the opening of the birth canal).
The mother reports a strong urge to push.
Fig. 24-6: To assist with delivery, begin by positioning the
If these signs and symptoms are present, contact mother on her back, with her head and upper back raised, in a
medical direction for assistance. The decision will need clean environment.
to be made whether to deliver on-site. If an on-site
delivery does not occur within 10 minutes, you will Other items that can be helpful include
need medical direction’s decision to transport. supplemental oxygen, a bulb syringe to suction
secretions from the infant’s mouth and nose, gauze
pads or sanitary pads to help absorb secretions
DELIVERY and vaginal bleeding, and a large plastic bag or
Assisting with the delivery is often a simple towel to hold the placenta after delivery.
process. The expectant mother does all the work;
Continually check the mother for indications the
your job is to create a clean environment and to
baby is crowning. You may actually see the head
help guide the baby from the birth canal, minimizing
of the baby appear, or the vagina may be bulging.
injury to the mother and baby. Begin by positioning
Once crowning takes place, take the following
the mother. She should be lying on her back, with
steps to assist with delivery:
her head and upper back raised, not lying flat. Her
legs should be bent, with the knees drawn up and As crowning occurs, place a hand on the top
apart (Fig. 24-6). Position the mother in a way that of the baby’s head and apply light pressure. By
will make her more comfortable. doing so, you allow the head to emerge slowly, not
forcefully. Gradual emergence will help prevent
Establish a clean environment for delivery. Because
tearing of the vagina and injury to the baby.
it is unlikely that you will have sterile supplies, use
items such as clean sheets, blankets, towels or At this point, the expectant mother should stop
clothes. To make the area around the mother as pushing. Instruct the mother to concentrate on
sanitary as possible, place these items over the her breathing techniques. Have her pant. This
mother’s abdomen and under her buttocks and technique will help her stop pushing and help
legs. Keep a clean, warm towel or blanket handy to prevent a forceful birth.
wrap the newborn. Because you will be coming in You may have to puncture the amniotic sac with
contact with the mother’s and baby’s body fluids, your fingers if the water has not yet broken.
be sure to wear disposable latex-free gloves. Wear As the head emerges, the baby will turn to one side,
protective eyewear and a disposable gown, if they which enables the shoulders and the rest of the
are available, to protect yourself from splashing. body to pass through the birth canal (Fig. 24-7).
CRITICAL Assisting with the delivery is often a simple process. The expectant mother does all
FACTS the work; your job is to create a clean environment and to help guide the baby from
the birth canal, minimizing injury to the mother and baby.
564 | Emergency Medical Response
Fig. 24-7: Support the head as it emerges and the baby turns, which allows the shoulders
and rest of the body to pass through the birth canal.
Check to see if the umbilical cord is looped CARING FOR THE NEWBORN
around the baby’s neck. If it is, gently slip it
over the baby’s head. If you cannot slip it over
AND MOTHER
the head, slip it over the baby’s shoulders An obstetric pack contains items useful for help in
as they emerge. The baby can slide through caring for the newborn after delivery.
the loop.
Guide one shoulder out at a time. Do not pull Caring for the Newborn
the baby. Cutting the Umbilical Cord
As the baby emerges, the baby will be wet and The umbilical cord will stop pulsating not long after
slippery. Use a clean towel to receive/hold the the baby is born. When it does, clamp or tie the cord
baby. very securely with gauze in two places between
Place the baby on its side, between the mother the mother and child. The clamp closest to the
and you. By doing so, you can provide initial newborn should be about 6 inches from the baby.
care without fear of dropping the newborn. There should only be about 3 inches between the
If possible, note the time the baby was born. two clamps (Fig. 24-8). Follow local protocols and
medical direction for guidance on cutting the cord.
3”
6”
Fig. 24-8: Clamping the umbilical cord.
Chapter 24: Childbirth | 565
Assessing the Newborn Tally the five scores for a total score out of 10. Here
The APGAR scoring system is the universally are the guidelines for interpreting that score:
accepted method of assessing a newborn
at 1 minute and again at 5 minutes after
7 to 10 points: Active and vigorous newborn;
ready for routine care.
birth. However, if the baby is in distress and
needs lifesaving care, the APGAR score is not 4 to 6 points: Moderately depressed; provide
stimulation and oxygen based on local protocols.
a priority.
1 to 3 points: Severely depressed; provide
APGAR stands for Appearance, Pulse, Grimace, extensive care including administering
Activity and Respiration (Table 24-1). The baby is supplemental oxygen based on local protocols
assigned a number from 0 to 2 for each part of the with bag-valve-mask ventilations and CPR. Also,
assessment, for a total possible score of 10. stimulate the baby to encourage breathing by
tapping the soles of the feet or rubbing the back.
Table 24-1:
APGAR Scoring System
APGAR SCORE
Appearance
Cyanotic (blue) skin appearance all over 0
Cyanotic limbs but pink body 1
Pink body all over 2
Pulse (Count the heart rate for 30 seconds. If possible, use a stethoscope. If not, measure the pulse where
the umbilical cord meets the abdomen or at the brachial artery.)
No pulse 0
Pulse rate less than 100 beats per minute 1
Pulse rate more than 100 beats per minute 2
Grimace (reflex irritability) (Gently tap the soles of the newborn’s feet, or observe during suctioning.)
No activity or reflex 0
Some facial grimace 1
Grimace and cough, sneeze or cry 2
Activity (Observe movement/reflexes of the extremities or the degree of flexion of the extremities and the
resistance to straightening them.)
Limp, with no movement of extremities 0
Some flexion, without active movement 1
Actively moving around 2
Respiration (Observe for regular breathing and a vigorous cry. Poor signs include irregular, shallow, gasping
or absent respirations.)
No respiratory effort 0
Slow or irregular breathing effort with weak cry 1
Good respirations and strong cry 2
566 | Emergency Medical Response
Routine Care airway is clear. If the newborn does not breathe,
When handling a newborn, always be sure to you must begin giving ventilations.
support the newborn’s head. Newborns lose heat Most newborns begin crying and breathing
quickly; therefore, it is important to keep them warm spontaneously. If the newborn has not made any
and dry. Dry the newborn, particularly the head, and sounds, stimulate a cry reflex by tapping your
wrap the baby in a clean, warm towel or blanket. fingers on the soles of the feet.
Place the dried and wrapped newborn on their
side, with the head slightly lower than the trunk.
Resuscitation of the Newborn
It is vital you ensure that you clear the nasal Resuscitation of a newborn begins immediately if
passages and mouth thoroughly. You can do this any of these conditions exist:
by using your finger, a gauze pad or a bulb syringe
(Fig. 24-9). Squeeze a bulb syringe before insertion Respirations fall to less than 30 respirations
in the mouth and nose. Clear or suction the mouth per minute or the newborn is gasping or not
before the nose. Repeat this until you are sure the breathing normally.
Pulse is less than 100 beats per minute.
Cyanosis (bluish skin) around the chest
and abdomen persists after administering
supplemental oxygen.
If the newborn’s respirations are low (less than 30
breaths per minute) and/or the pulse rate is below
100 beats per minute, provide positive-pressure
ventilations.
If the newborn’s respirations are less than
30 breaths per minute or the newborn is
unresponsive:
Tap the bottom of the foot to stimulate a reflex
(Fig. 24-10, A).
Rub the lower back, firmly but gently
(Fig. 24-10, B).
Clear the airway again, with a bulb syringe.
Administer high-concentration oxygen based on
local protocols (Fig. 24-11).
Remember that a newborn’s lungs are very small
and they need very small puffs of air. You may
use a mask only if you have the appropriate size
for a newborn. If the newborn’s pulse drops to
less than 60 beats per minute or does not rise to
more than 60 beats per minute during ventilation
Fig. 24-9: A bulb syringe can be used to clear the newborn’s and the newborn shows signs of poor perfusion,
mouth and nasal passages. begin CPR.
CRITICAL The APGAR (appearance, pulse, grimace, activity and respiration) scoring system
FACTS is the universally accepted method of assessing a newborn at 1 minute and again at
5 minutes after birth. However, if the baby is in distress and needs lifesaving care,
the APGAR score is not a priority. The baby is assigned a number from 0 to 2 for
each part of the assessment, for a total possible score of 10.
When handling a newborn, always be sure to support the newborn’s head.
Newborns lose heat quickly; therefore, it is important to keep them warm and dry.
Chapter 24: Childbirth | 567
CRITICAL Resuscitation of a newborn begins immediately if respirations fall to less than 30
FACTS respirations per minute or the newborn is gasping or not breathing normally, if pulse
is less than 100 beats per minute or if cyanosis (bluish skin) around the chest and
abdomen persists after administering supplemental oxygen.
Fig. 24-11: Administering high-concentration oxygen to a
newborn.
Controlling Bleeding After Birth
B Expect some additional vaginal bleeding when the
Fig. 24-10, A–B: You may need to stimulate the newborn to
placenta is expelled. Using gauze pads or clean
breathe by (A) tapping the bottom of the foot or (B) rubbing the towels, gently clean the mother. Place a sanitary
lower back. pad or towel over the vagina; do not insert anything
into the vagina. Instruct the mother to place her
legs together.
Caring for the Mother
Delivery of the Placenta Feel her abdomen for the uterus, which will feel
like a grapefruit-sized mass in the lower sector.
Following delivery of the newborn, the placenta
Massage the uterus to help expel large blood
will still be in the uterus, attached to the baby by
clots and to help the uterus contract. This should
the umbilical cord. Uterine contractions usually
slow the bleeding. Watch for signs of shock from
expel the placenta within 10 minutes of delivery
uncontrolled bleeding. If signs and symptoms of
and almost always within 30 minutes. The mother
shock appear, care for the mother accordingly.
may experience strong contractions, similar to
childbirth, and you may have to tell her to bear
down in order for the placenta to be expelled. Providing Care
When the placenta appears, slowly guide it out of After delivery, be sure to continue caring for the
the vagina (do not pull) and place it in a clean towel mother, both emotionally and physically. Keep her
or container. calm and comfortable, and continue to monitor
568 | Emergency Medical Response
her vitals until more advanced medical care takes miscarriages occur during the first 12 weeks of
over. If available, offer her a cloth to dry her face, as pregnancy. During miscarriage, the woman will
well as a clean blanket if she is cold. Remove any experience vaginal spotting, bleeding and discharge,
bloody sheets, blankets and other supplies used as well as cramping. Miscarriage later in pregnancy
for delivery from the immediate area. is accompanied by severe cramping, resulting in the
expulsion of the fetus. The blood lost in these cases
Caring for the Mother’s Emotions with often contains mucus or clots.
Stillborn/Aborted Fetuses
Stillbirth, or fetal death, is the term for the death Ectopic Pregnancy
of a fetus prior to delivery but at 20 or more weeks In a normal pregnancy, the fertilized egg attaches
of gestation. The term miscarriage usually refers itself to the lining of the uterus. With an ectopic
to a pregnancy lost prior to 20 weeks of gestation. pregnancy, the fertilized egg most commonly
Whether the loss occurs early in the pregnancy implants in one of the fallopian tubes, which carry
or at 40 weeks of pregnancy or beyond, it can be eggs from the ovaries to the uterus. This type of
devastating. ectopic pregnancy is known as a tubal pregnancy.
Less commonly, an ectopic pregnancy occurs in
The mother should have time to grieve. The bond
the abdomen, ovary or cervix.
a parent makes with the unborn fetus begins
early on in the pregnancy, so it is normal to The fertilized egg of an ectopic pregnancy
experience a powerful sense of loss when their cannot survive, and the growing tissue may
baby dies. Sensitivity on the part of the EMR is of destroy various maternal structures. Therefore, if
utmost importance. It may be helpful to suggest a left untreated, life-threatening blood loss is possible.
referral to a counselor or clergy member who has Early treatment of an ectopic pregnancy, in the form
experience dealing with this kind of loss. Some of termination, is necessary to preserve the chance
people find it helpful to join a support group of for healthy pregnancies in the future.
parents who have had a similar experience where
they can share their feelings with others who Symptoms of an ectopic pregnancy include:
understand what it is like. Encourage them to seek
out a bereavement group in their area. Light vaginal bleeding (can be life threatening as
it can lead to severe bleeding).
Lower abdominal pain.
COMPLICATIONS DURING Cramping on one side of the pelvis.
PREGNANCY
In the case of the fallopian tube rupturing,
Complications during pregnancy are rare.
symptoms include:
Spontaneous Abortion Sharp, stabbing pain in the pelvis, abdomen or
even the shoulder and neck.
A miscarriage, or spontaneous abortion, is the
loss of a fetus due to natural causes before about Dizziness.
20 weeks of pregnancy. About 85 percent of Light-headedness.
CRITICAL Following delivery of the newborn, the placenta will still be in the uterus, attached
FACTS to the baby by the umbilical cord. Uterine contractions usually expel the placenta
within 10 minutes of delivery and almost always within 30 minutes.
Expect some additional vaginal bleeding when the placenta is expelled.
After delivery, be sure to continue caring for the mother, both emotionally and
physically. Keep her calm and comfortable, and continue to monitor her vitals until
more advanced medical care takes over.
Complications during pregnancy are rare.
A miscarriage, or spontaneous abortion, is the loss of a fetus due to natural causes
before about 20 weeks of pregnancy.
Chapter 24: Childbirth | 569
Preeclampsia (Toxemia) discharge tinged with blood may appear. This
and Eclampsia “bloody show” is normal when it occurs near the
end of pregnancy and indicates delivery may occur
Preeclampsia, or toxemia, is a common problem
in a week or two.
during pregnancy and is sometimes referred to as
pregnancy-induced hypertension. If left untreated, Since the nature and extent of most complications
eclampsia, the final and most severe phase of related to pregnancy can only be determined
preeclampsia, occurs. Eclampsia can cause coma by a medical professional through examination,
and even death of the mother and baby, and can you should not be concerned with trying to
occur before, during or after childbirth. diagnose a particular problem. Instead, concern
yourself with recognizing signs and symptoms
The only cure for preeclampsia is delivery of
that suggest a serious complication; two such
the baby and, when it occurs near the end
symptoms are vaginal bleeding and abdominal
of pregnancy, delivery is advised. Signs and
pain. Any persistent or profuse vaginal bleeding,
symptoms of preeclampsia include:
or bleeding in which tissue passes through the
High blood pressure. vagina during pregnancy, is abnormal, as is any
abdominal pain.
Excess protein in the urine after 20 weeks
of pregnancy. When bleeding is accompanied by the following
Severe headaches. symptoms, immediate attention is required:
Changes in vision, such as temporary loss of
vision, blurred vision or light sensitivity. Pain
Upper abdominal pain, usually under the ribs on Cramping
the right side. Fever
Nausea or vomiting. Chills
Dizziness. Contractions
Decreased urine output. Passing tissue from the vagina
Sudden weight gain, more than 2 pounds An expectant mother exhibiting these signs and
per week. symptoms needs to receive more advanced
Swelling (edema), particularly in the face medical care quickly. While waiting for an
and hands. ambulance or other transport vehicle, take steps to
Seizures, if eclampsia develops. minimize shock. These include:
Vaginal Bleeding in Pregnancy Helping the woman into the most comfortable
position.
Vaginal bleeding during the first trimester does
not typically require treatment. Spotting, or light, Controlling bleeding.
irregular discharges of a small amount of blood, may Keeping the woman from getting chilled or
be normal. More bleeding may indicate a problem overheated.
that needs a healthcare provider’s attention. Administering supplemental oxygen based on
local protocols.
When the thick plug of mucus that seals the
opening of the cervix is dislodged, a thick or stringy
CRITICAL With an ectopic pregnancy, the fertilized egg most commonly implants in one of the
FACTS fallopian tubes.
Preeclampsia, or toxemia, is a common problem during pregnancy and is sometimes
referred to as pregnancy-induced hypertension. If left untreated, eclampsia, the final
and most severe phase of preeclampsia, occurs.
Vaginal bleeding during the first trimester does not typically require treatment.
Spotting, or light, irregular discharges of a small amount of blood, may be normal.
570 | Emergency Medical Response
Trauma During Pregnancy Hemorrhage
Trauma during pregnancy can be caused by motor- The most common complication of childbirth is
vehicle collisions, falls, assaults or penetrating persistent vaginal bleeding, known as postpartum
injuries. When the placenta peels away from the hemorrhage. It is defined as the loss of more
inner wall of the uterus before delivery, it is called than 1 pint of blood following delivery of the
abruptio placentae. This occurs in 1 to 5 percent of placenta. It can occur right after delivery or as
patients with minor trauma and 20 to 50 percent of late as 1 month later. Hemorrhage can occur
patients with major trauma. Hemorrhage can occur when the uterus fails to contract after delivery,
from disruption of the placenta and spontaneous as this contraction facilitates the closing of blood
or traumatic uterine rupture. Pregnant women who vessels that were opened during detachment
have suffered an injury should be evaluated in the of the placenta. It can also occur if the uterus
emergency department. was stretched too much during pregnancy or
if a piece of placenta remains inside the uterus
If the patient appears to be in shock, remember following delivery. It occurs more commonly
that the treatment of shock in a pregnant patient following the birth of multiples, a prolonged or
differs from the treatment of shock in other adults abnormal labor, or when a woman has been
in two important respects. First, the organ systems pregnant several times. Women who have bled
change during pregnancy. Second, two patients excessively following labor in the past are at
are vulnerable: the mother and the fetus. Therefore, increased risk of reoccurrence.
obstetric critical care involves simultaneous
assessment and management of both the mother In the case of hemorrhage, summon more
and fetus. advanced medical care and take steps to minimize
shock. Massaging the lower abdomen and
The management of hemorrhagic shock encouraging breastfeeding can also help stimulate
requires immediate administration of supplemental the uterus to contract.
oxygen based on local protocols. Fetal
monitoring should be performed to detect fetal Other childbirth complications include a
distress or fetal hypoxia. prolapsed cord, breech birth, limb presentation,
multiple births, premature birth and meconium
Pregnant patients in the third trimester should aspiration.
be placed on their left side to avoid compression
of the inferior vena cava. If a spinal injury is
suspected, the backboard or other extrication Prolapsed Umbilical Cord
device should be tilted to the left after the patient is A prolapsed cord occurs when a loop of the
fully secured. umbilical cord protrudes from the vaginal opening
while the baby is still in the birth canal (Fig. 24-12).
This can threaten the baby’s life, because as the
COMPLICATIONS DURING baby moves through the birth canal, the cord will be
DELIVERY compressed against the unborn child and the birth
canal, cutting off blood flow. Without this blood
The vast majority of all births occur without flow, the baby will die within a few minutes from
complication, but this is only reassuring if the one lack of oxygen.
you are assisting with is not complicated. For the
few births that do have complications, delivery If you notice a prolapsed cord, have the expectant
can be stressful and even life threatening for the mother assume a knee-chest position as shown
expectant mother and the baby. All require the help in Fig. 24-13. This will help take the pressure off
of more advanced medical personnel. the cord. Cover any exposed cord with a moist,
CRITICAL The vast majority of all births occur without complication. The few births with
FACTS complications require the help of more advanced medical personnel.
The most common complication of childbirth is persistent vaginal bleeding, known
as postpartum hemorrhage.
Chapter 24: Childbirth | 571
attempt to push a protruding foot back up into
the birth canal. If a single limb is presenting, you
cannot successfully deliver the infant, and the
mother must be transported to a hospital as quickly
as possible. Call for more advanced medical
personnel if they have not already been contacted.
Place the mother in a head-down, hips-elevated
position, and cover the presenting limb with a
sterile towel. Do not attempt to push or pull on the
protruding limb.
Because the weight of the unborn baby’s head
lodged in the birth canal will reduce or stop blood
Fig. 24-12: A prolapsed cord can threaten the baby’s life. flow by compressing the umbilical cord, the unborn
baby will be unable to get any oxygen. Should the
unborn baby try to take a spontaneous breath, they
will also be unable to breathe because the face
is pressed against the wall of the birth canal. As
a result, if the head has not been delivered after
3 minutes, you will need to help create an airway
for the baby to breathe.
To help the baby breathe, place the index and
middle fingers of your gloved hand into the
vagina next to the baby’s mouth and nose.
Spread your fingers to form a V (Fig. 24-14).
Though this will not lessen the compression
Fig. 24-13: If you notice a prolapsed cord or there is a limb
presentation, place the mother in a knee-chest position. on the umbilical cord, it may allow air to enter
the baby’s mouth and nose. You must maintain
this position until the baby’s head is delivered.
sterile dressing. Never attempt to push the cord Administer supplemental oxygen to the mother
back into the vagina. Administer supplemental based on local protocols. Summon more
oxygen to the mother based on local protocols. advanced medical personnel, if they have not
Summon more advanced medical personnel, if they already been contacted. Should the unborn
have not already been contacted. baby’s head be delivered, check the infant for
breathing. Be prepared to provide ventilations
and perform CPR as necessary.
Breech Birth
Most babies are born headfirst. However, on
rare occasions, the newborn is delivered feet- Limb Presentation
or buttocks-first. This condition is commonly If the baby is delivered in an incomplete breech, or
called a breech birth. If you encounter a breech transverse lie (horizontal) position, the baby’s foot
delivery, support the newborn’s body as it leaves (or feet), arm or shoulder will appear first. This is
the birth canal while you are waiting for the head known as a limb presentation (Fig. 24-15). If you
to deliver. Do not pull on the newborn’s body. encounter this, do not attempt to deliver the baby
Pulling will not help deliver the head. Do not in the field. The mother should be transported to a
CRITICAL A prolapsed cord occurs when a loop of the umbilical cord protrudes from the
FACTS vaginal opening while the baby is still in the birth canal. It is life threatening to
the baby.
Most babies are born headfirst but, on rare occasions, the baby is delivered feet- or
buttocks-first. This is called a breech birth. In breech situations, support the body
until the head delivers. Do not pull on the body.
572 | Emergency Medical Response
Fig. 24-14: During a breech birth, position your index and middle fingers to allow air to enter the
baby’s mouth and nose.
medical facility. Never pull on the limb. Avoid even
touching the limb, as this can stimulate the baby to
try to take a breath, which can result in aspirating
amniotic fluid.
A cesarean section will be needed to deliver
the baby safely. Summon more advanced
medical personnel, if they have not already
been contacted. Administer supplemental
oxygen to the mother based on local protocols.
Place her in a knee-chest position with her
pelvis elevated. If she feels the need to push
with contractions, have her pant, which can
help ease the urge.
Multiple Births
Although most births involve only a single baby,
a few will involve delivery of more than one. If the
mother has had proper prenatal care, she will
probably be aware that she is going to have more
than one baby. Multiple births should be handled
in the same manner as single births. The mother
will have a separate set of contractions for each
child being born. There may also be a separate
placenta for each child, though this is not always
the case. Keep in mind that the risk of hemorrhage
following delivery is higher after giving birth to
Fig. 24-15: Limb presentation. multiples.
Chapter 24: Childbirth | 573
Premature Birth meconium will be greenish or brownish yellow
instead of clear. The presence of meconium-
When a baby is born before the end of 37 weeks
stained amniotic fluid is an indication that the
of pregnancy, it is called a premature birth.
baby experienced a period of oxygen deprivation
Premature babies require special care because
(hypoxia), which causes the baby to have a
they are not fully developed. They are at increased
bowel movement. The primary danger is that
risk for such complications as lung and breathing
the baby will aspirate the contaminated fluid,
problems, infections and digestive difficulties. They
which can result in complications including a
are also more vulnerable to hypothermia.
blocked airway or respiratory distress, pneumonia
Premature infants can typically be identified by and infection.
their small, thin appearance and red, wrinkled skin.
If you observe meconium staining in the amniotic
They also typically have a single crease along the
fluid, it is important that you clear the mouth
sole of the foot; fuzzy, fine scalp hair; and ears that
and nose before the baby takes the first breath.
are not fully developed.
Suction the baby’s mouth and nose with a bulb
After the delivery of a premature baby, dry the syringe as soon as the baby emerges from the
infant thoroughly and wrap the baby in blankets, birth canal. Avoid stimulating the baby in any
preferably warmed, or in a plastic bubble-bag way before clearing the mouth and nose, as this
swaddle. Cover the head, leaving the face clear can induce the baby to try to take a breath. Do
so the baby can breathe. Keep the baby in a warm not squeeze the baby’s chest or put your finger
place. Use a bulb syringe to gently suction away in the baby’s mouth to try to prevent meconium
fluid from the baby’s mouth and nose. Tie off the aspiration.
umbilical cord immediately, as a premature infant
Administer supplemental oxygen to the baby
cannot tolerate even the smallest loss of blood.
based on local protocols. Summon more
Administer supplemental oxygen by blowing
advanced medical personnel if they have not
oxygen across (not directly into) the baby’s face
already been contacted. Keep the baby as warm
based on local protocols. Reduce the risk of
and calm as possible and maintain the airway,
infection by minimizing the number of people who
if needed.
handle the child. Do not let anyone breathe into
the baby’s face.
PUTTING IT ALL TOGETHER
Meconium Aspiration Ideally, childbirth should occur in a controlled
Meconium is the baby’s first bowel movement. environment under the guidance of healthcare
Amniotic fluid that is contaminated with professionals trained in delivery. In a controlled
CRITICAL If the baby is delivered in an incomplete breech, or transverse lie (horizontal)
FACTS position, the baby’s foot (or feet), arm or shoulder will appear first. This is known as
a limb presentation. The mother must be transported to a medical facility. Never pull
the limb. Avoid touching it.
Multiple births should be handled in the same manner as single births. The mother
will have a separate set of contractions for each child being born.
When a baby is born before the end of 37 weeks of pregnancy, it is called a
premature birth. Premature babies require special care because they are not
fully developed.
Meconium is the baby’s first bowel movement. Amniotic fluid that is contaminated
with meconium will be greenish or brownish yellow instead of clear. If this
contaminated fluid is aspirated, it can cause a blocked airway, respiratory distress,
pneumonia and infection.
574 | Emergency Medical Response
environment, the necessary medical care is four stages of labor and knowing how to prepare
immediately available for mother and baby, should the expectant mother for delivery, assist in the
any problem arise. However, unexpected deliveries delivery and provide proper care for the mother
do occur outside of the controlled environment and and baby, you will be able to successfully assist in
may require your assistance. By understanding the bringing a new child into the world.
You Are the Emergency Medical Responder
While approaching the young woman who is in labor, her sister tells you that the patient is
26 years old. The pregnant woman is yelling, “The baby is coming!” She tells you that this will
be her fourth child. What should you do?
Chapter 24: Childbirth | 575
ENRICHMENT
More Complications During Pregnancy
and Delivery
Placenta Previa
In most pregnancies, the placenta implants itself on the upper
part of the uterine wall to establish its rich blood supply. In about
one out of every 200 to 250 pregnancies, the placenta implants
lower on the uterine wall, touching or covering the cervix,
resulting in placenta previa (Fig. 24-16). The condition can be:
Marginal: The placenta touches the edge of the cervix.
Partial: The placenta covers part of the cervix.
Total or complete: The placenta covers the cervix completely.
The danger occurs if the placenta pulls away from the uterine
wall, causing bleeding of oxygen-rich blood. Causes of the
placenta tearing away include:
Labor.
Dilation of the cervix.
Fetal movement.
The initial and only symptom of placenta previa is painless vaginal
bleeding. To provide care, arrange for immediate transport.
Elevate the patient’s legs and maintain body temperature.
Fig. 24-16: Placenta previa.
Abruptio Placentae
Abruptio placentae is a life-threatening emergency for both
mother and child in which the placenta prematurely detaches
from the uterus either partially or completely (Fig. 24-17). It
occurs in about one out of every 120 to 150 pregnancies and
can occur at any time after 20 weeks gestation. The chance of its
occurrence rises if it occurred in a previous pregnancy. Abruptio
placentae can occur spontaneously or as a result of hypertension
or maternal injury (trauma).
Symptoms of abruptio placentae, also called placental
abruption, are:
Abdominal pain.
Back pain.
Rapid uterine contractions.
Uterine tenderness.
Vaginal bleeding.
Bleeding may not be apparent at first, as blood accumulates
between the placenta and uterine wall. Therefore, the first signs
of abruptio placentae may be pain, abdominal rigidity and shock.
To provide care, arrange for immediate transport. Monitor vital
signs and treat for shock if necessary. Fig. 24-17: Abruptio placentae.
576 | Emergency Medical Response
ENRICHMENT
More Complications During Pregnancy
and Delivery continued
Ruptured Uterus
Rupture of the uterus is rare, but its occurrence is associated
with a high incidence of infant fatality, reportedly as high as
65 percent. Maternal mortality associated with a ruptured
uterus is significantly lower, but it can occur if significant time
passes between the event and medical intervention.
The uterine wall, which thins during pregnancy, can rupture
spontaneously or as the result of an abdominal trauma
(Fig. 24-18). Women who have had prior caesarian sections
are at a higher risk of experiencing a ruptured uterus than
women with first-time pregnancies or those who have delivered
vaginally previously. Advanced maternal age is also a risk factor.
Signs and symptoms of a ruptured uterus are:
Abdominal pain.
Abnormal fetal heart pattern.
Cessation of contractions.
Deceleration of fetal heartbeat.
Failure of labor to progress.
Hyperstimulation of the uterus (excessive contractions).
Signs of shock. Fig. 24-18: Ruptured uterus.
Vaginal bleeding.
Once a uterine rupture is suspected, arrange for immediate transport. Stabilization of the mother and
delivery of the fetus is imperative. The time available for intervention is only 18 minutes before the baby
experiences significant hypoxia, and only 30 minutes until the baby suffers major neurological impairment.
Shoulder Dystocia
Shoulder dystocia occurs when the fetus’s shoulders are larger in width than the head. When the mother
begins to deliver the baby, the head will emerge from the vagina, but a shoulder or both shoulders becomes
caught between the maternal symphysis pubis (joint between the pubic bones) and the sacrum (base of
the spine).
Other than a large fetus, often due to maternal diabetes, no risk factors for shoulder dystocia are
recognized. If the fetal head emerges from the vagina and then retracts, it is considered a symptom
of shoulder dystocia. This is often called the “turtle sign.” Shoulder dystocia has no other recognized
symptoms. The danger with shoulder dystocia lies with the umbilical cord being compressed between
the fetus and the maternal pelvis.
Do not apply excessive force, as this is unlikely to free the fetus and may cause injury. The HELPERR
mnemonic is a tool used by healthcare providers that describes a set of maneuvers for managing shoulder
dystocia during childbirth.
Continued on next page
Chapter 24: Childbirth | 577
ENRICHMENT
More Complications During Pregnancy
and Delivery continued
These maneuvers are only performed by a healthcare provider and are presented here for information only,
as EMRs do not perform them:
Help: Request the appropriate personnel to respond.
Evaluate: Evaluate for episiotomy (incision between the vaginal opening and anus to prevent a more
extensive vaginal tear during delivery will not release the shoulder on its own, as shoulder dystocia is a
bone impaction).
Legs: Maneuver the mother’s legs in the McRoberts maneuver (repositions the baby).
Pressure: Apply suprapubic pressure (making a fist, placing it just above the maternal pubic bone and
pushing the fetal shoulder in one direction or the other).
Enter: Enter maneuvers (internal rotation of the fetus).
Remove: Remove the posterior arm from the birth canal.
Roll: Roll the patient onto an all-fours position, which may dislodge the impaction; gravity may also assist.
578 | Emergency Medical Response
25 You Are the Emergency Medical Responder
PEDIATRICS
You are working as the camp health officer at a local summer camp when a young girl
approaches you complaining that she has a rash. She says that she is allergic to certain
things and may have come into contact with something that has now given her hives.
How would you respond?
KEY TERMS
Adult: For the purpose of providing emergency Infant: For the purpose of providing emergency
medical care, anyone who appears to be medical care, anyone who appears to be younger
approximately 12 years old or older. than about 1 year of age.
Apparent life-threatening event (ALTE): Pediatric Assessment Triangle: A quick initial
A sudden event in infants under the age of assessment of a child that involves observation of
1 year, during which the infant experiences the child’s appearance, breathing and skin.
a combination of symptoms including apnea,
change in color, change in muscle tone and Respiratory failure: Condition in which the
coughing or gagging. respiratory system fails in oxygenation and/
or carbon dioxide elimination; the respiratory
Child: For the purpose of providing emergency system is beginning to shut down; the person may
medical care, anyone who appears to be between alternate between being agitated and sleepy.
the ages of about 1 year and about 12 years;
when using an automated external defibrillator Retraction: A visible sinking in of soft tissue
(AED), different age and weight criteria are used. between the ribs of a child or an infant.
Child abuse: Action that results in the physical or Reye’s syndrome: An illness brought on by high
psychological harm of a child; can be physical, fever that affects the brain and other internal
sexual, verbal and/or emotional. organs; can be caused by the use of aspirin in
children and infants.
Child neglect: The most frequently reported type
of abuse in which a parent or guardian fails to Seizure: A disorder in the brain’s electrical activity,
provide the necessary, age-appropriate care to a sometimes marked by loss of consciousness and
child; insufficient medical or emotional attention or often by uncontrollable muscle movement; also
respect given to a child. called a convulsion.
Croup: A common upper airway virus that affects Shaken baby syndrome: A type of abuse in which
children under the age of 5. a young child has been shaken harshly, causing
swelling of the brain and brain damage.
Epidemiology: A branch of medicine that deals with
the incidence (rate of occurrence) and prevalence Status asthmaticus: A potentially fatal episode of
(extent) of disease in populations. asthma in which the patient does not respond to
usual inhaled medications.
Epiglottitis: A serious bacterial infection that causes
severe swelling of the epiglottis, which can result Sudden infant death syndrome (SIDS): The
in a blocked airway, causing respiratory failure in sudden death of an infant younger than 1 year that
children; may be fatal. remains unexplained after the performance of a
complete postmortem investigation, including an
Febrile seizures: Seizure activity brought on by an autopsy, an examination of the scene of death and
excessively high fever in a young child or an infant. a review of the care history.
Fever: An elevated body temperature, beyond Thready: Used to describe a pulse that is barely
normal variation. perceptible, often rapid and feels like a fine thread.
LEARNING OBJECTIVES
After reading this chapter, and completing the class • Describe components of a pediatric assessment.
activities, you will have the information needed to: • Describe how to conduct a SAMPLE history for a
• Identify anatomical differences among adults, pediatric patient.
children and infants. • Identify common problems in pediatric patients.
• Describe the general age groups for the purposes • Describe common respiratory problems in children.
of emergency medical care. • Describe how to assess for and manage seizures
• Describe the stages of child development. in children.
• List the general considerations for assessing • Describe considerations for children with special
children and infants. healthcare or functional needs.
580 | Emergency Medical Response
INTRODUCTION Children and infants have proportionately larger
tongues than do adults, so it is easier for the
In an emergency, you should be aware of the tongue to block the airway. Placing pressure
special healthcare or functional needs and under the chin, which can occur during the
considerations of children and infants. Knowing head-tilt/chin-lift or jaw-thrust (without head
these needs and considerations will help you extension) maneuvers, can cause the tongue
better understand the nature of the emergency and to be pushed back and block the airway.
provide appropriate care. A young child may be Newborns and infants prefer to breathe through
scared or nervous due to the circumstances of the the nose and may not open their mouths when
emergency, because they are being assessed by a their nose is blocked, so they are more likely
stranger, a combination of those reasons or some to develop respiratory distress if the nose
other reason. Being able to communicate with and is blocked.
reassure children and infants can be crucial to your
ability to care for these patients effectively. Additionally, the epiglottis is much higher in
children and infants than it is in adults. A newborn’s
trachea is also very narrow, only about 4 or
ANATOMICAL DIFFERENCES 5 mm wide, so swelling, for example due to
It is important to be aware of the anatomical inhaling toxic fumes, can become life threatening
differences among adults, children and infants. very quickly.
The most significant of these differences involve
Children and infants younger than age 5 also
the airway and breathing (Fig. 25-1, A–B).
breathe at a rate two to three times faster than
that of adults, and their breathing is shallower,
as less volume and pressure are needed to
ventilate the lungs.
Determining the Age Group of
the Patient for the Purpose of
Providing Emergency Medical Care
At times, care must be provided according
Nose to the age of the patient and it is not always
easy to determine exact age. The American
Mouth Red Cross follows established age categories
for emergency care that are based on
Tongue epidemiological patterns of injury including care
needed, while at the same time being easy to
Epiglottis recognize based on the patient’s appearance.
Trachea Always follow local protocols and medical
direction when deciding how to care for a child
A versus an adult.
In general, children and infants predominantly
suffer respiratory emergencies, which, if untreated,
Nose can lead to cardiac emergencies. Adolescents and
adults will often suffer primarily cardiac events.
Mouth Lastly, an individual can generally look at a patient
and determine if the patient is an adult, a child
or an infant. At times, a small 13 month old may
Tongue be categorized as an infant, or a small 13 year
Epiglottis old as a child. However, the difference between
the perceived age category and the actual age
would not have any significant impact on care.
B Trachea Additionally, the easy recognition of a perceived
age category helps to provide appropriate
Fig. 25-1, A–B: The most significant anatomical differences
between (A) adults and (B) children involve the airway care quickly, a benefit that far outweighs any
and breathing. age discrepancy.
Chapter 25: Pediatrics | 581
Based on this physiological, epidemiological and Crying makes it difficult for them to communicate.
recognition approach, the following general age Some toddlers relate well to stuffed animals,
groups have been developed: to help them calm down and demonstrate
what the problem may be. When dealing
Infant—Anyone who appears to be younger with an unknown emergency with a toddler,
than about 1 year of age. keep in mind that toddlers’ curiosity about the
Child—Anyone who appears to be between the world around them makes poison ingestion a
ages of about 1 year and about 12 years. For common injury.
automated external defibrillator (AED) purposes,
based on U.S. Food and Drug Administration
(FDA) approval of pediatric-specific devices, Preschoolers (3 to 5 Years)
a patient who is between the ages of 1 and 8 Preschoolers communicate their ideas more
or weighs less than 55 pounds is considered a effectively than toddlers, but they may have
child. If precise age or weight is not known, the difficulty with certain concepts (Fig. 25-2, B).
responder should use best judgment and not They may have difficulty understanding complex
delay care to determine age. sentences that contain more than one idea, so
speak in simple terms. Children at this stage often
Adult—Anyone approximately 12 years old
or older. feel that bad things are caused by their thoughts
and behaviors. Their fears may seem out of
proportion to the events. The sight of blood may
CHILD DEVELOPMENT be disturbing, but often a dressing or bandage can
Infants (Birth to 1 Year) help calm the situation.
Infants’ inability to do anything for themselves and
their inability to communicate where there may School-Age Children (6 to 12 Years)
be pain or discomfort makes them among the
most vulnerable of children and patients. After Children of school age have been exposed
the first few weeks of birth, an infant can usually to more unfamiliar faces and are more likely
recognize a parent’s or caregiver’s voice. After a to cooperate with strangers (Fig. 25-2, C).
few months, facial recognition becomes possible. With reassurance from familiar faces
The quality of crying usually differs according to (parents, caregivers, guardians, teachers),
the cause, but the subtleties of the differences they are likely to understand the situation
may only be recognized by the parent or caregiver. once it has been explained, and are able to
Crying could be triggered by hunger, the need cooperate with emergency responders. This
for diapers to be changed, pain, fear or for age group is often fascinated with the topic
unknown reasons. of death and may have strong fantasies or
imaginary ideas. Children of school age need
continual reassurance.
Toddlers (1 to 3 Years)
Toddlers can readily recognize familiar faces
and may be fearful of strangers (Fig. 25-2, A). Adolescents/Teens (13 to 18 Years)
They may not be cooperative when dealing The characteristics of adolescents and teens
with an unknown person, even if the parent or vary quite a bit from the beginning of the age
caregiver is in the room. Toddlers may also fear group (age 13) to the end (age 18) (Fig. 25-2, D).
being separated from the people they know. Thirteen year olds are just leaving the school-age
CRITICAL It is important to be aware of the anatomical differences among adults, children and
FACTS infants. The most significant of these differences involve the airway.
In general, children and infants predominantly suffer respiratory emergencies,
which, if untreated, can lead to cardiac emergencies.
Anyone who appears younger than 1 year of age should be considered an infant,
1 to 12 years a child, and 12 and older an adult.
582 | Emergency Medical Response
A B
C D
Fig. 25-2, A–D: (A) Toddler; (B) preschooler; (C) school-age child; (D) teen.
group, and 18 year olds are on the cusp of ASSESSING PEDIATRICS
adulthood and already may have had to take on
adult responsibilities. Generally, adolescents are General Considerations
more able to provide accurate information and Assessing an injured or sick child is similar to
cooperate with emergency responders. However, assessing an adult, with a few differences. Primary
they may be apt to fall into mass hysteria, in which assessments on a conscious child should be done
multiple adolescents feel they are all experiencing unobtrusively, so the child has time to get used to
the same problems or symptoms. This requires you and feel less threatened. Try to carry out as
understanding and tolerance on behalf of the many of the components of the initial evaluation
emergency responder. Generally, this group is by careful observation, without touching the child
quite modest and will require privacy. They are or infant. Approach the parent or caregiver, if
also aware of the potential for fatality or permanent possible, as the child will see you communicating
disability and often fear they will experience this. with them and subsequently may feel more
Chapter 25: Pediatrics | 583
comfortable with your exam and treatment. (position and location), keep in mind that the child
If appropriate, a parent or caregiver may hold may have been moved by well-meaning adults.
the child during assessment and treatment. Be sure to ask as part of your patient history. If you
have confirmation that the patient has been moved,
Observe the young patient to assess for ask the adults where the child was and how the
breathing, the presence of blood, movement and child was found.
general appearance. If the child is showing signs
or symptoms of a serious injury or illness, start
the assessment using the head-to-toe approach. Assessment
If the child is agitated or upset and there are no
Pediatric Assessment Triangle
signs or symptoms of a serious injury or illness,
the assessment can be done toe to head, which The Pediatric Assessment Triangle is a quick
allows the patient to get used to you rather initial assessment of a child that takes between
than have you in their face from the start. When 15 and 30 seconds and provides a picture of
treating children, remember that you are also the severity of the child’s or infant’s injury or
treating their parent or caregiver as they, too, illness. This is done during the scene size-up
are likely to be scared or stressed. Reassess as part of forming your general impression and
continuously as you wait for more advanced before beginning the primary assessment. It does
medical support to arrive. Document and report all not require touching the patient, just looking
your findings to more advanced medical personnel and listening.
when they arrive. You should observe three components in the
child—appearance, work of breathing and skin:
Scene Size-Up
Begin observing the scene from the moment you
Appearance: Does the child appear to have
normal muscle tone? Is the child crying, talking
arrive. The big picture will allow you to assess the or moving about? Is the child able to interact
situation and may give clues to other issues, such with you or other adults in the area? Is the child
as child abuse. As usual, also assess the scene for able to make eye contact or be consoled?
personal safety.
Breathing: Does the child appear to be
Be alert for any signs that may indicate poisoning breathing? Does breathing require great effort
(empty bottles, for example) and look for signs (flaring nostrils, indrawn area just below the
of child abuse. Are the adults responding in an throat or use of abdominal muscles)? Is the child
appropriate manner? Are they appropriately leaning forward in an attempt to breathe? Is any
concerned, or are they angry or indifferent? Does noise coming from the child, such as wheezing
the child seem frightened of them and/or their or any other abnormal sound?
reactions? Does the parent or caregiver answer Skin (Circulation): When looking at the child, is
your questions directly? Is the environment safe for the skin pale, mottled or cyanotic (bluish)? Are
a child? While noting how the patient was found any signs of trauma or bleeding present?
CRITICAL Assessing an injured or sick child is similar to assessing an adult, with a
FACTS few differences. Primary assessments on a conscious child should be done
unobtrusively, so the child has time to get used to you and feel less threatened.
Try to carry out as many of the components of the initial evaluation by careful
observation, without touching the child or infant.
Observe the young patient to assess for breathing, the presence of blood,
movement and general appearance. Unless the child is agitated or upset, start the
assessment using the head-to-toe approach.
The Pediatric Assessment Triangle is a quick initial assessment of a child that takes
between 15 and 30 seconds and provides a picture of the severity of the child’s or
infant’s injury or illness. This is done during the scene size-up and before beginning
the primary assessment. It does not require touching the patient, just looking
and listening.
584 | Emergency Medical Response
Equipment for Assessing and Caring child or infant; a combination of skills may be
for Children and Infants needed to clear the airway including abdominal
As children come in all different sizes, so does the thrusts and back blows for a child, or back blows
equipment used to assess them. A wide range of and chest thrusts for an infant. If secretions are
sizes should be available for assessing children, to blocking the airway, suctioning will help remove
provide optimal care. them. The suction may need to be repeated
frequently to maintain an open airway, so the child
Essential equipment and supplies include: should be monitored at all times.
Bag-valve-mask (BVM) resuscitators with
Ventilation/Oxygenation
oxygen reservoirs.
A child who is in respiratory distress may be agitated
Oxygen masks.
or drowsy. Agitation results from trying to get air;
Non-rebreather masks. drowsiness is the result of insufficient oxygenation.
Airway adjuncts. The breathing effort increases in many cases, but
Bulb syringe. as respiratory failure sets in, the breathing effort
Portable suction unit with regulator. may decline considerably as the child weakens.
Additionally, a combination can occur; the child may
Suction catheters.
breathe with great effort for periods, followed by
Cervical immobilization devices.
declining efforts as the child tires.
Backboard and other extrication devices.
Extremity splints. If the child is not breathing adequately or is not
breathing at all, ventilation and/or oxygenation
Stethoscope for pediatrics.
will be required (Fig. 25-3). Signs of the need for
Blood pressure cuffs.
this assistance would be agitation or drowsiness,
Thermal blankets. limp muscles, inability to respond and a pale or
Water-soluble lubricant. cyanotic appearance.
A new, clean stuffed animal and references for the
Glasgow Coma Scale and Pediatric Trauma Score Circulation
are also recommended. Circulation in a child is similar to that of an adult,
though the average child’s pulse is more rapid than
Airway an adult’s.
An airway that is open, even if only partially open, Observe the child for signs and symptoms of
will allow the child to cough, cry or breathe. Even shock, which include restlessness; cold, clammy,
with an open airway, the child should be observed pale or ashen skin; rapid or irregular breathing;
closely for any change in status. A child whose falling blood pressure; altered mental status;
airway becomes compromised or shows signs rapid, weak or thready pulse; delayed capillary
or symptoms of inadequate breathing or a lack of refill; and an absence of tears if the child or infant
oxygen will need immediate care. is crying. Place the child in the supine position
(flat on their back).
A child’s airway can be blocked by anatomical or
mechanical obstructions. For example, illness can A child who is in shock or is at risk of going
cause constriction of the bronchi and upper airway into shock must be kept from getting chilled or
as in status asthmaticus (asthma) or anaphylaxis overheated. Place a blanket over the child to help
(anatomical). Infection and trauma can also cause maintain the body temperature. Monitor the child
swelling and block the airway. Children are prone closely for any changes in status.
to airway obstruction caused by small objects as
well as food (mechanical). Choking hazards among Determining the Level
children include small objects such as coins,
of Consciousness
buttons, small toys and parts of toys and balloons,
as well as certain food items. While hazardous for Using the AVPU scale, you can start to determine
all children, these objects generally pose a larger the child’s level of consciousness (LOC). The
threat to children under age 4. AVPU scale is a mnemonic that describes stages
of awareness: Alert (the patient can respond
If a solid object is blocking the child’s upper airway, to questions and is aware of the surroundings),
oxygen may not enter the lungs. This situation Voice (the patient responds to verbal stimuli),
requires immediate care for a conscious choking Pain (the patient only responds to painful stimuli)
Chapter 25: Pediatrics | 585
Fig. 25-3: If a child is not breathing adequately, give ventilations or administer supplemental oxygen, based on local protocols.
and Unresponsive (the patient does not respond the lower part of the blanket to examine the
to any stimuli). The AVPU scale is covered more lower body.
thoroughly in Chapter 7.
Be swift and cover the child as quickly as possible.
Another way to determine the LOC is pupil Because a large proportion of body heat is lost
assessment, which involves checking to see if the through the head and neck, cover the child’s head
pupils react to light. Shine a flashlight or penlight to minimize the loss of body heat.
quickly into and then out of the child’s eye. In a
normal reaction, the pupil constricts in response
to the light and then dilates again after the light SAMPLE History
is removed. When taking a child’s SAMPLE (signs and
symptoms, allergies, medications, pertinent
Movement is another good indication of LOC.
medical history, last oral intake and events
Observe the child. A fully alert child will have
leading up to the incident) history, you will
spontaneous movements and as LOC diminishes,
need the parent’s or caregiver’s cooperation
so will the movement.
(Fig. 25-4). Encourage this cooperation by
remaining respectful and polite during the
Exposure conversation, even if the adult is difficult or if
Despite the need to keep the child covered if you you suspect child abuse or child neglect. Ask
are concerned about shock, you must be able to questions that require detailed answers, not
assess the child properly and thoroughly, barring yes-or-no questions. If the child is young but
any life-threatening situation. Check the child for wants to participate, welcome this. An older child,
any other injuries or signs of trauma. You do not particularly an adolescent, may want to speak with
need to uncover the child completely. You may you privately. Keep this in mind if you must ask
remove the top part of the blanket to examine sensitive questions about topics such as sexual
the upper body, cover the child and then remove activity or drug use.
586 | Emergency Medical Response
Fig. 25-4: When obtaining a SAMPLE history for a child, keep the child with the parent or caregiver.
If you are not sure that the answers you receive Allergies
are accurate or contain enough information, try Ask the parent, caregiver or child, if appropriate, if
asking the question in another manner, using they have any allergies. While obtaining a patient
different phrasing. Use feedback, repeating the history, inquire about allergies to:
answers as you make note of them, to be sure you
heard correctly. Medications.
Food.
Symptoms and Duration Environmental elements, such as dust, pollen
or bees.
Ask the parent, caregiver, or child, if appropriate,
about the symptoms, any changes (worsening or
easing) and how long they have been present. Medications
While obtaining a patient history, inquire about: Ask the parent or caregiver about medications
the child might take. Does the child take any
Fever. prescription medications or has the parent or
Unusual activity level. caregiver given any over-the-counter medications
History of eating, drinking and urine output. recently? Does the child have any allergies to
medications? Could the child have gotten into
History of vomiting, diarrhea and abdominal
someone else’s medications?
pain.
CRITICAL You will need the parent’s or caregiver’s cooperation while taking a child’s SAMPLE
FACTS history. Be respectful and polite, even if you suspect child abuse or neglect. Avoid
asking yes-or-no questions. Allow a child to participate; older children may want
to talk privately, especially if you must ask sensitive questions concerning sexual
activity or drug use.
Chapter 25: Pediatrics | 587
Pertinent Past Medical Problems or COMMON PROBLEMS
Chronic Illnesses IN PEDIATRIC PATIENTS
Ask the parent or caregiver if something like this
Certain problems are unique to children, such as
has ever occurred before. If so, what caused it
specific kinds of injury and illness.
before and what happened in the long run? Does
the child have any chronic illnesses, such as
asthma or diabetes? Has the child been ill lately Airway Obstructions
with any other type of illness? Some of the most common airway problems you
may encounter with small children and infants are
airway obstructions. Airway obstructions may be
Last Oral Intake categorized as either partial or complete. Signs of
Ask the parent or caregiver when the child last a partial airway obstruction in a child or an infant
had something to eat or drink and what it was. who is alert and sitting up include:
Abnormal high-pitched musical sounds, crowing
or noisy respirations.
Events Leading Up to the Injury
or Illness Retraction.
Ask the parent or caregiver what specifically Drooling.
was going on when the injury or illness was first Frequent coughing.
noticed. What was the environment like (where did Keep the child or infant in a position of comfort,
it happen)? What was the child doing? What was possibly sitting on a parent’s or caregiver’s lap.
the child’s reaction? The child can stay there while you administer
supplemental oxygen based on local protocols.
Physical Exam A complete airway obstruction is a life-threatening
Conducting a physical exam of a child or an situation. A partial airway obstruction in a child or an
infant requires some special handling. Try to have infant who is showing signs of cyanosis should be
only one individual deal with the child, to reduce treated as a complete airway obstruction. Signs of a
the anxiety of being handled by multiple strangers. complete airway obstruction include:
If you can, crouch down to the child’s eye level.
Speak calmly and softly and maintain eye contact. Inability to cough, cry or speak.
Be gentle and never lose your temper. Involve Cyanosis.
people who are familiar to the child, if possible. Loss of consciousness.
For preschoolers, save frightening tools like Altered mental status.
stethoscopes until the child has had a chance to
Care includes clearing the airway and attempting
get used to you.
ventilation using the mouth-to-mask technique.
When examining a child, the standard procedure For more information on clearing airway obstructions
is to go from head to toe. For a very agitated child, in children and infants, refer to Chapter 11.
however, the exam may be more successful if it is
performed toe to head. Breathing Emergencies
Respiratory distress is apparent when the child
A head-to-toe exam involves the following
or infant begins to experience difficulty breathing.
components:
If uncorrected, respiratory distress can lead to
Head: Look for bruising or swelling. respiratory failure.
Ears: Look for drainage suggestive of trauma
Anatomic and Physiological
or infection.
Differences in Children
Mouth: Look for loose teeth, identifiable odors
or bleeding. Anatomical differences among adults, children
and infants can change their susceptibility to
Neck: Look for abnormal bruising.
respiratory difficulties and affect how to provide
Chest and back: Look for bruises, injuries
emergency care:
or rashes.
Extremities: Look for deformities, swelling or In children and infants, the tongue is larger in
pain on movement. relation to the space in the mouth than it is in
588 | Emergency Medical Response
adults. This can increase the risk of the tongue Cyanosis.
blocking the trachea. Altered mental status.
In children, the airway is smaller, resulting Grunting.
in more objects, such as different types of
solid foods, being a choking hazard. Their Respiratory failure occurs when the respiratory
smaller airway can make children more prone system is beginning to shut down. The child may
to developing infections or amassing liquid be sleepy and lethargic, or may alternate between
secretions. This also affects the choice of being agitated and sleepy. Muscle tone is generally
ventilation equipment used. limp, breathing is usually visible, and breathing
can decrease or alternate between increased and
In children, the trachea is not as long as it is
weak effort as the child becomes tired. The skin is
in adults, so any attempt to open the airway by
tilting the child’s head too far back will result in usually pale, mottled or cyanotic.
blocking the airway. Respiratory arrest occurs when the respiratory
Children breathe using their diaphragm, so ensure system shuts down. The child is unconscious and
nothing is pressing on the abdomen to prevent completely limp. Signs of breathing may be slight, but
this. Also, if possible, allow the child to sit up. are most likely absent, and the skin color is cyanotic.
Young children and infants do not usually
The importance of recognizing early signs of
breathe through their mouth; they breathe
through their nose. Ensure that the nose is respiratory distress cannot be emphasized enough.
as clear as possible for breathing. Early recognition of respiratory emergencies can
make the difference between life and death. More
information on the recognition and care of breathing
Pathophysiology emergencies can be found in Chapters 10 and 11.
The process of respiratory emergencies usually
follows the pattern of respiratory distress, followed Assessing Breathing Emergencies
by respiratory failure, which is then followed by
The child’s ability to breathe adequately must be
respiratory arrest if emergency interventions are
assessed by checking the mental status, muscle
not attempted or are not successful.
tone, breathing movement, breathing effort and skin
Respiratory distress occurs when the child is having color. Once you have made your assessment, be
trouble breathing but is visibly able to breathe. sure to frequently perform follow-up assessments
A child in respiratory distress may be mentally alert to note if there are any changes in the child’s
and/or agitated. The patient’s breathing effort is respiratory status.
increased and the skin color may be normal or pale.
Common Respiratory Problems
Respiratory distress preceding respiratory failure is
in Children
characterized by:
Although many types of breathing problems can
In infants, a respiratory rate of more than affect children, some will be seen by emergency
60 breaths per minute. responders more often than others, such as croup,
In children, a respiratory rate of more than epiglottitis, asthma and choking on an obstruction.
30 breaths per minute.
Croup is a common upper airway virus that affects
Flaring of the nostrils. children younger than 5. The airway constricts,
Use of neck muscles and muscles between and limiting the passage of air, causing the child to
below the margin of the ribs to aid in breathing. produce an unusual sounding cough that can
Abnormal, high-pitched sounds when breathing. range from a high-pitched wheeze to a barking
CRITICAL Certain problems are unique to children, such as specific kinds of injury and
FACTS illness. Some of the most common airway problems the emergency responder may
encounter with small children and infants are airway obstructions.
Anatomical differences among adults, children and infants can change their
susceptibility to respiratory difficulties and affect how to provide emergency care.
Chapter 25: Pediatrics | 589
cough. Croup occurs most often during the what has been taken and how often up to the time
evening and night hours. of your arrival.
A child with croup may progress quickly from The status of a child with asthma can change very
respiratory distress to respiratory failure. Children quickly, so constant monitoring is necessary. The
with croup may benefit from humidified oxygen. typical signs of asthma include rapid respirations
If you are transporting the child to the hospital, that take effort as respiratory distress develops,
you may see an improvement in the child once but the breathing may seem to become less
exposed to cool air outdoors. labored. This does not indicate improvement, but
rather deterioration in respiratory status.
Epiglottitis is a bacterial infection that causes
severe swelling of the epiglottis. While it is Choking is a common emergency in young children,
extremely rare, the symptoms may be similar to particularly once they become mobile and are able
croup; it is a more serious illness and can result in to explore on their own. Your interventions will be
death if the airway is blocked completely. based on your assessments as to whether the child
has a partial or complete airway obstruction.
If the child is older, you may see the tripod position,
where the child is sitting up and leaning forward,
perhaps with the chin thrust outward (Fig. 25-5). Providing Care for Breathing
Other signs are drooling, difficulty swallowing, Emergencies
voice changes and fever. Treatment of all respiratory emergencies is
generally the same. Use equipment that is properly
A child with epiglottitis can move from respiratory sized for the child, particularly if using an oxygen
distress to respiratory failure very quickly without mask (Fig. 25-6). The mask should fit the child and
emergency care. With epiglottitis, keeping the should deliver the appropriate amount of oxygen.
child as calm as possible is vital. Do not examine Monitor the airway and breathing continuously, and
the throat using a tongue depressor or place arrange for transport as quickly as possible.
anything in the child’s throat, as these can trigger
a complete airway blockage. Circulatory Failure
Asthma is a common illness and can be triggered As with adults, undetected and uncorrected
in many children by exposure to allergens. Air circulatory failure in children and infants can cause
is drawn into the lungs, but as the bronchioles cardiac arrest. Signs and symptoms of circulatory
constrict during an asthma attack, they also may failure include:
fill with mucus, blocking the air in the lungs from
exiting. This blockage results in the characteristic Increased heart rate (but can also
be decreased).
wheeze when the patient exhales. Ask the parent
or caregiver if the child is known to have asthma Unequal pulses (femoral compared with radial).
and, if so, if any rescue medications are available. Delayed capillary refill.
If medications have been administered, find out Changes in mental status.
Fig. 25-5: An older child with epiglottitis may demonstrate
the tripod position, in which the child sits up, leaning forward, Fig. 25-6: Equipment, particularly oxygen masks, should be
possibly with the chin thrust outward. properly sized for the child so that it fits correctly.
590 | Emergency Medical Response
Unlike adults, children seldom initially suffer a was the last time it was given? Does the parent
cardiac emergency. Instead, they suffer a respiratory or caregiver monitor the blood sugar level? If so,
emergency that develops into a cardiac emergency. what was the child’s blood sugar level when it
Motor-vehicle collisions, drowning, smoke inhalation, was most recently monitored?
poisoning, airway obstruction and falls are all Has the child begun taking any new medications
common causes of respiratory emergencies that lately? If the child takes medications, is it possible
can develop into a cardiac emergency. A cardiac there may have been an overdose? Could the
emergency can also result from an acute respiratory child have taken someone else’s medication?
condition, such as a severe asthma attack. Always
be prepared for the possibility of circulatory failure
Did the child have access to anything poisonous?
when dealing with a respiratory emergency. Has the child had an injury, particularly a head
trauma, recently?
Care for circulatory failure includes identifying Has the child seemed sick or had a high fever,
problems through assessment; assisting attempts to stiff neck or recent headache?
breathe by opening the airway, removing obstructions What did the seizure look like? Did it involve the
or providing ventilation; and observing for signs of child’s whole body, or only one half of the body?
cardiac arrest, performing CPR and using an AED. Did it start in one area and progress to the rest?
More information on the identification and care for Did the child fall when the seizure began and
circulatory failure can be found in Chapter 13. if so, was it possible the child’s head struck an
object or the floor?
Seizures
A seizure is a disorder in the brain’s electrical Managing Seizures
activity, sometimes marked by loss of consciousness The general principles of managing a seizure are to
and often by uncontrollable muscle movement; also prevent injury, protect the child’s airway and ensure
called a convulsion. A chronic condition, such as that the airway is open after the seizure has ended.
epilepsy, or an acute event may cause seizures. Call for more advanced medical personnel for a
child or an infant who has had a seizure and for a
In children, febrile seizures are the most common
young child or an infant who experienced a febrile
type of seizure. These seizures occur with a rapidly
seizure brought on by a high fever.
rising or excessively high fever, higher than 102° F
(38.9° C). Febrile seizures may have some or all of Do not put anything in the child’s mouth and do not
the following signs and symptoms: restrain the child. Ensure that the environment is as
safe as possible to prevent injury to the child during
Sudden rise in body temperature
the seizure by moving away any furniture or other
Change in LOC objects. Place the child in a side-lying recovery
Rhythmic jerking of the head and limbs position during the seizure, if it is possible and safe
Loss of bladder or bowel control to do so.
Confusion
After the seizure, ensure the child’s airway is open
Drowsiness and administer supplemental oxygen, based on
Crying out local protocols. Suctioning the airway may be
Becoming rigid necessary to remove excessive fluids. Also, after
Holding the breath the seizure, assess the patient for any injuries that
may have been sustained as a result of the seizure.
Rolling the eyes upward
If you have not already done so, position the child
Assessing Seizures or infant on their side so that fluids (saliva, blood,
vomit) can drain from the mouth.
When obtaining a history from the parent or
caregiver, you need to know several things to assess Care for a child or an infant who experiences a
what type of seizure the child may be having and febrile seizure is much the same as for any other
what may have caused it. Ask questions such as: seizure. Most febrile seizures last less than 5
minutes and are not life threatening. However,
Has the child ever had seizures before? If so,
immediately after a febrile seizure it is important to
does the child have medications for them? If not,
cool the body if a fever is present.
is there a family history of seizures?
Does the child have diabetes? If so, what type See Chapter 14 for more information on
of insulin/medication is being used and when managing seizures.
Chapter 25: Pediatrics | 591
Fever the speed with which it may develop. Children
can go into shock very quickly, regardless of
Fever is defined as an elevated body temperature.
the cause, and may go into cardiac arrest much
It signifies a problem and, in a child or an infant,
faster than adults.
can indicate specific problems. Often these
problems are not life threatening, but some can
be. A high fever in a child often indicates some Causes of Shock in Children
form of infection. In a young child, even a minor In addition to trauma, shock may also be caused by
infection can result in a rather high fever, which is infection. Infections can send the body into shock
often defined as a temperature higher than 102° F because of the body’s reaction to the infection.
(38.9° C). If a fever is present, call for more The risk of shock increases with the severity and
advanced medical help at once. centrality of the infection.
Your initial care for a child with a high fever is to Among children, the most common cause of shock
gently cool the child. Never rush cooling down a is vomiting or diarrhea. As they lose fluid from
child. If the fever has caused a febrile seizure, rapid the vomit and/or diarrhea, their body fluid volume
cooling could bring on another seizure. Parents or becomes depleted and their blood pressure drops.
caregivers often heavily dress children with fevers.
Remove the excess clothing or blankets. Do not Assessing Shock
use an ice water bath or rubbing alcohol to cool
When assessing shock, watch the child’s mental
down the body. Both of these approaches are
status, including any changes that have occurred
dangerous, and parents and caregivers should be
since you arrived on the scene. Some children
discouraged from ever using them.
may experience a change in mental status so
Do not give children or infants aspirin or products pronounced that it makes them unable to recognize
that contain aspirin when they show flu-like their parent or caregiver. This altered mental status
symptoms including fever, or if they may have a is a strong indicator that shock is developing
viral illness such as chicken pox, as this may result quickly and may result in cardiac arrest.
in an extremely serious medical condition called
Other signs and symptoms of shock include:
Reye’s syndrome. Reye’s syndrome is an illness
that affects the brain and other internal organs. Cold, clammy, pale or ashen skin, particularly in
Ask the parent or caregiver what medications they infants, as they are less capable of regulating
may have given the child so you can inform more body temperature.
advanced medical personnel.
Rapid, weak or thready pulse.
Rapid or irregular breathing.
Poisoning Lack of tears when crying.
Poisoning can cause many types of emergencies, Low or lack of urine output.
from seizures to cardiac arrest. Unintentional Falling blood pressure.
poisoning is a leading cause of unintentional death
in the United States for adolescents, children and
infants. Just under half of exposure cases managed Providing Care for Shock
by Poison Control Centers involve children younger Lay the child flat if possible, but do not force it
than 6. Children in this age group often become if the child is too agitated or upset. Constantly
poisoned by ingesting medications (typically those monitor the child’s respiratory and circulatory
intended for adults) and household products, such status. Have equipment available should the child
as laundry detergent pods and solid objects, like go into cardiac arrest.
batteries, particularly the watch-sized batteries
found in many children’s toys.
Altered Mental Status
Altered mental status in children and infants is
Shock another medical condition you may encounter.
Shock is the body’s reaction to a physical or This can be caused by low blood sugar, poisonings
emotional trauma in both adults and children. or overdoses, seizures, infections, trauma,
Physical trauma could include loss of blood. decreased level of oxygen and the onset of shock.
In small children, the loss of blood may be much When assessing altered mental status, use the
more significant than in adolescents or adults. AVPU scale, which is covered more thoroughly
This adds to the increased risk of shock and in Chapter 7.
592 | Emergency Medical Response
When arriving on the scene, determining the happened, as a severely injured child may not
cause of the alteration in mental status right away immediately show signs of injury.
is not essential. Your role is to support the patient
by maintaining an open airway and administering Laws requiring children to ride in safety seats or
supplemental oxygen based on local protocols. Any wear safety belts have been enacted to stop some
information you can gather from the parent, caregiver of the needless deaths of children associated with
or bystanders will help you care for the patient. motor-vehicle crashes. As a result, children’s lives
are being saved. However, you may have to check
and care for an injured child or infant while the child
Trauma is in a safety seat (Fig. 25-7). A safety seat does
Injury is the number-one cause of death for children not normally pose any problems when checking a
in the United States. Many of these deaths are child or an infant. Leave the child or infant in the
the result of motor-vehicle collisions. The greatest seat if the seat has not been damaged. If the child
dangers to a child involved in a motor-vehicle crash or infant is to be transported to a medical facility for
are airway obstruction and bleeding. Ensure an examination, the child can often be safely secured
open airway and control severe bleeding as quickly in the safety seat for transport.
as possible. A relatively small amount of blood lost
by an adult is a large amount for a child or an infant. Care for extremity injuries in a child or an infant in the
same way as for adults. When providing care for an
Because a child’s head is large and heavy in injured child or infant, use equipment of the proper
proportion to the rest of the body, the head is the size. If equipment of the proper size is not available,
most frequently injured part of the child’s body. manually stabilize extremity injuries until additional
A child injured as the result of force or a blow may help arrives. Information on the general management
also have sustained damage to the organs in the of extremity injuries can be found in Chapter 22.
abdomen and chest. Because children have very
soft, pliable ribs, such damage can cause severe Try to comfort, calm and reassure the child and
internal bleeding. Care for a child with a chest family members while waiting for additional
injury involves keeping an open airway, assessing emergency medical services (EMS) resources.
the chest for rise and fall, and administering
supplemental oxygen based on local protocols.
Child Abuse and Neglect
In a car crash, a child only secured by a lap belt You may at some point encounter a situation involving
may have serious abdominal or spinal injuries. You an injured child in which you believe or have reason to
may need to rely on bystanders’ reports of what suspect child abuse or neglect is involved.
Fig. 25-7: If the safety seat has not been damaged, leave the child in it while you are checking and
caring for the child.
Chapter 25: Pediatrics | 593
Types of Abuse Patterns of injury that include cigarette burns,
Child abuse, or non-accidental trauma, is the whip marks and handprints (Fig. 25-8, A–B)
physical, psychological or sexual assault of a child Obvious or suspected fractures in a child
resulting in injury and emotional trauma. Child younger than 2 years of age
abuse involves an injury or pattern of injuries that Any unexplained fractures
do not result from a mishap. You might suspect Injuries in various stages of healing, especially
child abuse if the child’s injuries cannot be bruises and burns (Fig. 25-8, C)
logically explained or a caregiver or parent gives
an inconsistent or suspicious account of how the
Unexplained lacerations or abrasions, especially
to the mouth, lips and eyes (Fig. 25-8, D)
injuries occurred. Perpetrators of child abuse may
often be evasive or volunteer very little information. Injuries to the genitalia
Pain when the child sits down
One type of abuse is shaken baby syndrome, More injuries than are common for a child of
which is the result of a young child being shaken that age
harshly—hard enough to cause brain swelling and
damage. Signs and symptoms of shaken baby
Repeated emergency calls to the same address
syndrome include unconsciousness, lethargy/
decreased muscle tone, extreme irritability, Managing Child Abuse and Neglect
difficulty breathing, seizures, inability to lift head, When caring for a child who may have been
inability of eyes to focus and decreased appetite. abused, your first priority is to care for the
Child neglect is insufficient attention given to or a child’s injuries or illness. An abused child may
lack of respect shown to a child who has a claim to be frightened, hysterical or withdrawn. Abused
that attention. Neglect is the most common type of children may also be unwilling to talk about the
child abuse reported. Signs and symptoms include: incident in an attempt to protect the abuser or
for self-protection. If you suspect abuse, explain
Lack of adult supervision. your concerns to the responding police officers
or emergency medical technicians (EMTs),
A child who appears underfed or malnourished.
if possible.
An unsafe living environment.
Untreated chronic illness; for example, a child When answering a call where you suspect abuse,
with asthma who has no medications available you must ensure your own safety. Do not place
despite being issued a prescription. the child in the awkward position of having to tell
you things that may cause tension with a parent or
Epidemiology of Child Abuse caregiver. Focus on treating the child and making
and Neglect your assessments. Never confront the parent or
Epidemiology studies show that child abuse is caregiver about your suspicions, as this could put
not limited to a certain sector of society but may you and/or the child at risk. If you need to transport
occur in any part. Every year in the United States, the child out of the environment, the parent’s or
almost 700,000 children are victims of child abuse caregiver’s support is essential.
and neglect, and more than 1,600 children die
from the abuse and neglect at a rate of 2.25 per Legal Aspects of Child Abuse
100,000 children. Of those, 75.3 percent were and Neglect
neglected, 17.2 percent were physically abused If you have reasonable cause to believe that abuse
and 8.4 percent were sexually abused. has occurred, you can report your suspicions
to a community or state agency, such as the
Assessing Child Abuse and Neglect Department of Social Services, the Department of
Upon arriving on the scene, note anything in the Children and Family Services, or Child Protective
child’s history or at the scene that causes concern or Services. You may be afraid to report suspected
suspicion of abuse or neglect. Watch the caregiver’s child abuse because you do not wish to get
behavior, which may be evasive; the caregiver (usually involved or are afraid of getting sued.
a parent) may not volunteer much information or may
contradict information already given. Also observe for You do not need to identify yourself when you
particular physical signs and symptoms: report child abuse, although your report will
have more credibility if you do. In some areas,
Injury that does not fit the description of what certain professions are legally obligated to report
caused it suspicions of child abuse as a mandated reporter.
594 | Emergency Medical Response
A B
C D
Fig. 25-8, A–D: When you arrive on the scene, observe for particular physical signs of child abuse or
neglect. These include (A) cigarette burns, (B) handprints, (C) burns and (D) unexplained lacerations.
Documenting Child Abuse of the unexplained death of an otherwise healthy
and Neglect child and the presence of bruise-like blotches that
As with all emergency calls, you must document sometimes appear on the infant’s body. However,
your observations and actions and the patient’s SIDS is not related to child abuse. SIDS is also not
response objectively. When dealing with suspected believed to be hereditary, but it does tend to recur
child abuse or child neglect, remain objective in in families.
your documentation. Do not write any supposition
or theories. If there is later legal action, your notes Epidemiology and Risk Factors
may be used in court. Your notes have a better The rate of SIDS occurrence is significantly
chance of being useful if they are thorough lower now than prior to 1992, when parents and
and objective. caregivers were first told to put infants to sleep on
their back or side. Even so, unfortunately, SIDS still
causes a significant number of deaths in infants
Sudden Infant Death Syndrome
younger than 1, and thousands of babies die of
Sudden infant death syndrome (SIDS), which SIDS in the United States each year.
used to be called crib death, is the unexplained
sudden death of an infant younger than 1, but it Parents and caregivers should not place
occurs most often between the ages of 4 weeks anything in the crib, including pillows, blankets
and 7 months. SIDS almost always occurs while or toys, and should try to ensure that the infant
the infant is sleeping. This condition does not is not exposed to any secondhand smoke.
seem to be linked to any disease. Because the Babies who die of SIDS are most often reported
cause or causes of SIDS are not yet understood, to have been perfectly healthy, although some
parents do not know if their child is at risk. SIDS reports indicate some infants had a cold prior
is sometimes mistaken for child abuse because to their death.
Chapter 25: Pediatrics | 595
Assessing and Managing SIDS
Lowering the Risk When called for a SIDS death, unless the infant
is very obviously dead (rigor mortis has set in),
for SIDS attempt resuscitation with CPR as per infant
protocols. Follow local EMS protocols for death in
Because it cannot be predicted or prevented, the field, and notify the appropriate authorities.
SIDS makes many new parents feel anxious.
However, there are several things they can If possible, try to obtain the following information:
do to lower the risk for SIDS. The American
Academy of Pediatrics has guidelines for safe When was the infant last checked on or put to
sleep, which include the following for the first bed and seen to be breathing?
year of an infant’s life: Who discovered the infant and what brought the
person into the room (concern of infant sleeping
• Always place an infant on their back for too long, time to get up, etc.)?
every sleep time including naps.
• Always use a firm sleep surface. Car
How was the infant lying in the crib, in what
position?
seats and other sitting devices are not
recommended for routine sleep. Was anything else in the crib?
• The infant should sleep in the same room Were any other adults or children in the house
as the parents or caregivers, but not in the while the infant was sleeping?
same bed. What was the infant’s state of health?
• Bed sharing is not recommended for Did the infant seem different, uncharacteristically
any infants. quiet or cranky, for example, when last put in
• Keep all soft objects or loose bedding out the crib?
of the crib. This includes pillows, blankets, Did the infant have any illnesses or allergies?
bumper pads and toys.
• Wedges and positioners should not be
Was the infant given any medications?
used. Were any medications or toxic substances
nearby?
• Do not smoke during pregnancy or
after birth. How warm was the bedroom?
• Offer a pacifier at nap time and bedtime. By the time the infant’s condition is discovered,
• Avoid covering the infant’s head or allowing the infant will likely be in cardiac arrest. Ensure
the infant to become overheated. that someone has called more advanced medical
• Do not use home monitors or commercial personnel, or call for help yourself. Give the infant
devices marketed to reduce the risk CPR until more advanced medical personnel
of SIDS. take over.
• Supervised, awake tummy time is
recommended daily to facilitate
Support for SIDS
development and minimize the occurrence
of positional plagiocephaly (flat head). Because of the circumstances of the death, the
• Make sure an infant has received all parents, caregivers and possibly siblings may be
recommended vaccinations. Evidence your patients as much as the infant. Shock can
suggests that immunization reduces the result from a severe emotional trauma, so observe
risk for SIDS by 50 percent. the parent or caregiver closely for signs and
• Breastfeeding is associated with a reduced symptoms of shock.
risk for SIDS and is recommended. When more advanced emergency personnel take
over the infant’s care, you can focus on the family.
For more information on the guidelines Encourage them to accompany the infant. If they
for sleep position for infants and reducing are concerned about leaving other children behind,
the risk for SIDS, visit healthychildren.org/ see if a neighbor or friend is able to stay with
safesleep. Additional information can be their children.
found on the National Institutes of Health
website at nichd.nih.gov/sids/.
Apparent Life-Threatening Events
Source: American Academy of Pediatrics: Ages & An apparent life-threatening event
stages: Reduce the risk of SIDS. healthychildren.org/
safesleep. Accessed December 2016. (ALTE) is a sudden event in infants younger
than 1, characterized by apnea, change in
596 | Emergency Medical Response
color, change in muscle tone, and coughing or THE EMERGENCY MEDICAL
gagging. About half the time, ALTE is linked to
an underlying digestive, neurologic or respiratory
RESPONDER’S NEEDS
health problem, but it remains unexplained in Dealing with emergency situations can be difficult
half of all cases. When linked to certain other for many emergency medical responders (EMRs).
conditions, ALTE is thought to be a risk factor The difficulty can be compounded when the
for SIDS. At one time it was believed these emergencies include children, particularly if they
two conditions were more strongly linked and involve suspected child abuse or SIDS. The death
it was questioned whether ALTE was simply a of a child, especially if declared on the scene of an
“near-miss” case of SIDS, but experts no longer incident, can be very difficult for any responder.
believe this is the case.
While you are on scene, caring for the child
and interacting with the parent, caregiver and/
Considerations for Children or bystanders, maintain a professional demeanor
with Special Healthcare or and control your emotions. This is easiest if you
Functional Needs focus on the task at hand and only the task.
However, once you are away from the scene, your
In addition to the more common problems any professional “mask” may be removed as you deal
child may have, a child with special healthcare with your own thoughts and emotions.
or functional needs may have additional health
concerns. When called to a scene with a child As a person, you are entitled to your own thoughts
with special healthcare or functional needs, the and emotions, be they anger, pain or sorrow. Feeling
parent or caregiver can generally provide you with anxious and helpless is common and normal after
the most information, because they are the most such events. However, these feelings must be put in
familiar with the medical equipment the child may context so they do not overwhelm you and interfere
use. Pieces of equipment may include: with your professional and personal life.
Power wheelchairs. Most emergency response teams have resources
Ventilators. available to help responders following a critical
event. More information on this topic can be found
Communication systems.
in Chapter 2.
Feeding apparatus.
While making your assessments, the parent
or caregiver can provide valuable insight into PUTTING IT ALL TOGETHER
the problem. They may suspect a specific Caring for children is similar in many ways to caring
issue, or perhaps a similar situation occurred for adults, but differences exist, both physical and
previously. emotional. Caring for a child often also means
providing support and care to the parent or
While assessing breathing and pulse, take caregiver, who are often stressed and anxious.
into account that if a child is on a respirator or
ventilator, the problem may not be with the child, Assessing breathing and pulse in children is, for
but with the machine. You may need to manually the most part, the same as assessing the same
give ventilations with a BVM or other device while things in adults. For both adults and children,
the machine is being checked. breathing and pulse are your priority and must be
assessed before all else. Although the airway must
When caring for children, you depend on your be patent in both adults and children, it is smaller
assessment skills to determine the child’s age and shorter in children, and their respirations are
and maturity level. When dealing with children generally more rapid than those of an adult. When
who have special healthcare or functional assessing circulation, a child who is bleeding may
needs, the child’s age and maturity level may go into shock more rapidly than an adult because
not be as straightforward, depending on the of the lower quantity of blood circulating in a
child’s disability. Do not assume a child’s child’s body.
mental capacity if the child is unable to express
thoughts or words. Ask the parent what the child Caring for children may also involve potentially
is capable of understanding, and speak directly to anxiety-provoking situations, such as child abuse
the child as you would to any other child. Do not or neglect. If you suspect child abuse or neglect,
speak to the parent or caregiver as if the child is you must perform your duties as a professional,
not in the room. and keep your personal feelings to yourself.
Chapter 25: Pediatrics | 597
You are not, however, helpless; you can report must remain professional while on the job, you
concerns of child abuse if you feel they are also must recognize that—as a person—you
warranted. have the right to feel upset, anxious, angry or
any other emotion. Take care of yourself so that
Finally, as an EMR, you will likely face death on these emotions do not overcome you and affect
occasion, and dealing with a child’s death may your life.
have an especially strong impact. Although you
You Are the Emergency Medical Responder
As you continue to monitor the child’s condition, you notice that the hives have spread beyond
the affected area. What care should you provide?
598 | Emergency Medical Response
26 OLDER ADULTS AND
PATIENTS WITH SPECIAL
HEALTHCARE OR
FUNCTIONAL NEEDS
You Are the Emergency Medical Responder
Your police unit responds to a scene where an older man appears lost and disoriented. He
does not know where he is, how he got there or how to get home. When you ask him what
his name is, he cannot remember. How would you respond?
KEY TERMS
Alzheimer’s disease: The most common type Dementia: A collection of symptoms caused
of dementia in older people, in which thought, by any of several disorders of the brain;
memory and language are impaired. characterized by significantly impaired
intellectual functioning that interferes with
Asperger syndrome: A disorder on the autism normal activities and relationships.
spectrum; those with Asperger syndrome have
a milder form of the disorder. Edema: Swelling in body tissues caused by
fluid accumulation.
Autism spectrum disorder (ASD): A group
of disorders characterized by some degree Hard of hearing: A degree of hearing loss that is
of impairment in communication and social mild enough to allow the person to continue to rely
interaction as well as repetitive behaviors. on hearing for communication.
Bereavement care: Care provided to families during Hospice care: Care provided in the final months of
the period of grief and mourning surrounding a life to a terminally ill patient.
death.
Mental illness: A range of medical conditions that
Catastrophic reaction: A reaction a person affect a person’s mood or ability to think, feel, relate
experiences when the person has become to others and function in everyday activities.
overwhelmed; signs include screaming, throwing
objects and striking out. Service animal: A guide dog, signal dog or other
animal individually trained to provide assistance to
Chronic diseases: Diseases that occur gradually a person with a disability.
and continue over a long period of time.
Sundowning: A symptom of Alzheimer’s disease
Cognitive impairment: Impairment of thinking in which the person becomes increasingly
abilities including memory, judgment, reasoning, restless or confused as late afternoon or
problem solving and decision making. evening approaches.
Deafness: The loss of the ability to hear from one
or both ears; can be mild, moderate, severe or
profound, and can be inherited, occur at birth or
be acquired at a later point in life, due to illness,
medication, noise exposure or injury.
LEARNING OBJECTIVES
After reading this chapter, and completing the class • List the types of elder abuse.
activities, you will have the information needed to: • List risk factors for elder abuse.
• Describe physical and mental differences that are • List signs and behaviors of elder abuse.
important in older adult patients. • Identify and describe chronic diseases
• Describe how to assess an older adult patient. and disabilities.
• Describe how to provide care for an older • Describe considerations for providing
adult patient. care to patients with special healthcare or
• Describe common problems in older adult functional needs.
patients.
600 | Emergency Medical Response
INTRODUCTION other special needs, such as visual impairment
or deafness. Special healthcare or functional
When responding to older adult patients,
needs also exist for the physically challenged,
remember that patience, kindness and respect
as well as for those suffering from chronic
will help you care for the patient in the most
diseases. In this section, you will learn about
effective manner. Misconceptions about older
important factors to take into account when
adult patients, such as that they are all weak or
sickly, hard of hearing and have difficulty learning caring for patients with conditions such as
new things, can often lead to older adults being arthritis, cancer, cerebral palsy and multiple
treated like children and not like responsible sclerosis.
adults. Explaining the steps you are taking to treat
and care for them, and using the same kind and
respectful manner you would use with younger OLDER ADULT PATIENTS
adult patients, will prove to be successful with The older adult population, those aged 65 years
older adult patients. and older, is the fastest-growing age group in
the United States (Fig. 26-1). Because people
This chapter will provide you with the information
are living longer, older adults make up a large
needed to assist older adult patients and identify
proportion of the population and, thus, make up
and deal with any special healthcare or functional
a greater segment of those requiring care. Older
needs they may have, such as dementia, including
adult patients are, in many ways, no different from
Alzheimer’s disease.
younger adult patients, but everyone undergoes
You will also learn about patients with special some changes in their physical and mental health as
healthcare or functional needs, such as those they age, and these changes need to be considered
with mental illness, intellectual disabilities and when providing care.
Fig. 26-1: The older adult population includes those aged 65 years and older.
CRITICAL As people age, normal changes in physical and mental functioning occur. These
FACTS changes occur in all body systems, including nervous, digestive, respiratory,
circulatory, musculoskeletal, integumentary, genitourinary and endocrine.
Chapter 26: Older Adults and Patients with Special Healthcare or Functional Needs | 601
Physical and Mental Differences Sense of Touch and Pain
to Consider in Older Adults Diminished pain sensation can also prove dangerous
As people age, normal changes in physical for older adults, as they may not be aware of an
and mental functioning occur. These changes injury or of the seriousness of an injury.
occur in all body systems, including nervous,
digestive, respiratory, circulatory, musculoskeletal, Diminished Taste and Smell
integumentary, genitourinary and endocrine. A decrease in sense of taste and/or smell can
lead to health problems such as poor nutrition,
Sensory Changes in Older Adults decreased appetite and even food poisoning, if an
Aging patients often have decreased sharpness older adult is unable to detect that food has gone
of the senses, and this loss of sensory awareness bad. A decrease in the ability to smell can also be
brings possible risks that are unique to this a safety concern, as odors such as natural gas,
age group. propane or gasoline may not be easily detected.
Vision Heart/Blood Vessels
Because vision in older adults may be poor due to Aging causes the heart to work harder. The heart
problems such as decreased night and peripheral muscle thickens and becomes less elastic, and
vision, farsightedness, cataracts and decreased arteries stiffen, which makes it harder for blood to
tolerance to glare, incidents are more likely to flow through them.
occur. Misreading instructions for medication, falls
and motor-vehicle crashes are common among Over the years, plaque can build up within the
older adults, and may be due, in part, to vision arteries and restrict or block blood flow in a
problems (Fig. 26-2). condition called atherosclerosis. Blood clots can
also form and further restrict blood flow, factors
which can lead to heart attack or stroke (Fig. 26-3).
Hearing
The ability to hear gradually diminishes with age, Heart failure also develops when the heart cannot
especially for higher frequency sounds. Hearing pump enough blood to meet the body’s demand.
loss can be an indirect cause of injury; for example, Valve problems, including narrowing or leaking
an older adult might have trouble hearing a warning of the aortic or mitral valve, are also common in
alarm or siren. older adults.
Fig. 26-2: Poor vision in older adults may result in an increased likelihood for misreading medication
instructions.
602 | Emergency Medical Response
Problems in various digestive organs can cause
different symptoms, such as difficulty swallowing,
stomachache, nausea, diarrhea and constipation.
This often affects appetite and nutrition, leading to
fatigue and weight loss.
Nervous System
Arteries of the heart The majority of middle-aged and older adults
retain their abilities to learn, remember and solve
problems. However, cognitive impairment,
exhibited by memory loss and other problems, such
as issues with perception, balance, coordination,
reasoning, judgment and sleep, can occur and are
not a normal part of aging. They can be the result
of reversible causes, such as acute illness, or the
side effects of medication. Cognitive impairment
also can be the result of certain neurological
disorders including a range of dementias. Some
changes also may be due to clinical depression,
which is more common in older adults.
Unblocked Partially Completely
blocked blocked
Fig. 26-3: Buildup of plaque on the inner walls of the arteries Muscles and Bones
reduces blood flow to the heart muscle and may cause a heart attack. Problems of the musculoskeletal system are
common in older adults and can range from minor
sprains or inflammation to fractures, arthritis or
Arrhythmias are usually categorized according to
cancer. Bones become less dense over time,
the affected part of the heart—the atrial (upper)
especially in women, and this can lead to fractures.
part, or the ventricular (lower) part of the heart—as
Musculoskeletal problems can also lead to a more
well as by the change in rhythm. An aneurysm is
sedentary lifestyle, and the inactivity itself can lead
a widening or ballooning out of a major artery that
to a further decline in function.
develops in the aorta or one of the other major
arteries in the chest or abdomen. Aneurysms are
common in older adults, especially those with high Other
blood pressure or coronary artery disease. Other common health issues for older patients
include urinary problems, skin diseases,
Lungs and Breathing decreased ability to fight off illness and
Aging also affects the lungs, which become nutritional problems.
stiffer and less elastic, shrinking the airways and
weakening the chest muscles. This causes the total Assessing and Caring for the
flow of air into and out of the lungs to decrease, Older Adult Patient
and increases the chances of developing breathing
problems. Older people are also more prone Assessing the Older Adult Patient
to lung infections, such as pneumonia, due to When assessing an older adult patient, follow the
changes in the lungs and immune system. same care and procedures, including checking
breathing and pulse, as you would for a younger
adult. However, you should keep the following
Stomach and Intestines points in mind when providing care.
With aging, the digestive tract becomes stiffer,
and the contractions that allow food to move Patients who appear untidy and uncared for
effectively through the digestive system decrease. may not be taking good care of themselves and
Older adults may also suffer from conditions and might have been neglectful in tending to their
diseases, such as hardening of the arteries and own medical needs. Whenever possible, speak
diabetes, which can upset the function of the to the patient’s family or caregivers to identify the
intestines and lead to symptoms and complications. patient’s usual behavioral patterns and whether
Medications commonly prescribed for older adults the patient is behaving normally or has changed
can also cause problems in the digestive tract. in response to an emergency.
Chapter 26: Older Adults and Patients with Special Healthcare or Functional Needs | 603
Fig. 26-4: Speak with older adult patients at eye level, and speak slowly and clearly, allowing time to
ensure they understand.
When speaking with older adult patients, speak medical services (EMS) personnel. The Vial of Life
a little more slowly and clearly, and allow time kit is offered to patients across North America and is
to ensure they understand, unless the situation kept on the patient’s refrigerator to alert responders
appears urgent. Speak to the patient at eye level, to the patient’s health conditions, medications and
and turn lights on to make it easier for the patient to any other medical information the patient wishes
see you (Fig. 26-4). to supply (Fig. 26-5). The kit includes a form, a
plastic bag to store the form and decals to inform
When obtaining the SAMPLE history from the responders that the information is available. One
patient, consider the following: decal is kept on the patient’s front door and the
other is on the bag. The kit is ideal for a situation
The patient may become tired easily.
in which a patient is unconscious, home alone
You will need to clearly explain what you are
and unable to provide vital information. Check the
doing before beginning the examination.
patient’s door and refrigerator to see if the patient is
The patient may downplay symptoms due to fear a participant in the program.
of institutionalization or losing independence.
It may be difficult to assess peripheral pulses. Caring for the Older Adult Patient
Some signs and symptoms you observe may be Some key considerations exist in the care of an
a part of normal aging; distinguish these from older adult patient:
any that may be related to the emergency.
Explain everything you are doing, calmly and slowly.
Due to many factors, including diminished senses,
an older adult may not show severe symptoms,
Handle the patient’s skin with special care, as it
can tear easily.
even if very ill. Continue to reassess the patient’s
condition, as it may deteriorate quickly. If the patient is responsive and a stroke is
suspected, the patient may have difficulty chewing,
Some older patients may be participants in the swallowing and clearing the airway of secretions.
Vial of Life program, which was designed to allow Dentures and other dental devices can cause
patients to provide medical information to emergency airway obstruction.
CRITICAL When assessing an older adult patient, follow the same care and procedures,
FACTS including checking breathing and pulse, as you would for a younger adult.
604 | Emergency Medical Response
Fig. 26-6: Place the patient in the Fowler’s position for transport
Fig. 26-5: Vial of Life kit. if they are responsive and breathing.
If artificial ventilation is required and the patient As a precaution, immobilize unresponsive
is wearing dentures, it may be easier to leave the patients during extrication from the scene to
dentures in place. the ambulance, based on local protocols.
If it is difficult to tilt the patient’s head back due
to conditions such as a curvature of the spine, Common Problems
perform a jaw-thrust (without head extension) in the Older Adult
maneuver.
Dementia
Blood-thinning medications and aspirin may
Older adult patients can become confused when
make any bleeding more difficult to control.
their cognitive functions decrease. Confusion is
If the patient’s mental status changes and the
a symptom of memory loss, and can be a sign of
patient is unable to maintain the airway, consider
cognitive impairment. Some types of cognitive
inserting an oropharyngeal airway (OPA). OPAs
impairment are chronic and cannot be reversed;
should only be used on unconscious patients
these are referred to as dementias. Dementia
with no gag reflex.
is a set of symptoms characterized by problems
Be prepared to assist with ventilation, but do not with memory, reasoning, orientation and personal
apply too much pressure, as this could result in care. A patient with dementia may behave oddly
chest injury. and become anxious or aggressive. As people with
Continue to re-evaluate during transport. dementia become increasingly unaware of their
surroundings, they ultimately become unable to
Consider the following conditions when positioning
perform normal tasks. Dementia is not caused by
a patient for transport:
stress or a crisis, but often during a time of crisis
If the patient is responsive and able to others may notice something is wrong, as the
breathe, place the patient in the Fowler’s person becomes increasingly confused. About 50
position (Fig. 26-6). percent of all people admitted to nursing homes
suffer from some type of dementia.
If the patient has an altered mental status and
you cannot protect the airway, place the patient
in a side-lying recovery position. Alzheimer’s Disease
If a spinal injury is suspected, a patient with Alzheimer’s disease is the most common type
a curvature of the spine could be injured if of dementia among older adults. Those with the
placed on a backboard. Use blankets or another disease have the same basic needs as other
extrication device such as a scoop stretcher patients. Alzheimer’s dementia is not a normal
for immobilization. part of growing older, but it is estimated that of
CRITICAL There are several considerations when caring for an older adult. These include
FACTS working calmly, slowly and with extra care; being aware of dentures and how to deal
with them; being aware of blood-thinning medications and aspirin; and knowing
what care procedures are appropriate for an older adult, such as being aware of the
amount of pressure you use when assisting with ventilation to avoid chest injury.
Chapter 26: Older Adults and Patients with Special Healthcare or Functional Needs | 605
the 5.5 million Americans living with dementia, These patients may exhibit the following types
an estimated 5.3 million are age 65 and older. of behavior:
This means approximately 1 in 10 people (or
10 percent) age 65 and older has Alzheimer’s Restlessness, anxiety
dementia. Witnessing a patient behaving Worried expression
dysfunctionally can be frustrating, but try to Reluctance to enter their own room
focus on the patient and their attempts to tell you Reluctance to enter brightly lighted areas
something is wrong. Your job is to find out what the
patient is trying to communicate, so that you can
Crying
provide appropriate care. Wringing hands
Pushing others away
A person with Alzheimer’s disease may Gritting teeth
demonstrate some common patterns such as:
Taking off clothing
Putting up a social facade by pretending not to These behaviors may represent real physical needs,
know or remember a certain situation. such as needing to use the bathroom or being
Pacing and wandering. hungry, uncomfortable or in pain. Responding in a
Rummaging and hoarding. kind, gentle manner will help calm the patient so
Extreme catastrophic reactions, such as you can discover what the problems are.
screaming, throwing objects or striking out.
Sundowning (restlessness and confusion in Elder Abuse
the evening). Elder abuse occurs when someone does
Speaking nonsense. something that harms or threatens the health and
welfare of an older adult, or when a caregiver fails
Hallucinating or believing things that are not true.
to provide adequate care for an older adult.
Exhibiting depression, anger or suspicion.
Research suggests that 4 percent of adults older
If you know how to respond to these behaviors, you
than 65 are subjected to elder mistreatment in
can provide better care and treat the patient with
the United States. This mistreatment can occur
dignity and respect. If you encounter a patient who
within the family, in formal care settings, or in the
is walking aimlessly and then walking away, ask if
community or society at large. Elder abuse within
you may walk with them, and use this as a way to
the family is often the result of a caregiver being
guide the patient back to the appropriate place.
overwhelmed or not knowing what is needed
Talk to the patient and listen carefully to what the
when providing care for an older adult. Reluctance
patient has to say. Take steps to prevent the patient
to provide care can also lead to mistreatment.
from leaving.
Mistreatment in a formal care setting is often
In the case of a catastrophic reaction, reassure the attributable to staff who have not had adequate
patient that you are not going to cause any harm training in providing direct patient care.
and that you also will not allow them to hurt anyone.
Elder abuse can include:
Let the patient know the limits by saying something
such as, “It’s not okay to hit someone.” Physical abuse.
A person with Alzheimer’s disease may become Emotional abuse.
increasingly restless or confused as late Neglect (intentional or unintentional).
afternoon or evening approaches, becoming more Financial exploitation.
demanding, upset, suspicious or disoriented.
This type of behavior is called sundowning and
Abandonment.
is common in people with Alzheimer’s disease. Any combination of the above.
CRITICAL Older adults can become confused when their cognitive functions decrease.
FACTS Confusion is a symptom of memory loss, and can be a sign of cognitive impairment.
Some types of cognitive impairment are chronic and cannot be reversed; these are
referred to as dementias.
Alzheimer’s disease is the most common type of dementia among older people.
606 | Emergency Medical Response
Fading Memories
According to the Alzheimer’s Association, need help with basic services such as
Alzheimer’s disease affects an estimated nutrition and transportation. A visiting nurse
5.5 million Americans, making it the only or nutritionist and volunteer programs such
disease among the top 10 causes of death as Meals on Wheels may be helpful, and
without prevention, a cure or a way to slow volunteer or paid transportation services may
its progression. While most people with the be available.
disease are older than 65, Alzheimer’s disease
can strike people in their 40s and 50s. Men Visiting nurses, home health aides and
and women are affected almost equally. homemakers can come to their home and
At this time, scientists are still looking for give help with healthcare, bathing, dressing,
the cause. shopping and cooking. Many adult day care
centers provide recreational activities designed
Signs and symptoms of Alzheimer’s disease for people with Alzheimer’s disease. Some
develop gradually and include confusion; hospitals, nursing homes and other facilities
progressive memory loss; and changes may take in people with Alzheimer’s disease for
in personality, behavior, and the ability to short stays.
think and communicate. Eventually, people
with Alzheimer’s disease become totally For persons with Alzheimer’s disease who
unable to care for themselves. While there can no longer live at home, group homes or
are no treatments to stop or reverse a foster homes may be available. Nursing homes
person’s mental decline from Alzheimer’s offer more skilled nursing care, and some
disease, several drugs are now available specialize in the care of those with Alzheimer’s
to help manage some of these symptoms. or similar diseases. A few hospice programs
In addition, because a number of disorders accept persons with Alzheimer’s disease who
have signs and symptoms similar to those of are nearing the end of their lives. Caregivers may
Alzheimer’s disease, and can be treated, it is need to search to find out which, if any, services
very important for anyone who is experiencing are covered by Medicare, Medicaid, Social
memory loss or confusion to have a thorough Security, disability or veterans’ benefits in their
medical examination. state. A lawyer or a social worker may be able to
help them.
Most people with illnesses such as Alzheimer’s
disease are cared for by their families for much of To locate services that can help the caregiver,
their illness. Giving care at home requires careful the person with Alzheimer’s disease and
planning. The home has to be made safe, and other family members, individuals can
routines must be set up for daily activities, such search for social service organizations and
as mealtimes, personal care and leisure. state and local government listings on the
Internet or in the phone book. They can
It is important for anyone caring for a person also contact their local health department,
with Alzheimer’s disease or a related problem to area office on aging or department of
realize that they are not alone. There are people social services. Senior centers, as well as
and organizations that can help them and the churches, synagogues and other religious
person with Alzheimer’s disease. For healthcare institutions, may also have information and
services, a physician—perhaps their family programs. Another great resource is the
physician—or a specialist can give them medical Alzheimer’s Association. To locate the
advice, including help with difficult behavior and chapter nearest to them, individuals can
personality changes. call the association’s 24-hour, toll-free
number: 800-272-3900 or log onto alz.org.
When caring for a person with Alzheimer’s
disease living at home, people may also Source: Alzheimer’s Association. alz.org. Accessed April
2017.
Chapter 26: Older Adults and Patients with Special Healthcare or Functional Needs | 607
Risk factors for elder abuse include: Malnourishment.
Mental impairment in the dependent person or Lack of energy or spirit.
caregiver (or both). Poor hygiene.
Isolation of the dependent person or the Reports of the patient being left in unsafe
caregiver (or both). situations or having an inability to get
needed medication.
Inadequate living arrangements for the
dependent person. Maintain a proper perspective if you suspect an
Inability to perform daily functions. abusive situation. Do not confront the suspected
abuser. Take note of any inconsistencies between
Frailty.
the reports received from the patient and the
Family conflict.
suspected abuser. Follow local protocols in relation
Family history of abusive behavior, alcohol or drug to elder abuse and the legal obligations to report
abuse, mental illness or intellectual disability. suspected elder abuse. Document your findings as
Stressful family events. per local protocols and report your suspicions to
Poverty. the hospital upon arrival.
Financial stress, especially related to
healthcare needs.
PATIENTS WITH SPECIAL
In situations where frail or debilitated older people HEALTHCARE OR
cannot help themselves at all, they may need more FUNCTIONAL NEEDS
care than the caregiver is able to provide. Mentally
ill people who hit, spit or scream can cause stress Mental Illness
to the caregiver, causing the caregiver to respond Mental illness is a broad term that describes a
with some form of elder mistreatment. range of medical conditions that affect a person’s
mood or ability to think, feel, relate to others and
Watch for visible signs and certain behaviors by function in everyday activities. About one-quarter
either the older adult patient or the caregiver that of Americans suffer from a diagnosable mental
may provide clues that elder abuse has occurred. disorder in a given year, though some of these
Some signs that may raise suspicion of elder abuse are temporary conditions. About 6 percent of
include: Americans suffer from serious mental illnesses,
such as schizophrenia, major depression, panic
A person who is frequently left alone.
disorder, bipolar disorder or personality disorder,
A history of frequent trips to the
although many are treatable with medication and
emergency department.
psychosocial treatment.
Old and new fractures or bruises, especially
bruises on both sides of the inner arms and thighs. The National Institute of Mental Health describes
several types of mental illnesses:
Repeated falls.
Unexplained hair loss, skin rashes, irritation or Mood disorders; for example, major depression
skin ulceration. and bipolar disorder
Inappropriate dress. Schizophrenia
CRITICAL Elder abuse takes many forms: physical, emotional, neglect, financial exploitation,
FACTS abandonment or any combination of these.
Risk factors of elder abuse include mental impairment or isolation of the patient
and/or caregiver, inadequate living situation, inability to perform daily functions,
frailty, family conflict, abuse or stress or history of these, poverty and financial
stress.
Signs of possible elder abuse include a patient who is frequently left alone, a
history of emergency department visits, old and new injuries, unexplained skin
problems or hair loss, inappropriate dress, poor hygiene, malnourishment and a lack
of energy or spirit.
608 | Emergency Medical Response
Anxiety disorders; for example, panic unfamiliar sights and sounds disorienting and
disorder, obsessive-compulsive disorder and may be frightened. Explain what is happening
posttraumatic stress disorder at the scene, what the sounds and smells are,
Eating disorders and what may happen at the scene such as
additional loud sounds caused by equipment
Attention-deficit/hyperactivity disorder (ADHD)
or traffic.
Autism
Alzheimer’s disease If a patient wears glasses, try to find them at the
scene or in the home. This is especially important
for older adults, who may try to hide the fact that
Intellectual Disabilities
they are visually impaired. As with all patients,
Patients with an intellectual disability have a reassure them, explain what you are doing and
significantly below-average score on a test use a gentle touch to keep them calm. Explain
of mental ability or intelligence. Their ability what is happening at each step so the patient
to function in areas of daily life, such as feels more in control. Nearly two-thirds of children
communication, self-care, and getting along with visual impairment also have one or more
in social situations and school activities, is other disabilities, such as intellectual disability,
also limited. Different degrees of intellectual cerebral palsy, deafness or epilepsy. Children
disability exist, and a person’s level can be with more severe visual impairment are more likely
defined by the intelligence quotient (IQ), or than children with milder visual impairment to have
on how dependent the person is on others to additional disabilities.
perform daily needs.
Deaf and Hard of Hearing
Down Syndrome Deafness is the loss of the ability to hear from
Down syndrome is a genetic condition that one or both ears. It can be inherited, occur at
results from having an extra copy of chromosome birth, or be acquired at a later point in life due to
21. Both mental and physical symptoms will be illness, medication, noise exposure or injury. The
evident, although the symptoms can range from severity of the deafness can be mild, moderate,
mild to severe. Individuals with Down syndrome severe or profound. Two main types of deafness
have mild-to-moderate intellectual impairment. exist, and they are defined by the location of the
Additionally, other health problems, such as heart problem. A conductive hearing loss occurs when
disease, dementia, hearing loss, and problems there is a problem with the outer or middle ear; a
with the intestines, eyes, thyroid and skeleton, are sensorineural hearing loss is due to a problem with
common in people with Down syndrome. It is not the inner ear and possibly the nerve that goes from
uncommon for people with Down syndrome to live the ear to the brain. Some people have both types
productive lives well into adulthood. of deafness.
The term “deaf” describes someone who is unable
Visually Impaired to hear well enough to rely on hearing as a means
When a person is visually impaired, their eyesight of communication. The term hard of hearing
cannot always be corrected to a “normal” level. can be used to describe people who have a less
Types of visual impairments include a loss of visual severe hearing loss and are still able to rely on their
acuity, where the eye does not see objects as hearing for communication.
clearly as normal, or a loss of visual field, where the
eye cannot see as wide an area as normal without Hearing loss is a disability that may not be
moving the eyes or turning the head. immediately obvious to you when approaching
a patient. Be certain a patient can hear you,
When approaching patients, look for signs of especially when treating older adults. Identify
visual impairment, such as glasses or a white yourself, and speak slowly and clearly, but
cane. When approaching someone you know do not shout. Ask if the patient can hear you.
has a visual impairment, announce that you Position yourself so the patient can hear you
are approaching, who you are and why you are better by facing the patient; some patients who
there so that the patient is not frightened. Ask are hard of hearing can read lips. You can also try
if the person can see. Keep in mind that some speaking directly into the person’s ear. If possible,
blind patients are able to use other senses to turn off background noise, such as a television
compensate for their lack of sight. Especially at or radio. If this does not work, write down your
an incident scene, these patients may find the questions.
Chapter 26: Older Adults and Patients with Special Healthcare or Functional Needs | 609
Physically Challenged
A person who is physically challenged may have
been born with the condition or may have acquired
it later in life. The person may have a general
diminished ability to move due to injury or illness,
and may use a mobility aid, such as a walker,
wheelchair or cane (Fig. 26-7, A–B). If you are aware
that someone is physically challenged, ask what
help the patient needs, for example to transfer from
one surface to another (bed to chair) or to walk.
Traumatic Brain Injury
Someone who has suffered a traumatic brain
injury may have been involved in a motor vehicle
collision, suffered a fall or been the victim of an
assault. Someone who has survived a traumatic
brain injury may have permanent cognitive and
physical problems. Cognitive impairment often
includes difficulty with attention, memory, judgment,
reasoning, problem solving and decision making.
Physical problems can range from mild to severe
and may result in the person moving slowly or relying
on a mobility aid, such as a walker or wheelchair.
Chronic Diseases and Disabilities A
Illnesses that occur gradually and continue over
a long period of time are referred to as chronic
conditions. Often, a chronic condition lasts
throughout the person’s life. Chronic conditions
include heart disease, diabetes and arthritis.
Patients with some chronic conditions, such as
multiple sclerosis, can live for years with few
symptoms and then suddenly experience a flare-up
with many symptoms appearing at once. In such
an acute phase, the patient will often consult a
physician and, following treatment, the acute phase
may be resolved. However, the patient will continue
to live with the effects of the chronic condition.
Arthritis
Arthritis is a condition that causes joints to become
inflamed, swollen, stiff and painful. A few or many
joints may be affected as the smooth tissues that
cover the ends of bones become rough or wear
away, causing painful friction between bones upon
movement. Because of this friction, tissues around
the joints swell, leading to stiffness, which makes
normal movement difficult.
When providing care for a patient with arthritis,
keep the following in mind:
Assure the patient that you are aware that B
movement is painful, and that you are there Fig. 26-7, A–B: A person who is physically challenged may use a
to help. mobility aid, such as (A) a walker or (B) a cane.
610 | Emergency Medical Response
Never move a joint that is painful, red or swollen.
Service Animals Handle the patient’s joints carefully, supporting
the areas above and below the joint when you
A service animal is any guide dog, signal dog move them.
or other animal individually trained to provide
assistance to an individual with a disability. Cancer
These animals are considered service animals Cancer is the abnormal growth of new cells that
under the Americans with Disabilities Act can spread and crowd out or destroy other body
(ADA), whether or not they have been licensed tissues in the form of a malignant tumor, which
or certified by a state or local government. is a solid mass or a growth of abnormal cells
that can grow anywhere in the body. Malignant
Service dogs perform some of the functions tumors can spread to other parts of the body,
and tasks that the individual with a disability growing quickly and invading and destroying other
cannot perform independently. These dogs body tissue.
receive special training to help assist patients
with many different types of disabilities, such Typically, cancer is treated according to the type
as visual impairment, limited mobility, balance and location of the cancer, and whether or not it
problems, autism, seizures, or other medical has spread. The three most common approaches
problems like low blood sugar or psychiatric to treatment are surgery, chemotherapy and
disabilities. Services include retrieving objects, radiation. Common side effects of chemotherapy
pulling wheelchairs, opening and closing doors, include nausea, diarrhea, loss of hair and extremely
turning light switches off and on, barking when dry skin. Many people will experience skin burns,
help is needed, finding another person, leading fatigue, and possibly nausea and vomiting with
the person to the handler, assisting with radiation treatment; others may experience
balance and counterbalance, providing deep hair loss as a result of the radiation treatment.
pressure and many other individual tasks.
When providing care for a person being treated
A service animal is not a pet and can be identified for cancer, infection control is important because
by either a backpack or special harness. By chemotherapy and radiation affect a person’s
law, service animals must be allowed into most immune system. Strict hand-washing guidelines
establishments. EMRs should not handle the and standard precautions must be taken. Never
service animal unless absolutely required. Never provide care for a patient who is receiving cancer
separate the patient from the service animal, as treatment if you have a cold or flu.
this could cause stress, agitation and anxiety to
both parties which can complicate patient care. A patient receiving chemotherapy or radiation
It could also become a safety issue. treatment may feel tired. Skin changes and rashes
from some drugs or burns from radiation treatment
are common, so be gentle.
Cerebral Palsy
Cerebral palsy is the name given to a group of
disorders affecting a person’s ability to move and
maintain balance and posture. It does not get
worse over time, although symptoms can change
over a patient’s lifetime.
Cerebral palsy causes damage to the part of
the brain that controls the amount of resistance
to movement in a muscle (muscle tone), which
allows you to keep your body in specific postures
or positions.
Cystic Fibrosis
Cystic fibrosis (CF) is an inherited disease of the
A service animal has been individually trained to
provide assistance to an individual with a disability. mucous and sweat glands, affecting the lungs,
Never separate an individual from their service animal. pancreas, liver, intestines, sinuses and sex organs.
CF causes mucus to become thick and sticky,
Chapter 26: Older Adults and Patients with Special Healthcare or Functional Needs | 611
CRITICAL Illnesses that occur gradually and continue over a long period of time (even lifetime)
FACTS are referred to as chronic conditions. Chronic conditions include heart disease,
diabetes and arthritis. Patients with some chronic conditions, such as multiple
sclerosis, can live for years with few symptoms and then suddenly experience a
flare-up with many symptoms appearing at once.
blocking the airways. This makes it easy for bacteria Muscular Dystrophy
to grow, which leads to repeated serious lung Muscular dystrophy is a group of genetic disorders
infections. These infections can cause serious in which patients suffer progressive weakness and
damage to the lungs. Mucus can also block tubes, degeneration of the muscles. About a quarter of a
or ducts, in the pancreas, so that digestive enzymes million children and adults are living with the disease
cannot reach the small intestine. Without these, the in the United States. In the most common form,
intestines cannot absorb fats and proteins fully. Duchenne muscular dystrophy, the disease begins
The most common symptoms of CF include: in early childhood; in other forms, it begins later in
life. People with muscular dystrophy may have mild-
Frequent coughing that brings up thick sputum, to-severe muscle weakness, depending on the type.
or phlegm. Although the disorder primarily affects the skeletal
Frequent bouts of bronchitis and pneumonia muscles—the muscles that allow you to move—
that can lead to inflammation and permanent some types of muscular dystrophy affect cardiac
lung damage. muscles. In the later stages of the disease, patients
with muscular dystrophy often develop respiratory
Salty-tasting skin.
problems and may require assisted ventilation.
Dehydration.
Infertility (mostly in men).
Autism
Ongoing diarrhea or bulky, foul-smelling and
Autism spectrum disorder (ASD) consists
greasy stools.
of a range of developmental disorders, including
Huge appetite but poor weight gain and growth. autism at the more severe end of the spectrum and
Stomach pain and discomfort caused by gas. Asperger syndrome at the less severe end. The
diagnosis of autism seems to have become more
Multiple Sclerosis common in recent years. The Centers for Disease
Multiple sclerosis (MS) is a chronic disease that Control and Prevention reports that the rate of ASD
destroys the coating on nerve cells in the brain and is 14.6 per 1000 for children 8 years of age, and
spinal cord, interfering with the nerves’ ability to that in this age group, males are 4.5 times more
communicate with each other. MS is more common likely to have ASD than females.
in females than in males, and the onset typically
Children with ASD have deficits in social interaction
occurs as early as the teen years and as late as
and communication, and exhibit repetitive behaviors
age 50. Symptoms usually appear and disappear
and interests. Some may also have sensory
over a period of years and can include:
disturbances. People with these disorders interpret
Feelings of numbness, tingling and burning. the world only through verbal reasoning.
Overwhelming fatigue at all times. Children with autism exhibit unusual behaviors
Vision problems. that are usually noticed first by the parents. A baby
Insomnia. may seem unresponsive to people or focus intently
Speech problems. on one item for long periods of time. However,
symptoms can also appear in older children who
Bowel and bladder problems.
have been developing normally. A normal child
Fits of anger or crying.
who has shown affection and spoken as a toddler
Paralysis. can become silent, withdrawn, self-abusive or
Forgetfulness and slowness in understanding. indifferent to social overtures.
Edema and cold feet due to lack of circulation.
Remember that patients with autism might not
When treating patients with MS, help them focus look at you directly and physical touch may be
on what they can do. disturbing to them. Avoid interpreting these
612 | Emergency Medical Response
mannerisms or responses as being unsociable. or other caregiver when, for example, a patient
When communicating with patients with becomes short of breath. You may be required
autism, it may help to use verbal explanations of to attend to a patient who has made special
emotions. arrangements regarding their treatment or care
in an emergency, such as the patient’s wishes
Hospice Care regarding resuscitation. You must understand
the type of hospice you are being called to and
Hospice care is the care provided to a terminally any living wills or advance directives that may be
ill patient in the final 6 months of life, consisting of in place. You may require official forms, such as
a group of caregivers who offer medical, mental, do not resuscitate (DNR) orders, as confirmation
physical, social, economic and spiritual support. regarding a living will.
Central to the hospice way of thinking are the ideas
that the dying person is an individual who should
not be separated from the family or support system, PUTTING IT ALL TOGETHER
and that dying is a normal and expected part of the
life cycle. The family is encouraged and trained to In this chapter, you have learned the importance of
participate in the care. treating all patients with respect, regardless of age,
health condition, mental status or physical ability.
The focus of hospice care is on keeping the person You have learned about common issues the older
as comfortable and pain-free as possible, because adult may face and how to deal with challenges
the fear of pain greatly contributes to the person’s such as hearing loss, loss of sensory acuity and
stress, as well as that of the family and caregivers. other health conditions. You are now aware of the
The emphasis is not on curing the illness, but different types of dementias you may encounter
rather on providing physical, emotional, social and with older adult patients, including Alzheimer’s
spiritual comfort to the dying person. The hospice disease, and the importance of recognizing
philosophy also provides practical assistance, that not all older adults have diminished
emotional support and bereavement care to the cognitive abilities.
dying person’s family. Pain relief is administered
without the use of needles; instead, caregivers use Along with the challenges the older adult faces,
oral medications, pain-relieving patches and pills you have also learned about dealing with different
that can be given between the cheek and gums. chronic illnesses and the importance of dealing
with patients on an individual basis in accordance
Emergency medical responders (EMRs) are usually with their specific symptoms and difficulties. All
not required during hospice care. However, you patients require clear communication and respect
may sometimes be called in by a family member during assessment and treatment.
You Are the Emergency Medical Responder
As you continue your care, the man begins to remember small bits of information, but still does
not remember where he lives or where he is. He becomes agitated at the help being provided,
saying he does not need any help. How should you continue to provide care for the patient?
Chapter 26: Older Adults and Patients with Special Healthcare or Functional Needs | 613
UNIT 8
EMS Operations
27 EMS Support and Operations �������������������������������615
28 Access and Extrication���������������������������������������������635
29 Hazardous Materials Emergencies ���������������������646
30 Incident Command and Multiple-Casualty
Incidents �����������������������������������������������������������������������657
31 Response to Disasters and Terrorism �����������������672
32 Special Operations�����������������������������������������������������694
27
EMS SUPPORT
AND
OPERATIONS
You Are the
Emergency Medical
Responder
You are an emergency medical
responder (EMR) approaching
the scene of a two-car collision
at a busy intersection. It is rush
hour, and traffic is heavy. One of
the involved cars is situated on
the median strip, and the other
is off the road on the shoulder,
just past the intersection.
There are multiple occupants
in each vehicle. How would
you respond? What should you
consider when you size up the
scene?
KEY TERMS
Air medical transport: A type of transport to a Packaging: The process of getting a patient ready
medical facility or between medical facilities by to be transferred safely from the scene to an
helicopter or fixed-wing aircraft. ambulance or a helicopter.
Audible warning devices: Devices in an emergency Transferring: The responsibility of transporting a
vehicle to warn oncoming and side traffic of the patient to an ambulance, as well as transferring
vehicle’s approach; includes both sirens and information about the patient and incident to
air horns. advanced medical personnel who take over care.
Emergency medical dispatcher (EMD): Trauma alert criteria: An assessment system used
A telecommunicator who has received special by emergency medical services (EMS) providers
training for triaging a request for medical service to rapidly identify those patients determined
and allocating appropriate resources to the scene to have sustained severe injuries that warrant
of an incident, and for providing prearrival medical immediate evacuation for specialized medical
instructions to patients or bystanders before more treatment; based on several factors including
advanced medical personnel arrive. status of airway, breathing and circulation, as well
as Glasgow Coma Scale score, certain types of
Jump kit: A bag or box containing equipment used injuries present and the patient’s age; separate
by the emergency medical responder (EMR) when criteria for pediatric and adult patients.
responding to a medical emergency; includes
items such as resuscitation masks and airway Visual warning devices: Warning lights in an
adjuncts, disposable latex-free gloves, blood emergency vehicle that, used together with
pressure cuffs and bandages. audible warning devices, alert other drivers of
the vehicle’s approach.
Landing zone (LZ): A term from military jargon used
to describe any area where an aircraft, such as an
air medical helicopter, can land safely.
LEARNING OBJECTIVES
After reading this chapter, and completing the class • Define air medical transport and the criteria for
activities, you will have the information needed to: when it should be requested.
• Describe the roles of traditional and nontraditional • Discuss safety issues related to air medical
emergency medical responders (EMRs). transport and landing zones (LZs).
• Explain all phases of an emergency medical • Discuss emergency vehicle safety and other safety
services (EMS) response and associated issues during response.
responsibilities of an EMR. • Identify and describe high-risk situations.
• Identify the basic equipment used by an EMR. • Summarize patient care issues in the ambulance.
INTRODUCTION support and operations, including the phases
of an ambulance or other transport vehicle call
In earlier chapters, you learned how to care for and air medical response. As an EMR, you may
persons who are injured or ill. Although these skills never be involved in all of these situations but, as
are important for emergency medical responders a functioning part of the EMS system, you should
(EMRs) to learn, certain nonmedical operational have a brief overview of some of the aspects of
skills are just as important. In this chapter, you will out-of-hospital care.
learn about emergency medical services (EMS)
616 | Emergency Medical Response
ROLES OF THE EMR IN THE 5. Transferring the patient to the ambulance.
EMS SYSTEM 6. En route to the receiving facility.
7. Arrival at the receiving facility.
The term EMR can mean different things to
different people. In general, EMRs are individuals 8. Clear medical facility.
who have been trained to provide a minimum 9. Available for next emergency call.
standard of care according to the current national
scope of practice and EMS educational standards. Phase 1: Preparation for an
While EMRs may function as regular members of Emergency Call
an ambulance crew in some states, in other states
To be ready to respond to a scene, it is important
and areas they have other roles. There are also
to spend time preparing yourself, your equipment
several types of EMRs, ranging from those who
and your vehicle. As an EMR, you have a
stabilize and transport patients to those who can
responsibility to keep yourself physically fit and
provide prehospital medical care in the field, but do
mentally prepared for the challenges of responding
not transport.
to an emergency. Part of preparing for the call
involves the initial training you receive as an EMR.
Traditional EMRs It is important to remember that the end of your
When we talk about traditional EMRs, we EMR training is the beginning of having a duty to
generally refer to people who function within the respond to emergencies. You have a responsibility
9-1-1 system. These traditional EMRs are usually to continue your training through refresher, national
affiliated with a service, such as EMS systems, competency and continuing education programs.
law enforcement, fire rescue, search and rescue Some EMRs take more advanced training to
or sometimes lifeguarding and ski patrol. Another become emergency medical technicians (EMTs)
area in emergency medical response is hazardous and then perhaps advanced emergency medical
material (HAZMAT) or hazardous waste operations technicians (AEMTs) or paramedics.
and emergency response (HAZWOPER).
In preparing to respond to an emergency, you
should have basic medical equipment on hand.
Nontraditional EMRs Jump kits come in a variety of sizes and shapes
Nontraditional EMRs have had the same training and are commercially available. The contents may
as traditional EMRs but work in less traditional be regulated by a certifying agency or by your
settings. These people include athletic trainers, unit. In either case, be familiar with the contents
park rangers, trip leaders and others. You also and layout of the jump kits used by your unit
find these EMRs working as members of industrial or organization.
medical emergency response teams (MERTs), or
In some areas, EMRs work in a system in which
those involved in rope rescue, specialized trench
they may be involved in transporting the patient to
rescue or confined space rescue. Any EMR,
the receiving facility. If this is the case, the EMR
traditional or nontraditional, should be familiar
will have to prepare and inspect the ambulance
with the EMS system and their role in it.
or transport vehicle before every shift. Local
EMS systems and state regulations determine
PHASES OF A RESPONSE what equipment and supplies must be in the
vehicle, and any vehicle safety and readiness
A typical EMS response has nine phases. inspections required.
They are:
In other areas or circumstances, EMRs may be the
1. Preparation for an emergency call. only emergency personnel responding to a scene.
2. Dispatch. You should review state and local policies, rules
3. En route to the scene. and regulations regarding the minimum staffing
4. Arrival at the scene and patient contact. requirements in your area.
CRITICAL A typical EMS response has nine phases, from preparation for an emergency call to
FACTS availability for the next emergency call.
Chapter 27: EMS Support and Operations | 617
Phase 2: Dispatch at the scene. This will ensure that the appropriate
personnel arrive at the scene as quickly and safely
In many areas of the country, a communications
as possible. In cases of possible cardiac arrest, the
center/public safety answering point (PSAP)
EMD will ask if an automated external defibrillator
has a central access number such as 9-1-1
(AED) is available and being used.
for ambulance, police or fire rescue personnel.
Specially trained personnel, known as emergency A call taker is used by most communications centers
medical dispatchers (EMDs), often staff these that handle many calls. The call taker processes the
communications centers and are available on a information from the caller and provides the EMD
24-hour basis. They assist by obtaining the caller’s information. The information is then transferred
location and information critical to dispatching the to the dispatcher, who transmits the data to the
appropriate personnel and equipment. They are appropriate units. The call taker stays on the phone,
specially trained to help the caller care for patients providing prearrival information and gathering further
until emergency personnel arrive. information as the situation unfolds (Fig. 27-1).
Environments in which a call taker and dispatcher
During the call, the EMD will ask the caller specific
perform identical functions include rural areas or a
questions that will determine the appropriate
communications center with a minimal call load.
emergency personnel to dispatch. The EMD will ask
the nature of the emergency and the mechanism of
injury (MOI) or nature of illness. The EMD will ask Phase 3: En Route to the Scene
for the caller’s name, location and call-back number. To help a patient, you must be able to reach the
Additional information, such as the exact location scene safely. The most important skill to use at this
of the patient (e.g., second floor, back apartment), time is common sense. Walk with purpose—do
number of patients and the severity of the injuries, not run—to any emergency scene or your vehicle.
can be relayed to those responding to the Pacing yourself allows you to think clearly, survey
emergency after the initial dispatch has been issued. the area and plan for arrival at the scene. It also
Also, the EMD will obtain information from the caller reduces the risk of injuries from tripping and falling.
relating to unusual situations, conditions or problems
Fig. 27-1: A call taker in a communications center processes information from the caller and relays it to the
EMD, then stays on the phone to provide further information as the situation unfolds.
CRITICAL In many areas of the country, a communications center/PSAP has a central access
FACTS number such as 9-1-1 for ambulance, police or fire rescue personnel.
618 | Emergency Medical Response
If you are in a vehicle, whether a personal or responders or the patients? Look up, look down
emergency vehicle, you must always use a safety and look all around. What was the MOI or nature
belt. Some areas require all personnel working in of illness? Is there any severe, life-threatening
the EMS system to attend an emergency vehicle bleeding? How many patients are there? Do you
operator-training program. If you function in an need any additional help?
EMS system that requires response in a private
vehicle, become aware of the state and local laws Safety issues may necessitate assistance from law
and regulations that govern operation of private enforcement with crowd control. Assess as much
vehicles as emergency vehicles in that area. In all as possible from inside your vehicle. Ensure your
cases, when responding to an emergency, EMRs vehicle can leave the scene quickly if needed. For
should use appropriate driving behavior, including example, have your vehicle pointing toward the exit
consideration for the safety of others. Emergency of a dead-end street, so you do not waste time
response to the scene does not exempt any leaving a dangerous situation.
emergency personnel from traffic laws. The driver There may be local protocols for when you should
must know the traffic laws that govern the use of leave your vehicle given certain circumstances.
lights, sirens and intersection procedures. If protocols indicate you should wait for law
enforcement personnel to arrive, do not exit the
Phase 4: Arrival at the Scene vehicle before their arrival.
and Patient Contact After the scene size-up has been completed,
In this phase of response, you should be slow primary, secondary and ongoing patient
and cautious in your approach (Fig. 27-2). If you assessments will begin. Additionally, history taking,
have access to the appropriate communications including baseline vital signs and initial care, will be
equipment, notify the EMD of your arrival. As you provided to stabilize the patient(s) prior to transport.
enter the area, size up the scene and the situation.
If the scene is not safe, notify dispatch to send
personnel from the agencies necessary to make it Phase 5: Transferring the Patient
safe. Never endanger your life or the life of anyone to the Ambulance
else responding or already at the scene. Though transport is not a traditional role for an
EMR, at times you may be part of the ambulance
When approaching the scene, follow standard crew or be asked to help transfer a patient to the
precautions before making any contact with the ambulance (Fig. 27-3). By the time the ambulance
patient. Use disposable latex-free gloves, gown, arrives, you may have completed the primary
mask and protective eyewear when appropriate. assessment, the physical exam, the patient’s
Be sure to ask yourself critical questions. Is history and begun care. You may have recorded
the scene safe? Are there any hazards to the the vital signs and started packaging the patient for
Fig. 27-2: Size up the scene to ensure your safety before approaching patients. Photo: courtesy of Ted Crites.
Chapter 27: EMS Support and Operations | 619
Fig. 27-3: At times, you may be asked to help transfer a patient to the ambulance. Photo: courtesy of Terry Georgia.
transfer. Packaging refers to getting the patient The transport crew members provide ongoing
ready for transport, and moving the patient onto the medical care and psychological support for the
stretcher to support the patient during transport. patient until arrival at the hospital. They may ask
Transferring the patient means more than moving additional questions, document the history and care
the patient to the ambulance. You also have a of the patient, and continue to monitor vital signs.
responsibility to transfer information about the
patient and the incident to more advanced medical As soon as possible, the transport crew notifies the
personnel who take over care. receiving facility about the patient and the expected
time of arrival. The receiving facility is informed if
there are any changes in the patient’s status or
Phase 6: En Route to the condition. The driver may have to adjust the driving
Receiving Facility speed to meet what the crew member in charge
Once the patient is loaded into the ambulance, says about the patient’s needs.
all personnel should wear safety belts or safety
restraints. The communications center is notified, Phase 7: Arrival at the
and the crew member in charge of caring for Receiving Facility
the patient determines whether the trip to the
receiving facility will be fast, at a normal speed or During this phase, transport crew members
slow (Fig. 27-4). transfer the patient to the care of the nurses and
physicians at the receiving facility (Fig. 27-5). Crew
members never leave patients unattended during a
call or during the transfer of care. At the hospital,
crew members give information about the scene
and the patient. They also complete whatever
documentation is necessary to meet local and
state standards and their organization’s protocols.
If necessary, crew members begin some of the
post-run responsibilities such as exchanging or
restocking medical supplies. The cleaning of the
ambulance is also performed during this phase.
Personnel should wear disposable latex-free
gloves and follow local procedures for disposal of
soiled linen and supplies. The ambulance stretcher
should be cleaned and made ready for the next
Fig. 27-4: Once the patient is loaded into the ambulance, notify call. Members of the crew should wash their hands
the communications center. thoroughly after every response.
620 | Emergency Medical Response
Fig. 27-5: Upon arrival at the hospital, the patient is in the care of the nurses and physicians.
Phases 8 and 9: Clear Medical
Facility and Available for Next
Emergency Call
When returning to the station (phase 8),
the operator of the vehicle should notify the
communications center. During the ride back to
the station, personnel should take the opportunity
to review details of the run and discuss how things
could have been done differently or more efficiently.
The ride back provides opportunities for crew
members to air concerns or diffuse any stress that
may have developed during the response. Doing
these things helps the crew to prepare physically
and emotionally for the next response.
In the last phase of response (phase 9), the
emergency vehicle should be refueled if necessary
and any repairs or adjustments should be made
(Fig. 27-6). Fuel tanks should never be allowed
to get below half full. If necessary, restock any
disposable items in the vehicle’s medical supplies.
Reports and any unfinished paperwork should be
completed, and the communications center should Fig. 27-6: Once back at the station, the emergency vehicle and
be notified that the unit is back in service and ready equipment are prepared for the next response. Photo: courtesy
of Terry Georgia.
for another call. Always follow local procedures
established by your service or organization.
Uniforms or clothing soiled with the patient’s
Once back at the station, crew members should blood or OPIM should not be taken home to be
also prepare themselves for the next response. laundered; they should be laundered by a laundry
Preparation may include removing and laundering service that deals with contaminated clothing or as
contaminated clothing as soon as possible. specified in the organization’s protocols.
Chapter 27: EMS Support and Operations | 621
AIR MEDICAL TRANSPORT criteria vary from state to state and are driven
by local protocols. Also, the Centers for Disease
CONSIDERATIONS Control and Prevention (CDC) has published
In certain situations, it is sometimes best for the national guidelines for field triage of trauma
patient to be transported to the receiving medical patients that should be used as part of the
facility by helicopter (Fig. 27-7). This type of decision-making process. The guidelines call for
transport enables severely injured or ill persons patients to be transported to the highest level of
to be transported quickly to specialty centers care within the system. These include patients
and large treatment facilities. Geography and who fit at least one of the criterion in each of the
other circumstances play a large role in this type following two areas:
of transport decision, and emergency personnel
should follow local and state protocols. Vital signs and level of consciousness:
yyGlasgow Coma Scale ≤ 13
When to Request Air yySystolic blood pressure of < 90 mmHg
Medical Transport yyRespiratory rate of < 10 or > 29 breaths per
minute (< 20 in infants aged < 1 year) or a
In most situations where air medical transport
need for ventilatory support
is requested, it is needed because one or more
patients is in critical condition. During air medical Anatomic:
operations you must always keep the safety of yyAll penetrating injuries to the head, neck,
everyone present the top priority. torso and extremities proximal to the elbow
or knee
Trauma alerts and air medical transport may
be required for a number of different MOIs yyChest wall instability or deformity
(e.g., flail chest)
and natures of illness. Specific trauma alert
Fig. 27-7: Transport by helicopter allows severely injured or ill patients to be transported quickly. Photo:
courtesy of Ted Crites.
CRITICAL Helicopters can be the best transportation choice when dealing with severely
FACTS injured or ill persons who need quick transport to specialty centers or large
treatment facilities. Geography and circumstances play a role in the decision,
and local and state protocols should always be followed.
622 | Emergency Medical Response
yyTwo or more proximal long-bone fractures Air medical transport should also be considered
yyCrushed, de-gloved, mangled or for the following:
pulseless extremity
A situation where there are multiple injured or
yyAmputation proximal to the wrist or ankle ill people
yyPelvic fractures Critical stroke and cardiac alert patients,
yyOpen or depressed skull fractures if ground transport by ambulance exceeds
yyParalysis 45 minutes to the receiving facility
Patients who fit one of the following MOI criteria Critical trauma patients, who should be
transported by air transport if ambulance
should be transported to a trauma center, but it
transport to the trauma center exceeds
need not be the highest level of care:
30 minutes
Falls:
The distance to be traveled and the time it will take
yyAdults: > 20 feet (one story = 10 feet) to transport the patient(s) must be considered.
yyChildren: > 10 feet or two to three times the Patients with conditions that are time-critical include
height of the child those with chest or abdominal injuries with signs
High-risk motor-vehicle crash: of respiratory shock or distress; patients in shock
yyIntrusion, including roof: > 12 inches or experiencing an acute stroke; patients who have
occupant site; > 18 inches any site sustained any serious injury and show altered vital
signs; patients with head injuries with altered mental
yyEjection (partial or complete) from motor status; and those patients with a penetrating injury
vehicle
or in any other situation where time is obviously
yyDeath in the same passenger compartment critical (such as a severe poisoning [e.g., carbon
yyVehicle telemetry data consistent with a high monoxide], heart attack, stroke or amputation).
risk for injury
Automobile versus pedestrian/bicyclist thrown, Requesting air medical transport is reasonable
run over or with significant (> 20 mph) impact when:
Motorcycle crash > 20 mph
It will take more than 30 minutes by ambulance
Additionally, the following special patients, along to transport the patient to a trauma center.
with system considerations, should be considered It will take longer to transport the patient to a
for transport to a trauma center for evaluation and trauma center by ambulance than by air transport.
initial management: The patient’s transport will be delayed by
more than 30 minutes because of the need
Older adults: for extrication.
yyRisk for injury/death increases after age 55 The patient will require rapid transport to a
yySystolic blood pressure < 110 mmHg might specialty center. This could include a burn
represent shock after age 65 center or pediatric, comprehensive stroke or
yyLow-impact mechanisms (e.g., ground-level trauma center.
falls) might result in severe injury
Children: Advantages
yyShould be triaged preferentially to pediatric- In some situations, you may need to request
capable trauma centers air transport for your patient because they are
Anticoagulants and bleeding disorders: unstable and the length of time for ground
yyPatients with a head injury are at high risk for transport would lower the chances of survival.
rapid deterioration If the helicopter is carrying a medical crew, air
transport allows for quicker access to more
Burns:
advanced emergency care. The medical crews
yyWithout other trauma mechanism: triage to on air transport are highly trained and can include
burn facility
nurses, paramedics and/or physicians. There is
yyWith trauma mechanism: triage to trauma also specialized equipment that the medical crews
center are trained to use, including monitoring devices,
Pregnancy > 20 weeks intubation and advanced airway equipment, and
EMS provider judgment chest decompression kits. Collisions or crashes
Chapter 27: EMS Support and Operations | 623
that occur off-road or in remote areas may not be Considerations with Air
accessible by road vehicles; use of a helicopter Medical Transport
allows for patient evacuation. Another advantage
of using air transport is that many large hospital Types
centers and trauma centers have helipads to allow There are two main types of air medical transport,
for helicopter landings. rotorcraft and fixed-wing. Rotorcrafts (e.g.,
helicopters) are used to get into areas that are not
accessible to any other type of rescue craft. Their
Disadvantages
maneuverability allows them to move up and down
Helicopter transport is affected by weather and side to side as needed, allowing for special
conditions. If conditions are unfavorable, such rescue procedures such as hoisting. Fixed-wing
as high winds or low visibility, the patient cannot crafts (e.g., planes, jets) are used to transport over
be transported. The altitude available for a safe long distances, usually between medical facilities.
rescue may be vital in determining whether the
rescue is feasible. If there is not enough room for
the helicopter to hover or land safely, the rescue is Weather
not possible. There may be airspeed restrictions Weather plays a significant role in the use of
imposed by air control authorities in certain aircraft for rescue and transport. Pilots must have
designated areas that could impede the aircraft’s a minimum amount of visibility, and air temperature
arrival at the receiving medical facility. Another affects the altitude at which the helicopter can hover.
possible disadvantage is that helicopter size varies
considerably, depending on the model. Smaller Space and Load
helicopters may not be able to accommodate The amount of space available in a helicopter
patients and responders, as well as necessary depends on the type of helicopter and its maximum
equipment. Landing in mountainous terrain or among takeoff and landing weights. When calculating
forested areas can be very difficult for a helicopter space, responders must take into account how
pilot. The area must be safe and there must be a many patients require transport, the responders who
viable landing site. Air transport is also significantly must accompany the patient(s) and any essential
more costly than ground transportation. lifesaving equipment. In calculating weight, the pilot
must take into account not only the passengers and
Activation equipment, but the fuel load as well.
Air medical activation must follow local and state
guidelines. There are also state statutes, which Control Systems
vary across the country. It is essential that you Flying helicopters is an extremely demanding task
review your state’s protocols for activation of the because of their complex function. The pilot must
helicopter emergency medical system (HEMS). In coordinate the lift of the vehicle with the forward or
addition, rules vary according to institution, locale side-to-side movement, if any, or the altitude and
and state. There are also ordinance standards air temperature if attempting to hover. Because
for each city, county and/or district. However, of the design of the vehicle, the pilot cannot see
resources should be consistent with the standards below the helicopter, which is why guidance is
developed by the Commission for the Accreditation always needed.
of Medical Transport Systems.
Landing Zones
Indications for Patient Transport
Choosing a safe landing zone (LZ) for a helicopter
In general, air medical transport is used for
is paramount (Fig. 27-8). The pilot cannot see the
several reasons including medical (e.g., stroke
area directly below the aircraft and must be guided.
or cardiac alert) and trauma. With these types of
The pilot must also have a visual reference point at
emergencies, time is of the essence. This type of
all times. Ideal conditions for LZs include:
transport may be needed in situations involving
spinal injuries, burns, organ procurement, high- A minimum 10,000-square-foot area (100 feet
risk obstetrics and premature babies. Helicopters by 100 feet). Some pilots prefer a rectangular
are also used in the field in search and rescue landing area to allow for a 45-degree approach.
missions. They are able to cover more terrain than Some aircraft may need a larger area.
land vehicles and can be used to rescue patients
from inaccessible locations.
Flat land.
624 | Emergency Medical Response
Fig. 27-8: A safe landing zone is paramount to the safety of a helicopter transport.
Firm land. Avoid dusty ground or powdery Patient Transfer
snow if possible, as these conditions can impair
vision as the helicopter rotors churn up the
Interacting with Flight Personnel
wind. Also, loose rocks can become dangerous If you are transferring a patient to the care of
projectiles when a helicopter lands or takes flight personnel, you will have to provide all the
off. There is no guarantee that ice on a body information you have obtained about the situation.
of water would ever be strong enough for a This includes patient history, injury or illness
helicopter landing. history, presentation of the patient when you came
upon the scene, any changes while waiting for the
An area clear of any obstacles, such as trees
helicopter, and status and vital signs (Fig. 27-9).
or utility poles.
An area clear of any type of vehicular traffic or
pedestrians.
One person should be in charge of the LZ,
coordinating the scene. To prevent distraction
or confusion, this is the only person who should
be communicating with the pilot. The coordinator
should ensure that the LZ is well marked with
cones or a flameless light source in all four corners.
Nighttime landings can be guided with vehicle
lights or any other nonflame light source, but the
lights should always remain at ground level, never
directed toward the pilot.
To help with the helicopter landing, the coordinator
should be protected with a fastened helmet,
hearing and eye protection, long sleeves and
pants. The coordinator is then stationed outside
the landing perimeter, usually with their back to
the wind unless the pilot instructs an alternate
landing approach. If possible, people should also
be stationed at the left and the right outside the
landing perimeter. Any bystanders not involved in
the landing should be kept a minimum of 200 feet
away from the site.
Fig. 27-9: Provide all information on a patient to flight personnel.
Photo: courtesy of Ted Crites.
Chapter 27: EMS Support and Operations | 625
Patient Packaging and Preparation Tail rotors are very dangerous, and a person
Preparation for transport may include securing assigned as a tail rotor guard may be posted to
the patient’s airway, immobilizing, splinting and prevent people from coming near or approaching
the completion of emergency care procedures the aircraft from the rear. Allow the medical
necessary for safely transferring a patient from the crew from the aircraft to approach you instead.
scene to an ambulance or helicopter. Approaching from the front or side allows the pilot
to see the responders (Fig. 27-10).
Scene Safety Your posture should be crouched over somewhat
It is essential that no loose objects be allowed and, if there is an incline of any sort, you must
within the LZ. They may become projectiles, approach from the lowest point and always
causing damage or injury. Objects such as medical from the side or front, never the rear. Even if
equipment, linens or sheets, bags and other loose approaching from the side, you must remain in the
objects can become airborne from the rotary pilot’s view. You should not be wearing a hat of
winds (rotor wash) and may strike the rotor blades any type; only a fastened helmet is permitted. Do
or get sucked up into engine intakes causing a not wear billowing clothing. If carrying equipment,
breakdown or injuries. Secure everything that can such as an IV pole, this must be kept low and
be secured and move anything else as far away as parallel to the ground so it does not get struck by
possible from the LZ. If the land is sandy or dusty, the blades.
it should be wet down to limit the amount of dirt
and dust churned up by the rotor wash.
Special Tactics
Only those personnel who must approach the
Responders may be called to participate in rescues
aircraft should be permitted within the LZ, and
using mechanical hoists or special insertion and
only after the pilot has signaled that it is safe to
extrication (SPIE) lines. Because these responders
approach. Make eye contact with the pilot to
have special training, your role would be to
confirm your permission to approach, and maintain
ensure that the area is as safe as possible for
eye contact until you have arrived at the door of
the specialty team.
the helicopter.
Fig. 27-10: Tail rotors are dangerous. Approach only if given permission by the pilot and only from the front or
side so the pilot sees you. Photo: courtesy of Ted Crites.
626 | Emergency Medical Response
EMERGENCY VEHICLE SAFETY Safety Issues During Response
Apparatus Preparedness During a response, safety is paramount. All
personnel must be properly seated and use
Part of being prepared to respond to emergencies
safety belts. All equipment in the cab area, rear of
is being able to depend on your equipment and
ambulance and any compartment areas should be
transportation. This means performing regular
appropriately secured.
daily checks, more often if the situation warrants
it. While checking for adequate tire inflation,
also check the tires for wear and tear as well as Consideration of Use of Lights
anything unusual, like nails or debris in the tire. and Sirens
Ensure that warning devices (lights, siren, horn) are Emergency response to a scene does not exempt
in working order. any emergency personnel from traffic laws. It is the
driver’s responsibility to make sure they know the
Check with your employer and/or state regarding traffic laws that govern the use of lights, sirens and
checklists for required vehicle maintenance. Such intersection procedures.
checklists should include items such as checking
the fluid circulation system and wiper fluid levels. Risk/Benefit Analysis
Use of lights and sirens is becoming increasingly
Equipment Preparedness questioned in emergency rescue services.
You should also ensure that the appropriate safety Numerous studies have been conducted about
equipment is available and in working order. the effectiveness versus the safety aspect of the
Personal protective equipment (PPE) must be in full practice. Learn your agency’s protocols for when
working condition for you to do your job effectively the patient’s condition and situation warrants use
and safely. Depending on what is required in your of lights and sirens.
situation, PPE may include helmets, work gloves,
steel-tipped boots and structural firefighting Audible Warning Devices
protective clothing. It also includes protective Audible warning devices include both the siren
eyewear, hearing protection, appropriate outerwear and the air horn. You should be familiar with your
for the season and the task, portable radio and agency’s requirements concerning the use of both.
body armor if considered necessary.
The purpose of using your siren is to warn traffic in
Rescues often take place in the dark or in inclement front of you that you are approaching and to warn
weather, where visibility may be poor. It is important oncoming and side traffic of your presence. It is also
for you to wear reflective clothing, ideally a reflective used to ask for the right of way. Because today’s
safety vest, but reflective tape on your clothing and vehicles are better insulated from outside noise and
other gear also works well (Fig. 27-11). because many drivers and passengers listen to loud
music or have loud conversations inside, do not
assume they can hear you approach. The outside
environment may also be noisy and affect their
ability to hear a siren. Alternatively, they may hear
you but not fully realize from which direction you are
coming. If you feel that your siren was not heard,
do not come up behind a vehicle and turn your
siren on suddenly, as this may startle the driver and
cause a crash. Also, be aware that the siren can
have an effect on you in the ambulance. There can
be a hypnotizing effect that may make you pay less
attention to your surroundings and your driving.
Your air horn can be used to clear traffic in a single
situation, like an intersection. Like the siren, do not
use the air horn behind or close to another vehicle
as it may startle the driver into losing control. Do
Fig. 27-11: Wear reflective clothing, such as a safety not use it continuously, but it can be used with or
vest, or reflective tape to increase your visibility during
rescues, especially when it is dark or in inclement weather. without your siren, depending on what the local
Photo: courtesy of Captain Phil Kleinberg, EMT-P. and state laws are for your area.
Chapter 27: EMS Support and Operations | 627
Visual Warning Devices Know your state’s laws to ensure your safety and
Using visual warning devices, such as warning the safety of those around you.
lights and emergency lights, depends on local and
state laws. It is highly recommended that you do Speed Considerations
not use emergency lights without your siren; they You should only travel at increased speed, beyond
should be used together or not at all. Headlights posted speed limits, when using lights and
should be on, day or night, but high beams should sirens, and only if permitted by local and state
not be used as emergency lights as they can blind laws. If driving at a high speed, weather and road
oncoming drivers, as well as drivers in front of you conditions must also be taken into consideration,
through their rearview mirror. and extra caution should be taken when going
around curves, going over hills, going down hills,
If using a siren and/or lights, many drivers choose turning corners and braking.
to turn them off a few blocks before the destination
to avoid attracting attention.
Driving Distractions
Be sure to eliminate all possible distractions, as
Respond with Due Regard
your ability to concentrate and drive safely is of
Rescue vehicle drivers should obey traffic utmost importance. Typical distracting factors
laws, be careful at intersections and only drive include mobile computers, Global Positioning
in emergency mode when lights and sirens Systems (GPSs), mobile radios, vehicle stereo,
are employed. Factors such as weather, road wireless devices, and eating and drinking.
conditions and traffic must be taken into
consideration when making driving decisions.
Inclement Weather
High-Risk Situations Driving in inclement weather can make emergency
response more stressful. Be sure to leave extra
Intersections
distance between you and the car in front of you—
Collisions at intersections can occur when the especially on wet pavement, which usually requires
rescue driver has a green light and does not double the normal distance to ensure enough
expect a driver to run a late yellow light or a red braking room. If driving on ice or snow, count on
light, or when a pedestrian or cyclist may be about five times the normal distance needed.
crossing and not be visible to the driver due to
other vehicles. Slow down and come to a complete Most drivers are aware of the risk of skidding on
stop at intersections, and ensure that all drivers ice, but hydroplaning—riding on a film of water—is
are aware of your presence before proceeding. a very real risk in rain. If you do begin to hydroplane,
Another dangerous situation arises when more corrective actions are similar to those of skidding on
than one emergency vehicle is responding, ice: take your foot off the accelerator and, unless you
either in the same direction or from different have an anti-lock braking system (ABS), pump the
directions. Ensure that all emergency vehicles are brake gently. Do not try to turn out of the hydroplane.
obvious to all motorists and to people around the
intersections, so they know to expect more than When driving in fog or any other situation where
one emergency vehicle. vision is greatly diminished, you must slow
down; do not brake suddenly in case someone
is following too closely behind you. Use your
Highway Access headlights, but not your high beams. If legal in your
Always use caution when entering roads or locale or state, use your four-way flashers/hazard
highways. Be especially careful when using lights if driving slower than the posted limit. If
the shoulder in rush hour or gridlock situations. about to use your brake, warn those behind you by
Follow the rules of the road and do not assume tapping your brake, activating your brake lights.
other drivers are aware of your presence. State
laws differ in regards to how other drivers
Aggressive Drivers
should respond when emergency vehicles are
approaching. For example, some states require Aggressive drivers can be found anywhere, at any
that drivers pull to the right to allow the emergency time. They have less concern for other drivers and
vehicle to pass without a problem, while other are generally frustrated. An aggressive driver is
states do not require drivers to pull to the right. someone who not only threatens other drivers
628 | Emergency Medical Response
verbally or with gestures, but who also ignores Fatigue
traffic laws such as running stop signs and red There may be times when an EMS vehicle driver feels
lights, making unsafe lane changes, weaving sleepy while driving, especially on long transports.
in and out of traffic and tailgating other drivers. This may be especially true on longer shifts. Avoid
Aggressive drivers may disregard ambulances caffeine and sugar; they may provide energy in the
and other emergency vehicles. Be cautious when short term, but cause a rebound drop in energy a
confronted with an aggressive driver and do not few hours later, which can make you feel even more
react to the driver’s behavior or actions. Back off sleepy as well as disturb sleep. Fresh air is a better
if needed and do not assume an aggressive driver alternative, as is 10 minutes of deep breathing. Open
will obey the rules of the road. When encountering the vehicle’s window or get out of the vehicle if you
an aggressive driver, notify law enforcement can for a few minutes. Stretching also helps. If you
immediately. Obtain a tag number and vehicle take prescribed medications that cause sleepiness
description, if it is safe to do so. and impair your ability to perform your job safely,
seek help and avoid driving when the medication is
Unpaved Roadways interfering. If you are using antihistamines, choose
Unpaved roadways, such as dirt roads or gravel- ones that cause less drowsiness.
covered surfaces, can pose unsafe driving
conditions that include marginal traction; muddy, 360-Degree Assessment
slick conditions during rainy weather; and uneven
When approaching an emergency, dangers can be
surfaces. Always drive with extra caution on unpaved
present all around you. Be sure to scan up, down and
roads, and never drive faster than conditions safely
behind you, as well as looking forward and side-to-
permit when driving on any road surface.
side as you size up the scene (Fig. 27-12). This will
help you more thoroughly assess the entire situation.
Responding Alone
In many traffic-related emergencies requiring Downed Electrical Lines
fire rescue units to respond, they will position
When a vehicle is in contact with an electrical
their larger vehicles in such a way as to protect
wire, consider the wire energized (live) until you
the scene and allow for emergency care. When
know otherwise. Water is an effective conductor
responding alone, or when you are first on scene,
of electricity, so be especially careful of downed
be especially careful when approaching and when
electrical wires in a wet or rainy environment. When
exiting your vehicle. Check your mirrors, look back
you arrive at the scene, your first priority is to ensure
for traffic and open your door slowly especially
your safety and that of others in the immediate area.
if it opens toward traffic. Wear proper reflective
A safety area should be established at a point twice
gear. Request assistance from law enforcement
the length of the span (distance between the poles)
personnel to assist with traffic control.
Fig. 27-12: Dangers or unsafe conditions can be present all around you. Assess the scene from all angles.
Photo: courtesy of Captain Phil Kleinberg, EMT-P.
Chapter 27: EMS Support and Operations | 629
Fig. 27-13: Downed electrical wires are extremely dangerous and require that a safety area is
established. Photo: courtesy of Captain Phil Kleinberg, EMT-P.
of the wire (Fig. 27-13). Attempt to reach and move Trapped or Ejected Patients
patients only after the power company has been As you size up the scene, check for trapped
notified and has secured any electrical current from patients. If a patient is trapped in a vehicle, the
reaching downed wires or cables. Tell occupants fire and rescue department may have specialized
inside an involved vehicle to remain in the vehicle. extrication equipment to help get the patient safely
If needed, you may be able to give them instructions out of the vehicle. Also, look around the area to
on how to provide some basic first aid care for see if any patients were ejected from the vehicle
any injured patients in the vehicle until they can be upon impact.
safely reached by professional responders. Do not
attempt to deal with any electrical hazards unless
you are specifically trained to do so and have the
Mechanism of Injury/Nature of Illness
proper equipment. Once the current has been shut As you approach the patient, consider the MOI or
down, the vehicle can be safely approached. nature of illness. Doing so involves trying to find out
what happened. Look around the scene for clues
as to what caused the emergency and the extent
Leaking Fuel or Fluids of the damage. Consider the force that may have
Check to see if there is any fuel or fluid leaking been involved in creating an injury. This will cause
from the vehicle. Check for a source that could you to think about the possible type and extent
ignite a fire. If there is a source, the fire department of the patient’s injuries. Take in the whole picture.
must be notified if you have not done so already. How a motor vehicle is crushed or nearby objects
such as shattered glass, a fallen ladder or a spilled
Smoke or Fire medicine container may suggest what happened.
If smoke or fire is present, the fire department must If the patient is unconscious, considering the MOI
be notified if you have not already done so. If you or nature of illness may be the only way you can
attempt a rescue, approach the vehicle from the determine what happened.
side only, to lessen the risk should explosion occur.
Patient Care in the Ambulance
Broken Glass All personnel, including the driver and others
Broken glass from windows or windshields can riding in the ambulance, must be properly seated
be anywhere on the scene. If it poses a risk and and secured with safety belts for their own safety
cannot be avoided, covering it may reduce the as well as for the safety of others in the vehicle,
chances of injury. unless they are moving about for essential tasks
630 | Emergency Medical Response
Fig. 27-14: Patients in an ambulance should always be properly secured, and all personnel should be
cautious when moving to provide care. Photo: courtesy of Captain Phil Kleinberg, EMT-P.
in the patient compartment (Fig. 27-14). Do not ambulance movement. If you hook your foot around
remove your safety belt just before arrival to save the stretcher bar as you are seated, this gives an
time, as research shows the last few minutes of the extra measure of safety and security.
emergency response drive are the most dangerous
to team members. CPR may be necessary en route to the hospital.
This requires extra care for the responder. Maintain
If safety belts must be removed while you are in the balance as much as possible and have the driver
patient compartment to provide care to the patient, call out if any bumpy areas (e.g., railroad tracks or
precautions must be taken regarding how you potholes) or severe turns are coming up, so that
position yourself and how you move. Always hold you may brace yourself.
on to something secure inside the compartment
when moving about unsecured. While performing CPR, spread your feet to
shoulder width to maintain a more secure stance
Patients should always be properly secured while and bend your knees to lower your center of gravity.
in the patient compartment. All stretcher straps are If possible, have someone help you by holding
to be appropriately in place and tightened. on to your belt to stabilize you. That other person
should be secured with a seat belt.
Patient care in the ambulance can be hazardous
because of the movement necessary by the
responder. While remaining as safe as possible, Securing Equipment
the responder must be able to carry out certain All moveable equipment in the cab must be
procedures. Check the protocols in your local area secured for your safety. In the event of a motor-
or state regarding which procedures these might vehicle collision, all unsecured items have the
be, as they may require that the ambulance not be potential of becoming life-threatening projectiles.
in motion at that time. This includes personal items left on the dashboard,
such as pens and notebooks.
Move deliberately and slowly, keeping your feet well
placed, shoulder width apart, on the floor to maintain Unless using a piece of equipment, it must be
stability. Responders should practice the idea that securely stored to prevent injury in the case of
three of five essential body parts should be safely a sudden stop, swerve or motor-vehicle crash.
“hugging” the ambulance at all times. The five body This includes everything from heavier monitoring
parts are the two hands, two feet and backside, equipment and AEDs to lighter clipboards
which should be seated as much as possible during and cups.
Chapter 27: EMS Support and Operations | 631
LEAVING THE SCENE and should be recorded on the prehospital care
report for any possible follow ups. While generally
Before you leave the scene, ensure all hazards one only transfers care to a higher-level certified
have been mitigated. Pick up and dispose of all emergency responder, there may be situations that
equipment and trash properly. All used sharps necessitate turning over care to a lower certified
must be placed in a closed, puncture-resistant, responder. For example, in a multi-casualty incident
leak-proof, tamper-proof biohazard sharps (MCI), responders may be required to move on
container. All contaminated clothing, products or to the next patient for assessment, leaving the
material must be placed in a biohazard container. patient with a lower certified responder, after an
All containers must be stored in a safe manner appropriate briefing.
and, if leakage occurs, they must be placed in a
second leak-proof container. Check with your local
and state laws about proper disposal of these
contaminated items.
EMS EQUIPMENT
Maintaining equipment readiness is essential. If
All reusable equipment must be collected from the you are involved in transporting patients to the
scene for cleaning and restocking. All disposable receiving facility, you will have to prepare and
equipment must be discarded in appropriate inspect the ambulance before every shift. Local
containers and replaced with new equipment after EMS systems and state regulations determine what
the emergency. equipment and supplies must be in the vehicle.
Turn the scene over to the appropriate authority
prior to leaving. There may be situations when Jump Kit
EMRs must turn over care of their patient to other In preparing to respond to an emergency, you should
emergency personnel, including law enforcement, have basic medical equipment on hand. Always have
fire suppression, highway department and other a jump kit fully stocked and ready to go should an
personnel. The names of the initial responders emergency occur (Fig. 27-15). Do not overfill the
should be given to the crew taking over care jump kit, but minimum supplies should include:
Fig. 27-15: Jump kit.
CRITICAL Jump kits should always be on hand and fully stocked. Supply essentials include
FACTS oral airways, suction equipment, artificial-ventilation devices, and supplies for basic
wounds and severe, life-threatening bleeding.
632 | Emergency Medical Response
Airways (oral). as regular members of an ambulance crew in
Suction equipment. some states, while in others they may work in
nontraditional settings as trip leaders or athletic
Artificial-ventilation devices (e.g., resuscitation
trainers. There are also several types of EMRs,
mask or bag-valve-mask [BVM] resuscitator).
including those with additional training who are
Basic wound supplies (e.g., dressings and
able to transport patients as well as provide
bandages).
advanced, prehospital medical care.
Supplies for severe, life-threatening bleeding
(tourniquets, pressure dressings and hemostatic A typical EMS response has nine phases:
dressings). preparation for an emergency call, dispatch, en
route to the scene, arrival at the scene and patient
Other supplies to include are: contact, transferring the patient to the ambulance,
en route to the receiving facility, arrival at the
PPE, such as disposable latex-free gloves,
receiving facility, clear medical facility and available
protective eyewear, masks and face shields.
for next emergency call.
Maps.
Scissors. In certain situations, it may be best for patients
Blood pressure cuff. to be transported to a medical facility by air. This
method enables severely injured or ill persons to
Stethoscope.
be transported quickly to specialty centers and
Flashlight.
large treatment facilities. Geography and other
Note pad and pen. circumstances play a large role in this type of
Hand sanitizer. transport decision, and emergency personnel
Any other equipment required by local or should follow local and state protocols.
state standards.
To be prepared to answer emergencies, EMRs
must be able to depend on their equipment and
PUTTING IT ALL TOGETHER transportation. This means performing regular
checks of the vehicle’s tires and audible and
EMRs are individuals who have been trained to a visual warning devices to make sure everything is
minimum standard of care according to the current in working order, and ensuring that all necessary
national scope of practice and EMS educational equipment and supplies are on hand.
standards. They may function in traditional roles
You Are the Emergency Medical Responder
Additional fire rescue, police and EMS units arrive. You see that one of the occupants of the
vehicle that is on the shoulder of the road apparently was not wearing a seat belt, was ejected
from the vehicle and is not moving. The driver of the car on the median strip is conscious, but
because of traffic you cannot get to that vehicle. What are some safety considerations and
issues with this situation? With heavy traffic backing up in all directions, and one patient with
severe trauma, what transport options should be considered?
Chapter 27: EMS Support and Operations | 633
ENRICHMENT
Operational Safety and Security Measures
Personnel
The beginning of each shift should involve a briefing, either in person or through written notes, about any issues
involving crew safety. These issues could involve personal threats against the unit or specific responders, or be
general threats. Security measures should have been discussed previously in training and reviewed as needed.
Vehicles
The threat of stolen vehicles is very real. Under no circumstances should an ambulance or rescue vehicle be left
running or unattended with the key in the ignition.
All vehicles must be monitored, whether in or out of service. Any vehicles that are no longer to be used for
emergency or rescue purposes must be stripped of all emergency equipment, lights, sirens and markings.
All use of ambulances and rescue vehicles must be tracked to avoid unauthorized use. If ambulances or rescue
vehicles need repair or servicing outside of authorized areas, they must be secured in such a way that they cannot
be used by unauthorized personnel.
634 | Emergency Medical Response
28 You Are the Emergency Medical Responder
ACCESS AND
EXTRICATION
You are an emergency medical responder (EMR) and a member of a rural volunteer
rescue squad. There has been a motor-vehicle crash on a main county road in which
the driver apparently lost control of his car on a curve and struck a large tree. There
is major damage to the car. The driver (and sole occupant) most likely impacted the
steering wheel with his upper body. He appears to be pinned. Fire rescue personnel
are on scene. As you size up the scene, with the car tilted along the shoulder, you
notice that fluids are leaking from the vehicle and there is a steady flow of traffic on the
road. What potential safety issues should be considered? How might your ability to
provide emergency medical care be affected by this situation?
KEY TERMS
Access: Reaching a patient who is trapped in a motor “Rule of thumb”: A guideline for positioning oneself
vehicle or a dangerous situation, for the purpose of far enough away from a scene involving hazardous
extrication and providing medical care. material (HAZMAT): one’s thumb, pointing up at
arm’s length, should cover the hazardous area from
Complex access: In an extrication, the process one’s view.
of using specialized tools or equipment to gain
access to the patient. Simple access: In an extrication, the process of
getting to the patient without the use of equipment.
Cribbing: A system using wood or supports,
arranged diagonally to a vehicle’s frame, to safely Vehicle stabilization: Steps taken to stabilize
prop it up, creating a stable environment. a motor vehicle in place so that it cannot move
and cause further harm to patients or responders.
Extrication: The safe and appropriate removal
of a patient trapped in a motor vehicle or a
dangerous situation.
LEARNING OBJECTIVES
After reading this chapter, and completing the class • Describe unique hazards that may exist at an
activities, you will have the information needed to: emergency scene.
• Have a basic understanding of access • Define hazardous material (HAZMAT).
and extrication. • List basic safety procedures associated with
• Explain the role of the emergency medical a HAZMAT situation.
responder (EMR) in an extrication operation. • Describe the importance of vehicle stability.
• List basic extrication equipment. • List the general steps to stabilize a vehicle.
• Describe basic personal protective equipment • Know the difference between simple access and
used in extrication operations. complex access.
• Describe steps necessary to ensure patient safety • Know how to provide care to patients who require
during extrication. extrication at the scene.
• List the reasons for controlling traffic at an
emergency scene.
INTRODUCTION In these cases, you must immediately think of
how you can safely gain access to the patient.
One of your primary responsibilities as an If you cannot reach the patient, you cannot
emergency medical responder (EMR) is to provide provide medical care. Always remember, when
care for an injured or ill patient. Sometimes, attempting to reach someone, your safety is the
however, providing care is not possible because most important consideration. Protect yourself and
you cannot reach the patient. One example is a the patient by doing only what you are trained to
situation in which someone is able to call 9-1-1 or do, using equipment you are trained to use and
the designated emergency number for help but is wearing clothing appropriate for the situation. Items
unable to unlock the door of a home or office to such as helmets, face shields, protective eyewear
let responders inside. This situation also occurs and heavy-duty gloves will help keep you safe as
in a large number of motor-vehicle collisions, with you attempt to gain access to a trapped patient.
locked or crushed vehicle doors, tightly rolled up Simple tools can also be helpful.
windows or unstable vehicles. In other instances,
fire, water, fuel leaks or other elements may prevent
you from reaching the patient.
636 | Emergency Medical Response
FUNDAMENTALS OF as the natural gas company or the power company,
or could include hazardous material (HAZMAT)
EXTRICATION AND RESCUE responders. HAZMAT responders provide medical
OPERATIONS care and extrication of patients from a hot zone
Role of the EMR (area with the highest degree of danger in a
Extrication is the safe and appropriate removal of HAZMAT emergency scene), where potentially
a patient trapped in a motor vehicle or a dangerous hazardous chemical spills are involved. In the case
situation. At times, an EMR may be called upon to of fuel spills or other potential hazards associated
help care for someone in this type of situation. It with extrication, the fire department may deploy
will be your role to administer the necessary care a charged hose line to protect the scene, the
to the patient before extrication and ensure that the patient and rescue personnel.
patient is removed in a way that minimizes further Depending on the severity of the injuries and
injury. Providing care for the patient may come location of the scene, patient transportation by an
before the extrication process; however, in many air medical service may be required. Other activities,
instances, patient care will occur simultaneously such as patient decontamination, may be required
with the extrication process. During any extrication, prior to transport by ground ambulance or other
it is critical that those providing medical care ground transport vehicle, or by air medical services.
and those who are performing extrication are
in constant communication with each other to
maintain safety and avoid aggravating the patient’s Scene Safety
injuries or causing further pain. Personal Safety
The first priority for all EMRs is their own safety.
Although fire rescue workers, emergency medical
All personnel involved at the scene should wear
technicians (EMTs) and other specially trained
protective clothing and follow guidelines set
personnel will perform most extrication procedures,
up by state and local protocols. The National
when EMRs are involved in this type of rescue,
Fire Protection Association (NFPA) and the
they should work closely with other responders to
Occupational Safety and Health Administration
protect the patient. A chain of command through
(OSHA) have guidelines to follow when
the incident command system should also be
considering the purchase of safety clothing.
established to ensure that the scene is well
At a minimum, when responding to a motor-vehicle
managed and the patient’s care remains a priority.
collision or other extrication situation, EMRs should
have the following equipment:
Additional Resources
Basic extrication equipment includes crowbars, Protective helmet with chin strap
screwdrivers, chisels, hammers, pliers, work gloves Protective eyewear
and goggles, wrenches, shovels, car jacks, tire Puncture- and flame-resistant outerwear
irons, knives, and ropes or chains. (turnout gear)
Many emergency scenes draw crowds of onlookers
Heavy, protective gloves
and individuals wishing to help. Law enforcement Boots with steel toes and insoles
personnel will play a major role in helping to As with any emergency, begin by sizing up the
secure the scene and control the crowd while the scene to see if it is safe. If it is not safe, determine
extrication is in progress. whether you can make it safe so you can attempt
to gain access to the patient. Well-intentioned
Also, consider the need for specialists to handle
EMRs and others are injured or killed each year
or help control any hazards present. This could
while attempting to help patients involved in motor-
include representatives from utility providers, such
vehicle collisions. Such unfortunate instances are
CRITICAL Extrication is the safe and appropriate removal of a patient trapped in a motor
FACTS vehicle or a dangerous situation.
Basic extrication equipment includes crowbars, screwdrivers, chisels, hammers,
pliers, work gloves and goggles, wrenches, shovels, car jacks, tire irons, knives,
and ropes or chains.
Chapter 28: Access and Extrication | 637
preventable by taking adequate measures to make patients if they are prepared as each step takes
the scene safe before trying to gain access and place will also help them feel more in control of the
provide care. situation and less panicked or frightened.
It is also important to continue to monitor patients
Patient Safety throughout the process and, if their condition
Once you have obtained safe access to a trapped changes, immediately inform the rescue crew
patient, provide the same care you would to any of any growing danger.
trauma patient. Ensure you maintain spinal motion
restriction, complete the primary assessment and Caution bystanders in the area to stay away from
provide critical interventions as necessary. Patients the scene. Their presence can cause additional
will require protection from the debris created by confusion and increase the risk of injury.
the extrication process. Cover patients with tarps or
Ensure spinal motion restriction, if possible, before
blankets to protect them from broken glass, sharp
removing the patient from the vehicle (Fig. 28-1).
metal and other hazards, including the environment.
The only time you should consider an emergency
Lessen their fears by explaining what you will
move without spinal motion restriction is in an
do and any noise that may occur in the process.
emergency when there is an immediate threat to
Establishing a rapport with patients will help them
life, such as from cardiac arrest, fire or other
focus on your support and listen to your instructions
critical situation.
and guidance throughout the extrication. Asking
Fig. 28-1: Ensure spinal motion restriction, if possible, before removing the patient from the vehicle. Photo:
courtesy of Captain Phil Kleinberg, EMT-P.
CRITICAL Protective clothing is essential on the scene. Follow state and local protocols
FACTS and familiarize yourself with guidelines put forth by NFPA and OSHA. Minimum
equipment when dealing with collisions and extrications includes protective helmets
and eyewear, turnout gear, protective gloves, and boots with steel toes and insoles.
Once you have obtained safe access to a trapped patient, provide the same care
you would to any trauma patient. Ensure you maintain spinal motion restriction,
complete the primary assessment and provide critical interventions as necessary.
638 | Emergency Medical Response
Scene and Traffic Control Establish advance warning for vehicles by using
There are several important reasons to control traffic cones or flares. Place these at 10- to
traffic at the scene: to protect the scene from 15-foot intervals, to create a safe zone in a radius
further potential collisions, prevent injury to the of at least 50 feet around the scene. If using flares,
rescue team, ensure minimal disruption and allow be sure there are no fluid leaks.
emergency vehicles to reach the scene. On
arrival, request the assistance of additional law Unique Hazards
enforcement and fire services personnel to help
Alternative-Fueled Vehicles
control the scene and assign a scene safety officer.
It is important to understand the differences
Emergency vehicles should be placed in optimal between gasoline- and alternative-fueled
positions for safety and for easy patient loading. vehicles, especially hybrid and electric vehicles.
Blocking is a technique of positioning emergency Many people are concerned about the risk of
vehicles at an angle to traffic lanes (Fig. 28-2). This electrocution. Following safety precautions and the
creates a physical barrier between the work area manufacturer’s recommendations reduces the risk
and traffic flowing toward the emergency scene. of injury to responders and vehicle occupants.
The scene should be protected with the first-
arriving apparatus; block off at least one additional As with any conventional vehicle, removing the
lane. Ambulances should park within the “shadow” ignition key and disconnecting the battery will
created by the larger apparatus. The apparatus disable a hybrid’s high-voltage controller. Keep
should also “block to the right” or “block to the in mind that some hybrid vehicles do not have
left,” so as not to obstruct the loading doors of an ignition key, but do have an on/off switch that
ambulances. The ambulance patient loading area must be pressed before disconnecting the battery.
should be facing away from the closest lane of However, some models may remain “live” for up to
moving traffic. All patient loading into ambulances 10 minutes after the vehicle is shut off or disabled.
is carried out from within the protected work zone Responders must always follow the manufacturer’s
that is created by the positioning of the other emergency response guidelines for the specific
rescue apparatus. make and model of the vehicle.
Fig. 28-2: Blocking is a method of controlling traffic in which emergency vehicles are positioned to create a physical
barrier between the emergency scene and the flow of traffic. Photo: courtesy of Captain Phil Kleinberg, EMT-P.
CRITICAL Blocking is a positioning technique that creates a physical barrier between the work
FACTS area and traffic flowing toward the emergency scene. It creates a safer environment
and provides an optimal position for patient loading.
Chapter 28: Access and Extrication | 639
One important difference is that a hybrid vehicle system. Do not cut or drill into the air bag module.
can remain silent and still be operational if the Also, do not apply heat to the area of the steering
collision is minor and/or did not activate any of the wheel hub, as an undeployed air bag inflates in
collision sensors. Therefore, it is essential a normal manner if the chemicals sealed inside
that responders chock or block the wheels to the air bag module reach a temperature above
prevent the vehicle from moving under power or 350° F (177° C).
by gravity. Be careful not to place cribbing under
any high-voltage (usually orange in color) cabling. HAZMAT
Hybrid and electric automobile manufacturers As an EMR, you may find yourself involved in
publish emergency response guides for each a situation in which there are chemical or other
model of vehicle they produce. Responders should harmful or toxic substances. EMRs must be trained
be familiar with the safety procedures provided in to quickly identify such situations and access
these resources. specially trained personnel to deal with the situation.
A hazardous material is any chemical substance or
Undeployed Vehicle Safety Devices material that can pose a threat to the health, safety
In some collisions, air bags may not have deployed and property of an individual. A HAZMAT incident
and may present a hazard during extrication. The is any situation that deals with the release of
force of a deploying air bag can turn access and hazardous material. When dealing with a HAZMAT
extrication tools into destructive missiles that can situation, work within a structured system that
cause serious injury to responders and patients. provides guidance in managing this type of scene.
Air bags can be found in several locations
throughout a vehicle and can number as many as Unless you have received special training in
a dozen separate units depending on the vehicle HAZMAT handling and have the necessary
make and model. If a patient is pinned directly equipment to do so without danger, stay well
behind an undeployed air bag, both battery cables away from the area or in the designated cold zone
should be disconnected, following established (support area in the outer perimeter of a HAZMAT
safety protocols. Ideally, wait for deactivation of the emergency scene) (Fig. 28-3). While en route
system before attempting to extricate the patient. to a potential HAZMAT scene, obtain as much
Do not mechanically cut through or displace the prearrival information as possible from dispatch.
steering column until after deactivation of the Stay out of low areas where vapors and liquids
Fig. 28-3: Unless you have received special training in HAZMAT handling, stay away from the area. Photo:
courtesy of Captain Phil Kleinberg, EMT-P.
640 | Emergency Medical Response
may collect, and stay upwind and uphill of the It is on a slippery surface.
scene. Be alert for wind changes that could cause It is overturned or on its side.
vapors to blow toward you. Do not attempt to be
a hero. It is common for responding ambulance Stabilizing an upright vehicle is a relatively simple
crews approaching the scene to recognize a task. Placing blocks or wedges against the wheels
HAZMAT placard and immediately move to a safe of the vehicle will greatly reduce the chance of the
area and summon more advanced help. When vehicle moving. This process is called chocking
approaching the scene, use binoculars from a safe (Fig. 28-4). You can use items such as rocks, logs,
distance to look for potential hazards and to obtain wooden blocks and spare tires. If a strong rope or
the placard number. Refer to the Department of chain is available, attach it to the frame of the car
Transportation’s Emergency Response Guidebook and then secure it to strong anchor points, such as
for detailed information. large trees, guardrails or another vehicle. Letting
the air out of the car’s tires also reduces the
Many fire departments have specially trained possibility of movement.
HAZMAT teams to handle incidents involving
these materials. While awaiting help, keep people To stabilize a vehicle, take the following steps:
away from the danger zone. One easy method to
determine the danger zone area is called “rule of Put the vehicle in “park,” or in gear (if a manual
transmission).
thumb.” The “rule of thumb” states that, to be safe,
position yourself far enough away from the scene Set the parking brake.
that your thumb, pointing up at arm’s length, covers Turn off the vehicle ignition and remove the key.
the hazardous area from your view. If there are no patients in the seats, move the
seats back and roll down the windows.
When approaching any scene, be aware of
dangers involving chemicals. Whether a motor- Disconnect the battery or power source.
vehicle collision or an industrial emergency is Identify and avoid hazardous vehicle safety
involved, you should be able to recognize clues components such as seat-belt pretensioners,
that indicate the presence of hazardous materials. undeployed air bags, integrated child booster
These include signs (placards) on vehicles or seats, and a lower anchors and tethers for
storage facilities identifying the presence of these children (LATCH) system.
materials, evidence of spilled liquids or solids, Depending on the condition and positioning of the
unusual odors, clouds of vapor and leaking vehicle, further steps must be taken to ensure the
containers. vehicle cannot fall or roll. Cribbing is a system
that creates a stable environment for the vehicle.
VEHICLE STABILIZATION
Any movement of the vehicle during patient care or
extrication can prove dangerous or even deadly to
patients with severe spinal injuries, or could result
in injury to the rescue team. Local fire department
and rescue squad personnel specially trained in
vehicle stabilization and extrication will respond
to the scene when requested.
To make the scene as safe as possible, it is
important to ensure that the motor vehicle is stable.
You can assume a vehicle is unstable if:
It is positioned on a tilted surface.
It is stacked on top of another vehicle,
even partly. Fig. 28-4: Chocking. Photo: courtesy of Ted Crites.
CRITICAL A hazardous material is any chemical substance or material that can pose a threat
FACTS to the health, safety and property of an individual.
Chapter 28: Access and Extrication | 641
It uses wood or supports, arranged diagonally GAINING ACCESS
to the vehicle’s frame, to safely prop up a vehicle
(Fig. 28-5). Cribbing should not be used under Simple Access
tires because it tends to cause rolling. There The term simple access describes the
should never be more than 1 to 2 inches between process of getting to a patient without the use
the cribbing and vehicle. of equipment. Although simple access does not
require the use of equipment, the EMR should
For vehicles remaining upright, use blocks or remember to wear protective equipment and use
wedges to prevent rolling. When possible, position standard precautions as appropriate. Methods of
the wheels against the curb. The tire valve stem simple access include:
may also be cut so the car rests safely on its rims.
The rims should also be chocked as a precaution. Trying to open each door.
Overturned vehicles must have a solid object such Trying to open the windows.
as a wheel chock, timber, spare tire or cribbing Having the patient(s) unlock the doors or open
and roll down the windows.
between the roof and roadway. A jack can be used
to angle the vehicle against the object. Hook a chain When you arrive on the scene, if specialized
to the axle, and loop the chain to a tree or post. equipment and personnel are necessary to access
patients, call to have these units dispatched.
If after accessing the patients you realize that
the additional personnel and equipment are not
necessary, you can easily cancel them.
Complex Access
Complex access describes the process of using
specialized tools or equipment to gain access
to a patient (Fig. 28-6). Several types of rescue
training courses are available that deal with vehicle
and rope rescue. Other types of programs provide
training in trench, high-angle and water rescue.
As an EMR, you may encounter situations in which
you will use basic equipment and techniques
to gain access to a patient.
Tools
There are different types of extrication tools used
to access patients (Fig. 28-7). Hand tools might
Fig. 28-5: 6� × 7� × 24� super crib with lanyards. Photo:
courtesy of Turtle Plastics. include a “come-along,” a ratcheting cable device
CRITICAL A vehicle should be considered unstable if it is on a tilted or slippery surface,
FACTS completely or partly on top of another vehicle, or overturned or on its side.
To stabilize a vehicle, take the following steps:
• Put the vehicle in “park,” or in gear (if a manual transmission).
• Set the parking brake.
• Turn off the vehicle ignition and remove the key.
• If there are no patients in the seats, move the seats back and roll down
the windows.
• Disconnect the battery or power source.
• Identify and avoid hazardous vehicle safety components.
642 | Emergency Medical Response
Fig. 28-6: Complex access requires the use of specialized tools or equipment to gain
access to a patient. Photo: courtesy of Captain Phil Kleinberg, EMT-P.
Fig. 28-7: Extrication tools used to access patients include hand tools, pneumatic tools,
hydraulic tools, cutters and rams. Photo: courtesy of Ted Crites.
used for pulling. Pneumatic tools might include air dash area forward. Hydraulic tools, such as a jack,
bags, which can be used to aid with lifting. may also be used to lift the vehicle.
The most commonly used extrication tool is the Other frequently used tools are cutters, which can
power hydraulic tool, such as the Hurst Jaws of employ 30,000 to 60,000 psi. Cutters do as their
Life®. This tool uses anywhere from 20,000 to name suggests—cut. Most often, they are used
40,000 pounds per square inch (psi) to spread to cut the posts that hold up the roof of a motor
apart metal, and is most commonly used to remove vehicle. There are also hydraulic tools that combine
the doors from a vehicle. However, it can also be cutters and jaws into one tool.
beneficial for crushing and pulling or pushing the
Chapter 28: Access and Extrication | 643
A third type of extrication tool is the ram, which Shovel
uses its force to spread. This is in similar fashion to Tire irons
the action of a jaws tool but with a much straighter
and wider spread. Often the ram is used to push
Wrenches
the dash area away from the front passenger Knives, including linoleum knives
compartment of a vehicle. Car jacks
Ropes or chains
EXTRICATION Extricating the Patient
Role of the EMR Extricating the patient is a task carried out by
During extrication, ensure your own safety. Contact specially trained personnel. Of primary concern
the communications center immediately and request is preventing further harm to the patient. The
that fire and law enforcement personnel respond most important factor in achieving this is proper
to the scene. Information regarding number of training of personnel, so that everyone is familiar
vehicles, number of patients and the presence of with extrication procedures and team members
any hazardous substances is very important. communicate effectively.
Wearing the proper equipment is essential to Every extrication is different, and some can be
ensure your safety; however, this is not enough quite complex. In some situations, the patient may
in the case of some incident scenes. Ensure be trapped in the car seat or partially trapped
the scene is safe before approaching a patient. under the seat. When this happens, it may be
Once the scene is secure and the vehicle stable, possible to alleviate the situation by using the
attempt to reach the patient and complete the car’s seat adjustment lever. If this is insufficient,
primary assessment. Together with other rescue the seat can be taken out by removing the nuts
personnel, establish a chain of command to ensure securing the seat or by forcing the seat using
the utmost safety and care for patients and rescue portable rams, spreaders or come-alongs. This
team members. latter option may involve rough movement, which
may not be a viable option, depending on the
patient’s condition.
Extrication Tools
It is important to be prepared in case the local
rescue squad cannot make it to the scene as Providing Care
quickly as necessary. In these situations, the It is important to have a sufficiently large number
following tools and equipment are key to of skilled personnel available during extrication,
assisting in the safe extrication of a patient as as there are multiple tasks to look after at the same
quickly as possible: time. Always try to move the device, not the patient,
during extrication. At all times, maintain spinal
Hammer motion restriction. Use the path of least resistance
Screwdriver when making decisions regarding equipment and
Chisel moving the patient.
Crowbar Once you have gained access to the patient, follow
Pliers procedures for suspected head, neck and spinal
Work gloves and goggles injuries. Complete the primary assessment and
provide the appropriate care.
CRITICAL The term simple access describes the process of getting to a patient without the
FACTS use of equipment. Complex access describes the process of using specialized
tools or equipment to gain access to a patient.
644 | Emergency Medical Response
CRITICAL Extricating the patient is a task reserved for specially trained personnel. Preventing
FACTS further harm to the patient is a primary concern in extrication.
Be sure to stay with the extricated patient at all times. Continually monitor
their condition.
Stay with the patient at all times and continually the vehicle, attempting to gain access to patients
monitor their condition. If it worsens, communicate inside the vehicle and, if unable to do so, carrying
this to the rest of the team members, as they may out the steps involved in extricating the patients
wish to change the method to a more rapid type from the vehicle in the safest manner possible.
of extrication.
All steps in the vehicle extrication process
require specialized training and must be carried
PUTTING IT ALL TOGETHER out by a team of rescue personnel. During the
procedure, it is critical that EMRs take steps to
There are times when an EMR may not be able to
ensure their own safety. Sadly, some EMRs and
provide immediate care for an injured or ill person
others are injured or killed each year when struck
because the EMR cannot reach the person. This
by an oncoming vehicle while attempting to help
can happen as a result of motor-vehicle collisions,
patients involved in motor-vehicle collisions. Be
fire, water or other elements.
sure to take adequate measures to make the
While fire rescue personnel and others have scene safe before trying to gain access and
special training and equipment, an EMR may be provide care. When providing care, responders
called upon to assist in vehicle extrication. Vehicle should take steps to protect the patient’s head,
extrication involves multiple steps—stabilizing neck and spine.
You Are the Emergency Medical Responder
As you perform the primary assessment, the patient complains of numbness and tingling in his
hands. What type of injury do you suspect the patient may have and what other steps would
you take as you provide care for this patient?
Chapter 28: Access and Extrication | 645
29 HAZARDOUS
MATERIALS
EMERGENCIES
You Are the Emergency Medical Responder
You are the first emergency medical responder (EMR) to arrive at the scene of a freight
train derailment. According to the train’s placards and signage, several of the cars are
carrying liquefied chlorine gas. At least two cars are leaking, and there is a yellowish
cloud hanging low over the area. The winds are light, about 5 to 10 miles per hour
(mph), and are coming from the northeast. Would you know how to respond? What
would you do?
KEY TERMS
Cold zone: Also called the support zone, this area Safety Data Sheet (SDS): A sheet (provided by
is the outer perimeter of the zones most directly the manufacturer) that identifies the substance,
affected by an emergency involving hazardous physical properties and any associated hazards
materials. (e.g., fire, explosion and health hazards) for a given
material, as well as emergency first aid; formerly
Emergency Response Guidebook: A resource called a Material Safety Data Sheet (MSDS).
available from the U.S. Department of
Transportation (DOT) to help identify hazardous Shipping papers: Documents drivers must carry by
materials and appropriate care for those exposed law when transporting hazardous materials; list the
to them. names, possible associated dangers and four-digit
identification numbers of the substances.
Flammability: The degree to which a substance
may ignite. Staging area: Location established where resources
can be placed while awaiting tactical assignment.
Hazardous material (HAZMAT) incident: Any
situation that deals with the unplanned release of Toxicity: The degree to which a substance is
hazardous material. poisonous or toxic.
Hot zone: Also called the exclusion zone, this is Warm zone: Also called the contamination reduction
the area in which the most danger exists from a zone; the area immediately outside the hot zone.
HAZMAT incident.
Reactivity: The degree to which a substance may
react when exposed to other substances.
LEARNING OBJECTIVES
After reading this chapter, and completing the class • Have a basic understanding of placards and the
activities, you will have the information needed to: Emergency Response Guidebook.
• Define hazardous materials (HAZMATs). • List basic personal protective equipment (PPE)
necessary for responding to a HAZMAT incident.
• Describe the basic response to a HAZMAT
incident. • Know other resources available to respond to
HAZMAT incidents.
• Know where to find available resources regarding
training and response to HAZMAT incidents. • Understand the principles of decontamination and
providing care during a HAZMAT incident.
INTRODUCTION and various public places. Whenever there is any
leaking or spilling of chemicals, the potential of a
As an emergency medical responder (EMR), HAZMAT incident exists.
you may find yourself involved in a situation in
which there are chemical or other harmful or toxic
substances. EMRs must be trained to quickly HAZARDOUS MATERIALS
identify such situations and activate specially What are Hazardous Materials?
trained personnel to deal with them.
Hazardous materials are everywhere.
The possibility of being involved in a hazardous A hazardous material (HAZMAT) is any chemical
material (HAZMAT) incident should be an substance or material that can pose a threat to
everyday concern of all personnel involved in the the health, safety and property of an individual
emergency medical services (EMS) system. Most (Fig. 29-1). These materials are wastes, chemicals
people think that a HAZMAT incident only involves and other dangerous products, including
train and truck crashes, but hazardous materials explosives, poisonous gases, corrosives,
can also be found in the home, school, industry radioactive materials, compressed gases,
Chapter 29: Hazardous Materials Emergencies | 647
Safety Data Sheets (SDSs). Sheets
(provided by the manufacturer) that identify
the substance, physical properties and any
associated hazards (e.g., fire, explosion and
health hazards) for a given material, as well
as emergency first aid.
Reactivity. The degree to which a substance
may react when exposed to other substances.
Shipping papers. Documents drivers must
carry by law when transporting hazardous
materials; the papers list the names, associated
dangers and four-digit identification numbers of
the substances.
Staging area. The location established where
resources can be placed while awaiting tactical
assignment.
Toxicity. The degree to which a substance is
poisonous or toxic.
Identifying Hazardous Materials
Resources
In addition to Safety Data Sheets provided
by manufacturers, the U.S. Department of
Fig. 29-1: Any chemical substance or material that poses Transportation (DOT) has several books
a health, safety or property threat is a hazardous material. available to help identify hazardous materials and
Photo: courtesy of Captain Phil Kleinberg, EMT-P.
appropriate care procedures. The Emergency
Response Guidebook is one such reference
oxidizers, and flammable solids and liquids. For
book (Fig. 29-2). The guidebook is available in
example, hospitals may have radioactive materials
English and Spanish and can be downloaded
if they practice nuclear medicine. Farms and
to mobile devices for easy and quick access to
lawn and garden companies stock fertilizers,
information on handling hazardous materials.
insecticides and pesticides. Various waste
The Chemical Transportation Emergency
products from any number of manufacturers may
Center (CHEMTREC) can provide further
also be considered toxic or hazardous.
information and guidance on hazardous
If you work as part of an EMS system, you should materials. The CHEMTREC 24-Hour HAZMAT
participate in a First Responder/Emergency Communications Center toll-free phone number
Medical Responder Awareness Level Hazardous is 800-424-9300.
Materials training program. This program provides
CAMEO® is an online library of more than
training in recognizing a HAZMAT incident and how
6000 data sheets containing response-related
to approach it safely.
information and recommendations for hazardous
Terms you should familiarize yourself with when materials that are commonly transported, used
dealing with a HAZMAT incident include: and/or stored in the United States. It is designed
to plan for and respond to chemical emergencies
Flammability. The degree to which a and was developed by the Environmental
substance may ignite. Protection Agency’s (EPA’s) Office of Emergency
HAZMAT. Any chemical substance or material Management (OEM) and the National Oceanic and
that can pose a threat or risk to life, health, safety Atmospheric Administration’s (NOAA’s) Office of
or property if not properly handled or contained. Response and Restoration (OR&R).
CRITICAL A HAZMAT is any chemical substance or material that can pose a threat to the
FACTS health, safety and property of an individual.
648 | Emergency Medical Response
Placards often clearly identify the danger of the
substance. Terms such as “explosive,” “flammable,”
“corrosive” and “radioactive” are frequently used.
Universally recognized symbols are also used.
Fig. 29-3 shows some common labels and
placards for identifying hazardous materials.
Shipping papers, also called manifests or waybills,
are a means of identifying hazardous substances
being transported from one location to another.
HAZMAT INCIDENTS
A hazardous material (HAZMAT) incident
is any situation that deals with the release of
hazardous material. When dealing with a HAZMAT
incident, you work within a structured system that
provides guidance in managing this type of scene.
Preparing for a HAZMAT Incident and
Activating the Plan
Establishing command at a HAZMAT incident may
be your responsibility as an EMR. The following
steps should be taken in preparation for the
worst-case scenarios developing at the scene:
Establish a clear chain of command.
A single command officer must be assigned
Fig. 29-2: Several books available from the DOT, such as the to maintain control of the situation and to
Emergency Response Guidebook, help identify hazardous make decisions at every stage of the rescue.
materials and appropriate care procedures.
The rescue team must be aware of who is in
command and when decision-making powers
are transferred to another officer.
The National Institute for Occupational Safety Establish a system of communication that is
and Health (NIOSH) is the federal agency accessible and familiar to all responders.
responsible for conducting research and
making recommendations for the prevention of Establish a receiving facility that is as close
to the scene as possible, and that is able to
work-related injury and illness. NIOSH provides receive and handle the number of patients and
free resources on various chemicals and also continued decontamination processes required.
publishes a pocket guide to chemical hazards.
Once the plan has been established, the EMR
Regulatory Requirements must stay in command until relieved by someone
EMRs should review the Occupational Safety and higher in the chain of command. The following
Health Administration (OSHA) and EPA safety information must be transferred to the new
guidelines as well as the National Fire Protection command officer:
Association (NFPA) HAZMAT requirements for
EMS providers.
Nature of the substance and problems
Identity of the hazardous materials
Placards and Shipping Papers Kind of containers and their condition
Placards, or signs, are required by federal law to Weather conditions, especially wind direction
be placed on any vehicles that contain specific Time since the emergency occurred
quantities of hazardous materials. In addition, Stage of the rescue and what steps are already
manufacturers and others associated with the in place
production and distribution of these materials are Number of patients involved
required by law to display the appropriate placard. Possibility of additional patients
Chapter 29: Hazardous Materials Emergencies | 649
A B
Fig. 29-3, A–B: Universally recognized symbols are used to identify the dangers of hazardous materials.
Recognizing a HAZMAT Incident
When approaching any scene, you should be aware of
dangers involving chemicals. Whether a motor-vehicle
collision or an industrial emergency, you should be
able to recognize clues that indicate the presence of
hazardous materials (Fig. 29-4). These include:
Signs (placards) on vehicles or storage facilities.
Spilled liquids or solids.
Unusual odors.
Clouds of vapor, including colored vapor.
Smoking or burning materials. Fig. 29-4: Unusual placement or conditions and leaking
containers are indications of the presence of hazardous
Boiling or spattering of materials. materials. Photo: courtesy of Capt. Tony Duran, Los Angeles
Unusual condition of containers County Fire Department.
(e.g., unexpected peeling or deterioration).
Leaking containers with possible frost near
the leak.
CRITICAL Indications of the presence of hazardous materials include placards; spilled,
FACTS splattered or boiling materials; unusual odors; vapor clouds; and containers that are
leaking, in deteriorating condition or are otherwise atypical.
650 | Emergency Medical Response
Also, observe for clues of possible terrorism. In Identifying the Hazardous Substance
some cases, such as a nuclear attack or explosion, Once a HAZMAT incident has been identified,
the possibility that a terrorist attack has taken place and you are in a safe position, try to identify the
will be more obvious. However, when dealing with hazardous substances and the seriousness of
a chemical or biological attack, it may be more the incident. Look for placards; NFPA numbers;
difficult to confirm your suspicions. There are some warning signs like “flammable,” “explosive,”
general clues you can use when approaching a “corrosive” or “radioactive”; shipping papers; or
disaster scene: areas where materials or containers are held or
stored (Fig. 29-5). By law, any business holding
When called to an incident at well-populated
materials considered hazardous must have permits
areas such as airports, subways, government
buildings, schools or large public gatherings, to hold or contain those materials. Containers
always use caution and suspect the possibility should be identified in order to assess the danger
that terrorism exists. level of leaks or further contamination. Containers
can include:
When called to a scene where numerous
patients are suffering from an unidentifiable Rooms, buildings or outside areas.
illness, the possibility you are entering a
potentially dangerous environment is also high.
Aboveground tanks and vats.
Individual containers, cartons and packages.
When called to a scene where animals in the
area are dead or appear incapacitated, the As already mentioned, placards will identify the
possibility of chemical exposure may exist. This exact substances in question. When dealing
includes the presence of odors resembling those with a vehicular incident, shipping papers
of bitter almonds, peaches, mustard, freshly cut will be held by the driver as reference to the
grass, garlic, or pungent or sweet odors. substances involved.
Unfortunately, in those cases where biological agents When in doubt, remember that the Emergency
have been released, it is not always obvious there Response Guidebook, CHEMTREC, CAMEO
is danger. Pathogens can enter a person’s system and NIOSH resources are available to you as well.
and not be evident until symptoms become evident, The HAZMAT team ultimately will be responsible
sometimes days after exposure. Often it becomes for identifying the substance, but in your role as
difficult to contain the spread of an outbreak, an EMR you could be able to provide the initial
particularly through the community of caregivers who identification. If arriving on the scene, collect the
may be infected in the vicinity of the attack. information and report to dispatch.
When called to a HAZMAT incident, it may be your
responsibility as an EMR to help lay the groundwork
for the rescue scene. As a responder you should:
Be able to identify the unsafe materials and the
scene as a HAZMAT incident.
Help establish or assign a safe location to
position yourself and the rescue team.
Always approach a suspected or real HAZMAT
incident from upwind and uphill.
Help establish the command and control zones
as well as a medical treatment area.
Always ask yourself:
yyWhat has been done?
yyWhat is being done? Fig. 29-5: By law, specific types of placards must indicate the
yyWhat actions need to be taken next? presence of hazardous materials.
CRITICAL Stay away from a HAZMAT scene unless you are properly trained and have the
FACTS proper equipment.
Chapter 29: Hazardous Materials Emergencies | 651
SCENE SAFETY AND PERSONAL While awaiting help, you may be tasked to keep
people away from the danger zone.
PROTECTIVE EQUIPMENT
Unless you have received special training in Especially in the case of radiation exposure, the
handling hazardous materials and have the following safety precautions must be taken to
necessary equipment to do so without danger, you ensure scene safety:
should stay well away from the area. While en route
to a potential HAZMAT incident, obtain as much From a distance, survey the area for the radiation
symbol on vehicles, buildings or containers.
prearrival information as possible from dispatch.
When on the scene, stay out of low areas where Determine the source of the radiation without
vapors and liquids may collect, and always stay moving closer to the scene.
upwind and uphill of the scene. Be alert for wind Position your vehicle upwind and uphill of the leak.
changes that could cause vapors to blow toward Do not park near liquid spills or containers that
you and other responders. Do not attempt to be a may be cracked or leaking.
hero. It is not uncommon for responding ambulance Be aware of the possibility of contamination
crews approaching the scene to recognize a from other substances.
HAZMAT placard and immediately move to a safe
area and call for additional resources.
When radiation is suspected, immediately don
a positive-pressure self-contained breathing
Many fire departments have specially trained teams apparatus (SCBA) and protective clothing
to handle incidents involving hazardous materials. (Fig. 29-6, A–B). Seal off all openings with
A B
Fig. 29-6, A–B: (A) Protective clothing and (B) an SCBA can help protect you in cases of radiation. Photos: courtesy of Ted Crites.
652 | Emergency Medical Response
duct tape. Wear double gloves and two pairs of Establishing Safety Zones
paper shoe covers under heavy rubber boots.
To decrease the risk of the HAZMAT incident
If radiation is suspected, do not attempt a expanding, it is necessary to establish a safety
rescue. Radiation cannot be felt, smelled or zone. Three control zones are created in these
heard. EMRs could be exposed to lethal doses situations, including (Fig. 29-7):
without any immediate signs or symptoms.
For your own personal protection consider:
The hot zone or exclusion zone. This is the area
in which the most danger exists. Entry is only
allowed with the proper PPE. The only reason
The time you have been exposed to the radiation
to be inside the hot zone is for rescue, treatment
source.
for any conditions that are life threatening and
The distance between you and the source.
initial decontamination.
The density of your protective clothing.
The warm zone or contamination reduction
The amount of radioactive material you and the zone. This is the area immediately outside the
patient have been exposed to. hot zone. PPE is necessary here as well. This is
Whenever possible, remove yourself and the where complete decontamination of the patient
patient from the contaminated area or the takes place. The purpose of this zone is for
contaminated material from the patient. The lifesaving emergency care—for example, airway
longer the time, the closer the distance and management and immobilization.
the more materials you are exposed to, the worse The cold zone or support zone. This the outer
the situation and the more protection you will perimeter; entry into this area is not permitted
require to decrease your risk of exposure. unless all contaminated PPE and equipment
are removed.
Some hazardous materials, such as natural gas,
are flammable and can cause an explosion.
Even turning on a light switch or using a
telephone or radio may create a spark that sets
off an explosion. When you call for additional
resources, use a telephone or radio well away
from the scene.
In certain situations, you may come across
methamphetamine (meth) labs. Meth labs are
very hazardous due to inhalation hazards and the
possibility of absorption of dangerous compounds
to all exposed. An even greater hazard is the
instability and highly explosive nature of these
labs. Meth labs can be set up in homes, trailers
and even the trunks of cars. Even a small
electrical spark, such as the flick of a light switch,
near the types of compounds found in these
locations could cause a significant explosion.
Always use caution if you suspect that there might
be a meth lab at the location you are attempting Fig. 29-7: In HAZMAT situations, three control zones are
to access. designated, from most to least dangerous: hot, warm and cold.
CRITICAL If you must work near a radiation source, think about your personal protection as
FACTS well as your patient’s. Consider how much time you have spent near the source, the
distance between you and the source, the density of your PPE, and the amount of
radioactive material you and the patient are exposed to.
In HAZMAT situations, three control zones are designated, from most to least
dangerous: hot, warm and cold.
Chapter 29: Hazardous Materials Emergencies | 653
Entry into these zones is established by the CONTAMINATION AND
amount of training a responder or member
of the rescue team has completed. The
DECONTAMINATION
warm and hot zones can only be entered by Contamination and Routes
those who have received OSHA Hazardous of Exposure
Waste Operations and Emergency Response A patient may have suffered from contamination
(HAZWOPER) training at the first responder via several possible routes, including topical (through
awareness level and who are dressed in the skin), respiratory (inhaled), gastrointestinal
appropriate PPE and SCBA. (ingested) or parenteral (intramuscular [IM],
intravenous [IV] or subcutaneous [sub-Q]). Potential
signs and symptoms for each are as follows:
HAZMAT—Recognition, Cardiovascular: Abnormally rapid heart rhythms,
specifically in the lower chambers of the heart
Identification and (ventricular arrhythmias), including rapid or
irregular heartbeats. Both are life threatening.
Determination Blood pressure lower than 90/60 mmHg
(hypotension).
Hazardous materials are often present at
incident sites and in emergency settings. Respiratory: Swelling and/or fluid accumulation
An EMR who is first on scene to a possible in the lungs (acute pulmonary edema) or larynx
hazardous materials spill should follow these (laryngeal edema), which can lead to impaired
three steps: recognition, identification and gas exchange and respiratory failure. Abnormal
determination. contraction of the smooth muscle of the bronchi,
causing an acute narrowing and obstruction
The first and most basic issue is recognition of the respiratory airway (bronchospasm) or a
of the presence of a hazardous material. high-pitched, whistling breathing caused by a
Prompt recognition and awareness of blockage in the throat or larynx (stridor), cough,
hazardous materials is very important to the dyspnea and chest pain. Respiratory symptoms
safety of the public and for the safety of the may be delayed.
responders. Contact dispatch and report Central nervous system: Stupor, lethargy, coma
specific details of the scene. and the possibility of seizures.
Once the presence of a hazardous material Gastrointestinal (GI): GI bleeding due to
has been determined, its specific identity liquefaction necrosis (irreversible death of cells)
and characteristics can be established. This of the GI tract.
is known as identification. The EMR should Eye: Vapor contamination can result in chemical
relay information regarding placard colors and conjunctivitis. Necrosis and blindness can
numbers, and any label information. Shipping result from exposure to liquids and anhydrous
papers that include SDSs will also help to (ammonia) gas.
identify the hazardous material(s).
Determination of the extent of involvement Decontamination
a hazardous material plays in an incident is There are several methods of decontamination,
necessary to determine if it is responsible for including gross, dilution, absorption, neutralization
injuries or damage at the scene of the incident. and isolation/disposal. Initial or “gross”
Often, hazardous materials may be present but decontamination is performed as the person enters
pose no immediate, serious threat. the warm zone. Any immediate life-threatening
conditions are addressed during this stage.
It cannot be overemphasized that until it has Soap and copious amounts of water are used,
been determined that hazardous materials are and any clothing, equipment and tools must be
not responsible for injuries or damage at an left in the hot zone (Fig. 29-8). At this point, a
incident, EMRs should take every precaution primary assessment is carried out. Dilution refers
to protect themselves and the public to the method of reducing the concentration of
from exposure. a contaminant to a safe level. Isolation/disposal
refers to the method of decontamination in which
654 | Emergency Medical Response
CRITICAL Possible routes of exposure and contamination include topical, respiratory,
FACTS gastrointestinal and parenteral.
Methods of decontamination include gross, dilution, absorption, neutralization and
isolation/disposal.
Emergency Medical Treatment
Establishing a Location
Establishing a clear perimeter between zones
is of critical importance to prevent the spread
of contamination. When selecting the location
for the command post and staging area, it is
necessary to position support equipment upwind
and uphill of the hot zone. Equipment that may
be required during the rescue process should be
kept in the staging areas beyond the crowd control
line. Access to the different zones must be safely
controlled, limiting access as much as possible.
Providing Care
When you arrive at the scene, park upwind and
uphill from the scene at a safe distance. Keep
bystanders and any other unnecessary people
away from the scene. Isolate the scene and
establish hot, warm and cold zones, keeping
people out of areas accordingly. Do not enter
these zones unless you are trained to an OSHA
HAZWOPER first responder awareness level or
higher, and you have appropriate PPE and SCBA.
Avoid any contact with the hazardous material. If
there is no risk to EMS personnel, HAZMAT teams
should move patients to a safe zone.
Fig. 29-8: During initial decontamination, soap and Determine the number of patients involved in
copious amounts of water are used to address any immediate the incident and evaluate the need for additional
life-threatening situations. Photo: courtesy of Captain Phil
Kleinberg, EMT-P. resources. Follow safety practices that minimize your
exposure and that of other people at the scene.
contaminated equipment and materials are bagged When assessing and treating a patient in a
or covered and set aside, usually for subsequent HAZMAT incident, it is important to concentrate
shipment to an approved landfill for disposal. on the life-threatening signs and symptoms as
Absorption is the process of using material opposed to strictly dealing with the contamination
that will absorb and hold contaminants such as and exposure itself. Removing the patient from a
corrosive and liquid chemicals. Neutralization scene involving hazardous materials should be
involves chemically altering a substance to render done as quickly as possible to decrease exposure.
it harmless or make it less harmful. Assessment and management of the patient
CRITICAL When assessing and treating a patient in a HAZMAT incident, it is important to
FACTS concentrate on the life-threatening signs and symptoms as opposed to strictly
dealing with the contamination and exposure itself.
Chapter 29: Hazardous Materials Emergencies | 655
should then be carried out as you would normally. A HAZMAT incident is one in which dangerous
When radiation is a concern, contact the national chemicals have somehow been released and
Poison Help line at 800-222-1222 or consult with pose a threat to life. When dealing with a
medical direction. HAZMAT incident, work within a structured
system that provides guidance in managing this
type of scene.
PUTTING IT ALL TOGETHER
Several available resources can assist you in
Hazardous materials are everywhere around us identifying hazardous materials and the
and there is always a possibility of a HAZMAT steps involved in providing care. In a HAZMAT
incident. As an EMR, you may find yourself incident, your priorities are to protect the
involved in a situation in which there are chemical safety of responders and patients at the
or other harmful or toxic substances. EMRs must scene by providing care and assisting with
be trained to quickly identify such situations and decontamination. Planning for HAZMAT
activate specially trained personnel to deal with incidents is essential for an effective response.
the situation.
You Are the Emergency Medical Responder
Since you recognize the scene as a HAZMAT incident, what questions should you ask yourself
immediately? What initial actions should you take and why?
656 | Emergency Medical Response
30
INCIDENT
COMMAND AND
MULTIPLE-CASUALTY
INCIDENTS
You Are the
Emergency Medical
Responder
A school bus carrying 30 students
is involved in a collision and is
severely damaged near the front
of the bus. The students are
scared, and some are injured.
People are starting to crowd
around the area, and the local
fire department already is on
scene. As an emergency medical
responder (EMR) on scene, what
should you do?
KEY TERMS
Deceased/non-salvageable/expectant (Black): Multiple- (or mass-) casualty incident (MCI):
A triage category of those involved in a An incident that generates more patients
multiple- (or mass-) casualty incident (MCI) who than available resources can manage using
are obviously dead or who have suffered routine procedures.
non-life-sustaining injuries.
National Response Framework (NRF): The
Delayed care (Yellow): A triage category of those guiding principles that enable all response
involved in an MCI with an injury, but whose partners to prepare for and provide a unified
chances of survival will not be reduced by a delay. national response to disasters and emergencies—
from the smallest incident to the largest
Immediate care (Red): A triage category of those catastrophe. The Framework establishes a
involved in an MCI whose needs require urgent comprehensive, national, all-hazards approach
lifesaving care. to domestic incident response.
Incident command system (ICS): A standardized, Simple Triage and Rapid Transport (START):
on-scene, all-hazards incident management A method of triage that allows quick assessment
approach that allows for the integration of and prioritization of injured people.
facilities, equipment, personnel, procedures and
communications operating within a common Triage: A method of sorting patients into categories
organizational structure; enables a coordinated based on the urgency of their need for care.
response among various jurisdictions and
functional agencies, both public and private; Triage tags: A system of identifying patients during
and establishes common processes for an MCI; different colored tags signify different
planning and managing resources. levels of urgency for care.
Incident commander: Through delegated authority Walking wounded (Green): A triage category of
of a local government, the incident commander (IC) those involved in an MCI who are able to walk by
is responsible for establishing the incident themselves to a designated area to await care.
objectives and managing resources, including
assessing the situation, deciding what calls
to make and what tasks need to be done, and
assigning those tasks to appropriate personnel.
LEARNING OBJECTIVES
After reading this chapter, you will have the • Define multiple-casualty incidents.
information needed to: • Explain the principles of triage.
• Describe the purpose of the National Response • Conduct a triage assessment.
Framework (NRF). • Understand different triage systems and
• Describe the purpose and functional positions of pediatric variations.
the incident command system (ICS). • Understand the stressors associated with
• Explain the role of the emergency medical multiple-casualty incidents (MCIs).
responder (EMR) in the ICS.
658 | Emergency Medical Response
INTRODUCTION Incident Command System
As an emergency medical responder (EMR), To effectively manage an emergency situation
you are likely to be required to assist with an and to provide appropriate care, an incident
emergency with multiple victims, and to do so command system (ICS) must be established,
you need a plan of action to enable you to rapidly organizing who is responsible for overall direction,
determine what additional resources are needed the roles of other participants and the resources
and how best to manage them. During a serious required. Although the ICS is capable of providing
incident, you may be on the scene for 15 minutes a management structure for incidents both
or longer before adequate resources are available large and small, it is scalable based on incident
to care for a large number of injured people. requirements. Establishing the ICS is particularly
important in a multiple- (or mass-) casualty
Management of an appropriate initial response can incident (MCI) to effectively manage many
eliminate potential problems for arriving personnel resources. The EMR is highly encouraged, and
and possibly save the lives of several injured in some cases, mandated by local and state
people. To accomplish this, you must be able to regulations to take the following independent-
make the scene safe for you and others to work, study, interactive web-based ICS courses:
delegate responsibilities to others, manage available
resources, identify and care for the patients most ICS-100: Introduction to the Incident
in need of care, and relinquish command as more Command System
highly trained and qualified personnel arrive. ICS-700: National Incident Management
System: An Introduction
NATIONAL INCIDENT IS-800: National Response Framework:
An Introduction
MANAGEMENT SYSTEM
The ICS is a management system, originally
According to the Federal Emergency developed in the early 1970s in California to help
Management Agency (FEMA), “The National manage the process of fighting forest fires, that
Incident Management System (NIMS) provides has since evolved into an all-hazards incident
a systematic, proactive approach to guide management system. It has proven especially
departments and agencies at all levels of effective as a strategy in emergencies involving
government, nongovernmental organizations and multiple patients because of its ability to manage
the private sector to work seamlessly to prevent, many functions and resources.
protect against, respond to, recover from and
mitigate the effects of incidents, regardless of To understand the ICS, think of it as an
cause, size, location or complexity, in order to organization composed of responders working
reduce the loss of life and property and harm to together to achieve a common goal. The
the environment.” incident commander (IC), through delegated
authority of a local government, is tasked with
“NIMS works hand in hand with the National the responsibility of establishing the incident
Response Framework (NRF). NIMS provides objectives and managing resources. The IC
the template for the management of incidents, while supervises these resources utilizing the ICS. Also,
the NRF provides the structure and mechanisms depending on the size of the incident, the IC may
for national-level policy for incident management.” need to establish branches for logistics, finance/
administration, operations and planning as part of
The National Response Framework the IC structure.
The NRF (or Framework) is a guide to how the
nation conducts all-hazards response. It is built EMS Roles in the ICS
upon scalable, flexible and adaptable coordinating In any emergency, the incident commander is
structures to align key roles and responsibilities responsible for assessing the situation, deciding
across the nation. It describes specific authorities what calls to make and what tasks need to be done,
and best practices for managing incidents that range and assigning those tasks to appropriate personnel
from the serious but purely local, to large-scale (Fig. 30-1). The responder who assumes the role as
terrorist attacks or catastrophic natural disasters.
Chapter 30: Incident Command and Multiple-Casualty Incidents | 659
incident commander remains in that role until a more If the incident is small and contained, it is likely
senior or experienced person arrives on the scene that one person in the incident commander role
and assumes command, or until the incident is over. may handle all aspects of directing care. However,
in situations with multiple casualties and/or
When transitioning command to a more senior events, the incident commander must delegate a
person, the outgoing incident commander must variety of roles to other responders. While not all
ensure that everything necessary has been of these functional positions may be necessary,
done before leaving the scene or accepting these are the ones most often required—the
another assignment. larger the incident, the more functional positions
are required:
The triage officer supervises the initial triage,
tagging and moving of patients to designated
treatment areas.
The treatment officer sets up a treatment area
and supervises medical care, ensuring triage
order is maintained and changes the order if
patients deteriorate and become eligible for
a higher triage category.
The transportation officer arranges for
ambulances or other transport vehicles while
tracking priority, identity and destination of all
injured or ill people leaving the scene.
The staging officer releases and distributes
resources as needed to the incident and works
to avoid transportation gridlock.
The safety officer maintains scene safety by
identifying potential dangers and taking action to
prevent them from causing injury to all involved.
Other roles that may need to be filled include:
Supply.
Mobile command/communications.
Extrication.
Fig. 30-1: In an emergency, the incident commander is Rehabilitation.
responsible for assessing the situation, deciding what calls to
make and what tasks need to be done, and assigning the tasks Morgue.
to appropriate personnel. Photo: courtesy of Ted Crites. Logistics.
CRITICAL As an EMR, you are likely to be required to assist with an emergency with multiple
FACTS victims, and to do so you need a plan of action to enable you to rapidly determine
what additional resources are needed and how best to manage them.
The ICS is a management system, originally developed in the early 1970s in
California to help manage the process of fighting forest fires, that has since evolved
into an all-hazards incident management system. In any emergency, the incident
commander is responsible for assessing the situation, deciding what calls to make
and what tasks need to be done, and assigning the tasks to appropriate personnel.
If you are the first and most senior EMR on the scene, you are the incident
commander until someone more experienced arrives. As incident commander, it
is your responsibility to identify a scene as an MCI, assess the scene safety and
determine if any action is required to secure the scene.
660 | Emergency Medical Response
The Role of the Emergency officer. You will then be tasked to a detail where
Medical Responder you are most needed, based on your experience
and capability. This could be assisting medical
Your role as an EMR is to fit into the team wherever
personnel, aiding in crowd or traffic control,
you are assigned by the IC or their designee. You
helping to maintain scene security or helping to
may find yourself acting as incident commander
establish temporary shelter. By using the ICS in
until someone more experienced arrives. If you are
numerous emergencies, the tasks of reaching,
with a partner or co-worker, the most senior person
caring for and transporting injured or ill people are
takes on the role of incident commander. Your
performed more effectively, thereby saving more
responsibility is to identify if this is an MCI and
lives. Since there are variations in the plan for
assess the scene’s safety to determine if any action
managing MCIs with ICS throughout the country,
must be taken to secure the scene to prevent
you should become familiar with the MCI plan for
further injury.
your location.
After assessing safety, as incident commander, you
must account for the number of patients, including
those who may not appear to be injured, determine MULTIPLE-CASUALTY INCIDENTS
whether anyone needs rescuing (extrication), An MCI is an incident that generates more patients
determine the number of ambulances required, and than available resources can manage using routine
indicate the number of functional positions and procedures. As the term implies, an MCI refers
extra personnel required. You must also ensure to a situation involving two or more people. You
access to areas to stage resources and make are most likely to encounter MCIs involving injury
note of any situations that may affect the scene, to small numbers of people, such as a motor-
including weather, difficulty accessing the site and vehicle crash involving the driver and a passenger.
the terrain. But MCIs can also be large-scale events, such
as those caused by natural disasters or those
You must be easily identifiable as the incident from materials/structures made by humans.
commander to prevent confusion. Determine Examples include:
local protocols in effect for identifying yourself
as the officer-in-charge and your vehicle as the Transportation incident.
initial command post (vests or a green light on Flood.
the command vehicle are common procedures).
Be sure to report all issues and necessary
Fire.
information—do not go into detail during radio Explosion.
transmission. This is the time for short, concise, Structure collapse.
accurate and pertinent bits of information. Train derailment (Fig. 30-2, A–B).
When someone with more experience or seniority
Airliner crash.
relieves you, be sure to relay all important and Hazardous material (HAZMAT) incident.
pertinent information verbally, including what has Earthquake.
been recorded. The person taking over will need Tornado (Fig. 30-3).
to know information such as when the incident Hurricane.
began, when you arrived on the scene, how many
people are injured, how many people are acting Some incidents can result in hundreds or even
as responders, any potential dangers, what has thousands of injured or ill people. Whether small
been done since the beginning of the rescue and or large scale, MCIs can strain the resources of
objectives that need to be accomplished. a local community. Coping effectively with an
MCI requires a plan that enables you to acquire
If you arrive on the scene after someone has and manage additional personnel, equipment
already taken command, identify yourself to the and supplies.
incident commander and report to the staging
CRITICAL An MCI is an incident that generates more patients than available resources can
FACTS manage using routine procedures.
Chapter 30: Incident Command and Multiple-Casualty Incidents | 661
A B
Fig. 30-2, A–B: Large-scale events involving human-made structures or materials, such as a train derailment, can result in an MCI.
Photos: courtesy of Capt. Tony Duran, Los Angeles County Fire Department.
Fig. 30-3: Natural disasters, such as tornadoes, can result in MCIs. Photo: courtesy of Captain Phil
Kleinberg, EMT-P.
TRIAGE The Triage Officer
In an MCI, you must modify your assessment skills The first step is to identify and assign a triage
and technique for checking injured or ill people. officer. This is a responsibility of the incident
This requires you to understand the priorities of commander. The triage officer is an integral
treatment and transportation. It also requires you position of the ICS in MCI management. If you
to accept death and dying because some patients, are the only person on the scene, the role falls
such as those in cardiac arrest who would normally on you until you receive help. The triage officer
receive CPR and be a high priority, will be beyond remains in that role until all patients are triaged
your ability to help in this situation. and until relieved or reassigned by the IC. The
triage officer determines the requirements for
To identify which patients require urgent care in an additional resources (to perform triage), performs
MCI, you use a process known as triage. Triage triage of all patients, and assigns personnel and
is a French term derived from “trier,” meaning “to equipment to the highest-priority patients in the
sort,” and was first used to refer to the sorting and triage area.
treatment of those injured in battle.
662 | Emergency Medical Response
Fig. 30-4: Triage is used on the scene to rapidly categorize the condition of patients. Photo: courtesy of
Captain Phil Kleinberg, EMT-P.
Primary and Secondary Triage
Primary triage is used on the scene to rapidly
categorize the condition of patients (Fig. 30-4).
When performing your first assessment, note the
approximate number and location of patients and
what the transportation needs are going to be, such
as stretchers, litters or special extrication equipment.
Keep in mind that these are just primary
assessments and patients may be re-triaged later;
their status may change accordingly. Using the
methods outlined by your locality, ensure that all
patients have the appropriate color tape or card
attached in a visible fashion. According to Simple
Triage and Rapid Transport (START) principles, it
should take no longer than 30 seconds per patient
to do your assessment and tagging.
Patient status can change quickly. If it is necessary
and there is time and space, a secondary triage
may be performed after the primary triage. This is
often performed after patients are moved to the
treatment area or at a funnel point just before they
enter the treatment area. If the status of a patient
changes, leave the first tag in place and draw a
bold line through it. Then, add the second, most
up-to-date assessment tag.
Note that slots on tags do not necessarily need to
Fig. 30-5: Triage tags are used to note the status of patients in
be completely filled out at once. As new information an MCI. Photo: courtesy of Terry Georgia.
becomes available, add that information to the
triage tag (Fig. 30-5).
Chapter 30: Incident Command and Multiple-Casualty Incidents | 663
Fig. 30-6: The METTAG™ patient identification system uses symbols, rather than words, to allow responders to
quickly identify patient status.
Triage Tagging Systems
There are a variety of triage tags you may use
or encounter in a triage area. Because large
disasters can bring responders in from a wide
area, internationally understood methods of
communication are essential. Thus, the colors
green, red, yellow and black are commonly used for
the triage tagging system.
The METTAG™ patient identification system uses
symbols, rather than words, to allow responders
to quickly identify patient status (Fig. 30-6). The
rabbit means urgent, the turtle means can be
delayed, the ambulance with a bold line through it
means that no urgent transport is needed, and a
Fig. 30-7: The Smart Tag™ features a folding design for ease
shovel and cross symbol is used for the dead. of use. All intellectual property rights of the items shown in
this image are the property of TSG Associates LLP. Written
Another option is the Smart Tag™, adopted by permission is required before use by any third party.
certain U.S. cities and states (Fig. 30-7). This tag
features a folding design for ease of use.
664 | Emergency Medical Response
these items, classify injured or ill people into one
of four levels that reflect the severity of their injury
or illness and the need for care. These levels are
“minor/walking wounded,” “delayed,” “immediate”
and “deceased/non-salvageable.” Some advanced
triage systems also include a fifth category, “hold,”
to indicate patients with minor injuries who do not
require a physician’s care.
Ambulatory (Walking Wounded)
The first step is to sort those who can walk on
their own, the ambulatory or walking wounded
(Green). To do this, use a public address (PA)
Fig. 30-8: Some states choose to customize their tag designs,
while some response systems use colored flagging tape. Photo:
method if possible. Get their attention and
courtesy of Captain Phil Kleinberg, EMT-P. direct these patients to move on their own to
a designated area. This allows you to find out
quickly who is not in grave danger and clears the
Additionally many states have adopted the START tag
emergency area of those who do not need to be
or adaptations of it. Some states choose to customize
there. Ambulatory patients are tagged as Green.
their tag designs, while some response systems
simply use colored flagging tape (Fig. 30-8).
Immediate
The first of the other categories is immediate
The START System care (Red). This categorization means that the
The Simple Triage and Rapid Transport patient needs immediate care and transport to a
(START) system is one of several triage methods medical facility. Patients are considered immediate
and is a simple way to quickly assess and prioritize if they are unconscious or cannot follow simple
injured or ill people. It requires you to check only commands, require active airway management,
three items: breathing, circulation and level of have a respiratory rate of greater than 30, have a
consciousness (LOC) (Fig. 30-9). As you check delayed (more than 2 seconds) capillary refill or
Fig. 30-9: The START triage system uses an assessment of breathing, circulation and LOC
to prioritize injured or ill patients.
CRITICAL The START system is a simple way to quickly assess and prioritize injured or ill
FACTS people. It requires you to check only three items: breathing, circulation and LOC.
Chapter 30: Incident Command and Multiple-Casualty Incidents | 665
absent radial pulse, or require bleeding control Once ambulatory patients are out of the area, you
for severe hemorrhage from major blood vessels. will need to check respiratory status of the remaining
Immediate patients are tagged Red. patients. If there are no respirations, clear the mouth
of any foreign objects and make sure the airway
Delayed is open. If there are still no respirations and the
The second category is delayed care (Yellow), patient does not begin breathing independently,
meaning patients who may be suffering severe even with the airway open, the patient is classified
injuries but a delay in their treatment will not reduce as “deceased/non-salvageable.” There is no need
their chance of survival. Those tagged delayed are to check the pulse. Place the appropriate tag on the
non-ambulatory and are breathing, have a pulse and patient and move on.
their LOC is within normal limits. While they do not If the patient begins to breathe independently when
have life-threatening injuries, they may have back you open the airway, classify the patient as needing
injuries with or without spinal cord damage, major immediate care and tag appropriately. Any individual
or multiple bone or joint injuries, or burns without who needs help maintaining an open airway is a
airway problems. However, the following types of high priority. Position the patient in a way that will
burns need immediate, advanced care: flame burns maintain an open airway, place the appropriate tag
that occurred in a confined space; burns covering on the person and move on to the next patient. Once
more than one body part; burns to the head, neck, triage of all injured or ill people is complete, you may
hands, feet or genitals; any partial-thickness or full- be able to come back and assist with care.
thickness burns to a child or an older adult; or burns
resulting from chemicals, explosions or electricity. If the patient is breathing when you arrive, check
Delayed patients are tagged Yellow. the rate of the patient’s breathing. Someone
breathing more than 30 times a minute should be
Deceased classified as immediate care.
The third category, deceased/non-salvageable/ The third step is to determine the perfusion
expectant (Black), is assigned to those individuals status. This is done by checking capillary refill
who are obviously dead or who have mortal injuries. and radial pulse, with the pulse being the more
Patients who are not breathing and who fail to reliable measure, as capillary refill is dependent on
breathe after attempts to open and clear the airway multiple factors. If you cannot find the radial pulse
(even if they have a pulse) are classified as deceased/ in either arm, then the patient’s blood pressure is
non-salvageable/expectant. This classification substantially low. Control any severe bleeding by
also applies to obvious mortal injuries such as using direct pressure and applying a bandage,
decapitation. Deceased patients are tagged Black. tourniquet or hemostatic dressing, based on your
available resources and local protocols. A large-
Hold scale incident with limited resources may require
Some advanced triage systems also include a hold the use of a tourniquet as the first option to control
category, to indicate patients with minor injuries who severe, life-threatening bleeding, as maintaining
do not require a physician’s care, such as minor direct pressure may not allow the responder to
painful, swollen, deformed extremities or minor soft continue to triage and care for other patients. If
tissue injuries. These patients may be tagged White this is the case, classify the patient as requiring
and dismissed, with a recommendation to obtain immediate care and move on to the next patient.
basic first aid care at home or elsewhere.
The fourth step is to determine the patient’s
LOC, by using the AVPU (Alert, Voice, Pain,
Assessment in Triage Unresponsive) scale. A patient who is alert
The START system is a popular method that and responds appropriately to verbal stimuli is
is simple and depends on condition-based classified as delayed care. This patient has some
classification. You determine the different levels by injury that prevents them from moving to safety, but
assessing four aspects that can be recalled with the condition is not life threatening. Someone who
the acronym ARPM. ARPM stands for: remains unconscious and responds only to painful
stimuli or responds inappropriately to verbal stimuli
Ability to get up and walk (ambulatory). is classified as immediate care.
Respiratory status.
Perfusion status.
Mental status.
666 | Emergency Medical Response
Other Methods of Triage antidotes. At this point, you would prioritize patients
for treatment and/or transport by assigning them
Besides the START triage system, there are others,
to one of five categories: Immediate, Expectant,
such as the Sort-Assess-Lifesaving Interventions-
Delayed, Minimal or Dead.
Treatment and/or Transport (SALT) Mass Casualty
Triage (Fig. 30-10). The SALT Mass Casualty
Triage was developed using all existing triage Treatment
systems, and is meant for all patients involved, even Following triage, patients must be processed
special populations and children. It sorts patients through the treatment area (Fig. 30-11). The
into three priorities: Priority 1: Still/obvious life treatment officer is appointed by the IC and
threat; Priority 2: Waving/purposeful movement; is responsible for identifying a treatment area
and Priority 3: Walking. It then goes on to include of sufficient space and with adequate ingress
individual assessments, beginning with limited, and egress for ambulances. The treatment
rapid lifesaving interventions (LSIs), such as officer ensures the appropriate medical care of
controlling severe bleeding; opening and clearing all patients, directs re-triage if indicated, and
the airway; or giving 2 ventilations if the patient communicates with the transportation officer
is a child, chest compressions or auto-injector regarding the transportation of the patients and
ventilations)
Fig. 30-10: The SALT Mass Casualty Triage system sorts patients into three priorities: still/obvious life threat, waving/purposeful
movement and walking.
CRITICAL Besides the START triage system, there are others, such as the SALT Mass
FACTS Casualty Triage.
The JumpSTART triage method should be used on anyone who appears to be a
child, regardless of actual chronological age, but is not used on infants younger
than 12 months old. Always remember that a multiple-casualty incident involving
children is handled differently than one involving adults.
Chapter 30: Incident Command and Multiple-Casualty Incidents | 667
appropriate destination hospital requirements
(trauma center consideration) in the correct order,
according to triage. Patients tagged as immediate
have priority and should be treated to correct
any life-threatening conditions. They should be
transported by the most appropriate means to the
various hospitals according to the local MCI plan.
Pediatric Considerations
JumpSTART Pediatric Triage
An emergency that involves children must be
handled differently from the way you would
an emergency with adults. The psychological
differences between adults and children
could cause errors in tagging children. The
JumpSTART triage method should be used on
anyone who appears to be a child, regardless
of actual chronological age, but is not used on
infants younger than 12 months old (Fig. 30-12).
Using the same START steps outlined
previously, you would assess whether the
child is ambulatory, the respiratory status,
whether there is any major bleeding and the
mental status.
Children who are ambulatory should be
tagged accordingly and escorted to the
proper area; do not send them alone. Children
Fig. 30-11: Following triage, patients are processed through
who are breathing must be monitored for the the treatment area, where patients are cared for, re-triaged or
rate. It should be between 15 and 45 breaths transported according to need. Photo: courtesy of Terry Georgia.
per minute. If it is any lower or higher, or if
they begin breathing spontaneously after
you open the airway, they should be tagged Staging
as immediate care. A child who does not The staging officer should be one of the first
breathe after the airway has been cleared officers assigned by the IC. It is important that the
and does not have a peripheral pulse should staging officer establish an area suitable to park
be tagged as deceased/non-salvageable. multiple units in an organized fashion. This officer
However, if a pulse is present, even if there is must maintain accountability of all units assigned
no breathing after the airway is cleared, you for immediate release to the transportation officer.
should give 5 ventilations before determining
the child’s status. Transportation
For circulation, or perfusion, check the child’s The transportation officer is assigned by the IC.
peripheral pulse. If there is none present, The major responsibility of the transportation officer
the child should be tagged for immediate is patient accountability. This is a documentation-
care. Finally, for mental status, see if the rich position, and aide(s) are often required based
child responds to your voice. Code the child on the scope and complexity of the incident. The
as delayed care if there is no response to transportation officer communicates with receiving
all stimuli. If the child does respond to pain hospitals, units assigned by the staging officer,
but only with sounds, the tag should be for the staging officer and the treatment officer. The
immediate care. transportation officer is responsible for assigning
patients to ambulances, helicopters and buses,
While patients are waiting for transport, they should assigning destination hospitals and maintaining
be continually monitored for changes in status. For patient tracking records.
example, it is always possible that a patient tagged
as delayed may experience deterioration in condition The ambulances, helicopters and buses will be
and need to be tagged as immediate. instructed which hospital is accepting their patient
668 | Emergency Medical Response
JumpSTART Pediatric MCI Triage©
Able to YES Secondary *Evaluate infants first in
MINOR secondary triage using
walk? Triage* the entire JS algorithm
NO
NO Position BREATHING
Breathing? IMMEDIATE
upper airway
APNEIC
NO
Definite pulse? DECEASED
YES
5 APNEIC
YES DECEASED
ventilations
BREATHING
IMMEDIATE
< 15 OR > 45
Respiratory IMMEDIATE
Rate
15 – 45
Definite NO
IMMEDIATE
Pulse?
YES
“P” (Inappropriate)
Posturing or “U”
AVPU IMMEDIATE
“A ”, “V” or “P”
(Appropriate)
DELAYED
©Lou Romig MD, 2002
Fig. 30-12: The JumpSTART triage method, used on children older than 12 months of age, uses the same START
steps to assess children.
Chapter 30: Incident Command and Multiple-Casualty Incidents | 669
or patients. They then radio ahead to the hospital, Some people are at greater risk of severe
notifying hospital personnel of their impending stress reactions. Children may react strongly,
arrival. This is the time when appropriate advance experiencing extreme fears of further harm. Older
information is given, such as the injuries involved adult patients and those who already suffer from
and estimated time of arrival. health problems, either physical or emotional, may
also be at increased risk.
Once all the immediate and delayed patients have
been transported, the ambulatory patients also may
be transported. Essential emergency equipment Responder Stress
and EMRs should be on the transport, in case a After each call, there should be opportunity to
patient deteriorates from ambulatory to delayed, or discuss how the call went, as well as any feelings
even immediate, care. or issues that may have resulted. This is particularly
important following an MCI, which can often seem
overwhelming and difficult to handle. Trained
STRESS AT AN MCI counselors may help lead the discussion and
Patient Stress reduce the risk of post-traumatic stress.
The impact of an MCI can reach far beyond visible Reducing stress during the MCI is also important.
injuries. The stress of living through such an event This can be done by ensuring that responders
can result in cognitive, emotional, physical and know exactly what is expected of them. If they do
behavioral responses. Some may occur right away, not understand their roles or duties, frustration
others may only appear days after the event. and stress may result. If responders are in roles
that match their specific strengths, this helps in
Patient stress can be the result of individual reducing stress.
injuries, but also concern over loved ones who may
have been involved in the MCI (Fig. 30-13). Not Ensure that responders get adequate rest,
knowing what is happening is very stressful and according to the protocols for your organization.
frightening, and can interfere with the physical care Rest and downtime are essential, regardless of the
of the patient. situation. This time can be used for the responders
to eat and drink (no alcohol), close their eyes or
talk. If possible, counselors on the scene can help
at this point.
Keep an eye on the responders. Even though they
may feel they are coping well, if you are on the
lookout for exhaustion or stress, you may be able to
intervene and provide rest and support.
Encourage responders to talk among themselves,
though their conversation must be kept professional
to avoid misunderstandings from other workers or
the patients.
Managing and Reducing Stress
Whenever possible, reunite family members. The
goal is to reduce their stress and fear, but this
can also be helpful for responders, since family
members can provide missing information and can
support each other.
Limit the information that may be getting out of
the scene. Only designated authorities should
be speaking to members of the media, and those
responders who are working on the scene should
not discuss individual patients with anyone other
Fig. 30-13: Patient stress can be the result of individual injuries than immediate family members who are on hand.
or concern over loved ones. Photo: courtesy of Ted Crites.
670 | Emergency Medical Response
CRITICAL Communication is a vital link to manage an MCI smoothly. However, if you find
FACTS yourself in a situation where communication is not ideal, remember that your
first priority is your patients and the care you are there to provide. Do not let the
frustration of difficulties with communication affect your work.
Be honest. Tell patients what is happening in terms PUTTING IT ALL TOGETHER
they can understand. Limit the use of official or
As an EMR, you may need to assist with an
medical language, as it can seem confusing and
emergency involving multiple people. To do so
frightening if misunderstood.
effectively requires a plan of action so that you can
If possible, for those who are able, assign tasks to rapidly determine what additional resources are
help others. This can help reduce stress and make needed and how best to use them. An appropriate
them feel useful. If patients are reluctant to receive initial response can eliminate potential problems
help, encourage them to accept it, so that perhaps for arriving personnel and possibly save the lives
they may return the favor at some point by helping of several injured people. You will need to be
someone else. able to make the scene safe for you and others
to work, delegate responsibilities to others,
Encourage questions and discussion. Fear of the manage available resources, identify and care for
unknown is often worse than reality. Be careful the patients most in need of care, and relinquish
not to offer false hope; if you cannot answer a command as more highly trained personnel arrive.
question, say so and see if you can determine the
answer from the right sources. MCIs can be stressful and challenging for EMRs.
By following set protocols for establishing
priority care, confusion can be minimized for both
COMMUNICATION responders and patients.
Communication is a vital link in the smooth running The two most important issues to remember are
of an MCI. However, it is important that responders assessment and communication. For patients
understand that communication is not always as in an MCI, your assessments differ from those
smooth and effective as would be desired. If you of one-on-one situations. In an MCI, you must
find yourself in a situation where communication is be able to provide care to as many patients as
not ideal, remember that your first priority is your possible, so you must focus on those who can be
patients and the care you are there to provide. saved or helped.
Do not let the frustration of difficulties with
communication affect your work. Communication between you and your colleagues
is vital in maintaining control of the situation,
To help communication run smoothly, remember minimizing stress and providing quality care.
to always speak as clearly as possible—do Communication with the patients and their loved
not rush your speech—because being asked ones will help keep them from panicking and help
to repeat or being misunderstood can cause them listen to instructions.
a delay in care or transport. Use simple, clear
language. Use communication tools such as radio Finally, equally important to caring for your patients
communications only when necessary, so as not to is caring for yourself. Be sure that you and your
clutter the airwaves. For obvious reasons, face-to- colleagues get enough rest and support during and
face communication is usually the easiest means after the MCI.
of communication.
You Are the Emergency Medical Responder
A number of students from the bus are yelling at you to help them, and one of the firefighters
asks you to come over and check the coach, whose pain in his abdomen and chest seems to
be getting worse. What should you do?
Chapter 30: Incident Command and Multiple-Casualty Incidents | 671
31 RESPONSE TO
DISASTERS AND
TERRORISM
You Are the Emergency Medical Responder
You are an emergency medical responder dispatched to the scene of an explosion. On
arrival you are staged with other emergency vehicles a safe distance away. You are told
that police suspect that a building was targeted by an extremist group and it is thought
there were no injuries from the blast. What should concern you at this time? How would
you respond? What should you consider when you size up the scene?
KEY TERMS
All-hazards approach: An approach to disaster High-order explosives (HE): Explosives such as
readiness that involves the capability of TNT, nitroglycerin, etc., that produce a defining
responding to any type of disaster with a range of supersonic over-pressurization shockwave.
equipment and resources.
Incendiary weapons: Devices designed to burn at
Asymptomatic: A situation in which a patient has extremely high temperatures, such as napalm and
no symptoms. white phosphorus; mostly designed to be used
against equipment, though some (e.g., napalm) are
Atropine: An anticholinergic drug with multiple designed to be used against people.
effects; used in antidotes to counteract the effects
of nerve agents and to counter the effects of Low-order explosives (LE): Explosives such
organophosphate (chemical compounds found in as pipe bombs, gunpowder, etc., that create
many common insecticides and used to produce a subsonic explosion.
toxic nerve agents, such as sarin) poisoning.
Morbidity: Illness; effects of a condition or disease.
Bioterrorism: The deliberate release of agents
typically found in nature, such as viruses, bacteria Mortality: Death due to a certain condition
and other pathogens, to cause illness or death in or disease.
people, animals or plants.
Nerve agents: Toxic chemical warfare agents that
Blast lung: Sometimes referred to as lung blast; the interrupt the chemical function of nerves.
most common fatal primary blast injury, describing
Pralidoxime chloride (Protopam Chloride;
damage to the lungs caused by the over-
2-PAM Cl): A drug contained in antidote kits
pressurization wave from high-order explosives.
used to counteract the effects of nerve agents;
B NICE: An acronym for the five main types of commonly called 2-PAM chloride.
terrorist weapons: biological contamination,
Primary effects: In referring to explosive and
nuclear detonation, incendiary fires, toxic chemical
incendiary devices, the effects of the impact
release and conventional explosions.
of the over-pressurization wave from HE on
CBRNE: The current acronym used by the body surfaces.
Department of Homeland Security to describe
Secondary effects: In referring to explosive and
the main types of weapons of mass destruction:
incendiary devices, the impact of flying debris and
chemical, biological, radiological/nuclear
bomb fragments against any body part.
and explosive.
Tertiary effects: The results of individuals being
DuoDote™: A kit with pre-measured doses of
thrown by the blast wind caused by explosive and
antidote used to counteract the effects of
incendiary devices; can involve any body part.
nerve agents.
WMD: Weapons of mass destruction.
LEARNING OBJECTIVES
After reading this chapter, and completing the class • Describe general steps of disaster response.
activities, you will have the information needed to: • Describe general steps of a CBRNE/
• Have a basic understanding of emergency medical WMD response.
services (EMS) operations during terrorist, public • List different types of WMD.
health, weapon of mass destruction (WMD) and • Describe the roles of emergency medical
disaster emergencies. responders (EMRs) during a natural, human-
• Describe the National Incident Management caused or biological disaster.
System (NIMS) and the National Response • Describe how to provide emergency medical care
Framework (NRF). during disaster or CBRNE/WMD response.
• Discuss basic elements of preparation and • Identify the basic equipment needed by EMRs for
planning for disaster and chemical, a CBRNE/WMD response.
biological, radiological/nuclear and explosive
(CBRNE)/WMD response. • List the steps to provide self-care and peer care in
response to nerve agent poisoning.
Chapter 31: Response to Disasters and Terrorism | 673
INTRODUCTION county agencies; it is also true of organizations at
the regional, federal and private levels.
The reality of potential terrorist attacks has grown
progressively since the Oklahoma City bombing in The organizational structure and roles each of
1995, but nothing has ever shown more powerfully these agencies plays in disaster response are
or more poignantly how quickly a terrorist attack ultimately coordinated at the federal level by the
can take place, and how devastating its effects, Federal Emergency Management Agency (FEMA).
than the September 11, 2001, attacks on the World FEMA coordinates the response to and recovery
Trade Center and the Pentagon. from disasters in the United States when the
disaster is large enough to overwhelm local and
Terrorism is not a new phenomenon. The United
state resources. FEMA also works collaboratively
States has witnessed a number of acts of terrorism
with other organizations such as state and local
over the years: the 1993 World Trade Center
emergency management agencies and federal
bombing; the 1998 bombings of U.S. embassies in
agencies and emergency response organizations
several East African countries; the USS Cole suicide
such as the American Red Cross.
bombing in 2000 in Yemen; the Boston Marathon
bombing in 2013; and the attacks in San Bernardino In 2008, FEMA developed and introduced the
(2015), the Orlando nightclub (2016) and the Fort National Response Framework (NRF), which
Lauderdale airport (2017), to name a few. guides all organizations involved in disaster
management on how to respond to disasters and
Not all disasters that have affected U.S. citizens
emergencies. The NRF identifies the National
were caused by terrorists. Some of the more
Disaster Medical System (NDMS) as the
destructive are natural disasters, such as
system to augment the nation’s medical
hurricanes, floods, earthquakes, wildland fires
response capabilities.
and tornadoes. Disasters can also be the result of
outbreaks of communicable diseases/pandemics The NDMS is a system that supports federal
or contamination of food or water supply. Biological agencies in managing and coordinating medical
disasters can result from naturally occurring response to major emergencies and disasters.
outbreaks or because of bioterrorism. One responsibility of the NDMS is to oversee
several different types of disaster medical teams,
With the growing threat of natural, biological and
including Disaster Medical Assistance Teams
human-caused disasters, the knowledge of how
(DMATs). DMATs are groups of professional and
to deal with such tragedies is just as important
paraprofessional medical as well as administrative
to responders as any other rescue call you may
and logistical personnel who provide medical care
receive. The goal of this chapter is to ensure you
during a disaster.
are able to deal successfully with such events
through careful preparation, ensuring safety for
yourself and others, and understanding the nature INCIDENT MANAGEMENT
of and appropriate response to disasters.
The National Incident Management System
(NIMS) is a comprehensive national framework for
PREPARING FOR DISASTERS managing incidents. It outlines the structures for
response activities for command and management.
AND TERRORIST INCIDENTS NIMS provides a consistent, nationwide
Preparedness for disasters and terrorist incidents response at all levels: federal, state, tribal and
involves many different agencies working together local governments; the private sector; and
in a coordinated effort, to meet a common goal. nongovernmental organizations (NGOs). With this
This is true at the local level, with police, fire, structure, agencies at all levels can work together
emergency medical services (EMS) personnel, in a consistent manner, to respond to incidents of
public health, transportation and other town or any type or size.
CRITICAL Preparedness for disasters and terrorist incidents involves many different agencies
FACTS working together in a coordinated effort to meet a common goal. In 2008, FEMA
introduced the NRF, which guides all disaster management organizations in
proper response. The NDMS is the system that augments the nation’s medical
response capabilities.
674 | Emergency Medical Response
NIMS provides a core set of common concepts,
principles, terminology and technologies in
these areas:
Warning Systems
Incident command system (ICS)
and Disaster
Multiagency coordination system (MACS) Communications
Unified command
Systems
Training
Identification and management of resources During a disaster, one of the most critical
aspects of response is the capability to
Mutual aid and assistance
communicate information about the disaster
Situational awareness
to the public. The Emergency Alert System
Qualifications and certification (EAS) is a nationwide public warning system
Collection, tracking and reporting of incident to alert and warn the public. It requires all
information broadcasters (cable television systems,
Crisis action planning wireless cable systems, satellite radio
Exercises services, etc.) to direct the communications to
the president, so that the president is able to
One of these components, the ICS, is a address the American public during a national
management system that allows effective emergency. State and local authorities may
incident management by bringing together also use the system for critical emergency
facilities, equipment, personnel, procedures and information such as America’s Missing:
communications within a single organizational Broadcast Emergency Response (AMBER)
structure, so that everyone involved in a disaster alerts and weather information targeted to a
has an understanding of their roles and is able to specific area.
respond effectively and efficiently. This system is
used by all levels of government, as well as many Once the president has been informed, as
NGOs and private organizations. well as other officials at the federal, state
and local levels, the public is made aware of
Incident command is structured in five main the disaster. The EAS is administered by the
functional areas: Department of Homeland Security (DHS)
through the Federal Emergency Management
Command
Agency (FEMA) and the National Oceanic
Operations and Atmospheric Administration’s National
Planning Weather Service (NWS). It is regulated
Logistics through the Federal Communications
Finance/administration Commission (FCC).
Among other roles within the ICS is the incident Once communications reach those
commander, who is responsible for all activities authorized in the federal government,
including resources and operations at the incident national alerts and warnings to the public
site. The incident commander also delegates duties are communicated through the EAS to state
to other responding staff. (See Chapter 30 for and local governments, so that emergency
further information about the ICS.) All emergency management officials can alert the public at
medical responders (EMRs) are required by the local level and mobilize the necessary
Homeland Security Presidential Directive-5 responding agencies.
(HSPD-5) to complete specific ICS training. For
more information, please visit training.fema.gov/IS/
crslist.asp.
CRITICAL NIMS is a comprehensive national framework for managing incidents. It outlines the
FACTS structures for response activities for command and management. NIMS provides a
consistent, nationwide response.
Chapter 31: Response to Disasters and Terrorism | 675
Also within the structure of NIMS are 16 capability; resource support (facility space,
emergency support functions (ESFs), mechanisms office equipment and supplies, contracting
for grouping the functions most frequently used to services, etc.)
provide emergency management support during ESF #8—Public Health and Medical Services:
emergency/disaster incidents and planned events. Public health; medical; mental health services;
Additional ESFs may be part of the Communities mass fatality management
Comprehensive Emergency Management Plan that
could include Animal Services, Special/Functional
ESF #9—Search and Rescue: Lifesaving
assistance; search and rescue operations
Needs, Damage Assessment, as well as Business
and Industry. Following is a list of the ESFs: ESF #10—Hazardous Materials Response:
Hazardous materials (chemical, biological,
ESF #1—Transportation: Aviation/airspace radiological, etc.) response; environmental
management and control; transportation short- and long-term cleanup
safety; restoration/recovery of transportation ESF #11—Agriculture and Natural Resources:
infrastructure; movement restrictions; damage Nutrition assistance; animal and plant disease
and impact assessment and pest response; food safety and security;
ESF #2—Communications: Coordination natural and cultural resources and historic
with telecommunications and information properties protection and restoration; safety and
technology industries; restoration and repair of well-being of household pets
telecommunications infrastructure; protection, ESF #12—Energy: Energy infrastructure
restoration and sustainment of national cyber assessment, repair and restoration; energy
and information technology resources; oversight industry utilities coordination; energy forecast
of communications within the federal incident ESF #13—Public Safety and Security: Facility
management and response structures and resource security; security planning and
ESF #3—Public Works and Engineering: technical resource assistance; public safety
Infrastructure protection and emergency repair; and security support; support for access, traffic
infrastructure restoration; engineering services and crowd control
and construction management; emergency ESF #14—Long-Term Community Recovery:
contracting support for lifesaving and life- Social and economic community impact
sustaining services including water supplies assessment; long-term community recovery
ESF #4—Firefighting: Coordination of federal assistance to states, local governments and the
firefighting activities; support to wildland, rural private sector; analysis and review of mitigation
and urban firefighting operations program implementation
ESF #5—Emergency Management Information ESF #15—External Affairs: Emergency public
and Planning: Coordination of incident information and protective action guidance;
management and response efforts; issuance media and community relations; congressional
of mission assignments; resource and and international affairs; tribal and insular affairs
human capital; incident action planning; ESF #16—Law Enforcement: Establishment
financial management of procedures for the command, control
ESF #6—Mass Care, Emergency Assistance, and coordination of all state and local law
Housing and Human Services: Mass care; enforcement personnel and equipment to support
emergency assistance; disaster housing; impacted local law enforcement agencies
human services
EMRs typically are supported by ESF #8 (Public
ESF #7—Logistics Management and Resource
Health and Medical Services) but may also
Support: Comprehensive, national incident
coordinate with ESFs #4 and #9 (Firefighting and
logistics planning, management and sustainment
Search and Rescue), depending on the complexity
CRITICAL If you are the first responder on the scene of a disaster, you may be called upon
FACTS to assume a leadership role. If someone else has assumed this role, it is your
responsibility to assist the leader or assume another role. It may be triaging patients,
providing medical care, providing patient reception at staging facilities or preparing
patients for evacuation.
676 | Emergency Medical Response
Fig. 31-1: If you are the first responder on the scene, you may have to assume a leadership role.
Photo: courtesy of Captain Phil Kleinberg, EMT-P.
of the incident or event. The American Red Cross DISASTER RESPONSE
is the primary agency for ESF #6 (Mass Care,
Emergency Assistance, Housing and Human Responding to a disaster call may prove to be the
Services). It also acts as a support agency for most challenging and mentally stressful scene
ESFs #3, 5, 8, 11, 14 and 15, and as a cooperating you ever attend. Every incident is different, and
agency for several of the support and incidents it is impossible to cover all of the specific steps
annexes (components of individual ESFs). and considerations for a specific scene. You will
need to be prepared to address various issues and
precautions simultaneously. The types of disasters
THE ROLE OF THE EMERGENCY you may respond to are varied, but fall into three
main categories: natural disasters, human-caused
MEDICAL RESPONDER disasters and biological disasters.
At the scene of a disaster, if you are the first
responder on the scene, you may be called upon
to assume a leadership role (Fig. 31-1). If someone Mutual Aid
else has assumed this role, it is your responsibility
to assist the leader or assume another role, Mutual aid is a formal agreement among
usually in triaging patients, providing medical care, emergency responders to lend assistance
providing patient reception at staging facilities or across the various jurisdictions of public
preparing patients for evacuation. services such as fire departments, EMS
operations and law enforcement during an
Upon arriving on the scene, assess for scene emergency situation or disaster that exceeds
hazards, the number of patients, patient priorities, local resources. Aid must be requested.
the need for extrication, the number of ambulances The following general information must be
or other transport vehicles needed, and any other supplied by the requesting community:
factors that affect the scene, as well as the need
for resources and where to stage those resources. • A description of the personnel, equipment
Radio your report with a request for any additional and other resources required
resources needed and then set up functions to • The estimated length of time resources
accommodate resources as they arrive, including may be required
staging, supply, extrication, triage, treatment, • The areas of experience, training and
transportation and rehab. abilities of the personnel, and the
capabilities of the equipment to be furnished
(Continued)
Chapter 31: Response to Disasters and Terrorism | 677
Mutual Aid continued
The person, service or agency receiving the
request must then let the community in which
the disaster took place know the estimated
time when assistance can arrive at the
designated location, as well as the names
of the people designated as supervisory
personnel.
The following rules will apply during the A
rescue efforts:
• The personnel and equipment of the
assisting team are under the direction and
control of the requesting community while
at the disaster site.
• Emergency personnel continue under
the command and control of their regular
leaders, but the organizational units
come under the operational control of
the emergency services authorities of
the community receiving assistance. The
receiving party is responsible for informing B
the responding party when their services
will no longer be required.
• All equipment and personnel provided
by the assisting team while at the site of
an emergency remain under the control
and direction of its own designated
representative, who can remove any
or all equipment or personnel from the
site at any time the representative deems
it appropriate.
• An assisting team’s priority lies with its own
jurisdiction, and the team must continue to
offer reasonable protection and services. C
Therefore, the assisting team has the right
to withdraw any and all aid provided, after
giving the disaster area notification of the
need to do so.
Natural Disasters
The devastating effects of natural disasters
have been felt worldwide. Damage caused
by earthquakes, hurricanes/tropical storms,
landslides, thunderstorms, tsunamis, winter storms,
tornadoes, heat waves, floods, wildfires and
volcanic eruptions can leave entire communities D
completely incapacitated, with large numbers of Fig. 31-2, A–D: Natural disasters, such as (A) wildfire (photo:
people seriously injured (Fig. 31-2, A–D). Massive courtesy of Jeff Zimmerman, Zimmerman Media LLC), (B) flood
infrastructure damage may occur, resulting in (photo: courtesy of Robert Baker), (C) earthquake (photo:
courtesy of Chris Helgren) or (D) tornado (photo: courtesy of
entire communities seeking shelter, food and Joseph Songer), can leave entire communities incapacitated
other assistance. and large numbers of people seriously injured.
678 | Emergency Medical Response
Fig. 31-3: Human-caused disaster. Photo: courtesy of Captain Tony Duran, Los Angeles County Fire Department.
Human-Caused Disasters food or water supply by pathogens, are all very real
possibilities. In addition to the threat of naturally
Human-caused disasters include terrorist
occurring outbreaks, biological disasters can also
attacks using chemical, biological, radiological/
be the result of bioterrorism.
nuclear and explosive weapons; fire (residential
or environmental); hazardous material (HAZMAT)
incidents; as well as large-scale multiple-
casualty incidents (MCIs) such as transportation
mishaps (Fig. 31-3).
Biological Disasters
Biological disasters are not just the creative
writing of science fiction. One need only look
back at the flu epidemic of 1918 to be reminded
of how real they are. In that epidemic, as many as
600,000 Americans lost their lives, as did some
40 million people worldwide. We have a lot more
knowledge about dealing with a biological disaster
today, but as we are warned by the World Health
Organization, other epidemics such as the avian
flu or the next flu pandemic could be only months
away (Fig. 31-4). Outbreaks of communicable Fig. 31-4: Immunizations provide some element of protection
against biological disasters. Photo: courtesy of Captain Phil
diseases/pandemics, as well as contamination of Kleinberg, EMT-P.
Chapter 31: Response to Disasters and Terrorism | 679
EMS Operations During Terrorist
Evacuations Attacks, Public Health Emergencies,
WMD Incidents and Disaster Events
In the case where a disaster has been In any kind of large-scale disaster, it is important
predicted, such as a wildland fire, hurricane to use an all-hazards approach, which means
or flood, steps must be taken to evacuate being prepared with the equipment and resources
a community. Local and state emergency needed to respond to many different types
management offices have the authority to of disasters.
order and implement evacuations. The keys to
a successful evacuation are communication Regardless of the type of disaster, until you are
and organization to avoid panic and the aware of the specific hazards involved, distance
possibility of injury to people and property. yourself from the scene and only approach when it
Therefore, alerts regarding the evacuation is safe to do so. Continue to monitor the scene, as
must be made often and with clarity to there may be secondary explosions, for example, or
residents who are affected by the need traps meant to injure and possibly kill responders.
to leave their homes. There may be some If you are arriving on the scene of an armed attack,
who will not believe the level of danger the communicate immediately with law enforcement.
impending disaster may have on them or
their property, and who may wish to remain Initiate incident command or, if it has already
in their homes. This reaction is normal, but it been initiated, expand as assigned and
is imperative to maintain communication with communicate your findings to the ICS. Within
these people and convince them of the level the ICS, the necessary emergency services are
of danger they will face if they remain. called and responsibility for different sections
can be assigned to the appropriate personnel
Evacuation warnings should communicate the as they arrive.
following points:
Establish a perimeter around the area in order
• The nature of the disaster and the to protect yourself and other responders as
estimated time until it will impact the area well as the public from injury. If you are at the
• The level of devastation the disaster is scene of a terrorist incident, establish an escape
expected to cause, to help convince people plan and a mobilization point. Designate the role
to leave of incident safety officer and assess command
• The routes assigned as safe for their post security.
evacuation
• The appropriate destinations where food,
shelter and water are available WMD (CHEMICAL, BIOLOGICAL,
RADIOLOGICAL/NUCLEAR AND
All possible means of communication should EXPLOSIVE INCIDENTS)
be used, including Mass Notification Systems,
Reverse 9-1-1, radio, television, loudspeakers Terrorism has been around for many years, yet the
and public address systems in buildings, threat of terrorism is something increasingly on
etc. Again, the sense of urgency and clarity the minds of Americans in recent years. The FBI
are the deciding factors for whether people defines terrorism according to the U.S. Code of
choose to flee or not. Federal Regulations (CFR):
CRITICAL In any kind of large-scale disaster, it is important to use an all-hazards approach,
FACTS which means being prepared with the equipment and resources needed to respond
to many different types of disasters.
680 | Emergency Medical Response
“Terrorism includes the unlawful use of force Chemical Weapons
and violence against persons or property
A chemical emergency occurs when a hazardous
to intimidate or coerce a government, the
chemical has been released and the release has the
civilian population, or any segment thereof, in
potential for harming people’s health. In the case of
furtherance of political or social objectives.”
a terrorist attack, the chemicals are released with
While these terrible crimes seem senseless, the deliberate purpose of causing harm.
the terrorists who commit them have specific
Chemical agents are difficult to turn into weapons,
goals they are trying to achieve. They seek to
as they disperse easily in open environments. This
incite fear, confusion and panic, as well as to
can reduce their destructive power. However,
inflict destruction on both physical and political
the public perceives chemical weapons as highly
infrastructure, and through these actions cause
effective, thus terrorists achieve their goal. The
intimidation to those in authority and others.
other major characteristic of chemical agents is
Terrorists may be motivated to inflict such
that they affect the body quickly, with symptoms
destruction and fear for different reasons, including
often appearing immediately, which is different from
political and religious beliefs, environmental
the impact of biological or nuclear agents, which
causes, racial bias or a desire for revenge.
may not occur until days after the event.
When terrorists strike, their most likely weapons
of choice are guns and explosives, as these are Providing Care
relatively inexpensive, easy to obtain and use, and Steps to provide care for patients exposed to
easy to transport. Less often, they may turn to chemical weapons vary according to the type of
weapons of mass destruction (WMD), which, by chemical. This is one of the great challenges in
their nature, cause widespread fear and destruction. responding to a chemical incident; symptoms are
not always obvious, and identifying the substance
EMRs need to be aware of public reaction when
is not always possible.
faced with WMD. While this type of weapon is
used less frequently, their power lies in their ability If you are unable to identify the chemical, prepare
to inflict significant fear and panic. yourself for the worst-case possibilities concerning
toxicity when selecting personal protective
These weapons are commonly classified by the
equipment (PPE) and decontamination procedures.
acronym CBRNE:
Assess the patient for traditional challenges such
Chemical as airway and circulation concerns, and check
for obvious symptoms such as neuromuscular,
Biological
dermatological and vascular findings. If necessary,
Radiological/Nuclear
maintain spinal motion restriction and apply a
Explosives cervical collar. Administer supplemental oxygen
This terminology is used by the Department of based on local protocols, and assist ventilation with
Homeland Security and understood internationally. a bag-valve-mask (BVM) resuscitator if necessary.
Another system of classifying WMD is B NICE, Prior to transportation, report the patient’s
which stands for biological, nuclear, incendiary, condition, treatment and estimated time of arrival
chemical and explosive. This system of to the base station and receiving medical facility. If
classification is similar to CBRNE, but it includes a chemical has been ingested, have several towels
incendiary weapons (e.g., napalm, magnesium, and open plastic bags ready to quickly clean up
phosphorous, etc.) as a separate type, whereas and isolate the patient’s toxic vomit. Consult with
these devices are included under the term the base station physician or regional Poison
“explosives” under CBRNE. The terms are, in Control Center for advice regarding triage of
general, used interchangeably.
CRITICAL The FBI defines terrorism as “the unlawful use of force and violence against
FACTS persons or property to intimidate or coerce a government, the civilian population or
any segment thereof, in furtherance of political or social objectives.”
There are four classifications of WMD: chemical, biological, radiological/nuclear
and explosives. The common acronym for these classifications is CBRNE.
Chapter 31: Response to Disasters and Terrorism | 681
multiple patients. Asymptomatic patients who are appear from several hours to a day after exposure,
discharged should be advised to seek medical care depending on the dose. If the patient has had a
promptly if symptoms develop. significant exposure, there may also be systemic
effects that cause damage to bone marrow and the
Chemical agents can be categorized into five epithelial lining of the gastrointestinal (GI) tract.
types: nerve agents, blister agents, blood agents,
pulmonary agents and incapacitating agents. There are no known antidotes or treatments for
exposure to blister agents; treatment of both the
Nerve Agents blisters and respiratory effects is supportive and
Nerve agents, such as tabun (GA) and nonspecific. Care includes decontamination by
methylphosphonothioic acid (VX), are particularly discarding contaminated clothing, and cleaning
toxic chemical agents that disrupt the chemical equipment with soap, water and diluted bleach
recovery phase following a neuromuscular (0.5–1.0 percent). Do not use bleach on patients.
signal. Nerve agents are liquid when at normal
temperatures but turn into a combination vapor/ “Blood” Agents
liquid when dispersed. They are usually odorless, Blood agents, such as cyanide, attack the body’s
although they may smell like fruit or fish. cellular metabolism. They do not actually affect the
blood, as was once thought, but disrupt cellular
Symptoms vary depending on the dose. A strong respiration. Cyanide can enter the body by being
dose can cause death within minutes, if inhaled or ingested, injected or inhaled, but not by being
absorbed into the skin. Signs and symptoms include absorbed into the skin. Despite its devastating
runny nose, watery eyes, twitching, pinpoint pupils, effects, if it dissipates into the air, it rapidly
painful eyes, blurred vision, drooling, excessive becomes harmless. Cyanide can be recognized by
sweating, coughing, weakness, drowsiness, its odor of bitter almonds, though not everyone is
headache, nausea, vomiting, abdominal pain, slow able to detect it.
or fast heart rate, abnormally high or low blood
pressure and more. Exposure causes irritation or Cyanide’s effect of poisoning the cells prevents
severe damage to the eyes and respiratory tract, and them from taking up oxygen, which in turn leads
may cause redness or severe blistering of the skin to asphyxia and cyanosis (blue tinge to the skin
with larger doses. The blisters are similar to those caused by a lack of oxygen). Cyanide is a quick-
caused by second-degree burns. These signs do acting agent, and can cause death within 5 to 8
not appear immediately but arise after several hours minutes if the exposure is severe.
or a day, depending on the dose.
Treatment for cyanide poisoning is by antidote,
When a patient has been exposed to a nerve agent, using a Cyanokit® (hydroxocobalamin), sodium
in general the priorities are to decontaminate, nitrite or sodium thiosulfate, all of which must be
ventilate (expose to fresh air), administer antidotes, administered immediately and intravenously.
administer valium (to prevent seizures) and provide
supportive therapy. Depending on the type of Pulmonary Agents
agent, different antidotes are available. Pulmonary agents include phosgene (CG), which
causes lung injury by forming hydrochloric acid
Blister Agents (HCl) when it contacts mucous membranes,
Blister agents, also called vesicants, include sulfur thereby irritating and damaging lung tissue. When
mustard (HD) and phosgene oxime (CX). These phosgene explodes, it turns into a colorless, watery
agents cause the skin and mucous membranes vapor with a smell that has been described as that
to form blisters on contact. Sulfur mustard can of new-mown hay.
sometimes be detected by its odor of garlic, onions
or horseradish, but it can be difficult to detect Signs and symptoms are severe illness and even
because the smell is faint. death from pulmonary edema and acute respiratory
distress syndrome.
When exposed to sulfur mustard, either in liquid or
vapor form, patients experience irritation or severe There is no specific antidote for phosgene. The
damage to the eyes and respiratory tract. Sulfur only way to provide care is to remove the person
mustard may cause redness or severe blistering from the agent and resuscitate. EMRs should take
of the skin with larger doses. As with the blisters measures to protect themselves in a situation
from nerve agents, these blisters resemble second- where phosgene may be present, by using a
degree burns. Also, as with nerve agents, signs chemical protective mask with a charcoal canister.
682 | Emergency Medical Response
Incapacitating Agents These agents and diseases pose the greatest
An incapacitating agent is defined by the threat to public health and national security, as
Department of Defense (DOD) as “an agent they can be easily spread from person to person
that produces temporary physiological or mental and result in high mortality (death) rates.
effects, or both, which will render individuals Class B biological agents/diseases include
incapable of concerted effort in the performance brucellosis, Q fever, glanders, alphaviruses,
of their assigned duties” (Source: University food pathogens (e.g., salmonella, Shigella,
of Albany). E. coli), water pathogens (e.g., Vibrio
cholerae and Cryptosporidium), Ricin toxin,
These agents, which include MACE, tear gas and staphylococcal enterotoxin B and epsilon toxin
pepper spray, contain a hallucinogenic agent, of Clostridium perfringens. This class of agents
3-quinuclidinyl benzilate, also referred to as BZ or and diseases poses a moderate level of risk, as
QNB. They are usually nonlethal and generally not they are moderately easy to spread and result
used by terrorists, but may be used, for example, in moderate morbidity (illness) rates and low
by law enforcement authorities to control a violent mortality rates.
crowd. The BZ may be dispersed as a fine aerosol
or dissolved in dimethyl sulfoxide (DMSO) and
Class C biological agents/diseases are those
considered to be emerging infectious diseases,
absorbed into the skin. such as hantavirus, Nipah virus, yellow fever,
Effects may be delayed for 30 minutes to 24 hours. multidrug-resistant tuberculosis and tickborne
Effects are both peripheral (external) and systemic viruses. These agents have the potential to be
(throughout the body). Peripheral effects include engineered for mass dissemination. They are
pupil dilation, dry mouth and skin, and flushing of easy to spread and have the potential for high
the skin, particularly the face and neck. Symptoms mortality and morbidity rates.
may appear similar to those seen in someone When a bioterrorism event has occurred, often
exposed to certain nerve agents and then treated there is a single suspected case of an uncommon
with an excess of atropine. Systemic effects disease or there are single or multiple suspected
include disturbances to consciousness, delusions cases of a common disease or syndrome that do
and hallucinations, impaired memory and poor not respond to treatment as expected. Clusters of
judgment, disorientation and ataxia (uncoordinated a similar illness may occur in the same timeframe
gait or manner of walking). Overall, effects depend in different locales. There may be unusual clinical,
on the dose and may last for up to 4 days. geographical, seasonal or temporal presentations
Monitor the patient who has been incapacitated of a disease and/or unusual transmission routes; an
by one of these agents and take precautions to unexplained increase in the incidence of an endemic
prevent yourself from being exposed. disease; or an unusual illness that affects a large,
disparate population or is unusual for a population
or age group. You may see an unusual pattern
Biological Weapons of illness or death among animals or humans, or
Bioterrorism is the deliberate release of agents a sudden increase in nonspecific illnesses such
typically found in nature, such as viruses, bacteria as pneumonia, bleeding disorders, unexplained
or other pathogens (agents), for the purpose of rashes and mucosal or skin irritation (particularly in
causing illness, disease or death in people, animals adults), neuromuscular symptoms (such as muscle
or plants. Often these agents can be changed, weakness and paralysis) or diarrhea.
increasing their potency and making them resistant
to current medications, or even increasing their For most of these diseases/agents, patients initially
ability to be spread into the environment. experience flu-like symptoms such as fever, aches
and listlessness or fatigue.
Types of Biological Agents/Diseases
Many diseases and biological agents have been
Providing Care
determined to be a threat. These are categorized While the early signs and symptoms may be
into three groups according to their level of threat, similar for different diseases/agents, treatment will
from highest to lowest: depend on the nature of the agent. For example,
those caused by a virus cannot be treated with
Class A biological agents/diseases include antibiotics, while those caused by a bacterium may
anthrax, plague, smallpox, tularemia, viral be treated with antibiotics.
hemorrhagic fevers (e.g., Ebola) and botulism.
Chapter 31: Response to Disasters and Terrorism | 683
Often, though, when these illnesses/diseases The detonation of a nuclear device, regardless of
are caused by a terrorist act, you will not know size, could prove catastrophic. A nuclear explosion
the cause right away. While it is essential to take has several damaging effects, caused by the air
steps to recognize the specific agent, provide blast, heat, ionizing radiation, ground shock and
supportive care right away, including assessing the secondary radiation.
patient for traditional challenges such as airway
and circulation concerns, and checking for obvious There are four types of radiation exposure. These
symptoms such as neuromuscular, dermatological include patients who:
and vascular findings. Once examined by a 1. Received a significant dose from an external
physician, the patient will likely be given specific source, including large radiation sources over
antibiotics or antitoxins. Immunizations may also be a short period of time, or smaller radioactive
given as a preventative measure for certain agents. sources over a long period of time.
Although most biological agents are not highly 2. Received internal contamination from inhalation
contagious, a few are, so it is essential to isolate and/or ingestion of radioactive material.
the patient, protect yourself with the proper PPE, 3. Have external contamination of the body surface
and use standard exposure control procedures and/or clothing by liquids or particles.
including high efficiency particulate air (HEPA) filter 4. Were exposed through a combination of
mask and gloves (Fig. 31-5). the above.
In general, determining that someone has been
Radiological/Nuclear Weapons exposed to radiation can be difficult. However,
The effects of a nuclear weapon detonation acute radiation syndrome follows a predictable
depend on the yield and success of the detonation. pattern that unfolds over several days or weeks
For example, a poorly maintained or manufactured after substantial exposure or catastrophic events.
bomb might produce no explosion, yet still Patients may present individually over a longer
spread radioactive material. Or the device could period of time after exposure to unknown radiation
have a partial nuclear detonation, which would sources. Specific symptoms of concern, especially
have a much greater impact than, for example, following a 2- to 3-week period with nausea and
the explosive that destroyed the Oklahoma City vomiting, are thermal burn-like skin lesions without
Federal Building in 1995. documented heat exposure, a tendency to bleed
Fig. 31-5: Always protect yourself from hazards by using appropriate PPE and following standard exposure
control procedures. Photo: courtesy of Captain Phil Kleinberg, EMT-P.
684 | Emergency Medical Response
(nosebleeds, gingival [gum] bleeding, bruising) and removal of their clothing. Do not remove patients
hair loss. Symptom clusters, as delayed effects from a backboard or other extrication device if one
after radiation exposure, include headache, fatigue, was used when packaging for transport.
weakness, partial- and full-thickness skin damage,
hair loss, ulceration, anorexia, nausea, vomiting, It is essential to use standard precautions to
diarrhea, reduced levels of white blood cells, help prevent the spread of contamination from
bruising and infections. injured patients to yourself or other emergency
personnel. Notify proper authorities and the
hospital of all pertinent information about patients
Providing Care and the scene. Ask for any special instructions
Assess and treat life-threatening injuries the hospital may have, such as using an entrance
immediately. Move patients away from the hot other than the routine emergency department
zone (the area in which the most danger exists) entrance for the purposes of radiological
using proper patient transfer techniques to prevent contamination control.
further injury (Fig. 31-6). Stay within the controlled
zone if contamination is suspected.
Explosives and Incendiary Weapons
Expose wounds and cover with sterile dressings, Traditional weapons and explosives still present
decontaminating open wounds as required. a very real threat for use in terrorist attacks on
Patients should be monitored at the control line for the United States. As an EMR, understanding the
possible contamination only after they are medically unique types of injuries associated with explosives
stable. Remove contaminated clothing only if is imperative to ensure appropriate treatment and
removal can be accomplished without causing handling of patients at a blast site.
further injury.
There are two major types of explosives:
Contaminated patients who do not have
life-threatening or serious injuries may be High-order explosives (HE), e.g., TNT, C-4,
decontaminated on site, starting with the Semtex, nitroglycerin, dynamite and ammonium
Fig. 31-6: When providing care in a situation of radiation exposure, move patients away from the hot zone using proper
patient transfer techniques. Photo: courtesy of Captain Phil Kleinberg, EMT-P.
Chapter 31: Response to Disasters and Terrorism | 685
nitrate fuel oil (ANFO), which produce a defining Providing Care
supersonic over-pressurization shock wave After performing a preliminary evaluation and
Low-order explosives (LE), including pipe establishing scene safety, EMRs should initiate
bombs, gunpowder and most pure petroleum- rescues of severely injured and/or trapped patients,
based bombs such as Molotov cocktails or evacuate ambulatory patients, perform triage and
aircraft improvised as guided missiles, which treat life-threatening injuries. Leave fatalities and
create a subsonic explosion their surroundings undisturbed, and avoid disturbing
areas not directly involved in rescue activities. Initiate
Blasts can also be caused by explosive and
documentation of the scene as soon as conditions
incendiary (fire) bombs, which are characterized
permit. The site of a bomb blast is a crime scene
based on their source. Manufactured weapons
and, as an EMR, although your primary responsibility
are military issued, mass produced and quality
is to rescue living people and provide treatment
tested, and are exclusively HE. Improvised
for life-threatening injuries, it is also important to
weapons are produced in small quantities, or
preserve evidence and avoid disturbing areas not
use a device outside its intended purpose, such
directly involved in the rescue activities, including
as converting a commercial aircraft into a
those areas containing fatalities.
guided missile.
There are three basic mechanisms of blast injury:
RESPONSE TO A CBRNE
Primary effects are unique to HE, and result WMD INCIDENT
from the impact of the over-pressurization wave
on body surfaces. The most common injuries are Preparation
to the lungs, GI tract, eyes, head and middle ear. Planning for a WMD incident involves several
Secondary effects are caused by flying debris aspects of preparation, including medical direction,
and bomb fragments; any body part may be personal preparation, equipment, transportation
affected. and communications.
Tertiary effects may occur from individuals Medical direction will be provided on a massive
being thrown by the blast wind, and also can scale during a WMD incident. Your EMS system
involve any body part. needs to include a larger number of care providers
Injury patterns will depend on whether you are from within your region as well as medical
dealing with HE or LE blasts as well as on the control systems from different areas. Disrupted
position of the body when the blast occurs. communications systems can make it difficult to
Patients who are standing or lying perpendicular to activate and summon appropriate medical services;
the blast will suffer greater injuries compared with therefore, preparing emergency measures as
those who are lying directly toward or away from standing orders is the most effective manner in
the blast. which to activate a plan. This leaves communication
channels available for scene updates, incoming
Lung injuries include blast lung, the most patient reports and the essential communications
common fatal primary blast injury. Blast lung is required in extraordinary circumstances.
caused by the HE over-pressurization wave. Middle
ear injury most commonly includes tympanic In all WMD case scenarios, the massive numbers
membrane (eardrum) perforation. Abdominal of responders involved could lead to scene
injuries include bowel perforation, hemorrhage, confusion. It is imperative, especially in cases where
mesenteric shear injuries, solid organ lacerations interagency coordination is required, that all levels
and testicular rupture. Injuries to the head include of support services define their respective roles and
concussion or mild traumatic brain injury (MTBI). responsibilities at the scene and are managed by
Other injuries include air embolism, compartment the ICS. Regional pre-planning, coordination and
syndrome, rhabdomyolysis (skeletal muscle tissue rehearsal are recommended in order to ensure all
damage) and acute renal failure. Also consider involved services are familiar with their roles and arrive
the possibility of exposure to inhaled toxins and at the scene prepared to perform those services
poisonings (e.g., carbon monoxide [CO], cyanide without conflict or delay. Planning must include
[CN], methemoglobin [MetHgb]) in both industrial an assessment of hazards, exposure potential,
and criminal explosions. Wounds can also be respiratory protection needs, entry conditions, exit
contaminated, as with tetanus. routes and decontamination strategies.
686 | Emergency Medical Response
The types of weapons used at a CBRNE incident be targets, so you must be wary of potential
cover a broad spectrum of dangers, including the secondary attacks.
possibility of exposure to pathogens, chemicals
and radiation. Because of this, it is important for Provide an initial on-scene report to dispatch, with
EMRs to understand the threats at the scene and a description of the incident along with the need for
why it is critical to take proper precautions first. For specialized resources, initial actions taken, number
example, it is critical to have necessary antidotes of injured, and the nature and quantity of additional
ready if there is a risk of exposure to nerve agents. resources required.
Look for outward signs and characteristics of
Equipment and Supplies terrorist incidents, such as mass casualties
Inventory of equipment and supplies will vary presenting with identical symptoms that have
depending on the type of WMD used in an no identifiable cause. Attempt to identify the
attack. In order to be able to respond as quickly weapon used by looking for outward signs of the
as possible with the appropriate equipment, use of WMD, such as strange odors like bitter
medications and personnel, lists of locations almond, peaches or fresh-cut grass. Consider the
of traditional storage areas must be kept and necessary protective actions according to the type
remain accessible to neighboring communities, of weapons: CBRNE.
to allow the dispatch center to quickly access the Determine the number of people involved and
resources regionally, statewide or nationwide. implement local protocols for mass casualty
In a large-scale incident, it is necessary to rely incidents as necessary. As part of your
on other services to supply the proper equipment assessment, evaluate the need for additional
and, in most cases, knowledge, to CBRNE calls. resources. Evaluate and alter plans as necessary,
Nerve agents require large amounts of certain including consideration of changing weather and a
drugs as well as ventilators. If you are called to change to incidents occurring at the site such as
the site of a chemical incident, you may require secondary attacks or injuries to responders.
specialized PPE such as self-contained breathing
apparatus (SCBA) or HAZMAT suits. If you are
responding to the scene of a large explosion, you Search and Rescue
may require heavy rescue equipment, search and
A variety of specialized services can be used
rescue units, devices for electronic detection and
when a search and rescue mission is required
trained search dogs. The proper protocols and
following a disaster. This may include building
procedures regarding mutual assistance setups
collapse, avalanche or ships lost at sea.
and the deployment of equipment must be followed
in accordance with your community’s plan. Search and rescue capabilities include
distress monitoring, communications, location
Arrival on Scene of distressed personnel, coordination and
execution of rescue operations including
On-site incident management allows responders
extrication or evacuation, along with the
to work together as effectively as possible. As a
provisioning of medical assistance and civilian
responder, the responsibility for preparing the site
services through the use of public and private
for rescue efforts may fall on you. If you are among
resources to assist persons and property in
the first to arrive on the scene of a WMD incident,
potential or actual distress.
your speedy and accurate assessment of the scene
and the actions you take to establish incident Emergency support function #9 (ESF #9)
command as quickly and efficiently as possible provides the following specialized search
are the most important steps you can take in and rescue services during incidents or
saving lives and helping the injured. Your instincts potential incidents requiring a coordinated
as an EMR will be to help patients first. However, federal response:
your scene size-up to measure the scope of the
disaster, and the information you collect to identify • Structure Collapse (Urban) Search and
the appropriate resources, are your first priorities. Rescue (US&R)
• Waterborne Search and Rescue
When approaching the scene, consider the time • Inland/Wilderness Search and Rescue
since the incident, your distance from it and any • Aeronautical Search and Rescue
necessary shielding. Remember, EMRs may
Chapter 31: Response to Disasters and Terrorism | 687
Scene Safety weapons. Because of the potentially large numbers
of patients who will need care in a short span of
Identifying the weapon involved is a major part of
time, you may quickly be in a situation where the
responding to a WMD scene. Once you are
ratio of patients to providers is much higher than to
aware of the hazards you are responding to, you
which you are accustomed.
can protect yourself, fellow responders and the
public effectively. In the case of mass casualties at a CBRNE scene,
you may be faced with multiple scenarios. Each
Approach the scene from upwind and uphill if
scenario, be it chemical, biological, radiation/
chemical, biological or nuclear weapons are
nuclear or explosive, will require a different
suspected. Avoid confined spaces where chemical
approach to treatment, potential for contamination
or biological agents may be trapped due to poor
and other considerations. Treating patients at such
ventilation. Be suspicious of a potential terrorist
a scene is different from any other scene to which
attack when called to a well-populated area, as
you may be called.
these are typical targets for attacks.
Written protocols will address the signs and
The possibility that secondary devices may have
symptoms associated with each type of WMD and
been planted at the scene is a real and serious
instruct you on the recommended treatment. You
threat to the teams responding to a CBRNE call.
must understand the danger each presents and
With this is mind, as with all calls, your own safety
then follow the recommended precautions before
must be your top priority. Remain aware of the
entering the scene, as well as how to provide care
dangers to your health when you are entering a
during and following the response.
scene and while you are offering assistance to
patients. Establishing what substances You may find that the types of injuries and patients
have been released, how and where, will help you encounter are similar in nature, due to the
to best ascertain the proper PPE required, effects of the incident. Massive soft tissue wounds
procedures to follow and the appropriate and burns are common injuries resulting from
patient treatment. explosions or nuclear ignition. Medications may be
required to treat patients who have been affected
Unlike other EMS calls, if terrorists are involved,
by chemical dispersal.
it is possible they will try to sabotage your efforts
to respond. Therefore, hospital facilities must take You may also face unique patient care challenges
security measures to limit the traffic in and out you would not normally encounter in other
of the area, setting safe perimeters around the emergency situations. For example, you may need
hospital and allowing access only to those with to administer high-dose atropine for nerve agents.
proper authorization. Secondary devices may be Also different from usual routines is that patients
used by terrorists to keep EMRs from responding, may remain in your care for much longer than
making it advisable for all units and agencies you are used to, and you may need to address
involved to be familiar with and able to operate their overall needs (nutrition, hydration and
under the ICS. personal hygiene).
Ascertain the proper PPE needed to enter the You may also find it especially difficult to attend to
scene, using an all-hazards safety approach. If you so many patients who are expected to die. While
are approaching a patient who is suspected of this may not be unusual for EMRs, the difference in
having a communicable disease, make sure to use the WMD situation is that you may be with patients
a HEPA or N95 mask, gloves, eye protection and longer and witness their conditions worsening to
gown for personal protection. This information must the point of death in front of you, without being
also be conveyed to the medical facility to which able to do anything to prevent their deaths. When
the patient is being transported, so that they may patients die, you also need to provide isolation
prepare for appropriate isolation. and storage until other, living patients have been
evacuated from the area.
Providing Care When carrying out triage, the concept of “greater
As you provide care, make sure to keep patients good” applies. This means that you must treat
informed of your actions and protect them from everyone according to their injury or illness, and
further harm. Be alert to specific signs and not according to who they are; this includes
symptoms associated with the different types of terrorists or criminals.
688 | Emergency Medical Response
PROVIDING SELF-CARE AND GI symptoms from another illness may be confused
with those from nerve agent effects.
PEER CARE FOR NERVE AGENTS
Poisoning by Nerve Agents When assessing someone who has been exposed
to a nerve agent, several potential findings will
Nerve agents are the most toxic of chemical agents
help you deduce required treatment. Triage
and are hazardous in both their liquid and vapor
as “immediate” if the patient is unconscious,
states. They are potent enough to cause death
convulsing, breathing with difficulty or has
within minutes after exposure. The clinical effects
apnea, and is possibly flaccid. Consider a patient
from nerve agent exposure are caused by excess
“expectant” if the patient shows all of the above
acetylcholine, a chemical in the brain.
symptoms, but has no pulse or blood pressure and
The initial effects of exposure to a nerve agent is therefore not expected to survive. Categorize
depend on the dose and route. The routes include as “minimal” a patient who is walking, talking,
inhalation via gas, absorption through the skin, breathing and whose circulation is intact. Consider
and ingestion from liquids or food. The dose and the person “delayed” if further medical observation,
amount of exposure to the agent work together to large amounts of antidotes or artificial ventilation is
cause varying effects. required after triage.
Nerve Agents—Liquid Providing Care
Exposure to a small droplet of liquid on the skin Ventilation is required when patients demonstrate
may produce few physical findings, whereas a large obvious symptoms. In this situation, remove
amount causes effects within minutes. Sweating, secretions, maintain an open airway, use artificial
blanching (whitening of the skin) and occasional ventilation if necessary and possible, and repeat
muscle twitching at the site may be present soon atropine immediately as directed.
after exposure of a small amount, but may no longer
The means of ventilation depends on the
be present at the onset of GI effects. Signs of a
equipment available at the scene. As these patients
large amount of exposure are the same as after
generally experience bronchoconstriction and
vapor exposure, and these appear within minutes.
lots of secretions, expect high airway resistance
Commonly there is an asymptomatic period of 1 to
(50 to 70 cm of water), which make initial
30 minutes before symptoms appear, including loss
ventilation difficult. Expect a noticeable decrease
of consciousness, seizure activity, apnea (periods
in resistance after atropine has been administered.
when breathing stops) and muscular flaccidity
Secretions may thicken with atropine and may
(loss of tone). Effects can be delayed for as long
make ventilation efforts difficult. If this occurs,
as 18 hours after contact with small amounts,
frequent suctioning is required for up to 3 hours.
and are initially GI related and not life threatening.
Generally, the longer symptoms are delayed, the Patients whose skin or clothing is contaminated
less likely it is that effects from exposure are severe. with a liquid nerve agent can contaminate you
by direct contact or through off-gasing vapor.
Nerve Agents—Vapor Decontamination of the skin is not required after
Effects from nerve agent vapor begin within exposure to vapor alone, but clothing should be
seconds to several minutes after exposure. After removed because it may contain “trapped” vapor.
exposure to a very low amount of vapor, miosis Atropine and pralidoxime chloride (Protopam
(constriction of the pupil of the eye) and other Chloride; 2-PAM Cl) are antidotes for nerve
effects may not begin for several minutes, and agent toxicity. Pralidoxime must be administered
miosis may not end for 15 to 30 minutes after within a short time—between minutes and a few
the patient is removed from the vapor. Effects hours following exposure (depending on the
may continue to progress for a period of time, specific agent) to be effective.
but usually not for more than a few minutes after
exposure stops. The effects caused by a mild When the nerve agent has been ingested,
vapor exposure may be easily confused with an exposure may continue for some time, due to slow
upper respiratory illness or even allergies. Miosis, absorption from the lower bowel, which can result
if present, will help to distinguish these. Likewise, in fatal relapses despite what appears to be an
Chapter 31: Response to Disasters and Terrorism | 689
initial improvement. Continued medical monitoring Administration of DuoDote™ Kit
and transport are mandatory for patients who have
1. Tear open the plastic pouch at any of
ingested a nerve agent.
the notches.
Decontamination is critical for skin exposure and 2. Remove the DuoDote™ Auto-Injector from
should be done with standard decontamination the pouch.
procedures. Patient monitoring should be directed 3. Place the DuoDote™ Auto-Injector in your
to the same signs and symptoms as with all writing hand.
nerve agent exposures. Keep a record of any 4. Firmly grasp the center of the DuoDote™
medications used. Auto-Injector with the green tip (needle end)
pointing down. Do not touch the green end.
Nerve Agent Antidote 5. Pull off the gray safety release.
Auto-Injector Kit 6. Quickly and firmly push the green tip straight
There is currently one main nerve agent antidote down (at a 90-degree angle) against the
kit: the DuoDote™. DuoDote™ is an auto-injector mid-outer thigh. The DuoDote™ Auto-Injector
that provides simple, accurate drug administration can inject through clothing, but pockets must
of a premeasured, controlled dose of medication be empty.
used to relieve, counteract or reverse the effects of 7. Continue to push firmly until you feel the
poisons or drugs such as nerve agents. DuoDote™ Auto-Injector trigger.
8. Remove the DuoDote™ Auto-Injector from the
In 2007, the U.S. Food and Drug Administration
thigh and look at the green tip. If the needle is
(FDA) approved DuoDote™ for use by trained
not visible, the injection has not been made.
EMS personnel to treat civilians exposed to nerve
Check to be sure the gray safety release has
agents. It contains both atropine and 2-PAM
been removed, and repeat from step 4. You
chloride in one auto-injector syringe.
must press hard enough to ensure that the
Atropine increases heart rate, dries secretions, injection has been made.
decreases gastric upset and dilates pupils. 9. Push the needle against a hard surface to
2-PAM chloride reverses some effects of nerve bend the needle back against the DuoDote™
agent poisoning such as muscle twitching and Auto-Injector.
difficulty breathing. 10. Put the used DuoDote™ Auto-Injector back
into the plastic pouch. Keep the DuoDote™
If you or a peer show signs or symptoms that
Auto-Injector with the patient.
indicate the presence of nerve agent poisoning,
and if you are authorized to do so by medical
direction, administer a nerve agent auto-injector kit.
If you self-administer the antidote and there is no
PUTTING IT ALL TOGETHER
improvement in 10 minutes, look for a fellow EMR One of the most challenging roles for an EMR
or caregiver at the site to assist in evaluating your is to be called to respond to a disaster, whether
condition before further antidote is given. If you are an intentional one such as a terrorist attack,
severely ill (e.g., gasping respirations, twitching, possibly using WMD, or a manmade disaster
etc.), a fellow caregiver should administer the like a hurricane. The only way to respond to such
antidote immediately. catastrophic events is to be properly trained and
prepared to respond.
Always follow medical direction and the
manufacturer’s instructions for use of any nerve WMD can be divided into five major categories,
agent antidote auto-injector. collectively referred to as CBRNE: chemical,
CRITICAL If you or a peer show signs or symptoms that indicate the presence of nerve agent
FACTS poisoning, and if you are authorized to do so by medical direction, administer a
nerve agent auto-injector kit.
690 | Emergency Medical Response
biological, radiological/nuclear and explosive. trained personnel, equipment and supplies,
Each of these types of weapons has unique communication systems and the appropriate
characteristics in the nature of the damage it can protocols, so that all personnel know what to do.
inflict, the hazards with which they are associated,
the signs and symptoms of exposure, and the It is important to understand the nature of nerve
specific care required to help people involved in agents, how they enter the body, and the signs and
the disaster. symptoms they produce. In the event of exposure
to poisoning by a nerve agent, you may be required
In any wide-scale disaster such as these, it is to provide self-care or care to a peer.
critical to be prepared with sufficient appropriately
You Are the Emergency Medical Responder
There is some question about the cause of the explosion, but police strongly suspect that
it was a terrorist act using a WMD, most likely a high-order explosive. While waiting at the
staging area, you notice a large trash bag near a dumpster in close proximity to staged
apparatus. You should be alert for what other types of situations, and how would you react
upon their discovery?
Chapter 31: Response to Disasters and Terrorism | 691
ENRICHMENT
Preparing for a Public Health Disaster—
Pandemic Flu
Pandemic influenza (or pandemic flu) is virulent human influenza A virus that causes a global outbreak of serious
illness in humans. As there is little natural immunity, the disease spreads easily and is sustainable from person
to person. In situations where the fatality rate is higher than expected during a normal flu season, this type
of influenza virus can seriously impact the nation, affecting and even halting its healthcare delivery system,
transportation system, economy and social structure.
As an EMR, your services are in high demand during a public health disaster. Yet you and your unit may
be faced with some of the same challenges many businesses and organizations do during such times, such
as increased employee absenteeism, disruption of supply chains, and increased rates of illness and death.
Both 9-1-1 systems and EMS personnel are well integrated into the nation’s pandemic influenza planning, and
response is essential to the nation’s health and safety in the event of a pandemic.
The National Strategy for Pandemic Influenza identifies responsibilities for federal, state and local governments
as well as nongovernmental organizations, businesses and individuals, and is built on three pillars:
Preparedness and communication: Acts taken Surveillance and detection: Domestic and
before a pandemic to ensure preparedness, and international systems set up to detect the earliest
the communication and coordination of roles and warning possible to protect the population
responsibilities to all levels of government, segments Response and containment: Actions to limit the
of society and individuals spread of the outbreak and to mitigate the health,
social and economic impacts of a pandemic
Both EMS and 9-1-1 system planning for pandemic influenza should be carried out in the context of the following
phases of pandemic influenza identified by the World Health Organization (WHO) and the U.S. government:
Early detection The use of infection control measures to
Treatment with antiviral medications prevent transmission
Vaccination
Interventions used to help contain the spread of the virus include the following:
Treatment with influenza antiviral medications and coupled with protecting children and teenagers
isolation of all persons with confirmed or probable through social distancing in the community
pandemic influenza Use of social distancing measures to reduce contact
Voluntary home quarantine of members of between adults in the community and workplace,
households with confirmed or probable influenza including cancellation of large public gatherings and
case(s) alteration of workplace environments and schedules
Dismissal of students from school and school- to offer a healthy workplace without disrupting
based activities, and closure of childcare programs, essential services
Disease surveillance plays an important role in pandemic influenza mitigation, and both EMS and 9-1-1 systems
play a large part in maintaining and collecting patient information such as fever, reporting updated information on
an emerging pathogen (e.g., during the SARS epidemic, questions pertaining to foreign travel were pertinent), and
identifying probable signs and symptoms of an emerging viral strain.
692 | Emergency Medical Response
ENRICHMENT
Personal Preparedness
In a disaster or emergency situation, EMRs are likely to be concerned with the well-being of their own families and
friends. It is important for their own reassurance, and for the purposes of educating the public, that responders
understand how to prepare on an individual basis for disasters. The American Red Cross suggests three basic
steps to prepare to respond to a disaster or life-threatening emergency:
1. Get a kit.
2. Make a plan.
3. Be informed.
Get a Kit
When assembling or restocking your kit, store at least 3 days’ worth of food, water and supplies in an easy-to-carry
preparedness kit. Keep extra supplies on hand at home in case you cannot leave the affected area. Keep your kit
where it is easily accessible. Remember to check your kit every 6 months and replace expired or outdated items.
Whether you purchase an official Red Cross preparedness kit or assemble your own, you should include what
you need to provide comfort for everyday scrapes or life-threatening emergencies. A standard preparedness kit
should include water, food, medications, radio, first aid kit, personal documents, contact information, map, money,
clothing, sanitary supplies, pet supplies and tools.
Make a Plan
When preparing for a disaster, always talk with your family, plan, and learn how and when to turn off utilities
and use lifesaving tools such as fire extinguishers. Tell everyone where emergency information and supplies are
stored. Provide copies of the family’s preparedness plan to each member of the family. Ensure that information is
always up-to-date, and practice evacuations, following the routes outlined in your plan. Identify alternative routes
and make sure to include pets in your evacuation plans.
As an element of your preparedness plan, choose an out-of-area contact to call in case of an emergency. Tell all
family and friends that this out-of-area contact is the person they should all phone to relay messages. Your contact
should live far enough away that the person will not be affected by the disaster. You should also predetermine two
meeting places, to save time and minimize confusion: 1) right outside your home, e.g., in cases such as a home fire;
and 2) outside your neighborhood or town, for when you cannot return home or you must evacuate.
Be Informed
In addition to preparing a kit and making a plan, you should also know different ways to get informed, including
ways you and your family would get information during a disaster or emergency, learning about the disasters that
may occur in your area by knowing your region and learning first aid. Visit the Red Cross website (redcross.org/
get-help/how-to-prepare-for-emergencies) for information on how to prepare for emergencies.
Chapter 31: Response to Disasters and Terrorism | 693
32 You Are the Emergency Medical Responder
SPECIAL
OPERATIONS
You are the emergency medical responder (EMR) at the scene of a construction
site cave-in. On arrival, you find a man who was working in an open trench that has
collapsed around him to mid-chest level. How would you respond? What are your
immediate concerns?
KEY TERMS
Confined space: Any space with limited access that Non-swimming rescues and assists: Rescues
is not intended for continuous human occupancy; and assists that can be performed from a pool
has limited or restricted means of entry or exit. deck, pier or shoreline by reaching, by using an
extremity or object, by throwing a floating object or
Distressed swimmer: A swimmer showing anxiety by standing in the water to provide either of these
or panic; often identified as a swimmer who has assists; performed instead of swimming out to the
gone beyond their swimming abilities. person in distress.
Drowning: An event in which a victim experiences Rappelling: The act of descending (as from a cliff)
respiratory impairment due to submersion in water. by sliding down a rope passed under one thigh,
Drowning may or may not result in death. across the body and over the opposite shoulder or
through a special friction device.
Drowning victim—active: Someone who is vertical
in the water but has no supporting kick, is unable Reaching assist: A method of rescuing someone
to move forward and cannot call out for help. in the water by using an object to extend the
responder’s reach or by reaching with an arm or leg.
Drowning victim—passive: Someone who is
not moving and is floating either face-up or Throwing assist: A method of rescuing someone in
face-down, on or near the surface of the water, or the water by throwing the person a floating object,
is submerged. with or without a line attached.
Litter: A portable stretcher used to carry a patient Wading assist: A method of rescuing someone in
over rough terrain. the water by wading out to the person in distress.
LEARNING OBJECTIVES
After reading this chapter, and completing the class • Be familiar with non-swimming rescues and assists.
activities, you will have the information needed to: • Have a basic understanding of special rescue
• Have a basic understanding of specialized situations such as ice rescues, hazardous terrain,
rescue units. confined space rescues, cave-ins, crime scenes,
fireground operations and special events.
• Recognize the signs of distressed swimmers or
drowning victims.
INTRODUCTION The Fire Rehabilitation Unit: to provide “rest,
rehydration, nourishment and medical evaluation
As an emergency medical responder (EMR), you to members (firefighters) who are involved in
may be involved in rescues that find you in some extended or extreme incident scene operations”
precarious and dangerous situations. These (Source: NFPA 1584).
situations will require special operations units to
assist in the rescue efforts. These units may include: The Disaster/Multiple-Casualty Incident (MCI)
Response Unit: to support responders at MCIs,
The Tactical Emergency Medical Services major incidents and those responding to other
(EMS) Unit: for situations such as hostage disasters with basic MCI equipment such as
barricades, active shooters, high-risk warrants caches of backboards, splinting equipment,
and other situations requiring a tactical wound care supplies and IV administration
response team. supplies. Equipment also may include multi-
patient oxygen delivery systems. This unit also
The Hazardous Materials (HAZMAT) EMS
provides services for managing large-scale or
Response Unit: for situations involving weapons
of mass destruction (WMD) and HAZMAT special rescue situations.
incidents, to provide EMS care to patients in the The Search and Rescue (SAR) Unit: to support
warm zone, the area immediately outside the hot search and rescue operations.
zone (the area in which the most danger exists).
Chapter 32: Special Operations | 695
The Specialized Vehicle Response Unit: to
support operations involving all-terrain response
vehicles required for difficult-to-reach or
hazardous terrains.
Water Rescue
Some people who drown never intended to be in
the water. They may have simply slipped in and
did not know what to do. Drowning is the fifth
most common cause of death from unintentional
injury in the United States among all ages, and it
rises to the second leading cause of death among
those 1 to 14 years of age. More than 3500
Americans die annually from drowning. Children Fig. 32-1: A distressed swimmer is able to stay afloat and
breathe, but may be too tired to get to shore or to the side of
with seizure disorders are 13 times more likely to the pool.
drown than those without such disorders. Males
are more than three times more likely to drown
than females. stay afloat and breathe and may be calling for help
Younger children can drown at any moment, even (Fig. 32-1). The person may be floating, treading
in as little as an inch of water. Young children water or clinging to an object or a line for support.
commonly drown in home pools. But, children can Someone who is trying to swim but making little or
also drown in many other types of water settings, no forward progress may be in distress. Without
including drainage canals, irrigation ditches, and assistance, a person in distress may lose the ability
even bathtubs, large buckets and toilets. to float and begin to drown.
Alcohol and water do not mix. Drinking alcohol in, A drowning victim—active could be at the
on or around water is dangerous. The U.S. Coast surface or sinking. They could also be positioned
Guard reports that more than half of boating- vertically in the water and leaning back slightly.
related drowning deaths involve alcohol. This victim is unlikely to have a supporting kick or
the ability to move forward. The person’s arms are
Being able to recognize that an individual is having at the sides, pressing down in an attempt to keep
trouble in the water may help save that person’s life. the mouth and nose above water to breathe. All
Most people who are drowning cannot or do not call energy is going into the struggle to breathe, and
for help. They spend their energy trying to keep their the person cannot call out for help.
mouth and nose above the water to breathe. They
might slip underwater quickly and never resurface. A drowning victim—passive may have a
There are two kinds of water emergency situations—a limp body or convulsive-like movements. They
swimmer in distress and a drowning person. could be floating face-up or face-down on
or near the surface, or may be submerged
A distressed swimmer may be too tired to get (Fig. 32-2). Table 32-1 shows characteristics
to shore or to the side of the pool, but is able to of drowning persons.
CRITICAL Drowning is the fifth most common cause of death from unintentional injury in the
FACTS United States among all ages, and it rises to the second leading cause of death
among those 1 to 14 years of age. Males are more than three times more likely to
drown than females. A victim may have never intended on even being in the water.
Younger children can drown at any moment, even in as little as an inch of water.
Young children commonly drown in home pools. Children with seizure disorders are
13 times more likely to drown than those without such disorders.
Most people who are drowning spend their energy trying to keep their mouth and
nose above the water. Recognizing someone who seems to be having trouble in the
water, but is not calling out for help, may help save their life.
696 | Emergency Medical Response
You should not attempt a swimming rescue unless
you are trained to do so. Following these steps will
help to reduce your risk of drowning:
Look for a lifeguard to help before attempting
a rescue.
Make sure you have appropriate equipment for
your own safety and that of the drowning person.
Call for additional resources immediately if
proper equipment is not available.
Never swim out to a person unless you have the
proper training, skills and equipment.
Fig. 32-2: A drowning victim who is passive is not moving and To be prepared for an aquatic emergency, it is
will be floating face-up or face-down on or near the surface of
the water, or may be submerged. important to understand the environment. Pay
attention to the potential hazards that exist and
the conditions of the water. Familiarize yourself
Table 32-1:
Behaviors of Distressed Swimmers and Drowning Victims
Compared with Swimmers
DISTRESSED DROWNING DROWNING
SWIMMER
SWIMMER VICTIM—ACTIVE VICTIM—PASSIVE
Breathing Rhythmic Can continue Struggles to Is not breathing
breathing breathing and might breathe; cannot call
call for help out for help
Arm and Relatively Floating, sculling Holds arms to None
Leg Action coordinated or treading water; sides, alternately
might wave for help moving up and
pressing down; has
no supporting kick
Body Position Horizontal Horizontal, vertical Vertical Horizontal or vertical;
or diagonal, face-up, face-down or
depending on submerged
means of support
Locomotion Recognizable Makes little or no None; has only None
(ability to forward progress; 20 to 60 seconds
move from less and less able to before submerging
place to place) support self
CRITICAL There are three types of water-related victims: a distressed swimmer who is
FACTS too tired to continue but afloat; a drowning victim who is active, vertical but not
moving forward; and a drowning victim who is passive, floating or submerged and
not moving.
Only those trained in swimming rescues should enter the water to assist with
drowning emergencies. For your safety, look for a lifeguard before attempting
a rescue, have the appropriate safety equipment, call for additional resources
immediately if you do not have that equipment, and only swim out if you have the
proper training, skills and equipment.
Chapter 32: Special Operations | 697
with the common recreational activities in your
area and the potential hazards. Consider the age,
ability and physical challenges of participants in
those activities, and learn what kinds of local water
incidents and injuries are common in your area.
As in any emergency situation, proceed safely.
Make sure the scene is safe. If the person is in the
water, decide first whether help is needed in order
for the person to get out, and then act based on
your training. Look for anyone else who may be in
trouble. Look for bystanders who can call for help
or help you provide first aid.
During the emergency situation, your preparation Fig. 32-3: To perform a reaching assist, firmly brace yourself on
solid ground and reach out to the person in need of help with an
will allow you to respond quickly; you may only object that will extend your reach.
have seconds to act. Your first goal is to stay safe.
Rushing into the water to help someone may put
you at risk of drowning, too. Once you ensure your
own safety, your goal is to help get the person
out of the water. If the person is unconscious,
send someone to call for more advanced medical
personnel while you start the rescue. If the person
is conscious, first get the person out of the water
and then determine whether more advanced
medical personnel are needed.
You can help a person in trouble in the water by
using reaching assists, throwing assists or wading
assists. Whenever possible, start the rescue by
talking to the person. Let the person know help is
coming. If noise is a problem or if the person is too
far away to hear you, use nonverbal communication
strategies. Tell the person what to do to help with
the rescue, such as grasping a line, ring buoy or
other object that floats. Ask the individual to move
toward you, such as by using the back float with
slight leg movements or small strokes. Some people
reach safety by themselves with the calm and
encouraging assistance of someone calling to them.
Non-swimming rescues and assists include: Fig. 32-4: To perform a throwing assist, throw a floating
object with a line out to the person in need of help and pull the
Reaching Assists. Firmly brace yourself individual to safety once they have grasped the object.
on solid ground, such as a pool deck, pier or
shoreline, and reach out to the person with any Throwing Assists. An effective way to rescue
object that will extend your reach, such as a pole, someone beyond your reach is to throw a
oar or paddle, tree branch, shirt, belt or towel floating object with a line attached out to the
(Fig. 32-3). If no equipment is available, you can person (Fig. 32-4). Once the person grasps the
still perform a reaching assist by lying down and object, pull the individual to safety. Throwing
extending your arm or leg for the person to grab. equipment includes heaving lines, ring buoys,
CRITICAL Non-swimming rescues and assists include reaching, throwing and wading assists.
FACTS The distance of the victim and the conditions of the water will dictate which method
is best.
698 | Emergency Medical Response
throw bags or any floating object available, such HAZARDOUS TERRAIN
as a picnic jug, small cooler, buoyant cushion,
Nature can offer many challenges to the EMR when
kickboard or extra life jacket.
faced with a rescue in hazardous terrain. Whether
Wading Assists. If the water is safe and shallow it is challenging weather conditions or dangerous,
enough (not over your chest), you can wade in to rough terrain, special procedures must be in place
reach the person. If a current or soft or unknown to help provide safety for both the responder and
bottom makes wading dangerous, do not go in patient (Fig. 32-6).
the water. If possible, wear a life jacket and take
something with you to extend your reach such One of the challenges you may face is evacuating
as a ring buoy, buoyant cushion, kickboard, life a patient from a dangerous area where the terrain
jacket, tree branch, pole, air mattress, plastic is rough and difficult to maneuver over. The most
cooler, picnic jug, paddle or water exercise belt. common equipment used for this type of rescue
is the litter, or portable stretcher. Part of the
When the emergency is over, you may need to challenge offered by rough terrain evacuation is
assist with follow-up procedures that may include:
Confirming and documenting witness interviews.
Reporting the incident to the appropriate
individuals.
Filling out proper report forms to document
injuries for use in court or for insurance purposes.
Contacting the patient’s family or legal guardian.
Dealing with the media.
Assessing what happened and evaluating the
actions taken.
Critical incident stress may follow an incident in
which a serious injury or death occurs. The stress
of the experience may overcome your ability to Fig. 32-5: Use reaching and throwing assists to rescue a
cope, and some effects of critical incident stress drowning person who has fallen through the ice.
may appear right away while others may follow
days, weeks or even months after the incident.
Consider seeking professional help in these cases
to prevent posttraumatic stress disorder.
Ice Rescue
In icy water, a person’s body temperature begins
to drop almost as soon as the body hits the water.
The body loses heat in water 32 times faster than
it does in the air. Swallowing water accelerates this
cooling. As the body’s core temperature drops, the
metabolic rate drops. Activity in the cells comes
to almost a standstill, and the person requires very
little oxygen. Any oxygen left in the blood is diverted
from other parts of the body to the brain and heart.
If a person falls through the ice, do not go onto the
ice to attempt a rescue, as it may be too thin to
support you. It is your responsibility as a responder
to call for an ice rescue team immediately. In the
case of a drowning person, always attempt to
rescue the person using reaching and throwing
assists (Fig. 32-5). Continue talking to the person
Fig. 32-6: A rescue in hazardous terrain poses many challenges,
until the ice rescue team arrives. If you are able and special procedures must be in place to help provide safety
to pull the person from the water, provide care for both the responder and patient. Photo: courtesy of University
for hypothermia. of Utah, Remote Rescue Training.
Chapter 32: Special Operations | 699
that it takes 18 to 20 people to carry a patient over In the case of a low-angle rescue, a rope may
1 mile of rough terrain. This is why teams must be not be required. These scenarios would include
selected in groups of four, and to ensure equal situations where:
balance of the litter, team members should be as
close in height as possible. The reason 18 to 20 The slope is less than 40 degrees.
people are required is to ensure no one on the Approaching or evacuating the patient, hands
team overtires. After a short distance, teams should are not required to provide balance.
rotate positions, changing sides and positions after Slips or falls would not prove life threatening or
each progression. It is then advised that teams result in serious injury.
alternate, giving each team a chance to rest. This
will ensure a safe rescue, without anyone becoming As with any emergency scene, it is your responsibility
exhausted and unable to complete the evacuation. as a responder to assess the situation and call
for the proper rescue team. While waiting for the
Another factor during a hazardous terrain rescue is team to arrive, follow proper procedures, including
the position of the patient in relation to the terrain: assessment of the patient as appropriate.
the more drastic the angle of the terrain, the more
risky the rescue. To avoid dropping the patient or
falling during the rescue, a rope system can be CONFINED SPACE
used to lift or lower the patient on the litter. A high- Any space with limited access that is not intended
angle rescue, such as from a cliff, gorge or side of a for continuous human occupancy is considered a
building, would entail lifting or lowering a patient with confined space (Fig. 32-7). Rescues in confined
these ropes. In severe cases, a high-angle rescue spaces are usually for falls, explosions, asphyxia,
team may be required. These scenarios may include: medical problems or machinery entrapment.
Confined spaces may be at ground level, above
A slope of more than 40 degrees.
ground or below ground.
Terrain below and around the slope that poses
serious danger for slips and falls. Silos used to store agricultural materials are often
Terrain that requires rescue teams to approach designed to limit oxygen and, therefore, present the
and evacuate using a secured rope (rappelling). hazard of poisonous gases caused by fermentation
Fig. 32-7: Confined spaces include any space with limited access that is not
intended for continuous human occupancy. Photo: courtesy of Chief Carle L.
Bishop, Clermont Fire Department.
CRITICAL Any space with limited access that is not intended for continuous human occupancy
FACTS is considered a confined space. Rescues in confined spaces are usually for falls,
explosions, asphyxia, medical problems or machinery entrapment. Confined spaces
may be at ground level, above ground or below ground.
700 | Emergency Medical Response
as well as the danger of engulfment by the trench deeper than 5 feet, to prevent walls from
contained product in the silo. Grain bins and grain giving way. If a worker is involved in a cave-in, the
elevators pose the same dangers as silos. person may be buried either completely or partially.
If a second worker jumps in to save that person,
Low oxygen levels in these spaces pose a the worker may cause a secondary collapse and
significant risk, as do poisonous gases such as become buried as well.
carbon monoxide, hydrogen sulfide and carbon
dioxide. Atmospheres containing other gases also It is easy to underestimate the danger of being
may be explosive. covered in soil, but it weighs about 100 pounds
per cubic yard. Buried under only 2 feet of soil
Below-ground confined spaces, such as may mean a worker is under about 1000 pounds
underground vaults or utility vaults for water, sewers of weight, which can cause respiratory problems
or electrical power, also can pose situations in which if the soil is covering the person’s chest. It is
poisonous gases may be present. Electrical vaults imperative to call a specialized trench team for
pose the added danger of possible electrocution. rescue at a cave-in. Do not let anyone enter the
Wells, culverts and cisterns containing water may trench or the area immediately around it; once
also present a high risk of drowning. there has been a cave-in, the likelihood of a
Upon arrival at the scene, determine the nature of secondary one is increased.
the emergency and find out if there are any permits
for the site so that you can determine the type of
work being done. Without entering the site, try CRIME SCENE
to determine how many workers are involved and Law enforcement officers are in charge of a crime
whether there are any hazards present. Next, call scene. It is your responsibility to keep in mind the
for a specialized rescue team and establish a safe importance of maintaining the integrity of evidence
perimeter around the area, preventing anyone from that can be compromised or destroyed when you
entering. Do not enter the scene unless you are enter a crime scene. Always consult with police
sure it is safe. When able, assist in the rescue and officers before disturbing items that may be
offer medical assistance if appropriate. evidence of a crime. You must take precautions
to avoid disturbing crime scene evidence (e.g.,
There are specific safety precautions dictated by weapons, bloodstains, vehicles, skid marks) or
the Occupational Safety and Health Administration other evidence that can be vital to investigators
(OSHA). These guidelines are intended to protect to reconstruct the crime or incident scene. It is
workers who must access confined spaces to also important not to introduce evidence into a
perform specific jobs. These safety precautions crime scene. In all such cases, direction will be
include requirements for proper ventilation and provided from the officer in charge and EMRs
monitoring for poisonous gases, safely locked should not take action without permission from law
electrical systems, dissipated stored energy and enforcement that it is clear for you to enter, usually
disconnected pipes. They also address the use of with an appropriate escort.
appropriate respiratory protection for responders,
including self-contained breathing apparatus You may be called to one of four types of crime
(SCBA) or supplied air breathing apparatus (SABA). scene situations:
A closed access to an unsecured crime scene
Cave-Ins means that a hazard still exists, such as in a
Cave-ins from a trench are associated with hostage situation, when the suspect(s) is
particular risk. To prevent cave-ins, OSHA has still on the scene or environmental hazards
rules about shoring or making a “trench box” in any are still present.
CRITICAL Cave-ins from a trench are associated with particular risk. To prevent cave-ins,
FACTS OSHA has rules about shoring or making a “trench box” in any trench deeper than
5 feet, to prevent walls from giving way.
Law enforcement officers are in charge of a crime scene. It is your responsibility
to keep in mind the importance of maintaining the integrity of evidence that can be
compromised or destroyed when you enter a crime scene.
Chapter 32: Special Operations | 701
A limited-access crime scene means that critical FIREGROUND OPERATIONS
evidence could be destroyed or compromised
on the scene and that hazards may still be Any fire can be dangerous. Make sure that the
present, including environmental hazards. local fire department has been summoned.
Only firefighters, who are highly trained and
An open-access crime scene still has evidence
use equipment that protects them against fire
to be collected. However, personnel have
and smoke, should approach a fire. Do not let
access to the entire area. It is still necessary to
others approach. Gather information to help
consult with police before disturbing anything,
the responding fire and EMS units. Find out the
as critical evidence could still be destroyed or
possible number of people trapped, their location,
compromised.
the fire’s cause and whether any explosives or
A cold crime scene no longer has evidential chemicals are present. Give this information to
concerns or hazards present. emergency personnel when they arrive. If you are
As a responder, when you arrive at a scene not trained to fight fires or lack the necessary
where criminal activity is suspected, take the equipment, follow these basic guidelines:
following steps:
Do not approach a burning vehicle.
Notify law enforcement personnel if they are not Never enter a burning or smoke-filled building.
already at the scene. If you are in a building that is on fire, always
Take precautions not to remove or disturb check doors before opening them. If a door is
anything at the scene unless it is absolutely hot to the touch, do not open it.
necessary to perform critical patient care. Since smoke and fumes rise, stay close to the
Document any situations in which you need to floor (Fig. 32-8).
disturb the scene in the interest of patient care. Never use an elevator in a building that may
In situations where sexual assault is suspected be burning.
or alleged by the patient, notify law enforcement
personnel and do not allow the patient to wash,
shower or change clothing.
When removing clothing following gunshot
wounds, stabbing or other assaults, if at all
possible, do not cut clothing through or near the
bullet or stab wound holes.
Allow bloody clothing to dry.
Avoid allowing blood or debris to contaminate
another area or clothing.
Do not roll clothes up in a ball.
Never put wet or bloody clothes in plastic bags.
Handle clothing as little and as carefully as
possible, as powder flakes from gunshot
wounds may be present and this may decrease
the value of powder-deposit examination.
Consider bagging the patient’s hands if the
situation permits, and if required by local
protocols.
Minimize the introduction of evidence into
a crime scene. Communicate with law
enforcement concerning any items you left
behind (such as medical supplies) and if you
disturbed anything (such as moving furniture to
access a patient).
Fig. 32-8: If you are in a burning or smoke-filled building, check
Yield to the primary investigative agency on all doors before opening them. If a door is hot to the touch, do
the scene. not open it. Stay close to the floor.
702 | Emergency Medical Response
As with a crime scene situation and law An individual, agency or organization may submit a
enforcement personnel, fireground operations request for an EMS team to be present at a special
always yield to the fire services department to lead event by providing a plan outlining the following
and coordinate operations. information to the appropriate agency:
Fire departments are uniquely equipped to The nature of the event and its location, length
simultaneously address patients’ needs at a and anticipated attendance
fire, including: The sponsor of the event
Physical rescue of patients. The qualifications of the special event supervisory
physician and the special event EMS incident
Protection from the dangers posed by a fire.
commander, as well as their names
Creation of a safe physical environment.
The number of emergency medical personnel
As always, scene safety is the primary objective involved and their qualifications
at every fire rescue. The rapid response times The type and quantity of emergency medical
of the fire department offer a crucial advantage vehicles, equipment and supplies required, in
to fire-related emergency situations. Most fire accordance with the anticipated number of
departments are equipped with automated participants or spectators
defibrillators. They are also equipped to perform A description of the on-site treatment facilities,
rapid multi-faceted response, rapid identification including maps of the special event site
and triage to the appropriate facility.
The level of care to be provided: basic life
support (BLS), advanced life support (ALS)
or both
SPECIAL EVENTS AND STANDBY
Patient transfer protocols and agreements
You may be assigned to a special event or be on
standby in case there is a need for emergency A description of the special event emergency
medical communications capabilities
medical attention. Such events could include major
sporting events like the Super Bowl or concerts, Plans for educating event attendees regarding
EMS system access, specific hazards or
large-scale conventions or other national security
severe weather
events (Fig. 32-9). The following general guidelines
are for awareness purposes and may vary by state Measures that will be taken to coordinate EMS
or EMS jurisdiction. care for the special event with local emergency
services and public safety agencies
Fig. 32-9: As an EMR, you may be assigned to be on standby at a special event in case there is a need
for emergency medical attention. Photo: courtesy of Captain Phil Kleinberg, EMT-P.
Chapter 32: Special Operations | 703
A special event EMS incident commander must points (PSAPs); and interface with other involved
be assigned at a special event to supervise public safety agencies. Receiving facilities and
the EMS team during the event. The director’s ambulances providing emergency transportation
responsibilities include: must also be ensured.
Preparation of the plan. The sponsoring agency is responsible for the
Management of the delivery of special event implementation of the plan and must ensure
EMS care. participants and spectators are aware of
the following:
Ensuring implementation and coordination of
details contained in the special event EMS plan.
The location of EMS providers at the
The special event EMS incident commander special event
must be experienced in the administration and How to obtain emergency medical care at the
management of prehospital care at the BLS or ALS special event
level. This person must possess experience in the The procedure in the case of specific hazards
medical supervision of prehospital care at the BLS or serious changing conditions, such as
or ALS level. severe weather
The required staff, qualifications and equipment for
a special event are as follows: PUTTING IT ALL TOGETHER
Special event emergency medical staff shall be As with all calls, the main focus of a special
certified at BLS or ALS levels. operations situation is to remember your safety
and the safety of the patient. Calling the proper
The number of staffed, licensed ambulances or
other transport vehicles required to be stationed service to assist in the rescue will contribute to the
on-site are as follows: success of the rescue efforts.
yyOne ambulance for known or expected Use reaching and throwing assists when
populations of 5000 to 25,000 participants attempting to retrieve a patient from water.
yyTwo ambulances for more than 25,000 but Remember never to enter fast-moving water, and
less than 55,000 participants to tether yourself or any rescue craft you may be
yyThree ambulances for more than 55,000 using in the rescue attempts. Watch for signs of a
participants distressed swimmer and an actively or a passively
yyPersonnel must be available to care for drowning victim when sizing up the scene. When
special event spectators or participants attempting ice rescues, remember the dangers thin
within 10 minutes of notification of the need ice can pose and the added consideration of how
for emergency care. hypothermia can affect a person’s ability to grasp
yyEMS personnel must be currently certified rescue equipment.
at the ambulance attendant, emergency
medical responder, emergency medical Confined space situations pose different
technician (EMT), advanced EMT, paramedic dangers during a rescue. The presence of gases,
or healthcare provider level. engulfment and possible drowning or electrocution
can all be factors, depending on the nature of
A special event where more than 25,000 the space.
participants or spectators are expected requires
an on-site treatment facility, providing protection The physical demands of litter rescue from
from weather or other elements to ensure patient hazardous terrain can require as many as 20
safety and comfort. Beds and equipment for at responders to ensure the safe evacuation of
least four simultaneous patients must be provided a patient. The slope of the area can also pose
for evaluation and treatment, with adequate lighting challenges and, in high-angle situations, a special
and ventilation. A special event EMS system must team is required to evacuate patients.
also have on-site communication capabilities,
When approaching a crime scene, remember that
to ensure uniform access to care for patients in
law enforcement personnel on the scene are in
need of EMS care; on-site coordination of the
charge. Always obtain permission to enter the scene
activities of EMS personnel; communication
with existing community public safety answering and, when attending to victims of a crime, ensure
that the scene is left as undisturbed as possible. If
704 | Emergency Medical Response
you are first on the scene, call for assistance and Finally, when attending a special event, remember
attend to the patient as best you can. to receive direction from the special event EMS
director and keep in mind that a special event
Management of fireground operations must be emergency supervisory physician will be present
passed on to the fire rescue team. Never enter a to assist in case of a serious medical emergency.
burning structure or vehicle. Always call for the fire The number of staffed, licensed ambulance
department when danger of fire exists, or whenever requirements stationed on-site is dictated by the
a team has not already been called. number of spectators or participants at the event.
You Are the Emergency Medical Responder
You find that the patient is conscious but appears to be in respiratory distress from the
compression of the soil surrounding him. What are your treatment priorities? What kind of
additional support will you need, and what are some special safety considerations you must
consider in order to rescue this patient?
Chapter 32: Special Operations | 705
Glossary
Abandonment: Ending the care of an injured or Adult respiratory distress syndrome (ARDS):
ill person without obtaining that patient’s consent A lung condition in which trauma to the lungs leads
or without ensuring that someone with equal or to inflammation, accumulation of fluid in the alveolar
greater training will continue care. air sacs, low blood oxygen and respiratory distress.
Abrasion: The most common type of open wound; Advance directive: A written instruction, signed
characterized by skin that has been rubbed or by the patient and a physician, that documents
scraped away. a patient’s wishes if the patient is unable to
communicate their wishes.
Abruptio placentae: Placental abruption; a
life-threatening emergency that occurs when the Advanced emergency medical technician
placenta detaches from the uterus. (AEMT): A person trained to give basic and
limited advanced emergency medical care and
Absence seizure: A type of generalized seizure transportation for critical and emergent patients
in which there are minimal or no movements; who access the emergency medical services
patient may appear to have a blank stare; also (EMS) system.
known as a petit mal or nonconvulsive seizure.
Agonal breaths: Isolated or infrequent gasping in
Absorbed poison: A poison that enters the body the absence of normal breathing in an unconscious
through the skin. person; can occur after the heart has stopped
beating. Agonal breaths are not normal breathing
Access: Reaching a patient who is trapped in
and are considered a sign of cardiac arrest.
a motor vehicle or a dangerous situation, for the
purpose of extrication and providing medical care. AIDS: A disease of the immune system caused by
infection with HIV.
Acute: Having a rapid and severe onset, then
quickly subsiding. Air medical transport: A type of transport to a
medical facility or between medical facilities by
Acute abdomen: The sudden onset of severe
helicopter or fixed-wing aircraft.
abdominal pain that may be related to one of
many medical conditions or a specific injury to Air splint: A hollow, inflatable splint for
the abdomen. immobilizing a part of the body.
Acute coronary syndrome (ACS): Term that Airway: The pathway for air from the mouth and
describes a range of clinical conditions, including nose through the pharynx, larynx and trachea and
unstable angina and myocardial infarction, that are into the lungs.
due to insufficient blood supply to the heart muscle
resulting from coronary heart disease (CHD). Airway adjunct: A mechanical device used to
help keep the tongue from obstructing the airway;
Acute myocardial ischemia: An episode of can be either nasal or oral.
chest pain due to reduced blood flow to the
heart muscle. All-hazards approach: An approach to disaster
readiness that involves the capability of responding
Adaptive immunity: The type of protection to any type of disaster with a range of equipment
from disease that the body develops throughout and resources.
a lifetime as a person is exposed to diseases or
immunized against them. Altered mental status: A disturbance in
a patient’s level of consciousness (LOC)
Addiction: The compulsive need to use a including confusion and delirium; causes include
substance; stopping use would cause the user to injury, infection, poison, drug abuse and fluid/
suffer mental, physical and emotional distress. electrolyte imbalance.
Adult: For the purpose of providing emergency Alzheimer’s disease: The most common type
medical care, anyone who appears to be of dementia in older people, in which thought,
approximately 12 years old or older. memory and language are impaired.
706 | Emergency Medical Response
Amniotic fluid: The fluid in the amniotic sac; Antivenom: A substance used to counteract the
bathes and protects the fetus. poisonous effects of venom.
Amniotic sac: “Bag of waters”; sac that encloses Anxiety disorder: A condition in which normal
the fetus during pregnancy and bursts during the anxiety becomes excessive and can prevent
birthing process. people from functioning normally; types include
generalized anxiety disorder, obsessive-compulsive
Amputation: The complete removal or severing of
disorder, panic disorder, post-traumatic stress
an external body part.
disorder, phobias and social-anxiety disorder.
Anabolic steroid: A drug sometimes used
by athletes to enhance performance and APGAR score: A mnemonic that describes
increase muscle mass; also has medical use in five measures used to assess the newborn:
stimulating weight gain for people unable to gain Appearance, Pulse, Grimace, Activity
weight naturally. and Respiration.
Anaphylaxis: A form of distributive shock caused Aphasia: A disorder characterized by difficulty
by an often sudden severe allergic reaction, or inability to produce or understand language,
in which air passages may swell and restrict caused by injury to the areas of the brain that
breathing; also referred to as anaphylactic shock. control language.
Anatomic splint: A splint formed by supporting Apnea: A condition that causes breathing to stop
an injured part of the body with an uninjured, periodically or be significantly reduced.
neighboring body part; for example, splinting one
finger against another; also called a self-splint. Apparent life-threatening event (ALTE): A
sudden event in infants under the age of 1 year,
Anatomy: The study of structures, including gross during which the infant experiences a combination
anatomy (structures that can be seen with the of symptoms including apnea, change in color,
naked eye) and microscopic anatomy (structures change in muscle tone and coughing or gagging.
seen under the microscope).
Applied ethics: The use of ethics in decision
Aneurysm: An abnormal bulging of an artery due making; applying ethical values.
to weakness in the blood vessel; may occur in
the aorta (main artery of the heart), brain, leg or Arrhythmia: Electrical disturbances in the regular
other location. rhythmic beating of the heart.
Angina pectoris: Pain in the chest that comes Arterial gas embolism: A condition in which air
and goes at different times; caused by a lack of bubbles enter the bloodstream and subsequently
oxygen reaching the heart; can be stable (occurring travel to the brain; results from a rapid ascent
under exertion or stress) or unstable (occurring at from deep water, which expands air in the lungs
rest, without reason). too quickly.
Angulation: An angular deformity in a Arteries: Large blood vessels that carry oxygen-
fractured bone. rich blood from the heart to all parts of the body,
except for the pulmonary arteries, which carry
Ankle drag: A method of moving a patient by
oxygen-poor blood from the heart to the lungs.
grasping the patient’s ankles; also known as the
foot drag. Artificial ventilation: A mechanical means used
Antibodies: A type of protein found in blood or to assist breathing, such as with a bag-valve-mask
other bodily fluids; used by the immune system to (BVM) resuscitator or resuscitation mask.
identify and neutralize pathogens, such as bacteria Asperger syndrome: A disorder on the autism
and viruses. spectrum; those with Asperger syndrome have a
Antidote: A substance that counteracts and milder form of the disorder.
neutralizes the effects of a poison.
Aspiration: To take, suck or inhale blood, vomit,
Antihistamine: A type of drug taken to treat saliva or other foreign material into the lungs.
allergic reactions.
Assault: A crime that occurs when a person tries
Anti-inflammatory drug: A type of drug taken to physically harm another in a way that makes the
to reduce inflammation or swelling. person under attack feel immediately threatened.
Glossary | 707
Asthma: An ongoing condition in which the Autism spectrum disorder (ASD): A group
airways swell; the air passages can become of disorders characterized by some degree of
constricted or blocked when affected by impairment in communication and social interaction
various triggers. as well as repetitive behaviors.
Asthma attack: The sudden worsening of asthma Automated external defibrillator (AED): A
signs and symptoms, caused by inflammation of portable electronic device that analyzes the heart’s
the airways and the tightening of muscles around electrical rhythm and, if necessary, can deliver an
the airways of a person with asthma, making electrical shock to a person in cardiac arrest.
breathing difficult.
AVPU: Mnemonic describing the four levels
Asthma trigger: Anything that sets off an asthma of patient response: Alert, Verbal, Painful
attack, such as animal dander, dust, smoke, and Unresponsive.
exercise, stress or medications.
Avulsion: An injury in which a portion of the skin,
Asymptomatic: A situation in which a patient has and sometimes other soft tissue, is partially or
no symptoms. completely torn away.
Asystole: A condition where the heart has Backboard: A piece of equipment used to secure
stopped generating electrical activity. a patient when extricating them from the scene and
moving them to a stretcher for transport.
Atherosclerosis: A condition in which deposits
of plaque, including cholesterol (a fatty substance Bacteria: One-celled organisms that can cause
made by the liver and found in foods containing infection; a common type of pathogen.
animal or animal products) build up on the inner
walls of the arteries, causing them to harden and Bag-valve-mask (BVM) resuscitator: A
narrow, reducing the amount of blood that can handheld breathing device consisting of a self-
flow through; develops gradually and can go inflating bag, a one-way valve and a face mask; can
undetected for many years. be used with or without supplemental oxygen.
Atrial fibrillation: Irregular and fast electrical Bandage: Material used to wrap or cover a part
discharges from the left or right atrium of the heart of the body; commonly used to hold a dressing or
that lead to an irregular heartbeat; one of the most splint in place.
common types of abnormal cardiac rhythm. Bandage compress: A thick gauze dressing
Atrioventricular (AV) node: A cluster of cells attached to a gauze bandage.
in the center of the heart, between the atria and Barotrauma: Injury sustained because of pressure
ventricles; serves as a relay to slow down the differences between areas of the body and the
signal received from the sinoatrial (SA) node before surrounding environment; most commonly occurs
it passes through to the ventricles. in air travel and SCUBA diving.
Atropine: An anticholinergic drug with multiple Battery: A crime that occurs when there is
effects; used in antidotes to counteract the effects unlawful touching of a person without the
of nerve agents and to counter the effects of person’s consent.
organophosphate (chemical compounds found in
many common insecticides and used to produce Behavior: How people conduct themselves or
toxic nerve agents, such as sarin) poisoning. respond to their environment.
Audible warning devices: Devices in an Behavioral emergency: A situation in which
emergency vehicle to warn oncoming and side a person exhibits abnormal behavior that is
traffic of the vehicle’s approach; includes both unacceptable or intolerable, for example violence
sirens and air horns. to oneself or others.
Aura phase: The first stage of a generalized Bereavement care: Care provided to families
seizure, during which the patient experiences during the period of grief and mourning
perceptual disturbances, often visual or olfactory surrounding a death.
in nature.
Binder: A cloth wrapped around a patient to
Auscultation: Listening to sounds within the securely hold the arm against the patient’s chest
body, typically through a stethoscope. to add stability; also called a swathe.
708 | Emergency Medical Response
Biohazard: A biological agent that presents a Blunt trauma: An injury in which a person is
hazard to the health or well-being of those exposed. struck by or falls against a blunt object such as a
steering wheel or dashboard, resulting in an injury
Bioterrorism: The deliberate release of agents that does not penetrate the body, may not be
typically found in nature, such as viruses, bacteria evident, and may be more widespread and serious
and other pathogens, to cause illness or death in than suspected.
people, animals or plants.
B NICE: An acronym for the five main types
Bipolar disorder: A brain disorder that causes of terrorist weapons: biological contamination,
abnormal, severe shifts in mood, energy and a nuclear detonation, incendiary fires, toxic chemical
person’s ability to function; the person swings from release and conventional explosions.
the extreme lows of depression to the highs of
mania; also called manic-depressive disorder. Body mechanics: The field of physiology that
studies muscular actions and the function of the
Birth canal: The passageway from the uterus
muscles in maintaining posture.
to the outside of the body through which a baby
passes during birth. Body substance isolation (BSI) precautions:
Protective measures to prevent exposure to
Blanket drag: A method of moving a patient,
communicable diseases; these precautions define
using a blanket, in an emergency situation where
all body fluids and substances as infectious.
equipment is limited and the patient is suspected
of having a head, neck or spinal injury. Body system: A group of organs and other
Blast injury: An injury caused by an explosion; structures that works together to carry out
may occur because of the energy released, the specific functions.
debris, or the impact of the person falling against Bone: A dense, hard tissue that forms
an object or the ground. the skeleton.
Blast lung: Sometimes referred to as lung
Brachial artery: The main artery of the upper
blast; the most common fatal primary blast injury,
arm; runs from the shoulder down to the bend of
describing damage to the lungs caused by the over-
the elbow.
pressurization wave from high-order explosives.
Braxton Hicks contractions: False labor;
Bleeding: The loss of blood from arteries, veins
irregular contractions of the uterus that do not
or capillaries.
intensify or become more frequent as genuine labor
Bloodborne: Used to describe a substance contractions do.
carried in the blood (e.g., bloodborne pathogens
are pathogens carried through the blood). Breathing emergency: An emergency in which
breathing is impaired; can become life threatening;
Bloodborne pathogens: Infectious also called a respiratory emergency.
microorganisms that are present in human blood or
other potentially infectious materials (OPIM) and Breathing rate: Term used to describe the
can cause disease in humans. number of breaths per minute.
Blood glucose level (BGL): The level of Breech birth: The delivery of a baby’s feet or
glucose circulating in the blood; measured using buttocks first.
a glucometer.
Bulb syringe: Small nasal syringe to remove
Blood pressure (BP): The force exerted by secretions from the newborn’s mouth and nose.
blood against the blood vessel walls as it travels
throughout the body. Burn: An injury to the skin or other body tissues
caused by heat, chemicals, electricity or radiation.
Blood volume: The total amount of blood
circulating within the body. Cannabis products: Substances such as
marijuana and hashish that are derived
Bloody show: Thick discharge from the vagina from the Cannabis sativa plant; can produce
that occurs during labor as the mucous plug feelings of elation, distorted perceptions of time
(mucus with pink or light red streaks) is expelled; and space, and impaired motor coordination
often signifies the onset of labor. and judgment.
Glossary | 709
Capillaries: Tiny blood vessels linking arteries Certification: Certification is achieved by
and veins that transfer oxygen and other nutrients obtaining and maintaining the National EMS
from the blood to all body cells and remove Certification (or state certification), taking
waste products. an approved EMS course and meeting other
requirements; this does not grant the right to
Capillary refill: A technique for estimating how practice as licensure may in some states.
the body is reacting to injury or illness by checking
the ability of the capillaries to refill with blood. Cervical collar: A commercially produced rigid
device that is positioned around the neck to limit
Carbon monoxide (CO): An odorless, colorless, movement of the head and neck; also called a
toxic gas produced as a byproduct of combustion. C-collar.
Cardiac arrest: A condition in which the heart has Cervix: The lower, narrow part of the uterus
stopped or beats too irregularly or weakly to pump (womb) that forms a canal that opens into the
blood effectively. vagina, which leads to the outside of the body;
upper part of the birth canal.
Cardiac Chain of Survival: A set of five critical
steps that, when performed in rapid succession, Cesarean section: C-section; delivery of a baby
increase the patient’s chance of surviving cardiac through an incision in the mother’s belly and uterus.
arrest; each link of the chain depends on, and is
connected to, the other links. Chemical burn: A burn caused by strong, caustic
chemicals damaging the skin.
Cardiac muscle: A specialized type of muscle
Chest compressions: A technique used in CPR
found in the heart.
in which external pressure is placed on the chest
Cardiogenic shock: The result of the heart being to help circulate oxygen-rich blood through the
unable to supply adequate blood circulation to the arteries and to the vital organs.
vital organs, resulting in an inadequate supply of Chest tube: A tube surgically inserted into the
nutrients; caused by trauma or disease. chest to drain blood, fluid or air, and to allow the
Cardiopulmonary resuscitation (CPR): A lungs to expand.
technique that combines chest compressions and Chief complaint: A brief description, usually in
ventilations to circulate blood containing oxygen to the patient’s own words, of why emergency medical
the brain and other vital organs for a person whose services (EMS) personnel were called to the scene.
heart and normal breathing have stopped.
Child: For the purpose of providing emergency
Cardiovascular disease: A disease affecting the medical care, anyone who appears to be between
heart and blood vessels. the ages of about 1 year and about 12 years; when
using an automated external defibrillator (AED),
Carotid artery: The major artery located on either different age and weight criteria are used.
side of the neck that supplies blood to the brain.
Child abuse: Action that results in the physical
Catastrophic reaction: A reaction a person or psychological harm of a child; can be physical,
experiences when the person has become sexual, verbal and/or emotional.
overwhelmed; signs include screaming, throwing
objects and striking out. Child neglect: The most frequently reported type
of abuse in which a parent or guardian fails to
CBRNE: The current acronym used by the provide the necessary, age-appropriate care to a
Department of Homeland Security to describe child; insufficient medical or emotional attention or
the main types of weapons of mass destruction: respect given to a child.
chemical, biological, radiological/nuclear
and explosive. Chocking: The use of items such as wooden
blocks placed against the wheels of a vehicle to
Cells: The basic units that combine to form all help stabilize it.
living tissue.
Cholesterol: A fatty substance made by the liver
Cerebrospinal fluid: A clear fluid that flows and found in foods containing animal or animal
within the ventricles of the brain, and around the products; diets high in cholesterol contribute to the
brain and spinal cord. risk of heart disease.
710 | Emergency Medical Response
Chronic: Persistent over a long period of time. Communications center (dispatch): The point
of contact between the public and responders
Chronic diseases: Diseases that occur gradually (also known as a public safety answering point, or
and continue over a long period of time. PSAP); responsible for taking basic information
from callers and dispatching the appropriate
Chronic obstructive pulmonary disease
personnel; in some communities it may also provide
(COPD): A progressive lung disease in which the
prearrival instructions to the 9-1-1 caller.
patient has difficulty breathing because of damage
to the lungs; airways become obstructed and the Compartment syndrome: Condition in which
alveolar sacs lose their ability to fill with air. there is swelling and an increase in pressure within
a limited space that presses on and compromises
Circulatory system: A group of organs and other
blood vessels, nerves and tendons that run through
structures that carries oxygen-rich blood and other
that limited space; usually involves the leg, forearm,
nutrients throughout the body and removes waste.
arm, thigh, shoulder or buttock.
Circumferential splint: A type of splint that
Competence: The patient’s ability to understand
surrounds or encircles an injured body part.
the emergency medical responder’s (EMR’s)
Clinical depression: A mood disorder in which questions and the implications of decisions made.
feelings of sadness, loss, anger or frustration Complex access: In an extrication, the process
interfere with everyday life for an extended period of using specialized tools or equipment to gain
of time. access to the patient.
Clonic phase: The third phase of a generalized Complex partial seizure: A type of partial
seizure, during which the patient experiences the seizure in which the patient may experience an
seizure itself. altered mental status or be unresponsive.
Closed fracture: A type of fracture in which the Concussion: A temporary loss of brain function
skin over the broken bone is intact. caused by a blow to the head; considered a
traumatic brain injury (TBI).
Closed-loop communication: A communication
technique in which the listener repeats orders word Conduction: One of the ways the body loses or
for word to ensure the message was heard and gains heat; occurs when the skin is in contact with
understood accurately. something with a lower or higher temperature.
Closed wound: A wound in which soft tissue Confidentiality: Protection of a patient’s privacy
damage occurs beneath the skin and the skin is and personal information.
not broken.
Confined space: Any space with limited access
Clothes drag: A type of emergency move that that is not intended for continuous human
uses the patient’s clothing; used for a patient occupancy; has limited or restricted means of entry
suspected of having a head, neck or spinal injury. or exit.
Clotting: The process by which blood thickens at Congestive heart failure: A chronic condition in
a wound site to seal an opening in a blood vessel which the heart no longer pumps blood effectively
and stop bleeding. throughout the body.
Cognitive impairment: Impairment of thinking Consent: Permission to provide care; given by an
abilities including memory, judgment, reasoning, injured or ill person to a responder.
problem solving and decision making.
Contraction: During labor, the rhythmic tightening
Cold zone: Also called the support zone, this and relaxing of muscles of the uterus.
area is the outer perimeter of the zones most
directly affected by an emergency involving Contusion: An injury to the soft tissues that results
hazardous materials. in blood vessel damage (usually to capillaries)
and leakage of blood into the surrounding tissues;
Commotio cordis: Sudden cardiac arrest from a caused when blood vessels are damaged or broken
blunt, non-penetrating blow to the chest, of which as the result of a blow to the skin, resulting in
the basis is ventricular fibrillation (V-fib) triggered swelling and a reddish-purple discoloration on the
by chest wall impact immediately over the heart. skin; commonly referred to as a bruise.
Glossary | 711
Convection: One of the ways the body loses or Cyanotic: Showing bluish discoloration of the
gains heat; occurs when air moves over the skin skin, nailbeds and mucous membranes due to
and carries away or increases heat. insufficient levels of oxygen in the blood.
Core temperature: The temperature inside DCAP-BTLS: A mnemonic to help remember the
the body. signs to look for during a physical exam, which is
often done during the secondary assessment; the
Coronary heart disease (CHD): A disease in initials stand for deformities, contusions, abrasions,
which cholesterol and plaque build up on the inner punctures/penetrations, burns, tenderness,
walls of the arteries that supply blood to the heart; lacerations and swelling.
also called coronary artery disease (CAD).
Deadspace: The areas within the respiratory
CPR breathing barrier: Device that allows for system between the pharynx and the alveoli that
ventilations without direct mouth-to-mouth contact contain a small amount of air that does not reach
between the responder and the patient; includes the alveoli.
resuscitation masks, face shields and bag-
valve-mask (BVM) resuscitators. Deafness: The loss of the ability to hear from one
or both ears; can be mild, moderate, severe or
Crackles: An abnormal fine, crackling breath profound, and can be inherited, occur at birth or
sound on inhalation that may be a sign of fluid in be acquired at a later point in life, due to illness,
the lungs; also known as rales. medication, noise exposure or injury.
Cravat: A folded triangular bandage used to hold Deceased/non-salvageable/expectant
splints in place. (Black): A triage category of those involved in
Crepitus: A grating or popping sound under a multiple- (or mass-) casualty incident (MCI)
the skin that can be due to a number of causes, who are obviously dead or who have suffered
including two pieces of bone rubbing against non-life-sustaining injuries.
each other. Decompression sickness: A sometimes fatal
Cribbing: A system using wood or supports, disorder caused by the release of gas bubbles into
arranged diagonally to a vehicle’s frame, to safely body tissue; also known as “the bends”; occurs
prop it up, creating a stable environment. when SCUBA divers ascend too rapidly, without
allowing sufficient time for gases to exit body
Cricoid: A solid ring of cartilage just below and tissues and be removed through exhalation.
behind the thyroid cartilage.
Defibrillation: An electrical shock that disrupts
Critical burn: Any burn that is potentially life the electrical activity of the heart long enough
threatening, disabling or disfiguring; a burn to allow the heart to spontaneously develop an
requiring advanced medical care. effective rhythm on its own.
Critical incident stress: Stress triggered by Dehydration: Inadequate fluids in the
involvement in a serious or traumatic incident. body’s tissues.
Croup: A common upper airway virus that affects Delayed care (Yellow): A triage category of
children under the age of 5. those involved in an MCI with an injury, but whose
chances of survival will not be reduced by a delay.
Crowning: The phase during labor when the
baby’s head is visible at the opening of the vagina. Dementia: A collection of symptoms caused by
any of several disorders of the brain; characterized
Crush injury: An injury to a body part, often an by significantly impaired intellectual functioning that
extremity, caused by a high degree of pressure; interferes with normal activities and relationships.
may result in serious damage to underlying tissues
and cause bleeding, bruising, fracture, laceration Dependency: The desire or need to continually
and compartment syndrome. use a substance.
Cyanosis: A condition in which the patient’s skin, Depressant: A substance that affects the central
nail beds and mucous membranes appear a bluish nervous system and slows down physical and
or greyish color because of insufficient levels of mental activity; can be used to treat anxiety, tension
oxygen in the blood. and high blood pressure.
712 | Emergency Medical Response
Dermis: The deeper layer of the skin; contains the this type of medical direction, the physician speaks
nerves, sweat glands, oil glands and blood vessels. directly with emergency care providers at the
scene of an emergency.
Designer drugs: Potent and illegal street drugs
formed from a medicinal substance whose drug Direct pressure: Pressure applied on a wound to
composition has been modified (designed). control bleeding.
Detailed physical exam: An in-depth head- Disease-causing agent: A pathogen or germ
to-toe physical exam; takes more time than the that can cause disease or illness (e.g., a bacterium
rapid assessment, and is only done when time and or virus).
the patient’s condition allow.
Dislocation: The displacement of a bone from its
Diabetes mellitus: A disease in which there normal position at a joint.
are high levels of blood glucose due to defects in
insulin production, insulin action or both. Dispatcher: Personnel trained in taking critical
information from emergency callers and call takers
Diabetic coma: A life-threatening complication of and relaying it to the appropriate rescue personnel.
diabetes in which very high blood sugar causes the
patient to become unconscious. Distressed swimmer: A swimmer showing
anxiety or panic; often identified as a swimmer who
Diabetic emergency: A situation in which a has gone beyond their swimming abilities.
person becomes ill because of an imbalance of
insulin and sugar in the bloodstream. Distributive shock: A type of shock caused
by inadequate distribution of blood, either
Diabetic ketoacidosis (DKA): An accumulation in the blood vessels or throughout the body,
of organic acids and ketones (waste products) in leading to inadequate volumes of blood returning
the blood; occurs when there is inadequate insulin to the heart.
and high blood sugar levels.
Do no harm: The principle that people who
Diastolic blood pressure: The force exerted intervene to help others must do their best to
against the arteries when the heart is between ensure their actions will do no harm to the patient.
contractions, or at rest.
Do not resuscitate (DNR) order: A type of
Digestive system: A group of organs and other
advance directive that protects a patient’s right to
structures that digests food and eliminates wastes.
refuse efforts for resuscitation; also known as a “do
Dilation: The process of enlargement, stretching not attempt resuscitation (DNAR) order.”
or expansion; used to describe blood vessels.
DOTS: A mnemonic to help remember what to look
During the first stage of labor, refers to the opening
for during the physical exam; the initials stand for
of the cervix to allow the baby to be born.
deformities, open injuries, tenderness and swelling.
Direct carry: A method of moving a patient from
Draw sheet: A method of moving a patient from
a bed to a stretcher or vice versa; performed by
a bed to a stretcher or vice versa by using the
two responders.
stretcher’s bottom sheet.
Direct contact: Mode of transmission of
pathogens that occurs through directly touching Dressing: A pad placed directly over a wound
infected blood or OPIM, or other agents such as to absorb blood and other body fluids and to
chemicals, drugs or toxins. prevent infection.
Direct force: A force that causes injury at the Droplet transmission: Mode of transmission
point of impact. of pathogens that occurs when a person
inhales droplets from an infected person’s
Direct ground lift: A nonemergency method of cough or sneeze; also known as respiratory
lifting a patient directly from the ground; performed droplet transmission.
by several responders.
Dropping: “Engagement” or “lightening”; when
Direct medical control: A type of medical the baby drops into a lower position and is
direction, also called “on-line,” “base-station,” engaged in the mother’s pelvis; usually takes place
“immediate” or “concurrent medical control”; under a few weeks before labor begins.
Glossary | 713
Drowning: An event in which a victim experiences Electrocardiogram (ECG or EKG): A diagnostic
respiratory impairment due to submersion in water. test that measures and records the electrical
Drowning may or may not result in death. activity of the heart.
Drowning victim—active: Someone who is Electrolytes: Substances that are electrically
vertical in the water but has no supporting kick, conductive in solution and are essential to the
is unable to move forward and cannot call out regulation of nerve and muscle function and fluid
for help. balance throughout the body; include sodium,
potassium, chloride, calcium and phosphate.
Drowning victim—passive: Someone who is
not moving and is floating either face-up or face- Embolism: A blockage in an artery or a vein
down, on or near the surface of the water, or caused by a blood clot or fragment of plaque that
is submerged. travels through the blood vessels until it gets stuck,
preventing blood flow.
Drug: Any substance, other than food, intended to
Embryo: The term used to describe the early
affect the functions of the body.
stage of development in the uterus, from
DuoDote™: A kit with pre-measured doses fertilization to the beginning of the third month.
of antidote used to counteract the effects of Emergency medical dispatcher (EMD): A
nerve agents. telecommunicator who has received special
training for triaging a request for medical service
Durable power of attorney for healthcare:
and allocating appropriate resources to the scene
A legal document that expresses a patient’s
of an incident, and for providing prearrival medical
specific wishes regarding their healthcare; also
instructions to patients or bystanders before more
empowers an individual, usually a relative or friend,
advanced medical personnel arrive.
to speak on behalf of the patient should they
become seriously injured or ill and unable to speak Emergency medical responder (EMR): A
for themselves. person trained in emergency care who may be
called on to give such care as a routine part of
Duty to act: A legal responsibility of some their job (paid or volunteer) until more advanced
individuals to provide a reasonable standard of emergency medical services (EMS) personnel take
emergency care. over; EMRs are often the first trained professionals
Eclampsia: A complication during pregnancy to respond to emergencies.
in which the patient has convulsions or seizures Emergency medical services (EMS) system:
associated with high blood pressure. A network of community resources and medical
personnel that provides emergency medical care to
Ectopic pregnancy: A pregnancy outside of the
people who are injured or suddenly fall ill.
uterus; most often occurs in the fallopian tubes.
Emergency medical technician (EMT): A
Edema: Swelling in body tissues caused by person who gives basic emergency medical
fluid accumulation. care and transportation for critical and emergent
patients who access the EMS system; EMTs are
Elastic bandage: A bandage designed to keep
typically authorized to function after completing
continuous pressure on a body part; also called an
local and state certification requirements; formerly
elastic wrap.
referred to as EMT-Basic.
Elder abuse: Action that results in the physical Emergency Response Guidebook: A resource
or psychological harm of an older adult; can be available from the U.S. Department of Transportation
physical, sexual, verbal and/or emotional, usually on (DOT) to help identify hazardous materials and
someone who is disabled or frail. appropriate care for those exposed to them.
Elder neglect: A type of abuse in which a Emphysema: A chronic, degenerative lung
caregiver fails to provide the necessary care to an disease in which there is damage to the alveoli.
older adult.
Endocrine system: A group of organs and other
Electrical burn: A burn caused by contact with structures that regulates and coordinates the
an electrical source, which allows an electrical activities of other systems by producing chemicals
current to pass through the body. (hormones) that influence tissue activity.
714 | Emergency Medical Response
Engineering controls: Control measures that develops when the body’s cooling mechanisms
eliminate, isolate or remove a hazard from the are overwhelmed and body systems begin to
workplace; things used in the workplace to help fail. People with EHS have exaggerated heat
reduce the risk of an exposure. production and an inability to cool themselves.
Epidemiology: A branch of medicine that deals Exposure: An instance in which someone is
with the incidence (rate of occurrence) and exposed to a pathogen or has contact with blood
prevalence (extent) of disease in populations. or OPIM or objects in the environment that contain
disease-causing agents.
Epidermis: The outer layer of the skin; provides
a barrier to bacteria and other organisms that can Exposure control plan: Plan in the workplace
cause infection. that outlines the employer’s protective measures to
eliminate or minimize employee exposure incidents.
Epiglottitis: A serious bacterial infection that
causes severe swelling of the epiglottis, which Expressed consent: Permission to receive
can result in a blocked airway, causing respiratory emergency care granted by a competent adult
failure in children; may be fatal. verbally, nonverbally or through gestures.
Epilepsy: A brain disorder characterized by External bleeding: Bleeding on the outside of
recurrent seizures. the body; often, visible bleeding.
Ethics: A branch of philosophy concerned with the Extremity: A limb of the body; upper extremity is
set of moral principles a person holds about what the arm; lower extremity is the leg.
is right and wrong.
Extremity lift: A two-responder, nonemergency
Evaporation: One of the ways the body loses lift in which one responder supports the patient’s
heat; occurs when the body is wet and the arms and the other the patient’s legs.
moisture evaporates, cooling the skin.
Extrication: The safe and appropriate removal
Evisceration: A severe injury that causes the of a patient trapped in a motor vehicle or a
abdominal organs to protrude through the wound. dangerous situation.
Exercise-associated muscle cramps: Formerly Fainting: Temporary loss of consciousness;
known as heat cramps, these muscle spasms can usually related to temporary insufficient blood flow
be intense and debilitating and typically occur in to the brain; also known as syncope, “blacking out”
the legs, arms and abdomen; painful involuntary or “passing out.”
muscle spasms occur during or after physical FAST: An acronym to help remember the symptoms
exertion, particularly in high heat and humidity, of stroke; stands for Face, Arm, Speech and Time.
possibly due to loss of electrolytes and water from
perspiration; not associated with an increase in Febrile seizures: Seizure activity brought on
body temperature. by an excessively high fever in a young child or
an infant.
Exertional heat exhaustion (EHE): An
inability to cope with heat and characterized by Fetal monitoring: A variety of tests used to
fatigue, nausea and/or vomiting, loss of appetite, measure fetal stress, either internally or externally.
dehydration, exercise-associated muscle cramps,
dizziness with possible fainting, elevated heart Fetus: The term used to describe the stage of
and respiratory rate, and skin that is pale, cool development in the uterus after the embryo stage,
and clammy or slightly flushed; if a core body beginning at the start of the third month.
temperature can be obtained, it is typically higher Fever: An elevated body temperature, beyond
than 104° F (40° C). The person may be weak and normal variation.
unable to stand but has normal mental status; often
results from strenuous work or wearing too much Finger sweep: A method of clearing the mouth of
clothing in a hot, humid environment, and may or foreign material that presents a risk of blocking the
may not occur with dehydration and electrolyte airway or being aspirated into the lungs.
imbalance.
Firefighter’s carry: A type of carry during which
Exertional heat stroke (EHS): The most serious the patient is supported over the responder’s
form of heat-related illness; life threatening and shoulders.
Glossary | 715
Firefighter’s drag: A method of moving a patient Glucose: A simple sugar that is the primary source
in which the patient is bound to the responder’s of energy for the body’s tissues.
neck and held underneath the responder; the
responder moves the patient by crawling. Golden Hour: A term that refers to the critical
first hour after a patient sustains a life-threatening
Flail chest: A serious injury in which multiple traumatic injury; the highest risk of dying from
rib fractures result in a loose section of ribs shock or bleeding occurs during this time;
that does not move normally with the rest of the providing early interventions and advanced
chest during breathing and often moves in the medical care to the patient as soon as possible
opposite direction. within the hour can result in the best chance of
patient survival.
Flammability: The degree to which a substance
may ignite. Good Samaritan laws: Laws that protect people
against claims of negligence when they give
Flowmeter: A device used to regulate, in liters per emergency care in good faith without accepting
minute (LPM), the amount of oxygen administered anything in return.
to a patient.
Grand mal seizure: A type of generalized
Focused trauma assessment: A physical exam seizure; involves whole-body contractions with loss
on a trauma patient, focused only on an isolated of consciousness.
area with a known injury such as a hand with an
obvious laceration. Hallucination: Perception of an object with
no reality; occurs when a person is awake and
Foreign body airway obstruction (FBAO):
conscious; may be visual, auditory or tactile.
The presence of foreign matter, such as food, that
obstructs the airway. Hallucinogen: A substance that affects mood,
sensation, thinking, emotion and self-awareness;
Fracture: A break or disruption in bone tissue.
alters perceptions of time and space; and
Free diving: An extreme sport in which divers produces hallucinations or delusions.
compete underwater without any underwater
Hard of hearing: A degree of hearing loss that is
breathing apparatus.
mild enough to allow the person to continue to rely
Frostbite: A condition in which body tissues on hearing for communication.
freeze; most commonly occurs in the fingers, toes,
Hazardous materials (HAZMATs): Chemical
ears and nose.
substances or materials that can pose a threat or
Full-thickness burn: A burn injury involving all risk to health, safety and property if not properly
layers of skin and underlying tissues; skin may be handled or contained.
brown or charred, and underlying tissues may appear
Hazardous material (HAZMAT) incident: Any
white; also referred to as a third-degree burn.
situation that deals with the unplanned release of
Generalized tonic-clonic seizures: Seizures hazardous materials.
that affect most or all of the brain; types
include absence (petit mal) seizures and grand Head-on collision: A collision in which a vehicle
mal seizures. hits an object, such as a tree or other vehicle,
straight on.
Genitourinary system: A group of organs
and other structures that eliminates waste and Head-tilt/chin-lift maneuver: A common
enables reproduction. method for opening the airway unless the patient
is suspected of having an injury to the head, neck
Gestational diabetes: A type of diabetes that or spine.
occurs only during pregnancy.
Healthcare proxy: A person named in a
Glasgow Coma Scale (GCS): A measure of level healthcare directive, or durable power of attorney
of consciousness (LOC) based on eye opening, for healthcare, who can make medical decisions on
verbal response and motor response. someone else’s behalf.
Glucometer: A medical device that measures the Heart: A fist-sized muscular organ that pumps
concentration of glucose in the blood. blood throughout the body.
716 | Emergency Medical Response
Heat index: An index that combines the air Hospice care: Care provided in the final months
temperature and relative humidity to determine the of life to a terminally ill patient.
perceived, human-felt temperature; a measure of
how hot it feels. Hot zone: Also called the exclusion zone, this is
the area in which the most danger exists from a
Heat stroke: The most serious form of heat- HAZMAT incident.
related illness; life threatening and develops when
the body’s cooling mechanisms are overwhelmed Hyperglycemia: A condition in which too much
and body systems begin to fail; can be classified as sugar is in the bloodstream, resulting in higher than
classic heat stroke or exertional heat stroke. normal BGLs; also known as high blood glucose.
Hematoma: A mass of usually clotted or Hyperkalemia: Abnormally high levels of
partially clotted blood that forms internally in soft potassium in the blood; if extremely high, can
tissue space or an organ as a result of ruptured cause cardiac arrest and death.
blood vessels.
Hyperresonance: Abnormal sounds during
Hemodialysis: A common method of treating percussion on the affected side of the chest.
advanced kidney failure in which blood is filtered
Hypertension: Another term for high
outside the body to remove wastes and extra fluids.
blood pressure.
Hemopneumothorax: An accumulation of blood
Hyperthermia: Overheating of the body; includes
and air between the lungs and chest wall.
exercise-associated muscle cramps, exertional heat
Hemorrhage: The loss of a large amount exhaustion and heat stroke (exertional and classic).
of blood in a short time or when there is
Hyperventilation: Rapid, deep or shallow
continuous bleeding.
breathing; usually caused by panic or anxiety.
Hemorrhagic shock: Shock due to excessive
Hypervolemia: A condition in which there is an
blood loss.
abnormal increase of fluid in the blood.
Hemostatic dressing: A dressing treated with an
Hypodermis: A deeper layer of skin located below
agent or chemical that assists with the formation
the epidermis and dermis; contains fat, blood
of blood clots; used with direct pressure to help
vessels and connective tissues.
control severe, life-threatening bleeding.
Hypoglycemia: A condition in which too little
Hemothorax: An accumulation of blood between sugar is in the bloodstream, resulting in lower than
the lungs and chest wall; caused by bleeding that normal BGLs; also known as low blood glucose.
may be from the chest wall, lung tissue or major
blood vessels in the thorax. Hypoglycemic shock: A type of shock that is a
reaction to extremely low blood glucose levels.
Hepatitis: An inflammation of the liver most
commonly caused by viral infection; there are Hypoperfusion: A life-threatening condition in
several types including hepatitis A, B, C, D and E. which the circulatory system fails to adequately
circulate oxygenated blood to all parts of the body,
High-order explosives (HE): Explosives such resulting in inadequate tissue perfusion; also
as TNT, nitroglycerin, etc., that produce a defining referred to as shock.
supersonic over-pressurization shockwave.
Hypotension: Abnormally low blood pressure.
High-performance CPR: Providing high-quality
chest compressions as part of a well-organized Hypothalamus: Control center of the body’s
team response to a cardiac arrest. temperature; located in the brain.
HIV: A virus that weakens the body’s immune Hypothermia: The state of the body being colder
system, leading to life-threatening infections; than the usual core temperature, caused by either
causes AIDS. excessive loss of body heat and/or the body’s
inability to produce heat.
Homeostasis: A constant state of balance or
well-being of the body’s internal systems that is Hypovolemia: A condition in which there is an
continually and automatically adjusted. abnormal decrease of fluid in the blood.
Glossary | 717
Hypovolemic shock: A type of shock caused by commander (IC) is responsible for establishing
an abnormal decrease in blood volume. the incident objectives and managing resources,
including assessing the situation, deciding what
Hypoxemia: A condition in which there are calls to make and what tasks need to be done, and
decreased levels of oxygen in the blood; can assigning those tasks to appropriate personnel.
disrupt the body’s functioning and harm tissues;
may be life threatening. Indirect contact: Mode of transmission of a
disease caused by touching a contaminated object.
Hypoxia: A condition in which insufficient oxygen
is delivered to the body’s cells. Indirect force: A force that transmits energy
through the body, causing injury at a distance from
Hypoxic: Having below-normal concentrations of the point of impact.
oxygen in the organs and tissues of the body.
Indirect medical control: A type of medical
Immediate care (Red): A triage category of direction, also called “off-line,” “retrospective” or
those involved in an MCI whose needs require “prospective” medical control; this type of medical
urgent lifesaving care. direction includes education, protocol review and
Immobilize: To use a splint or other method to quality improvement for emergency care providers.
keep an injured body part from moving.
Infant: For the purpose of providing emergency
Immune system: The body’s complex group of medical care, anyone who appears to be younger
body systems that is responsible for fighting disease. than about 1 year of age.
Impaled object: An object that remains Infection: A condition caused by disease-
embedded in an open wound; also referred to as producing microorganisms, called pathogens or
an embedded object. germs, in the body.
Implantable cardioverter-defibrillator (ICD): Infectious disease: Disease caused by the
A miniature version of an AED, implanted under the invasion of the body by a pathogen, such as a
skin, that acts to automatically recognize and help bacterium, virus, fungus or parasite.
correct abnormal heart rhythms.
Ingested poison: A poison that is swallowed.
Implantation: The attachment of the fertilized
egg to the lining of the uterus, 6 or 7 days In good faith: Acting in such a way that the goal
after conception. is only to help the patient and that all actions are
for that purpose.
Implied consent: Legal concept that assumes a
patient would consent to receive emergency care if Inhalant: A substance, such as a medication, that
they were physically able or old enough to do so. a person inhales to counteract or prevent a specific
condition; also a substance inhaled to produce
Incendiary weapons: Devices designed to burn mood-altering effects.
at extremely high temperatures, such as napalm
and white phosphorus; mostly designed to be used Inhaled poison: A poison breathed into the lungs.
against equipment, though some (e.g., napalm) are Injected poison: A poison that enters the body
designed to be used against people. through a bite, sting or syringe.
Incident command system (ICS): A
Innate immunity: The type of protection from
standardized, on-scene, all-hazards incident
disease with which humans are born.
management approach that allows for the
integration of facilities, equipment, personnel, Insulin: A hormone produced by the pancreas to
procedures and communications operating help glucose move into the cells; in patients with
within a common organizational structure; diabetes, it may not be produced at all or may not
enables a coordinated response among various be produced in sufficient amounts.
jurisdictions and functional agencies, both public
and private; and establishes common processes Integumentary system: A group of organs and
for planning and managing resources. other structures that protects the body, retains
fluids and helps to prevent infection.
Incident commander: Through delegated
authority of a local government, the incident Intercostal: Located between the ribs.
718 | Emergency Medical Response
Internal bleeding: Bleeding inside the body. Local credentialing: Local requirements EMRs
must meet in order to maintain employment or
Jaw-thrust (without head extension) obtain certain protocols so that they may practice.
maneuver: A maneuver for opening the airway in
a patient suspected of having an injury to the head, Log roll: A method of moving a patient while
neck or spine. keeping the patient’s body aligned because of a
suspected head, neck or spinal injury.
Joint: A structure where two or more bones
are joined. Low-order explosives (LE): Explosives such
as pipe bombs, gunpowder, etc., that create a
Jugular venous distension (JVD): Neck veins that subsonic explosion.
are swollen due to pressure from inside the vein.
Malpractice: A situation in which a professional
Jump kit: A bag or box containing equipment used fails to provide a reasonable quality of care,
by the emergency medical responder (EMR) when resulting in harm to a patient.
responding to a medical emergency; includes items
such as resuscitation masks and airway adjuncts, Mania: An aspect of bipolar disorder characterized
disposable latex-free gloves, blood pressure cuffs by elation, hyperexcitability and accelerated
and bandages. thoughts, speech and actions.
Kinematics of trauma: The science of the forces Manual stabilization: A technique used to
involved in traumatic events and how they damage achieve spinal motion restriction by manually
the body. supporting the patient’s head and neck in the
position found without the use of any equipment.
Labor: The birth process, beginning with the
contraction of the uterus and dilation of the cervix, Mechanism of injury (MOI): The force or energy
and ending with the stabilization and recovery of that causes a traumatic injury (e.g., a fall, explosion,
the mother. crash or attack).
Laceration: A cut, usually from a sharp object, Meconium aspiration: Aspiration of the first
that can have either jagged or smooth edges. bowel movement of the newborn; can be a
sign of fetal stress and can lead to meconium
Landing zone (LZ): A term from military jargon aspiration syndrome.
used to describe any area where an aircraft, such
as an air medical helicopter, can land safely. Medical control: Direction given to emergency
medical responders (EMRs) by a physician
Legal obligation: Obligation to act in a particular when EMRs are providing care at the scene of
way in accordance with the law. an emergency or are en route to the receiving
Level of consciousness (LOC): A person’s state facility; may be provided either directly via radio
of awareness, ranging from being fully alert to or indirectly by pre-established local medical
unconscious; also referred to as mental status. treatment protocols; also called standing orders.
Licensure: Required acknowledgment that the Medical direction: The monitoring of care
bearer has permission to practice in the licensing provided by out-of-hospital providers to injured or
state; offers the highest level of public protection; ill persons, usually by a medical director.
may be revoked at the state level should the bearer Medical director: A physician who provides
no longer meet the required standards. oversight and assumes responsibility for the
Ligament: A fibrous band that holds bones care of injured or ill persons provided in out-
together at a joint. of-hospital settings.
Litter: A portable stretcher used to carry a patient Medical futility: A situation in which a patient has
over rough terrain. a medical or traumatic condition that is scientifically
accepted to be futile should resuscitation be
Lividity: Purplish color in the lowest-lying parts of attempted and, therefore, the patient should be
a recently dead body, caused by pooling of blood. considered dead on arrival.
Living will: A type of advance directive that Meningitis: An inflammation of the meninges, the
outlines the patient’s wishes about certain kinds of thin, protective coverings over the brain and spinal
medical treatments and procedures that prolong life. cord; caused by virus or bacteria.
Glossary | 719
Mental illness: A range of medical conditions Mucous plug: A collection of mucus that blocks
that affect a person’s mood or ability to think, feel, the opening into the cervix and is expelled, usually
relate to others and function in everyday activities. toward the end of the pregnancy, when the cervix
begins to dilate.
Metabolic shock: A type of shock that is the
result of a loss of body fluid, which can be due to Multidrug-resistant tuberculosis (MDR TB): A
severe diarrhea, vomiting or a heat-related illness. type of tuberculosis (TB) that is resistant to some of
the most effective anti-TB drugs.
Metabolism: The physical and chemical
processes of converting oxygen and food into Multiple birth: Two or more births in the
energy within the body. same pregnancy.
Methicillin-resistant Staphylococcus aureus Multiple- (or mass-) casualty incident
(MRSA): A staph bacterium that can cause (MCI): An incident that generates more patients
infection; difficult to treat because of its resistance than available resources can manage using
to many antibiotics. routine procedures.
Midaxillary line: An imaginary line that passes Muscle: A tissue that contracts and relaxes to
vertically down the body starting at the axilla create movement.
(armpit); used to locate one of the areas for
listening to breath sounds. Musculoskeletal system: A group of tissues and
other structures that supports the body, protects
Midclavicular line: An imaginary line that passes internal organs, allows movement, stores minerals,
through the midpoint of the clavicle (collarbone) on manufactures blood cells and creates heat.
the ventral surface of the body; used to locate one
of the areas for listening to breath sounds. Myocardial infarction (MI): The death of cardiac
muscle tissue due to a sudden deprivation of
Midscapular line: An imaginary line that passes circulating blood; also called a heart attack.
through the midpoint of the scapula (shoulder
blade) on the dorsal surface of the body; Naloxone: A medication used to reverse the
used to locate one of the areas for listening to effects of an opioid overdose.
breath sounds.
Nasal cannula: A device used to administer
Minimum data set: A standardized set of data oxygen through the nostrils to a breathing person.
points about the response and care for patients;
Nasal (nasopharyngeal) airway (NPA): An
this information is included in the prehospital care
airway adjunct inserted through the nostril and into
report (PCR).
the throat to help keep the tongue from obstructing
Minute volume: The amount of air breathed in a the airway; may be used on a conscious or an
minute; calculated by multiplying the volume of air unconscious patient.
inhaled at each breath (in mL) by the number of National Response Framework (NRF): The
breaths per minute. guiding principles that enable all response partners
Miscarriage: A spontaneous end to pregnancy to prepare for and provide a unified national
before the 20th week; usually because of birth response to disasters and emergencies—from
defects in the fetus or placenta; also called a the smallest incident to the largest catastrophe.
spontaneous abortion. The Framework establishes a comprehensive,
national, all-hazards approach to domestic
Moral obligation: Obligation to act in a particular incident response.
way in accordance with what is considered
morally right. Nature of illness: The medical condition or
complaint for which the person needs care
Morals: Principles relating to issues of right and (e.g., shock, difficulty breathing), based on what
wrong and how individual people should behave. the patient or others report as well as clues in
the environment.
Morbidity: Illness; effects of a condition or disease.
Needlestick: A penetrating wound from a needle
Mortality: Death due to a certain condition or other sharp object; may result in exposure to
or disease. pathogens through contact with blood or OPIM.
720 | Emergency Medical Response
Negligence: The failure to provide the level of continually monitoring the patient; performed while
care a person of similar training would provide, awaiting the arrival of more highly trained personnel
thereby causing injury or damage to another. or while transporting the patient.
Nerve agents: Toxic chemical warfare agents that Open fracture: A type of fracture in which there is
interrupt the chemical function of nerves. an open wound in the skin over the fracture.
Nervous system: A group of organs and other Open wound: A wound resulting in a break in the
structures that regulates all body functions. skin’s surface.
Neurogenic shock: A type of distributive shock Opioid narcotics: Drugs often derived from
caused by trauma to the spinal cord or brain, where opium or opium-like compounds; used to reduce
the blood vessel walls abnormally constrict and pain and can alter mood and behavior; also known
dilate, preventing relay of messages and causing as opioids.
blood to pool at the lowest point of the body.
Opportunistic infections: Infections that strike
Next of kin: The closest relatives, as defined people whose immune systems are weakened.
by state law, of a deceased person; usually the
spouse and nearest blood relatives. OPQRST: Mnemonic to help remember the
questions used to gain information about pain; the
Non-rebreather mask: A type of oxygen mask
initials stand for onset, provoke, quality, region/
used to administer high concentrations of oxygen
radiate, severity and time.
to a breathing person.
Non-swimming rescues and assists: Rescues Oral (oropharyngeal) airway (OPA): An airway
and assists that can be performed from a pool adjunct inserted through the mouth and into the
deck, pier or shoreline by reaching, by using an throat to help keep the tongue from obstructing the
extremity or object, by throwing a floating object or airway; used only with unconscious patients.
by standing in the water to provide either of these Organ: A structure of similar tissues acting
assists; performed instead of swimming out to the together to perform specific body functions.
person in distress.
“O-ring” gasket: Plastic, O-shaped ring that
Normal sinus rhythm (NSR): The normal, regular
makes the seal of the pressure regulator on an
rhythm of the heart, set by the SA node in the right
oxygen cylinder tight; can be a built-in or an
atrium of the heart.
attachable piece.
Obstetric pack: A first aid kit containing items
especially helpful in emergency delivery and Other potentially infectious materials
initial care after birth; items can include personal (OPIM): Materials, other than blood, that can
protective equipment, towels, clamps, ties, sterile cause illness; these materials include body fluids
scissors and bulb syringes. such as semen and vaginal secretions.
Obstructive shock: A type of shock caused by Overdose: The use of an excessive amount of a
any obstruction to blood flow, usually within the substance, resulting in adverse reactions ranging
blood vessels, such as a pulmonary embolism. from mania (mental and physical hyperactivity) and
hysteria, to coma and death.
Occlusive dressing: A special type of dressing
that does not allow air or fluid to pass through. Overventilation: Blowing too much air into
the patient, which can enter the stomach,
Occupational Safety and Health causing gastric distention and likely vomiting.
Administration (OSHA): Federal agency Overventilation can also increase the amount
whose role is to promote the safety and health of pressure in the chest, which compresses the
of American workers by setting and enforcing blood vessels returning to the heart, thus limiting
standards; providing training, outreach and effective circulation.
education; establishing partnerships; and
encouraging continual process improvement in Oxygenation: The addition of oxygen to the body;
workplace safety and health. also, the treatment of a patient with oxygen.
Ongoing assessment: The process of repeating Oxygen cylinder: A steel or alloy cylinder that
the primary assessment and physical exam while contains 100 percent oxygen under high pressure.
Glossary | 721
Pacemaker: A device implanted under the skin, Pathogen: A term used to describe a germ; a
sometimes below the right collarbone, to help disease-causing agent (e.g., bacterium or virus).
regulate the heartbeat in someone whose natural
pacemaker (the sinoatrial node) is not functioning Pathophysiology: The study of the abnormal
properly, causing the heart to skip beats or beat changes in mechanical, physical and biochemical
too fast or too slow. functions caused by an injury or illness.
Packaging: The process of getting a patient Patient narrative: A section on the prehospital
ready to be transferred safely from the scene to an care report where the assessment and care
ambulance or a helicopter. provided to the patient are described.
Pack-strap carry: A type of carry in which Patient’s best interest: A fundamental
the patient is supported upright, across the ethical principle that refers to the provision of
responder’s back. competent care, with compassion and respect for
human dignity.
Palpation: Examination performed by feeling part
of the body, especially feeling for a pulse. Pediatric Assessment Triangle: A quick initial
assessment of a child that involves observation of
Pandemic influenza: A respiratory illness caused the child’s appearance, breathing and skin.
by virulent human influenza A virus; spreads easily
and sustainably, and can cause global outbreaks of Penetrating injury: An injury in which a person is
serious illness in humans. struck by or falls onto an object that penetrates or
cuts through the skin, resulting in an open wound
Panic: A symptom of an anxiety disorder, or wounds, the severity of which is determined by
characterized by episodes of intense fear and the path of the object (e.g., a bullet wound).
physical symptoms such as chest pain, heart
palpitations, shortness of breath and dizziness. Percussion: A technique of tapping on the
surface of the body and listening to the resulting
Paradoxical breathing: An abnormal type
sounds, to learn about the condition of the
of breathing that can occur with a chest injury
area beneath.
(e.g., flail chest); one area of the chest moves in
the opposite direction to the rest of the chest. Perfusion: The circulation of blood through the
body or through a particular body part for the
Paramedic: An allied health professional whose
purpose of exchanging oxygen and nutrients with
primary focus is to give advanced emergency
carbon dioxide and other wastes.
medical care for critical and emergent patients who
access the EMS system. Paramedics may also give Peritoneal dialysis: A method of treatment
nonemergency, community-based care based on for kidney failure in which waste products and
state and local community paramedicine or mobile extra fluid are drawn into a solution which has
integrated healthcare programs. been injected into the abdominal cavity and are
Paranoia: A condition characterized by feelings of withdrawn through a catheter.
persecution and exaggerated notions of perceived Peritoneum: The membrane that lines the
threat; may be part of many mental health disorders abdominal cavity and covers most of the
and is rarely seen in isolation. abdominal organs.
Parenchyma: Tissue that is involved in the
Personal protective equipment (PPE): All
functioning of a structure or organ as opposed
specialized clothing, equipment and supplies that
to its supporting structures.
keep the user from directly contacting infected
Partial seizures: Seizures that affect only part of materials; includes gloves, gowns, masks, shields
the brain; may be simple or complex. and protective eyewear.
Partial-thickness burn: A burn injury involving Phobia: A type of anxiety disorder characterized
the epidermis and dermis, characterized by red, by strong, irrational fears of objects or situations
wet skin and blisters; also referred to as a second- that are usually harmless; may trigger an anxiety or
degree burn. panic attack.
Passive immunity: The type of immunity gained Physical counter-pressure maneuver (PCM):
from external sources such as from a mother’s Physical maneuver used to hinder the progression
breast milk to an infant. from presyncope to syncope.
722 | Emergency Medical Response
Physical exam: Exam performed after the primary Pralidoxime chloride (Protopam Chloride;
assessment; used to gather additional information 2-PAM Cl): A drug contained in antidote kits
and identify signs and symptoms of injury and illness. used to counteract the effects of nerve agents;
commonly called 2-PAM chloride.
Physician Orders for Life-Sustaining
Treatment (POLST) form: Medical orders Preeclampsia: A type of toxemia that occurs
concerning end-of-life care to be honored by during pregnancy; a condition characterized by
healthcare workers during a medical crisis. high blood pressure and excess protein in the urine
after the 20th week of pregnancy.
Physiology: How living organisms function (e.g.,
movement and reproduction). Prehospital care: Emergency medical care
provided before a patient arrives at a hospital or
Placenta: An organ attached to the uterus and medical facility.
unborn baby through which nutrients are delivered;
expelled after the baby is delivered. Prehospital care report (PCR): A document
filled out for all emergency calls; used to keep
Placenta previa: Placental implantation that medical personnel informed so they can provide
occurs lower on the uterine wall, touching or appropriate continuity of care; also serves as
covering the cervix; can be dangerous if it is still a record for legal and billing purposes; may be
covering part of the cervix at the time of delivery. written or electronic; if electronic, it is then an
Pleural space: The space between the lungs and E-PCR.
chest wall.
Premature birth: Birth that occurs before the end
Pneumonia: A lung infection caused by a virus of the 37th week of pregnancy.
or bacterium that results in a cough, fever and
Pressure bandage: A bandage applied
difficulty breathing.
snugly to create pressure on a wound, to aid in
Pneumothorax: Collapse of a lung due to controlling bleeding.
pressure on it caused by air in the chest cavity.
Pressure regulator: A device on an oxygen
Poison: Any substance that can cause injury, cylinder that reduces the delivery pressure of the
illness or death when introduced into the body, oxygen to a safe level.
especially by chemical means.
Presyncope: The medical term for “faintness” or
Poison Control Center (PCC): A specialized “feeling faint”; symptoms include light-headedness
health center that provides information on poisons or dizziness, blurry vision and nausea, while signs
and suspected poisoning emergencies. include sweating and pallor.
Position of comfort: The position a patient Primary effects: In referring to explosive and
naturally assumes when feeling ill or in pain; the incendiary devices, the effects of the impact
position depends on the mechanism of injury or of the over-pressurization wave from HE on
nature of illness. body surfaces.
Positive pressure ventilation: An artificial Primary (initial) assessment: A check for
means of forcing air or oxygen into the lungs conditions that are an immediate threat to a
of a person who has stopped breathing or has patient’s life.
inadequate breathing.
Prolapsed cord: A complication of childbirth
Post-ictal phase: The final phase of a generalized in which a loop of the umbilical cord protrudes
seizure, during which the patient becomes through the vagina before delivery of the baby.
extremely fatigued.
Protocols: Standardized procedures to be
Power grip: A hand position for lifting that followed when providing care to injured or
requires the full surface of the palms and fingers to ill persons.
come in contact with the object being lifted.
Psychogenic shock: A type of shock that is due
Power lift: A lift technique that provides a stable to factors such as emotional stress that cause
move for the patient and protects the person lifting blood to pool in the body in areas away from the
from serious injury. brain, which can result in fainting (syncope).
Glossary | 723
Pulmonary embolism: Sudden blockage of an Recovery position: A side-lying posture used
artery in the lung; can be fatal. to help maintain a clear airway in an unresponsive
patient who is uninjured and breathing normally.
Pulse: The beat felt from each rhythmic
contraction of the heart. Refusal of care: The declining of care by a
competent patient; a patient has the right to refuse
Pulse oximetry: A test to measure the the care of anyone who responds to an emergency
percentage of oxygen saturation in the blood using scene, either before or after care is initiated.
a pulse oximeter.
Respiratory arrest: A condition in which there is
Puncture/penetration: A type of wound an absence of normal breathing.
that results when the skin is pierced with a
pointed object. Respiratory distress: A condition in which a
person is having difficulty breathing or requires
Rabies: An infectious viral disease that affects the extra effort to breathe.
nervous system of humans and other mammals;
Respiratory failure: Condition in which the
has a high fatality rate if left untreated.
respiratory system fails in oxygenation and/or
Radiation: One of the ways the body loses heat; carbon dioxide elimination; the respiratory system is
heat radiates out of the body, especially from the beginning to shut down; the person may alternate
head and neck. between being agitated and sleepy.
Radiation burn: A burn caused by exposure to Respiratory rate: The number of breaths per
radiation, either nuclear (e.g., radiation therapy) or minute; normal rates vary by age and other factors.
solar (e.g., radiation from the sun). Respiratory shock: A type of shock caused by
the failure of the lungs to transfer sufficient oxygen
Rales: An abnormal breath sound; a popping,
into the bloodstream; occurs with respiratory
clicking, bubbling or rattling sound, also known
distress or arrest.
as crackles.
Respiratory system: A group of organs and
Rape: Non-consensual sexual intercourse often other structures that brings air into the body
performed using force, threat or violence. and removes wastes through a process called
Rape-trauma syndrome: The three stages a breathing, or respiration.
person typically goes through following a rape: Restraint: A method of limiting a patient’s
acute, outward adjustment and resolution; a movements, usually by physical means such as
common response to rape. a padded cloth strap; may also be achieved by
chemical means, such as medication.
Rapid medical assessment: A term describing a
rapid head-to-toe exam of a medical patient. Resuscitation mask: A pliable, dome-shaped
breathing device that fits over the mouth and nose;
Rapid trauma assessment: A term describing a used to provide artificial ventilations and administer
rapid head-to-toe exam of a trauma patient. supplemental oxygen.
Rappelling: The act of descending (as from a cliff) Retraction: A visible sinking in of soft tissue
by sliding down a rope passed under one thigh, between the ribs of a child or an infant.
across the body and over the opposite shoulder or
through a special friction device. Return of spontaneous circulation (ROSC):
A term to describe the successful resuscitation
Reaching assist: A method of rescuing someone of a patient in cardiac arrest; a return of a pulse
in the water by using an object to extend the during resuscitative efforts.
responder’s reach or by reaching with an arm
or leg. Reye’s syndrome: An illness brought on by
high fever that affects the brain and other internal
Reactivity: The degree to which a substance may organs; can be caused by the use of aspirin in
react when exposed to other substances. children and infants.
Reasonable force: The minimal force necessary Rhonchi: An abnormal breath sound when
to keep a patient from harming themselves breathing that can often be heard without a
or others. stethoscope; a snoring or coarse, dry rale sound.
724 | Emergency Medical Response
Rigid splint: A splint made of rigid material such Secondary assessment: A head-to-toe physical
as wood, aluminum or plastic. exam as well as the focused history; completed
following the primary assessment and management
Risk factors: Conditions or behaviors that of any life-threatening conditions.
increase the chance that a person will develop
a disease. Secondary effects: In referring to explosive and
incendiary devices, the impact of flying debris and
Roller bandage: A bandage made of gauze or bomb fragments against any body part.
gauze-like material that is wrapped around a body
part, over a dressing, using overlapping turns until Seizure: A disorder in the brain’s electrical activity,
the dressing is covered. sometimes marked by loss of consciousness and
often by uncontrollable muscle movement; also
Rollover: A collision in which the vehicle rolls over. called a convulsion.
Rotational impact: A collision in which the Self-mutilation: Self-injury; deliberate harm
impact occurs off center and causes the vehicle to one’s own body used as an unhealthy
to rotate until it either loses speed or strikes coping mechanism to deal with overwhelming
another object. negative emotions.
Rule of Nines: A method for estimating the Self-splint: A splint formed by supporting one
extent of a burn; divides the body into 11 surface part of the body with another; also called an
areas, each of which comprises approximately 9 anatomic splint.
percent of the body, plus the genitals, which are
approximately 1 percent. Sepsis: A life-threatening illness in which the
body is overwhelmed by its response to infection;
“Rule of thumb”: A guideline for positioning commonly referred to as blood poisoning.
oneself far enough away from a scene involving
hazardous material (HAZMAT): one’s thumb, Septic shock: A type of distributive shock that
pointing up at arm’s length, should cover the occurs when an infection has spread to the
hazardous area from one’s view. point that bacteria are releasing toxins into the
bloodstream, causing blood pressure to drop
Run data: A section on the PCR where when the tissues become damaged from the
information about the incident is documented. circulating toxins.
Safety Data Sheet (SDS): A sheet (provided Service animal: A guide dog, signal dog or other
by the manufacturer) that identifies the substance, animal individually trained to provide assistance to
physical properties and any associated hazards a person with a disability.
(e.g., fire, explosion and health hazards) for a given
material, as well as emergency first aid; formerly Sexual assault: Any form of sexualized contact
called a Material Safety Data Sheet (MSDS). with another person without consent and
performed using force, coercion or threat.
SAMPLE history: A way to gather important
information about the patient, using the mnemonic Shaken baby syndrome: A type of abuse in
SAMPLE; the initials stand for signs and which a young child has been shaken harshly,
symptoms, allergies, medications, pertinent medical causing swelling of the brain and brain damage.
history, last oral intake and events leading up to
the incident. Shipping papers: Documents drivers must carry
by law when transporting hazardous materials; list
Schizophrenia: A chronic mental illness in the names, possible associated dangers and four-
which the person hears voices or feels that their digit identification numbers of the substances.
thoughts are being controlled by others; can cause
hallucinations, delusions, disordered thinking, Shock: A life-threatening condition that occurs
movement disorders and social withdrawal. when the circulatory system fails to provide
adequate oxygenated blood to all parts of the
Scope of practice: The range of duties and skills body, resulting in inadequate tissue perfusion; also
that are allowed and expected to be performed referred to as hypoperfusion.
when necessary, according to the professional’s
level of training, while using reasonable care Shoulder drag: A type of emergency move that is
and skill. a variation of the clothes drag.
Glossary | 725
Shunt: A surgically created passage between two Spinal motion restriction (SMR): A collective
natural body channels, such as an artery and a vein, term that includes all methods and techniques
to allow the flow of fluid. used to limit the movement of the spinal column of
a patient with a suspected spinal injury.
Side-impact collision: A collision in which the
impact is at the side of the vehicle; also known as a Splint: A device used to immobilize body parts.
broadside, t-bone or lateral collision.
Sprain: The partial or complete tearing or
Signs: Term used to describe any observable stretching of ligaments and other soft tissue
evidence of injury or illness, such as bleeding or structures at a joint.
unusual skin color.
Squat lift: A lift technique that is useful when
Signs of life: A term sometimes used to one of the lifter’s legs or ankles is weaker than
describe normal breathing and a pulse in an the other.
unresponsive patient.
Stabilization: The final stage of labor in which
Silent heart attack: A heart attack during which
the mother begins to recover and stabilize after
the patient has either no symptoms or very mild
giving birth.
symptoms that the person does not associate with
heart attacks; mild symptoms include indigestion
Staging area: Location established where
or sweating.
resources can be placed while awaiting
Simple access: In an extrication, the process of tactical assignment.
getting to the patient without the use of equipment.
Stair chair: Equipment used for patient transport
Simple partial seizures: Seizures in in a sitting position.
which a specific body part experiences
muscle contractions; does not affect memory Standard of care: The criteria established for the
or awareness. extent and quality of an EMR’s care.
Simple Triage and Rapid Transport (START): Standard precautions: Safety measures,
A method of triage that allows quick assessment including BSI and universal precautions, taken to
and prioritization of injured people. prevent occupational-risk exposure to blood and
OPIM; these precautions assume that all body
Sinoatrial (SA) node: A cluster of cells in the fluids, secretions and excretions (except sweat) are
right atrium that generates the electrical impulses potentially infective.
that set the pace of the heart’s natural rhythm.
Standing orders: Protocols issued by the medical
Smooth muscles: Muscles responsible for director allowing specific skills to be performed
contraction of hollow organs such as blood vessels or specific medications to be administered in
or the gastrointestinal tract. certain situations.
Soft splint: A splint made of soft material such as Status asthmaticus: A potentially fatal episode
towels, pillows, slings, swathes and cravats. of asthma in which the patient does not respond to
usual inhaled medications.
Soft tissues: Body structures that include the
layers of skin, fat and muscles.
Status epilepticus: An epileptic seizure (or
Sphygmomanometer: A device for measuring repeated seizures) that lasts longer than 5 minutes
BP; also called a BP cuff. without any sign of slowing down; should be
considered life threatening and requires prompt
Spinal column: The series of vertebrae extending advanced medical care.
from the base of the skull to the tip of the tailbone
(coccyx); also referred to as the spine. Stethoscope: A device for listening, especially
to the lungs, heart and abdomen; may be used
Spinal cord: A cylindrical structure extending together with a BP cuff to measure BP.
from the base of the skull to the lower back,
consisting mainly of nerve cells and protected by Stillbirth: Fetal death; death of a fetus at 20 or
the spinal column. more weeks of gestation.
726 | Emergency Medical Response
Stimulant: A substance that affects the central Sudden death: An unexpected, natural death;
nervous system and speeds up physical and usually used to describe a death from a sudden
mental activity. cardiac event.
Stoma: A surgical opening in the body; a stoma Sudden infant death syndrome (SIDS): The
may be created in the neck following surgery on sudden death of an infant younger than 1 year that
the trachea to allow the patient to breathe. remains unexplained after the performance of a
complete postmortem investigation, including an
Strain: The excessive stretching and tearing of autopsy, an examination of the scene of death and
muscles or tendons; a pulled or torn muscle. a review of the care history.
Stress: The body’s normal response to any Suicide: An intentional act to end one’s own life,
situation that changes a person’s existing mental, usually as a result of feeling there are no other
physical or emotional balance. options available to resolve one’s problems.
Stretcher: Equipment used for patient transport in Sundowning: A symptom of Alzheimer’s disease
a supine position. in which the person becomes increasingly
restless or confused as late afternoon or
Stridor: An abnormal, high-pitched breath sound evening approaches.
caused by a blockage in the throat or larynx; usually
heard on inhalation. Superficial burn: A burn injury involving only the
top layer of skin, characterized by red, dry skin;
Stroke: A disruption of blood flow to a part of also referred to as a first-degree burn.
the brain which may cause permanent damage
to brain tissue. Supine: The body position of lying flat on the back.
Subconjunctival hemorrhage: Broken blood Supplemental oxygen: Oxygen delivered
vessels in the eyes. to a patient from an oxygen cylinder through a
delivery device; can be given to a nonbreathing or
Subcutaneous emphysema: A rare condition breathing patient who is not receiving adequate
in which air gets into tissues under the skin that oxygen from the environment.
covers the chest wall or neck; may occur as a
result of wounds to those areas. Surrogate decision maker: A third party with
the legal right to make decisions for another person
Substance abuse: The deliberate, persistent, regarding medical and health issues through a
excessive use of a substance without regard to durable power of attorney for healthcare.
health concerns or accepted medical practices.
Swathe: A cloth wrapped around a patient to
Substance misuse: The use of a substance for securely hold the arm against the patient’s chest, to
unintended purposes or for intended purposes but add stability; also called a binder.
in improper amounts or doses.
Symptoms: What the patient reports
Sucking (open) chest wound: A chest wound experiencing, such as pain, nausea, headache or
in which an object, such as a knife or bullet, shortness of breath.
penetrates the chest wall and lung, allowing air to
pass freely in and out of the chest cavity; breathing Syncope: A term used to describe the loss of
causes a sucking sound, hence the term. consciousness; also known as fainting.
Suctioning: The process of removing foreign Synergistic effect: The outcome created when
matter, such as blood, other liquids or food two or more drugs are combined; the effects of
particles, by means of a mechanical or manual each may enhance those of the other.
suctioning device. Systolic blood pressure: The force exerted
Sudden cardiac arrest: A condition where the against the arteries when the heart is contracting.
heart’s pumping action stops abruptly, usually Tendon: A fibrous band that attaches muscle
due to abnormal heart rhythms called arrhythmias, to bone.
most commonly ventricular fibrillation (V-fib) or
ventricular tachycardia (V-tach); unless an effective Tension pneumothorax: A life-threatening injury
heart rhythm is restored, death follows within a in which the lung is completely collapsed and air is
matter of minutes. trapped in the pleural space.
Glossary | 727
Tertiary effects: The results of individuals being Transferring: The responsibility of transporting
thrown by the blast wind caused by explosive and a patient to an ambulance, as well as transferring
incendiary devices; can involve any body part. information about the patient and incident to
advanced medical personnel who take over care.
Tetanus: An acute infectious disease caused by
a bacterium that produces a powerful poison; can Transient ischemic attack (TIA): A condition
occur in puncture wounds, such as human and that produces stroke-like symptoms but causes
animal bites; also called lockjaw. no permanent damage; may be a precursor to
Thoracic: Relating to the thorax, or chest cavity. a stroke.
Thready: Used to describe a pulse that is barely Trauma alert criteria: An assessment system
perceptible, often rapid and feels like a fine thread. used by emergency medical services (EMS)
providers to rapidly identify those patients
Thrombus: A blood clot that forms in a blood determined to have sustained severe injuries that
vessel and remains there, slowing the flow of warrant immediate evacuation for specialized
blood and depriving tissues of normal blood flow medical treatment; based on several factors
and oxygen. including status of airway, breathing and
Throwing assist: A method of rescuing someone circulation, as well as Glasgow Coma Scale
in the water by throwing the person a floating score, certain types of injuries present and the
object, with or without a line attached. patient’s age; separate criteria for pediatric and
adult patients.
Tidal volume: The normal amount of air breathed
at rest. Trauma dressing: A dressing used to cover very
large wounds and multiple wounds in one body
Tissue: A collection of similar cells acting together area; also called a universal dressing.
to perform specific body functions.
Tolerance: A condition in which the effects of Trauma system: A regional or community-
a substance on the body decrease as a result of based system that provides definitive care for
continued use. injured (trauma) patients; provides patients with
a seamless transition from prehospital care to
Tonic phase: The second phase of a generalized acute and post-hospital care, leading to improved
seizure, during which the patient becomes patient outcomes. A comprehensive trauma system
unconscious and muscles become rigid. also participates in community outreach activities,
including injury prevention programs.
Tourniquet: A tight, wide band placed around an
arm or a leg to constrict blood vessels in order to Traumatic asphyxia: Severe lack of oxygen due
stop blood flow to a wound. to trauma, usually caused by a thoracic injury.
Toxemia: An abnormal condition associated with
Traumatic brain injury (TBI): An injury to the
the presence of toxic substances in the blood.
brain resulting from an external force such as a
Toxicity: The degree to which a substance is blow to the head or a penetrating injury to the
poisonous or toxic. brain; TBIs are associated with temporary and/or
permanent impairment to brain function, including
Toxicology: The study of the adverse effects of physical, emotional and cognitive functioning; a
chemical, physical or biological agents on the body. concussion is a common type of TBI.
Toxin: A poisonous substance produced by
Triage: A method of sorting patients into
microorganisms that can cause certain diseases
categories based on the urgency of their need
but is also capable of inducing neutralizing
for care.
antibodies or antitoxins.
Traction splint: A splint with a mechanical device Triage tags: A system of identifying patients
that applies traction to realign the bones. during an MCI; different colored tags signify
different levels of urgency for care.
Transdermal medication patch: A patch on the
skin that delivers medication; commonly contains Triangular bandage: A triangle-shaped bandage
nitroglycerin, nicotine or other medications; should that can be rolled or folded to hold a dressing
be removed prior to placing defibrillation pads on or splint in place; can also be used as a sling to
the chest. support an injured shoulder, arm or hand.
728 | Emergency Medical Response
Trimester: A three-month period; there are three Vehicle stabilization: Steps taken to stabilize a
trimesters in a normal pregnancy. motor vehicle in place so that it cannot move and
cause further harm to patients or responders.
Tripod position: A position of comfort that a
person may assume automatically when breathing Veins: Blood vessels that carry oxygen-poor blood
becomes difficult; in a sitting position, the person from all parts of the body to the heart, except for
leans slightly forward with outstretched arms, and the pulmonary veins, which carry oxygen-rich blood
hands resting on knees or an adjacent surface for to the heart from the lungs.
support to aid breathing.
Ventilation: The exchange of air between the
Tuberculosis (TB): A bacterial infection that
lungs and the atmosphere; allows for an exchange
usually attacks the lungs.
of oxygen and carbon dioxide in the lungs.
Twisting force: A force that causes injury when
one part of the body remains still while the rest of Ventricular fibrillation (V-fib): A life-threatening
the body is twisted or turns away from it. heart rhythm in which the heart is in a state of
totally disorganized electrical activity.
Two-person seat carry: A nonemergency method
of carrying a patient by creating a “seat” with the Ventricular tachycardia (V-tach): A life-
arms of two responders. threatening heart rhythm in which there is very
rapid contraction of the ventricles.
Type 1 diabetes: A type of diabetes in which
the pancreas does not produce insulin; formerly Vial of Life: A community service program that
known as insulin-dependent diabetes or provides emergency medical services (EMS)
juvenile diabetes. personnel and other responders with vital health
and medical information (including any advance
Type 2 diabetes: A type of diabetes in which
directives) when a person who suffers a medical
insufficient insulin is produced or the insulin is
emergency at home is unable to speak; consists
not used efficiently; formerly known as non-
of a label affixed to the outside of the refrigerator
insulin-dependent diabetes or adult-
to alert responders and a labeled vial or container
onset diabetes.
that has pertinent medical information, a list
Umbilical cord: A flexible structure that attaches of medications, health conditions and other
the placenta to the fetus, allowing for the passage pertinent medical information regarding the
of blood, nutrients and waste. occupant(s).
Universal precautions: A set of precautions Virus: A common type of pathogen that depends
designed to prevent transmission of HIV, on other organisms to live and reproduce; can be
hepatitis B virus (HBV) and other bloodborne difficult to kill.
pathogens when providing care; these precautions
consider blood and OPIM of all patients Visual warning devices: Warning lights in
potentially infectious. an emergency vehicle that, used together with
audible warning devices, alert other drivers of the
Uterus: A pear-shaped organ in a woman’s pelvis vehicle’s approach.
in which an embryo forms and develops into a
baby; also called the womb. Vital organs: Those organs whose functions
are essential to life, including the brain, heart
Vacuum splint: A splint that can be molded to
and lungs.
the shape of the injured area by extracting air from
the splint.
Vital signs: Important information about the
Vagina: Tract leading from the uterus to the patient’s condition obtained by checking respiratory
outside of the body; often referred to during labor rate, pulse and blood pressure.
as the birth canal.
Voluntary muscles: Muscles that attach to
Vector-borne transmission: Transmission of a bones; also called skeletal muscles.
pathogen that occurs when an infectious source,
such as an animal or insect bite or sting, penetrates Wading assist: A method of rescuing someone in
the body’s skin. the water by wading out to the person in distress.
Glossary | 729
Walking assist: A method of assisting a patient Wheezing: A high-pitched whistling sound
to walk by supporting one of the patient’s arms heard during inhalation but heard most loudly on
over the responder’s shoulder (or each of the exhalation; an abnormal breath sound that can
patient’s arms over the shoulder of one responder often be heard without a stethoscope.
on each side).
Withdrawal: The condition of mental and physical
discomfort produced when a person stops using or
Walking wounded (Green): A triage category
abusing a substance to which the person is addicted.
of those involved in an MCI who are able to
walk by themselves to a designated area WMD: Weapons of mass destruction.
to await care.
Work practice controls: Control measures that
reduce the likelihood of exposure by changing the
Warm zone: Also called the contamination
way a task is carried out.
reduction zone; the area immediately outside
the hot zone. Wound: An injury to the soft tissues.
730 | Emergency Medical Response
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Photo Credits
Select Photography: Barbara Chapter 21 Opener: Copyright Chapter 30 Opener: Image
Proud and Steven Kovich Marina Bartel/iStockphoto/ Copyright Marlene DeGrood,
Thinkstock 2010. Used under license from
Chapter 2 Opener: Courtesy of Shutterstock.com
Ted Crites Chapter 22 Opener: Courtesy of
the Canadian Red Cross Chapter 32 Opener: Image
Chapter 5 Opener: Courtesy of Copyright prism68, 2010. Used
Terry Georgia Chapter 23 Opener: Courtesy of under license from Shutterstock.
Terry Georgia com
Chapter 8 Opener: ©iStockphoto.
com/Frances Twitty Chapter 26 Opener: Image
Copyright Phase4Photography, Many thanks to the Canadian Red
Chapter 12 Opener: Image 2010. Used under license from Cross; Capt. Jerome Williams,
Copyright mangostock, 2010. Shutterstock.com Battalion Chief Kenny Wolfrey,
Used under license from Capt. William Bailey and the
Shutterstock.com Chapter 28 Opener: Fairfax County, Virginia, Fire and
©iStockphoto.com/Frances Twitty Rescue staff; and Executive
Chapter 14 Opener: Image
Copyright yamix, 2010. Used Chapter 29 Opener: Image Director Jim Judge, Capt. Deanna
under license from Shutterstock. Copyright TFoxFoto, 2010. Used Chapman, Capt. Phil Kleinberg
com under license from Shutterstock. and the Lake-Sumter EMS staff,
com for opening their facilities to us
Chapter 18 Opener: Courtesy of and providing their expertise and
Lake-Sumter Emergency Medical assistance with our photography
Services, Mount Dora, FL, and video shoots.
Captain Phil Kleinberg, EMT-P
734 | Emergency Medical Response
Index
Note: Page numbers with f indicate figure; t, table.
9-1-1, 7 Agonal breaths, 145, 154
Agricultural emergency, 522–526
Abandonment, 45, 55, 56f AIDS, 16, 24
Abdomen, physical assessment of, 184, 185f Air bags, 130–131, 460, 640
Abdominal cavity, 65f, 66, 66f, 485, 486f Air medical transport
Abdominal emergencies, 353 activation guidelines for, 624
Abdominal injuries advantages of, 623–624
assessment of, 493, 493f considerations with, 624
care for, 493–494 definition of, 616
evisceration as, 494–495, 494f disadvantages of, 624
impaled object and, 495 by helicopter, 622, 622f
organs affected by, 492 indications for, 624
signs and symptoms of, 492–493 landing zones for, 624–625, 625f
Abdominal pain, 351–353 patient packaging and preparation, 626
Abdominal thrust, 264, 264f patient transfer in, 625, 625f
Abrasion, 464, 467–468, 468f scene safety and, 626, 626f
Abruptio placentae, 557, 571, 576, 576f when to request, 622–623
Absence seizure, 339, 344 Air splint, 498, 508
Absorbed poison, 365, 369–371, 370f Airway
Access, 636, 642–644 assessment of, 145
Acetaminophen, 302 assessment of child’s, 585
Activated charcoal, 382, 382f of child vs. adult, 581, 581f, 588–589
Acute abdomen, 339, 351, 492 CPR and advanced, 310
Acute coronary syndrome (ACS), 295, 299 definition of, 145
Acute infection, 16, 20 lower, 72, 72f, 228
Acute myocardial ischemia, 295, 299 opening of, 233
Adaptive immunity, 16, 20 adult vs. child, 317–318, 318t, 321t
Addiction, 365, 372 infant, 319, 321t
Adolescents signs of inadequate, 233–234
characteristics of, 582–583, 583f signs of open, 233
substance abuse and misuse and, 379 upper, 71–72, 72f, 228
Adrenal glands, 80, 80f Airway adjunct, 259, 261–262, 261f–263f
Adrenaline, 80 Airway obstruction
Adult, 580, 582 anatomical and mechanical, 263
Adult respiratory distress syndrome (ARDS), causes of, 234
445, 462 in children, 588
Advanced emergency medical technician (AEMT) foreign body (FBAO), 226, 234, 263–266
definition of, 3 shock and, 439
training level of, 9 Skill Sheets, 274–275, 276–277
Advance directives, 33, 45, 50–55 techniques to clear, 234
Advanced medical personnel in unconscious patient, 265, 265f
for burns, 476–477 Airway status, 151–153
documentation for transferring care to, Alcohol abuse and misuse, 43, 376, 379
222–223 Allergies
for seizures, 345–346 common, 400
when to summon, 147–148, 195, 196t to insect stings, 403
AEMT. See Advanced emergency medical in patient history, 179
technician All-hazards approach, 673, 680
Age categories, 581–582 All-terrain vehicle (ATV) crashes, 131, 461
Index | 735
Altered mental status, 339 in CPR, 307–308
care for, 342 definition of, 226, 237
causes of, 341 mask-to-nose, 239
in children, 343, 592–593 mask-to-stoma, 239, 239f
signs and symptoms of, 342 mouth-to-mask, 237–238, 237f
See also Behavior emergencies; Psychological mouth-to-mouth, 238
emergencies vs. normal ventilation, 242
Alzheimer’s Association, 607 overventilation and hyperventilation in,
Alzheimer’s disease, 600, 605–606, 607 226, 241
AMBER alert, 675 during respiratory distress, 242–243
Ambulance. See Emergency vehicle Skill Sheets, 244–251
Amniotic fluid, 557, 558 special considerations in, 238–240
Amniotic sac, 557 in suspected head, neck or spinal injury,
Amphetamine, 375 239–240
Amputation, 464, 468, 468f, 472–473, 472f Artificial-ventilation rates, 156t
Anabolic steroids, 365, 374t, 377–378 Asperger syndrome, 600, 612
Anaphylaxis Aspiration, 226, 242
care for, 401 Aspirin, 302, 359–360, 360f, 592
definition of, 388, 440 Assault, 45, 55
epinephrine for, 401–403, 402f Assessment
in insect sting, 403 airway assessment, 151–153
signs and symptoms of, 400–401, 401t in behavioral emergency, 434
Anatomical terms, 63–66 breathing status, 153–157
Anatomic splint, 498, 508, 508f, 518–519 of children, 583–588
Anatomy, 61, 62 circulatory status, 157–160
Aneurysm, 339, 349, 349f, 603 general impression of patient, 148–149
Angina pectoris, 295, 300 Glasgow Coma Scale in, 170–171
Angulation, 498, 503, 503f of older adults, 603–604, 604f
Animal bites and stings. See Bites and stings ongoing, 194–195
Ankle, splinting of, 512 primary, 145, 319
Ankle drag, 85, 91, 92f, 107 responsiveness, 149–151
Anorexia nervosa, 378 secondary, 173, 179–181
Anterior, 63, 63f Skill Sheets, 162–164, 198, 199
Antibodies, 16, 20 vital signs in, 161
Antidote, 365, 366 Asthma
Antihistamine, 365, 370 assisting patient with, 253–254
Anti-inflammatory drug, 365, 370 in children, 590
Antivenom, 388, 405 definition of, 226
Anxiety disorder, 423, 426 overview of, 230–231, 231f
APGAR score, 161, 557, 566, 566t Skill Sheets, 255–257
Aphasia, 339, 350 Asthma attack, 226, 230
Apnea, 226, 234, 243 Asthma medications, 231, 231f, 253, 254
Apparent life-threatening event (ALTE), 580, Asthma trigger, 226, 230, 231
596–597 Asymptomatic, 673
Applied ethics, 45, 48 Asystole, 295, 312
ARPM mnemonic for triage, 666 Atherosclerosis, 295, 299, 299f
Arrhythmia, 295, 299, 300, 603 Athletic equipment, removal of, 550–552, 552f
Arterial bleeding, 448, 449f Atria, 74, 75f
Arterial gas embolism, 388, 420 Atrial fibrillation, 295, 300
Arteries, 74, 75f, 76, 76f, 445, 446 Atrioventricular (AV) node, 295, 297, 298f
Arthritis, 610–611 Atropine, 673, 683, 689
Artificial ventilation Audible warning devices, 616, 627
adequate rates of, 241 Aura phase, 339, 344
of apneic patient with pulse, 243 Auscultation, 173, 182
with bag-valve-mask resuscitator, 240–241, 240f Autism spectrum disorder (ASD), 600,
for child and adult, 321t 612–613
736 | Emergency Medical Response
Automated external defibrillator (AED) Bipolar disorder, 423, 427
chest hair and, 315 Birth. See Labor and delivery
for child and adult, 149, 319, 320t, 323–324t Birth canal, 557, 558
definition of, 295 Bites and stings
in hypothermia, 314–315 domestic and wild animals, 410
for infant, 322, 322f, 323–324t humans, 410
jewelry and body piercings and, 315 insects, 403–404, 403f
maintenance of, 315–316 marine life, 408, 409t
overview of, 310–312, 312f scorpions, 405–406, 405f
pacemakers and, 313–314 spiders, 404–405, 405f, 406
precautions for, 315 venomous snakes, 406–408, 407f
Skill Sheets, 330–332 Blackout, shallow water, 411
transdermal patches and, 314, 314f Bladder, 82, 82f
in trauma, 315 Blanket drag, 85, 91, 91f, 104–105
using, 312–313, 314 Blast injury, 121, 132–133, 133f, 462
Autonomic nervous system, 78 Blast lung, 673
AVPU mnemonic, 145, 150, 150t, 585–586 Bleeding
Avulsion, 464, 468, 469f bandages for, 450–451, 450f, 452f, 453f
Axial plane, 63 controlling post-birth, 568
definition of, 445, 446
Babesia infection, 404t dressings for, 449, 449f
Back, physical assessment of, 185, 185f external, 451, 453–455
Back blow, 264, 264f controlling with direct pressure, 457
Backboard, 85, 97, 98f, 553–554 controlling with tourniquet with windlass, 458
Bacteria, 16, 19, 19t open head wound, 543–544
Bacterial meningitis, 24–25 gastrointestinal, 353–354
Bag-valve-mask (BVM) resuscitation/resuscitator internal, 455–456
definition of, 226 of nose, 451, 453f, 536, 536f
flow rate and oxygen concentrations, 285t, 287 pregnancy-related vaginal, 570
one-responder, 156, 240–241 standard precautions and, 448
pediatric, 240, 240f types of, 448, 449f
Skill Sheets, 250–251 Blister agents, 682
two-responder, 156, 241 Blocking, 639, 639f
Baldwin, Charles, 29 Blood, components of, 74
Bandage compress, 445, 450 “Blood” agents, 682
Bandages Bloodborne, 16
application of, 450–451, 450f Bloodborne pathogens, 16, 20–23
definition of, 445, 450 Bloodborne Pathogens Standard 29 CFR
types of, 450, 450f 1910.1030, 31, 32
Barotrauma, 388, 420 Blood clotting, 77, 445, 454, 602, 603f
Battery, 45, 55 Blood glucose level (BGL), 80, 339, 346,
“Battle’s sign,” 532, 533f 363, 363f
Behavior, 423, 424 Blood pressure (BP), 77, 173, 188–193
Behavioral emergencies categories for adults, 191t
assessment in, 424–425 in children and infants, 193t
causes of, 425 equipment for measuring, 189–190, 189f,
definition of, 423, 424 190f, 192f
excited delirium syndrome and, 425 measuring of, 190–192, 191f,
scene size-up and personal safety in, 433–434 precautions for taking, 193t
Bereavement care, 600, 613 Skill Sheets, 204–206, 207–208
Binder, 498, 507, 507f, 516–517 Blood vessels
Biohazard, 16 anatomy of, 76, 76f
Biohazard containers, 29, 29f shock and, 439
Biohazard symbol, 29 Blood volume, 439, 445, 448
Biological weapons, 683–684 Bloody show, 557, 560
Bioterrorism, 673, 683 “Blow-by” technique, 288, 288f
Index | 737
Blunt trauma respiratory involvement and, 475–476, 476f
to chest, 486–487 Rule of Nines and, 464, 475, 475f
definition of, 121, 131 severity of, 476–477
B NICE, 673, 681 thermal, 477–478, 479f
Body cavities, 64, 65f, 66 Burn unit, 477
Body language, 219 Bystanders
Body mechanics, 85, 87 interviewing of, 218
Body positions, 64, 65f role of, 148
Body substance isolation (BSI) precautions, 16, safety of, 126, 127
26, 27
Body system(s) Caffeine, 375
circulatory system, 61, 66, 67t, 68, 74–77, 75f, CAMEO®, 648
157–160, 228 Cancer, 611
definition of, 61 Cannabis products, 365, 374t, 377, 379
digestive system, 61, 66f, 67t, 80–81, 81f Capillaries, 76, 76f, 445, 446
endocrine system, 61, 67t, 79–80, 80f Capillary bleeding, 448, 449f
integumentary system, 61, 67t, 78–79, 79f Capillary refill, 145, 160, 160f
musculoskeletal system, 61, 67t, 68–70, 71f Carbon monoxide (CO), 365, 369, 383–384
nervous system, 61, 67t, 77–78, 77f Car crash. See Vehicle crashes
overview of, 66, 67t, 68 Car crashes. See Vehicle crashes
reproductive system, 82, 83f Cardiac arrest, 295, 302
urinary system, 82, 82f Cardiac Chain of Survival, 295, 303–304
Body temperature, 390–391, 390f Cardiac emergencies
Bones, 68, 498, 499. See also Muscles, bones in children, 590–591
and joints injuries providing care for, 301–302, 302f
Brachial artery, 145, 158 signs and symptoms of, 300–301
Brachial pulse, 158f, 159 Cardiac muscle, 68, 498
Brain, 78, 78f Cardiogenic shock, 438, 440
Brain damage, 157f Cardiopulmonary resuscitation (CPR)
Brain injury, 535, 535f advanced airways and, 310
Braxton Hicks contractions, 557, 561–562 chest compressions in, 295, 304–307,
Breathing, 72, 74. See also Respiration; 304f–307f
Respiratory rate for children, 317–318, 320t, 321t, 323–324t
Breathing device, 259, 261 compression and breathing cycles in,
Breathing emergency. See Respiratory (breathing) 308, 309f
emergencies definition of, 295
Breathing rate, 145, 154, 154t in drowning, 310
Breath sounds, 187, 236, 252 hands-only, 307
Breech birth, 557, 572, 573f high-performance, 295, 316
Bronchi, 228 for infants, 319, 321–322, 321t
Bronchioles, 228 one-responder adult, 308, 308t
Bruise, 466, 466f overview of, 304–310
Buildings, unsafe, 140 Skill Sheets, 326–328, 329–332
Bulb syringe, 557, 564, 567, 567f stopping of, 310
Bulimia, 378 teamwork in, 316–317
Burns two-responder adult, 309–310, 309t
area of body and seriousness of, 476 ventilations in, 307–308
causes of, 476 Cardiovascular disease, 295, 299
chemical, 464, 480, 480f Carotid artery, 145, 158
children and, 478 Carotid artery injury, 539, 540f
classification of, 473–475 Carotid pulse, 158f, 159
definition of, 464, 466 Carrying, 90
electrical, 464, 480–481, 481f Catastrophic reaction, 600, 606
hypothermia and, 478 Cave-ins, 701
overview of, 473 CBRNE, 673, 681
radiation, 464, 481–482, 481f Cell phones. See Mobile phones
738 | Emergency Medical Response
Cells, 61, 66 APGAR score, 161
Cellular respiration, 74 assessment of, 583–588
Centers for Disease Control and Prevention automated external defibrillator (AED) and, 149
(CDC), 25 bag-valve-mask resuscitators for, 240, 240f
Central nervous system, 77–78, 77f blood pressure (BP) in, 192, 193t
Cerebral palsy, 611 breathing rate in, 154, 154t
Cerebrospinal fluid, 530, 532 burn assessment in, 475, 475f
Certification burns in, 478
achievement and maintenance of, 10, 13 capillary refill in, 160
definition of, 3 Cardiac Chain of Survival and, 303
levels of, 8–9 cardiac failure in, 590–591
Cervical collar, 414, 530, 535, 551, 551f checking responsiveness of, 150
Cervix, 557, 559, 559f choking in, 266, 590
Cesarean section, 557, 573 consent and, 49
Charcoal, activated, 382, 382f CPR for, 317–318, 320t, 321t, 323–324t
Chemical burn, 464, 480, 480f croup in, 580, 589–590
Chemical poisoning, 370–371, 371f definition of, 580, 582
Chemicals development of, 582–583, 583f
in farming, 526 epiglottitis in, 580, 590, 590f
flushing from eye, 537, 537f febrile seizures in, 344–345
in industry, 527–528 fever in, 592
See also Hazardous materials (HAZMATs) Glasgow Coma Scale for, 171
Chemical Transportation Emergency Center head-tilt/chin-lift maneuver in infant, 152, 152f
(CHEMTREC), 648 heart problems in, 299
Chemical weapons, 681–682 history taking and, 175
Chest ingested poisons and, 367, 367f
anatomy of, 64, 65f, 485, 485f oral (oropharyngeal) airway (OPA) in, 262, 263f
flail, 484, 488–489, 489f oxygen supplementation for, 288, 288f
physical assessment of, 184, 185f physical examination of, 180
Chest compression fraction (CCF), 316 poisoning in, 592
Chest compressions pulse oximetry in, 210
for child and adult, 318, 320t, 323t pulse rates in, 158, 188
definition of, 295 respiratory emergencies in, 233, 585, 588–590,
for infant, 319, 321, 323t 590f
overview of, 304–307, 304f–307f respiratory rates in, 186
Chest injuries respiratory system in, 72, 73
care for, 491–492 resuscitation masks for, 238, 238f
causes of, 485, 487f seizures in, 591
open and closed, 485 shock in, 441, 592
paradoxical breathing and, 236 Skill Sheets, 276–277, 329–332
shock and, 439 with special healthcare or functional
signs and symptoms of, 491 needs, 597
types of, 486–490 substance abuse and misuse in, 379
Chest thrust, 264f, 265 suctioning airway of, 261
Chest tube, 484, 489 trauma in, 593
Chief complaint, 173, 176, 176f triage for, 667, 668, 669f
Child abuse, 423, 431, 478, 580, 594–595, 595f vital signs of, 194t
Childbirth. See Labor and delivery See also Adolescents; Infants; Newborn
Child neglect, 423, 431, 580, 594 Chocking, 121, 130, 641, 641f
Child(ren) Choking
abdominal pain in, 353 in children, 266, 590
AED for, 149, 319, 320t universal sign of, 263, 263f
air bags and, 460 See also Airway obstruction
airway obstruction in, 588 Cholesterol, 295, 299, 336
airway of, 581, 581f, 588–589 Chronic diseases, 600, 610
altered mental status in, 343, 592–593 Chronic infection, 16, 20
Index | 739
Chronic obstructive pulmonary disease (COPD), Compressions-to-ventilations ratio, 318, 320t, 323t
226, 230 Concussion, 530, 532–533, 534t
Cincinnati Prehospital Stroke Scale, 350 Conduction, 388, 391
Circulatory system Confidentiality, 45, 56–57, 222
anatomy of, 74, 75f, 76, 76f, 297, 297f Confined space, 695, 700–701, 700f
assessment of child’s, 585 Congestive heart failure, 295, 300
definition of, 61 Consent, 45, 48–49
pathophysiology of, 299–300 Continuing education (CE), 11, 48
physiology of, 297–298, 298f Continuity of care, 9
in respiration, 228 Continuous quality improvement (CQI), 13
status of, 157–160 Contraction, 557, 560
structures and function of, 66, 67t, 68 Contusion, 445, 460, 466, 466f
Circumferential burns, 476 Convection, 388, 391
Circumferential splint, 498, 508 Core temperature, 388, 390
Clinical depression, 423, 426 Coronal plane, 63
Clonic phase, 339, 344 Coronary heart disease (CHD), 295, 299, 336
Closed fracture, 498, 501, 502f Counseling, for personal stress, 36
Closed-loop communication, 212, 216 CPR breathing barrier, 26, 125, 145, 155, 261
Closed wounds, 464, 466–467, 466f Crackles, 187, 226, 236
Clothes drag, 85, 91, 91f, 103 Cranial cavity, 64, 65f
Clotting, 77, 445, 454, 602, 603f Cravat, 498, 507
Club drugs, 375–376 Credentialing, 13
Cocaine, 375 Crepitus, 498, 504
CO detector, 383, 383f Crew resource management, in CPR, 317, 317f
Cognitive impairment, 600, 603 Cribbing, 636, 641–642, 642f
Cold pack, 467, 467f, 505 Cricoid, 226, 228
Cold-related emergencies Crime scene, 58–59, 135–136, 701–702
contributing factors in, 396 Critical burn, 464, 476–477
frostbite as, 388, 398–399, 399f Critical incident stress, 16, 35
hypothermia as, 389, 396–398, 398f Cross-finger technique, 152f
people at risk for, 391 Croup, 580, 589–590
prevention of, 400 Crowd, hostile, 142
Cold zone, 647, 653, 653f Crowd control, 124
Collarbone, splinting of, 509 Crowning, 557, 561, 561f
Commotio cordis, 295, 299 Crush injury, 464, 468–469, 469f
Communication Cyanide poisoning, 383, 384–386, 682
interpersonal, 217–219, 217f, 218f Cyanosis, 226, 232, 236, 237f
in multiple- (or mass-) casualty incident, 671 Cyanotic skin color, 145, 155
Communications center (dispatch), 212, 214–215, Cystic fibrosis (CF), 611–612
215f
Communications system DCAP-BTLS mnemonic, 173, 182
communication with dispatch in, 214–215, 215f Deadspace, 226, 237
communication with medical control in, 215–216 Deafness, 600, 602, 609
communication with medical personnel in, Death
216, 216f determination of, 33
communication with receiving facility in, 216 obvious cases of, 58
components of, 213 sudden, 33
mobile phones in, 217 Death and dying
radio communication in, 213–214 decision to resuscitate in, 33
Compartment syndrome, 464, 469 individual responses to, 33–34
Competence, 45, 47 stress of dealing with, 32
Complaint Deceased/non-salvageable/expectant (Black),
chief, 173, 176, 176f 658, 666
general medical, 341 Decision-making models, 48
Complex access, 636, 642, 643f Decompression sickness, 388, 420
Complex partial seizure, 339, 344 Deep, 64
740 | Emergency Medical Response
Defibrillation, 295, 311 Documentation
Deformity (angulation), 498, 503, 503f of child abuse and neglect, 595
Dehydration, 388, 392–393 of drug administration, 359
Delayed care (yellow), 658, 666 importance of, 219
Dementia, 600, 605 through prehospital care report (PCR), 212, 219,
Department of Transportation, U.S. (DOT) 220f, 221–222, 221f
Emergency Response Guidebook, 647, in transfer of care, 222–223
648, 649f Domestic violence, 136
National Standards Curricula (NSC), 6 Do no harm, 45, 48
Dependency, 365, 372 Do not resuscitate (DNR) order, 33, 45, 50, 52f,
Depressants, 365, 373t, 375–376, 379 53–55
Depression, clinical, 423, 426 DOTS mnemonic, 173, 181
Dermis, 464, 465 Down syndrome, 609
Designer drugs, 365, 374t, 377 Draw sheet, 85, 94, 95, 95f
Detailed physical exam, 173, 179, 182–186 Dressings
Dextroamphetamine, 375 application of, 449, 449f
Diabetes mellitus, 300, 339, 346 definition of, 445, 449
Diabetic coma, 339, 346–347 hemostatic, 445, 454–455, 455f
Diabetic emergency, 339, 346–348 types of, 449, 449f
Diabetic ketoacidosis (DKA), 339, 346 Driver’s license, as documentation of organ donor,
Diastolic blood pressure, 173, 190 58, 58f
Digestive system Droplet transmission, 16, 22, 22f
definition of, 61 Dropping, 557, 560
effects of aging on, 603 Drowning, 388, 410–411, 695, 696
organs of, 66f Drowning victim—active, 695, 696, 697t
overview of, 80–81, 81f Drowning victim—passive, 695, 696, 697f, 697t
structures and function of, 67t Drug, 365, 371. See also Medications
Dilation, 438, 440, 557, 560, 561f Drug abuse. See Substance abuse and misuse
Direct carry, 85, 94, 95, 95f Dry powder inhaler, 253
Direct contact, 16, 20, 21, 22f DuoDote™, 673, 690
Direct force, 498, 500, 501f Durable power of attorney for healthcare,
Direct ground lift, 85, 94, 94f, 115–116 45, 55
Directions and locations, body, 63–64, 63f Duty to act, 45, 46
Direct medical control, 3, 12, 13f
Direct pressure, 445, 449, 451, 457 Eclampsia, 557, 570
Disabilities, 610 Ecstasy, 375, 377
Disaster Medical Assistance Teams (DMATs), 674 Ectopic pregnancy, 557, 569–570
Disasters Edema, 600
biological, 679, 679f Ehrlichiosis, 404t
evacuations in, 680 Elastic bandage, 445, 450, 450f, 451, 453f
human-caused, 679, 679f Elbow, splinting of, 509, 510f
natural, 678, 678f Elder abuse, 423, 432, 606, 608
personal preparedness in, 693 Elderly. See Older adults
preparing for, 674 Elder neglect, 423, 432, 432f
role of EMR in, 677, 677f Electrical burn, 464, 480–481, 481f
search and rescue in, 687 Electrical lines, downed, 140, 629–630, 630f
warning systems in, 675 Electric vehicles, 639–640
Disease. See Infectious disease Electrocardiogram (ECG/EKG), 295, 298
Disease-causing agent, 16 Electrolytes, 388, 393
Dislocation, 498, 502, 502f Elevation, 505
Dispatcher, 121, 122, 214–215, 215f, 618 Emancipated minor, 49
Dispatch information, 122 Embolism, 339, 349
Disposable latex-free gloves, 18f, 26, 38–39, 125 Embryo, 557, 559
Distal, 63f, 64 Emergency Alert System (EAS), 675
Distressed swimmer, 695, 696, 696f, 697t Emergency medical dispatcher (EMD), 214–215,
Distributive shock, 438, 440 215f, 616, 618, 618f
Index | 741
Emergency medical responder (EMR) jump kit as, 616, 617, 632–633, 632f
characteristics and behavior of, 11, 12f for measuring blood pressure, 189–190, 189f,
definition of, 3 190f, 192f
health of, 40–43 for moving patients, 95–97
knowing physical limitations of, 86 preparing, for next response, 621, 621f
nontraditional, 617 for suctioning, 259–260, 260f
pediatric emergencies and emotional needs for WMD incident, 687
of, 597 Escherichia coli (E. coli), 21, 368
people in other occupations serving as, 9 Ethical responsibilities, 47–48
responsibilities of, 9–10, 10f Ethics, 45, 48
traditional, 617 Evacuations, 680
training level of, 8 Evaporation, 388, 391
and working with other responders, 9 Evisceration, 484, 494–495, 494f
Emergency Medical Services Act, 5 Excited delirium syndrome, 425
Emergency medical services (EMS) system Exercise-associated muscle cramps, 388, 393
components of, 6 Exertional heat exhaustion (EHE), 388, 393–395,
definition of, 3 394f
education agenda for, 6, 8 Exertional heat stroke (EHS), 388, 395
history and origins of, 4–5 Explosives, 685–686
phases of response in, 617–621 Exposure, 16
regulatory oversight of, 5 Exposure control plan, 16, 25–26
types of, 5 Exposure incident, 30–31
Emergency medical technician (EMT), 3, 8–9 Expressed consent, 45, 49
Emergency moves, 90–92. See also Patient moves Extension, 64, 64f
Emergency Response Guidebook, 647, 648, 649f External, 64
Emergency support functions (ESFs), 676–677 External bleeding, 445. See under Bleeding
Emergency vehicle Extremity(ies)
driving will fatigued, 629 definition of, 498
high-risk driving situations, 628–629 lower, 70
positioning of, 123, 639, 639f physical assessment of, 185
safety of patient in, 630–631, 631f splinting of lower, 510–511, 511f
securing equipment in, 631 splinting of upper, 508–510, 509f, 510f
use of lights and sirens, 627–628 upper, 69
Emetics, 374t, 378 Extremity lift, 85, 94, 95f, 117–118
Empathy, 217 Extrication
Emphysema, 226, 232–233 additional resources in, 637
EMR. See Emergency medical responder (EMR) care of patient after, 644–645
EMS Agenda for the Future (Agenda), 8 definition of, 636, 637
EMS Education Agenda for the Future: A Systems of patient, 644
Approach (Education Agenda), 8 patient safety in, 638
EMS system. See Emergency medical services role of EMR in, 637, 644
(EMS) system tools for, 642–644, 643f
EMT. See Emergency medical technician (EMT) Eye injuries
Endocrine system, 61, 67t, 79–80, 80f assessment, 536
Engineering controls, 16, 29 chemical exposure, 537, 537f
Ephedra, 375 foreign bodies, 537
Epidemiology, 580 impaled object, 537, 538f
Epidermis, 464, 465, 465f Skill Sheets, 546, 546
Epiglottis, 228 Eye protection, 26, 125
Epiglottitis, 580, 590, 590f
Epilepsy, 339, 345 Fainting (syncope), 339, 342–343
Epinephrine, 401–403, 402f, 415–417 Falls
Equipment as cause of traumatic brain injury, 530–531,
for assessing and caring for children, 585 531f
cleaning and disinfecting of, 29–30, 30f overview of, 132, 461, 462f
for extrication, 642–644, 643f Family, emotional support for, 34
742 | Emergency Medical Response
FAST, 339, 350 Glasgow Coma Scale (GCS), 145, 170–171, 350
Febrile seizures, 339, 344–345, 580, 591 Glucometer, 339, 347, 363, 363f
Federal Communications Commission (FCC), rules Glucose, 339, 347
for radio communication, 213–214 Glucose, oral, 361–362, 362f
Federal Emergency Management Agency (FEMA), Glucose tablets, 348, 348f
141, 674 Goggles, 26
Fees, certification and licensure, 11 Golden Hour, 445, 446
Femur, splinting of, 511, 512f Gonads, 80, 80f
Fetal monitoring, 557, 571 Good Samaritan laws, 45, 47
Fetus, 557, 560 Gown, disposable, 28, 125
Fever, 580, 592 Grand mal seizure, 339, 343–344
Fibula, splinting of, 512, 512f Grief, stages of, 33–34
“Fight-or-flight” response, 78
Fingers, splinting of, 510, 510f Hallucination, 423
Finger sweep, 226, 234, 259, 265 Hallucinogens, 365, 373t, 375
Firefighters, 4–5, 139, 702 Hand hygiene, 28, 28f
Firefighter’s carry, 85, 92, 92f, 109–110 Hands, splinting of, 510
Firefighter’s drag, 85, 91–92, 92f, 108 Hand sanitizer, 28
Fireground operations, 702–703 Hand washing, 28, 28f, 125, 126
Fires, 139–140 Hand-washing station, 28
Fixed-flow-rate oxygen, 283–284, 283f, 288 Hard of hearing, 600, 602, 609
Flail chest, 484, 488–489, 489f Hazardous materials (HAZMATs)
Flammability, 647, 648 definition and types of, 121, 640, 647–648
Flexion, 64, 64f identification of, 135, 648–649, 651
Flowmeter, 282, 285 universal symbols for, 650f
Flu pandemic, 17, 679, 692 See also Chemicals
Focused trauma assessment, 173, 180 Hazardous materials (HAZMAT) incident
Foodborne illness, 368, 369 appropriate behavior in, 135, 136t
Foot, splinting of, 512, 513f contamination and routes of exposure in, 654
Forearm, splinting of, 509–510, 510f decontamination in, 654–655, 655f
Foreign body airway obstruction (FBAO), 226, definition of, 640, 647, 649
234, 263–266 establishing command post and staging area for,
Fowler’s position, 64, 65f, 605, 605f 655
Fractures information transferred to new command officer,
closed, 498, 501, 502f 649
definition of, 498 overview of, 640–641, 640f
open, 498, 501, 502f positioning of emergency vehicle at, 123
rib, 487–488, 488f preparation for, 649
skull, 532, 533f providing care in, 655–656
Free diving, 388, 420, 421 recognition, identification and determination in,
Frontal plane, 63 654
Frostbite, 388, 398–399, 399f recognition of, 650–651, 650f
Full-face shield, 26 safety zones in, 653–654, 653f
Full-thickness burn, 464, 474–475, 474f, 477 scene and personal safety in, 652–654, 652f
Fungi, conditions cause by, 19t Hazardous terrain, rescues in, 699–700, 699f
Head
Gastrointestinal bleeding, 353–354 anatomy of, 531, 531f
Gastrointestinal system. See Digestive system physical assessment of, 183, 183f
Generalized tonic-clonic seizures, 339, 343–344 Head, neck and spinal injuries
General medical complaint, 341 artificial ventilation in patients with suspected,
Genitalia 239–240
anatomy of, 485, 486f manual stabilization in, 530, 535,
injuries of, 495–496 535f, 547
Genitourinary system, 61, 66f, 67t, 82 prevention of, 541–542
Gestational diabetes, 346339 Skill Sheets, 547–549
Glands, 79–80, 80f See also Neck and spine injuries
Index | 743
Head injuries Hemostatic dressing, 445, 454–455, 455f
care for brain injury and, 535, 535f Hemothorax, 484, 489–490, 490f
concussion as, 530, 532–533, 534t Hepatitis, 16
of eye, 536–537, 538f Hepatitis A (HAV), 23
of mouth, 538–539, 539f Hepatitis B (HBV)
nosebleeds, 451, 453f, 536, 536f risk of transmission of, 22–23
open and closed, 531–532 spread of, 20–21, 21t
penetrating wounds, 533–534 symptoms, medications, vaccine and, 23, 23f
scalp, 534, 534f Hepatitis C (HCV)
signs and symptoms of brain injury and, 535 risk of transmission of, 22–23
Skill Sheets, 543–546 spread of, 20–21, 21t
skull fracture as, 532, 533f symptoms of, 23
Head-on collision, 128, 129f, 445, 459 Hepatitis D (HDV), 23
Head-tilt/chin-lift maneuver, 145, 152, 152f Hepatitis E (HEV), 24
in adult vs. child, 317–318, 318t, 321t High-efficiency particulate air (HEPA) mask, 28
in infant, 319, 321t High-order explosives (HE), 673, 685–686
Health assessment, of EMR, 43 High-performance CPR, 295, 316
Healthcare Infection Control Practices Advisory Hip, splinting of, 511
Committee (HICPAC), 27 HIPAA. See Health Insurance Portability and
Healthcare proxy, 45, 55 Accountability Act (HIPAA)
Health information Hip bones, 69, 69f
permitted disclosure of, 57 Hip joint, 511f
protected, 56, 57 Hippocratic oath, 48
Health Insurance Portability and Accountability Act History. See Patient history
(HIPAA), 56–57, 222 HIV
Health Resources and Services Administration definition of, 16
(HRSA), EMS Agenda for the Future, 8 risk of transmission of, 22–23
Heart spread of, 20–21, 21t
anatomy of, 74, 75f, 297, 297f symptoms of, 24
definition of, 295 Homeostasis, 16, 20
muscles of, 68, 498 Hospice care, 600, 613
of older adult, 602–603, 603f Hospital
shock and, 439 arrival at, 620, 621f
Heart attack, 299, 300 communication with, 216
providing care for, 301–302, 302f Hostage situation, 143
signs and symptoms of, 300–301 Hostile patients and crowds, 141–142, 142f
women and, 300 Hot zone, 647, 653, 653f
Heat index, 388, 392 Humidity, 392, 392f
Heat-related illnesses Hybrid vehicles, 639–640
dehydration as, 392–393 Hyoid bone, 228
exercise-associated muscle cramps as, 393 Hyperglycemia, 339, 346–347, 347f
exertional heat exhaustion as, 393–395, 394f Hyperkalemia, 339, 354
heat stroke as, 395–396 Hyperresonance, 484, 490
humidity and, 392, 392f Hypertension, 295, 300
people at risk for, 391 Hyperthermia, 388, 391
prevention of, 400 Hyperventilation
risk factors for, 391–392 definition of, 226
Heat stroke, 388, 395–396 overview of, 232
Helicopter emergency medical system (HEMS), 624 in resuscitation, 241
Helmet removal, 541, 548–550, 549f, 550f by swimmers, voluntary, 411
HELPERR mnemonic, 577–578 Hypervolemia, 339, 354
Hematoma, 121, 131, 131f Hypodermis, 464, 465
Hemodialysis, 339, 354 Hypoglycemia, 339, 347, 347f
Hemopneumothorax, 484, 489 Hypoglycemic shock, 438, 440
Hemorrhage, 445, 446, 571 Hypoperfusion, 438
Hemorrhagic shock, 557, 571 Hypotension, 484, 490
744 | Emergency Medical Response
Hypothalamus, 79, 80f, 388, 390 preventing transmission of, 25–32, 41
Hypothermia, 389, 396–398, 398f, 478 spread of, 19, 20–23
Hypovolemia, 339, 354 Inferior, 63, 63f
Hypovolemic shock, 438, 439 Influenza pandemic, 17, 679, 692
Hypoxemia, 339, 343 Ingested poison, 365, 367–369
Hypoxia, 226, 229, 282 In good faith, 45, 48
Hypoxic, 145, 155 Inhalants, 365, 374t, 377
Inhaled poison, 365, 369
ICE (in case of emergency), 58 Inhalers, 253, 254, 255–257
Ice rescue, 140, 699, 699f Injected poison, 365, 371. See also Bites and
Immediate care (red), 658, 665–666 stings
Immobilize/immobilization, 498, 504, 505, Injury prevention, for EMR, 41
548–549 Innate immunity, 16, 20
Immune system, 16, 19, 20 Insect sting, 403–404, 403f
Immunity Insulin, 340, 347, 348f
adaptive, 16, 20 Integumentary system, 61, 67t, 78–79, 79f
innate, 16, 20 Intellectual disabilities, 609
passive, 17, 20 Intercostal space, 484, 490
Immunizations, 26 Internal, 64
Impaled object Internal bleeding, 445, 455–456
in abdomen, 495 Internal respiration, 74
in chest, 492 Interpersonal communication, 217–219, 217f, 218f
definition and overview of, 471–472, 471f, Involuntary muscle, 68
472f, 484 Islets of Langerhans, 80
in eye, 537, 538f
Skill Sheet, 546 Jaw-thrust (without head extension) maneuver, 145,
in skull, 533–534 153, 153f, 165
See also Puncture/penetration Jellyfish, 408, 409t
Implantable cardioverter-defibrillator (ICD), 295, Joints, 68, 70, 70f, 71f, 498, 499–500. See also
313–314, 314f Muscles, bones and joints injuries
Implantation, 557, 559 Jugular vein
Implied consent, 45, 49 distension of (JVD), 184, 184f, 484, 490
Incapacitating agents, 683 injury of, 539, 540f
Incendiary weapons, 673, 681, 685–686 Jump kit, 616, 617, 632–633, 632f
Incident commander, 658, 659, 660f JumpSTART triage, 667, 668, 669f
Incident command system (ICS), 658, 659–660
Incident stress management, 35–36 Kendrick Extrication Device (KED), 97, 98f
Indirect contact, 16, 20, 22, 22f Kidneys, 82, 82f
Indirect force, 498, 500, 501f Kinematics of trauma, 121, 127, 128f, 459–462
Indirect medical control, 3, 12 Knee, splinting of, 512
Industrial emergencies, 522, 526–528
Infants Labor, 557, 560
AED for, 322, 322f, 323–324t Labor and delivery
apparent life-threatening event in, 580, 596–597 assessment of labor, 561–562, 562f
CPR for, 319, 321–322, 321t, 324t assisting in delivery, 564–565, 564f, 565f
definition of, 580, 582 caring for mother in case of stillbirth, 569
development of, 582 complications during, 571–574, 576–578
recovery position for, 99, 100f controlling bleeding after, 568
Skill Sheet, 333–335 delivery of placenta after, 568
sudden infant death syndrome in, 580, 595–596 helping mother with, 563–564, 564f
See also Children preparation for, 563
Infection, 16 stages of, 560–562, 561f
Infectious disease See also Newborn
conditions for spread of, 20, 21f Laceration, 464, 469, 470f, 471, 539, 540f
definition of, 16 Landing zone (LZ), 616, 624–625, 625f
pathogens and, 19, 19t Laryngopharynx, 228
Index | 745
Lateral, 63 three forces in, 500, 501f
Lateral plane, 63 in vehicle crash, 630
Lateral recumbent position, right and left, in vehicle crashes, 127–131
64, 65f Meconium aspiration, 557, 571, 574
Latex-free gloves. See Disposable latex-free Medial, 63
gloves Medical control
Laxatives, 374t, 378 communication with, 215–216
Left, 64 definition of, 212
Legal obligation, 45, 47 direct and indirect, 12, 13f
Level of consciousness (LOC) Medical direction
assessment of, 149–151 definition of, 3, 13
assessment of child’s, 585–586 in drug administration, 359, 359f
AVPU mnemonic for checking, 150, 150t Medical director, 3, 12
correct approach to patient when checking, Medical futility, 45, 50
149, 149f Medical identification tag, 57–58, 57f, 175, 182,
definition of, 145 183f
using painful stimuli to check, 150, 151f Medical personnel, communication with,
Licensure 216, 216f
definition of, 3, 13 Medical terms, 62, 62t
levels of, 8–9 Medications
Ligaments, 68, 498, 499, 500 abused and misused over-the-counter, 374t,
Lightning, 418–419, 419f, 481 378, 378f
Litter, 695, 699 administration of, 357–359
Lividity, 16, 33 administration of, vs. assistance with,
Living will, 45, 50 358, 358f
Local credentialing, 3, 13 common forms of, 356
Locations, body, 63–64, 63f naming of new, 356
Log roll, 85, 88, 89f, 90, 100, 100f in patient history, 179
Los Angeles Prehospital Stroke Screen (LAPSS), prescribing information for, 357
350, 351 profile of, 356
Low-order explosives (LE), 673, 686 routes of administration for, 357
Lund-Browder diagram, 475, 475f See also Aspirin; Nitroglycerin; Oral glucose
Lung sounds, 187 Meningitis, 16, 24–25
Lyme disease, 404f, 404t Menstrual cycle, 82
Lysergic acid diethylamide (LSD), 375 Mental health, of EMR, 41, 42f
Mental illness, 425, 600, 608–609. See also
“Ma huang,” 375 Behavior emergencies; Psychological
Malpractice, 45, 46 emergencies
Mandated reporting, 58, 59, 223 Mental incompetence, consent and, 49
Mania, 423, 427 Mercury, 368
Manometer, 189–190, 190f Metabolic shock, 438, 440
Manual stabilization, 530, 535, 535f, 547 Metabolism, 389, 390
Marijuana, 374t, 377 Metered-dose inhaler, 253
Marine life stings, 408, 409t Methamphetamine, 375
Mask, 28, 125 Methicillin-resistance Staphylococcus aureus
Mask-to-nose ventilation, 239 (MRSA), 16, 25
Mass casualties. See Multiple- (or mass-) casualty Methylenedioxymethamphetamine (MDMA),
incident (MCI) 374t, 377
Mechanism of injury (MOI) METTAG™, 664, 664f
in blast injuries, 132–133 Midaxillary line, 226, 252
in blunt injuries, 131–132 Midclavicular line, 226, 252
definition of, 121, 127 Midscapular line, 226, 252
in falls, 132 Minimum data set, 212, 221–222
to neck and spine, 539 Minute volume, 145, 237
overview of, 147, 147f, 176–177 Miscarriage, 557, 569
in penetrating injuries, 132 Mobile data terminal, 213, 214f
746 | Emergency Medical Response
Mobile phones National Association of Emergency Medical
calling 9-1-1 on, 7 Technicians, Code of Ethics, 48
communication with, 217 National Disaster Medical System (NDMS), 674
medical identification information on, 57–58, 57f, National EMS Certification, 13
182, 183f National EMS Education and Practice Blueprint
Mobility aids, 610, 610f (Blueprint), 8
Moral obligation, 45, 47 National EMS Education Standards, 8
Morals, 45, 48 National EMS Scope of Practice Model, 11
Morbidity, 673, 683 National Highway Traffic Safety Administration
Mortality, 673, 683 (NHTSA)
Motorcycle crashes, 131, 460–461, 461f. See also EMS Agenda for the Future, 8
Helmet removal EMS Education Agenda for the Future, 8
Mottling, 236, 237f National EMS Education and Practice Blueprint, 8
Mouth, technique for opening, 151, 152f Office of EMS, 5
Mouth injuries, 538–539, 539f Technical Assistance Program Assessment
Mouth-to-mask ventilation. See Resuscitation mask Standards, 6
Mouth-to-mouth ventilation, 238, 308 National Incident Management System (NIMS),
Mouth-to-nose ventilations, 308 659, 674–677
Movements, anatomical, 64, 64f National Institute for Occupational Safety and
Moves, patient. See Patient moves Health (NIOSH), 649
Mucous membranes, 20 National Response Framework (NRF), 658,
Mucous plug, 557, 559 659, 674
Multidrug-resistant tuberculosis (MDR TB), 16, 24 National Standard Curricula (NSC), 6
Multiple births, 557, 562, 573 Natural disasters, 140–141, 141f
Multiple- (or mass-) casualty incident (MCI). Nature of illness, 121, 133–134, 147, 176–177,
definition of, 658 177f
examples of, 661, 662f Nebulizer, 253
incident command system in, 659 Neck
role of EMR in, 661 anatomy of, 531
staging in, 668 physical assessment of, 183–184, 184f
stress in, 670–671 Neck and spinal injuries
transportation of patients in, 668, 670 care for, 540–541
treatment in, 668, 668f helmet removal and, 541, 550–552, 551f, 552f
See also Triage mechanisms of, 539
Multiple sclerosis (MS), 612 neck lacerations and, 539, 540f
Muscles, 68, 68f, 74, 498, 499, 500f signs and symptoms of, 540
Muscles, bones and joints injuries See also Head, neck and spinal injuries
assessment of, 503–504 Needlestick, 16
care for, 504–505, 505f Needlestick Safety and Prevention Act, 31–32
causes of, 500 Negligence, 45, 46, 55–56
types of, 500–503 Nerve agents, 673, 682, 689–690
Muscular dystrophy, 612 Nervous system, 61, 67t, 77–78, 77f, 603
Musculoskeletal system, 61, 67t, 68–70, 71f, Neurogenic shock, 438
499–500, 603 Newborn
Mustard gas, 682 assessment of (APGAR score), 161, 557,
Mutual aid, 677–678 566, 566t
Mycobacterium tuberculosis, 24 cutting umbilical cord of, 565, 565f
Myocardial infarction (MI), 295, 299 resuscitation of, 567–568, 568f
routine care for, 567
N95 mask, 28 Next of kin, 45, 55
Naloxone, 365, 376–377, 376f, 381 NG911 system, 7
Nasal (nasopharyngeal) airway (NPA), 259, 261, Nicotine, 375
261f, 278, 279–280 Nitrogen narcosis, 421
Nasal cannula, 282, 285–286, 285f, 285t Nitroglycerin, 361
Nasal flaring, 235 Nitrous oxide, 377
Nasopharynx, 228 Nonemergency moves, 92–95
Index | 747
Non-rebreather mask, 282, 285t, 286–287, 286f “O-ring” gasket, 282, 285, 285f
Nonsteroidal anti-inflammatory drugs Oropharynx, 228
(NSAIDs), 302 Other potentially infectious materials (OPIM), 17
Non-swimming rescues and assists, 695 Overdose, 365
Nonverbal cues, 219 Overventilation, 226, 241
Noradrenaline, 80 Oxygenation
Normal sinus rhythm (NSR), 295, 298 adequate, 235
Nosebleed, 451, 453f, 536, 536f assessment of child’s, 585
Nuclear weapons, 684–685 definition of, 226, 229
Nutrition, for EMR, 41 inadequate, 236, 237f
Oxygen cylinder, 282, 284–285, 284f, 288, 289f
Obstetric pack, 557, 563, 563f
Obstructive shock, 438, 440 Pacemaker, 296, 313
Occlusive dressing, 445, 449 Packaging, 616, 620
Occupational Safety and Health Administration Pack-strap carry, 85, 92, 93f, 111–112
(OSHA) Palpation, 173, 182, 352
definition of, 17 Pandemic influenza, 17, 25
exposure control plan and, 25–26 Panic, 423, 426
guidelines for exposure incidents, 31 Paradoxical breathing, 226, 236
Older adults Paramedic, 3, 9
abdominal pain in, 353 Paranoia, 423, 427
abuse and neglect of, 423, 432, 432f, 606, 608 Parasitic worms, conditions caused by, 19t
aging effects on body systems of, 603 Parasympathetic nervous system, 78
Alzheimer’s disease in, 600, 605–606, 607 Parenchyma, 484, 489
assessment of, 603–604, 604f Partial seizure, 340, 344
care for, 604–605 Partial-thickness burn, 464, 474, 474f, 477
checking responsiveness of, 150 Passive immunity, 17, 20
communicating with, 217–218 Pathogen, 17, 19, 19t
dementia in, 605 Pathophysiology, 226
heart and blood vessels in, 602–603, 603f Patient data, 221
heart attack in, 300 Patient history
history taking and, 175, 175f additional questions in, 178
physical and mental functioning in, 602, 602f components of, 176–177
physical examination of, 180 older adults and, 175
respiratory emergencies in, 233 overview of, 174–175
substance abuse and misuse in, 378 pediatric considerations for, 174
Ongoing assessment, 173 SAMPLE mnemonic, 177–179
Open fracture, 498, 501, 502f Skill Sheet, 197
Open wounds Patient moves
amputations as, 464, 468, 468f, 472–473, 472f from bed to stretcher, 94–95
care for, 471 emergency moves, 90–92
definition of, 464, 466 equipment for, 95–97
impaled objects in, 471–472, 471f, 472f, 484 nonemergency moves, 92–95
Skill Sheet, 543–544 principles of, 87–90
types of, 467–469, 470f, 471 Patient narrative, 212, 221
OPIM. See Other potentially infectious materials Patients
(OPIM) assessing number of, 127
Opioid narcotics, 365, 373t, 376–377 hostile, 141–142, 142f
Opportunistic infections, 17 recognition of, in scene size-up, 147
OPQRST mnemonic, 173, 181 safety of, 126
Oral (oropharyngeal) airway (OPA), 259, 261–262, See also Assessment
261f–263f, 272–273, 605 Patient’s best interest, 45, 48
Oral glucose, 361–362, 362f Peak flowmeter, 253
Oral injuries, 538–539, 539f Pediatric Assessment Triangle, 580, 584
Organ, 61, 62 Pediatric considerations. See Children
Organ donors, 58 Pelvic cavity, 65f, 66
748 | Emergency Medical Response
Pelvis Poison sumac, 370f
anatomy of, 69, 69f Portuguese man-of-war, 409t
physical assessment of, 185 Position of comfort, 85, 97–98
splinting of, 510–511, 511f Positive pressure ventilation, 226, 242
Penetrating injury, 121, 132, 133f. See also Posterior, 63, 63f
Puncture/penetration Post-ictal phase, 340, 344
Percussion, 484, 490 Power grip, 85, 87, 88f
Perfusion, 77, 145, 159, 298–299, 298f, 445, 447 Power lift, 85, 87–88, 88f
Peripheral nervous system, 77, 77f, 78 Pralidoxime chloride (Protopam Chloride; 2-PAM
Peritoneal dialysis, 340, 354 CI), 673, 689, 690
Peritoneum, 484, 485 Precautions, standard. See Standard precautions
Personal preparedness, 693 Preeclampsia, 557, 570
Personal protective equipment (PPE) Pregnancy
definition of, 17 anatomy and physiology of, 558–559, 559f
for exposure prevention, 18f complications during, 569–571, 576–577
for HAZMAT incident, 652f normal, 559–560, 559f
overview of, 125, 126, 627 Prehospital care, 3
specialized, 126 Prehospital care report (PCR), 212, 219, 220f,
types of, 26, 27f 221–222, 221f
Personal relationships, 42 Premature birth, 558, 574
Personal safety, 123–124, 124f Preparedness, personal, 693
Petit mal seizures, 344 Preschoolers, 582, 583f
Pharynx, 228 Pressure bandage, 445, 450, 450f
Phobia, 423, 426 Pressure regulator, 282, 284–285, 284f
Phosgene, 682 Presyncope, 340, 342–343
Physical counter-pressure maneuver (PCM), Primary (initial) assessment, 145, 162–164, 319
340, 342 Primary effects, 673, 686
Physical exam, 173, 179, 180–181, 200–201, 588 Prions, conditions caused by, 19t
Physical fitness, of EMR, 40–41, 40f Privacy, 56–57
Physician Orders for Life-Sustaining Treatment Prolapsed cord, 558, 571, 572f
(POLST), 33, 45, 50, 53 Prone position, 64, 65f
Physiology, 61, 62 Protected health information (PHI), 56, 58
Pineal gland, 80, 80f Protocols, 3, 12
Pituitary gland, 79, 80, 80f Protozoa, conditions caused by, 19t
Placenta, 557, 559 Proximal, 63f, 64
Placenta previa, 557, 576, 576f Psychedelics (hallucinogens), 365, 373t, 375
Plants, poisonous, 369–370, 370f Psychogenic shock, 438, 440
Plasma, 74 Psychological emergencies, 426–427
Platelets, 74, 77 Pulmonary agents, 682
Pleural space, 484, 489 Pulmonary edema, 232
Pneumonia, 226, 231–232 Pulmonary embolism, 227, 232
Pneumothorax, 484, 489, 489f Pulmonary overinflation syndrome (POIS), 420
Poison Control Center (PCC), 365, 366, 367 Pulse, 77, 145, 157–159, 157t, 187–188, 202
Poison Help line, 368 Pulse, thready, 580, 585
Poison ivy, 370f Pulse oximeter, 209f
Poison oak, 370f Pulse oximetry, 173, 209–210, 210t
Poison/poisoning Pulse sites, 188f
absorbed, 369–371, 370f Puncture/penetration
carbon monoxide, 383–384 to chest, 491, 491f
in children, 592 definition and overview of, 464, 469, 470f
cyanide, 383, 384–386 to head, 533–534
definition of, 365, 366 kinematics of, 462
ingested, 367–369 Pupil assessment, 586
inhaled, 365, 369 Purkinje fibers, 298
injected, 365, 371 (See also Bites and stings) Pursed lips breathing, 235
overview of, 366 Pushing and pulling, 90
Index | 749
Quality improvement (QI), 13–14 Respiratory (breathing) emergencies
in children, 233, 585, 588–590, 590f
Rabies, 389, 410 definition of, 226, 228
“Raccoon eyes,” 532, 533f importance of time in, 157f, 229, 229f
Radial artery, 158f in older adults, 233
Radiation, 389, 391 signs and symptoms of, 230
Radiation burn, 464, 481–482, 481f specific conditions and, 230–233
Radiation exposure, precautions for, 652–653, types of, 230
685f Respiratory failure, 227, 236, 580, 585
Radio communication, 213–214 Respiratory rate, 173, 186–187, 187f
Radiological weapons, 684–685 Respiratory shock, 438, 440
Rales, 187, 227, 236, 252 Respiratory system
Rape, 423, 430–431 anatomy of, 67t, 71–72, 72f, 228
Rape-trauma syndrome, 423, 431 burns and, 475–476, 476f
Rapid medical assessment, 173 definition of, 61
Rapid patient assessment, 180, 181 effects of aging on, 603
Rapid trauma assessment, 173, 179 pathophysiology of, 229
Rappelling, 695, 700 pediatric considerations in, 72, 73
“Reach, throw, row then go,” 140, 412–413, 413f physiology of, 67t, 72, 74
Reaching Responsibilities, ethical, 47–48
guidelines for, 88 Responsiveness. See Level of consciousness
for log rolling, 88, 89f, 90 (LOC)
Reaching assist, 695, 698, 698f Restraints, 85, 100–102, 434
Reactivity, 647, 648 Resuscitation
Rear-end crash, 128–129 artificial-ventilation rates and, 156t
Reasonable force, 85, 101 in death and dying situation, 33
Reassessment, 194–195 of newborn, 567–568, 568f
Receiving facility. See Hospital Resuscitation mask
Recovery position definition of, 227
definition of, 85 overview of, 237–238, 237f
indications for, 98 with oxygen inlet, 285t, 286, 286f
for infant, 99, 100f Skill Sheets, 166–169
placing supine patient in, 99, 99f steps for using, 156
in respiratory emergency, 234, 235f Retraction, 580
supine, 99–100, 100f Return of spontaneous circulation (ROSC),
Recreational vehicle crashes, 131 296, 310
Red blood cells, 74 Reye’s syndrome, 580, 592
Reflective clothing, 627, 627f Rhonchi, 187, 227, 252
Refusal of care, 45, 49–50, 53, 222 Rib fracture, 487–488, 488f
Refusal of care form, 51f RICE, 504–505
Regulating agencies, 5 Rickettsia, conditions caused by, 19t
Regulations, 12 Right, 64
Reporting requirements, 58, 59, 223 Rigid splint, 498, 507–508, 507f, 514–515
Reproductive system, 82, 83f, 486f Risk factors, 296
Respiration Rocky Mountain spotted fever, 404t
assessment of, 235–237 Rohypnol, 375
heat loss through, 391 Roller bandage, 445, 450, 450f, 451, 452f
physiology of, 72 Rollover crash, 129, 130f, 445, 459, 459f
problems with, 229 Rotational impact, 129, 445, 459
signs of adequate, 235 Rule of Nines, 464, 475, 475f
signs of inadequate, 235–236, 237f “Rule of thumb,” 636, 641
Skill Sheet, 202 Run data, 212, 221
status of, 153–157, 155t Ruptured uterus, 577, 577f
vascular structures that support, 74
Respiratory arrest, 145, 157 Safety Data Sheet (SDS), 647, 648
Respiratory distress, 145, 156, 230, 242–243 Safety glasses, 26
750 | Emergency Medical Response
Safety seat, child, 593 Sharps, 29, 29f. See also Needlestick
Sagittal plane, 63 Shipping papers, 647, 648, 649
Salmonella, 368 Shock
SALT Mass Casualty Triage, 667, 667f care for, 442, 442f
SAMPLE history, 173, 177–179, 197, 586–588, in children, 441, 592
587f, 604 definition of, 161, 438
Scalp injury, 534, 534f overview of, 438–439
Scene, leaving, 632 reasons for, 439
Scene size-up signs and symptoms of, 440–441, 441f
in agricultural and industrial emergencies, types of, 439–440
522, 526 Shoulder
to assess safety of scene, 86, 122, 146–147 dystocia of fetus’s, 577–578
in behavioral emergencies, 433–434 splinting of, 509, 509f
components of, 146–148 Shoulder drag, 85, 91, 91f, 106
mechanism of injury and, 121, 127–133, Shunt, 340, 354
147, 147f Side-impact collision, 129, 445, 459
nature of illness and, 121, 133–134, 147 Side-lying recovery position, 99, 99f, 159f
in pediatric emergency, 584 Signs, 145, 148, 179
personal safety and, 123–124, 124f Signs of life, 145, 161
as phase in emergency response, 619, 619f Silent heart attack, 296, 300
re-evaluation in, 124 Simple access, 636, 642
safety and, 122–127 Simple partial seizure, 340, 344
situations needing additional resources/ Simple Triage and Rapid Transport (START), 658,
personnel, 134–136, 147–148 665–666, 665f
specific hazardous situations and, 138–143, Sinoatrial (SA) node, 296, 297, 298f
138t Skeletal muscle, 68
traffic control and, 122–123, 123f Skeletal system, 68–71, 69f
in vehicle crash, 629–630, 629f Skeleton, 68, 69f
Schizophrenia, 423, 427 Skill Sheets
School-age children, 582, 583f Anatomic Splint, 518–519
Scope of practice Ankle Drag, 107
criminal implications of working outside, 11 Asthma Inhaler, 255–257
definition of, 3, 8, 46 Blanket Drag, 104–105
Scorpions, 405–406, 405f Blood Pressure by Auscultation, 204–206
SCUBA diving emergency, 420–421 Blood Pressure by Palpation, 207–208
Search and rescue, 687 Choking—Adult and Child, 274–275
Seat belts, 130, 460, 593 Choking—Infant, 276–277
Sea urchin, 408, 409t Clothes Drag, 103
Secondary assessment Controlling Bleeding from Open Head Wound,
definition of, 173 543–544
overview of, 179–181 CPR/AED—Adult, 326–328
Skill Sheets, 198–199 CPR/AED—Child, 329–332
Secondary effects, 673, 686 CPR/AED—Infant, 333–335
Seizure Direct Ground Lift, 115–116
in children, 591 Direct Pressure to Control External Bleeding,
definition of, 340, 580, 591 457
overview of, 343–346 Epinephrine Auto-Injector, 415–417
Self-contained breathing apparatus (SCBA), Extremity Lift, 117–118
652–653, 652f Firefighter’s Carry, 109–110
Self-mutilation, 423, 429–430 Firefighter’s Drag, 108
Self-splint (anatomic), 498, 508, 508f, 518–519 Foreign Bodies in Eye, 545
Sepsis, 340, 343 Immobilizing Head, Neck or Spinal Injury,
Septic shock, 438, 440 553–554
Service animal, 600, 611 Impaled Object in Eye, 546
Sexual assault, 423 Jaw-Thrust (Without Head Extension)
Shaken baby syndrome, 580, 594 Maneuver, 165
Index | 751
Skill Sheets (Continued ) Solar (radiation) burn, 464, 481–482, 481f
Manual Suctioning Device, 270–271 Sort-Assess-Lifesaving Interventions-Treatment
Mechanical Suctioning Device, 268–269 and/or Transport (SALT) triage, 667, 667f
Nasal Airway, 279–280 Special events, 703–704, 703f
Oral Airway, 272–273 Special needs, patients with, 608–613
Oxygen Delivery, 290–292 Sphygmomanometer (BP cuff), 173, 189, 189f, 192f
Pack-Strap Carry, 111–112 Spiders, 404–405, 405f, 406
Physical Exam, 200–201 Spinal cavity, 64, 65f
Primary Assessment, 162–164 Spinal column, 69, 69f, 70f, 530
Removing Disposable Latex-Free Gloves, 38–39 Spinal cord, 530, 531
Resuscitation Mask, 166–167 Spinal motion restriction (SMR), 88, 90, 530, 541,
Resuscitation Mask—Head, Neck or Spinal Injury 547, 638, 638f
Suspected, 168–169 Spleen, 492
Rigid Splint, 514–515 Splint/splinting
SAMPLE history, 197 anatomic, 498, 508, 508f
Secondary Assessment for Responsive Trauma circumferential, 498, 508
Patient, 198 definition of, 498, 505
Secondary Assessment for Unresponsive Patient of lower extremities, 510–511, 511f
Breathing Normally, 199 for open wound in extremity, 455
Shoulder Drag, 106 purposes of, 505
Sling and Binder, 516–517 rigid, 498, 507–508, 507f
Soft Splint, 520–521 rules for, 506–507, 506f
Spinal Motion Restriction Using Manual Skill Sheets, 514–515, 518–521
Stabilization, 547 soft, 498, 507, 507f
Tourniquet with Windlass, 458 traction, 498, 508, 508f
Two-Person Seat Carry, 114 types of, 507–508, 507f, 508f
Ventilations—Adult and Child, 244–245 of upper extremities, 508–510, 509f, 510f
Ventilations—Bag-Valve-Mask Resuscitator, One vacuum, 498, 508
Responder, 250 Spontaneous abortion (miscarriage), 557, 569
Ventilations—Bag-Valve-Mask Resuscitator, Two Sprains, 498, 502, 503f
Responders, 251 Squat lift, 85, 88, 88f
Ventilations—Head, Neck or Spinal Injury Stabilization, 558, 561. See also Manual
Suspected, 248–249 stabilization
Ventilations—Infant, 246–247 Staging area, 647, 648
Vital Signs, 202–203 Stair chair, 85, 97, 97f
Walking Assist, 113 Standard of care, 45, 46
Skin. See also Soft tissue injuries Standard precautions
anatomy of, 78, 79f, 465–466, 465f in control of bleeding, 448
color of, 159–160 definition and types of, 17, 26
moisture of, 160 history of, 27
Skill Sheet, 203 for mouth-to-mouth ventilation, 238
temperature of, 160, 160f overview of, 125–126
Skull, 68 Standby, 703–704, 703f
Skull fracture, 532, 533f Standing orders, 3, 12
Sleep deprivation, of EMR, 41 START triage system, 658, 665–666, 665f
Sling, 507, 507f, 516–517 State EMS agencies, 5
Smartphone. See Mobile phones State EMS office, 12
Smart Tag™, 664, 664f Status asthmaticus, 580, 585
Smooth muscles, 68, 498 Status epilepticus, 340, 346
Snakes, venomous, 406–408, 407f Stethoscope, 173, 189, 189f, 190
Snowmobile crashes, 131 Stillbirth, 558, 569
Soft splint, 498, 507, 507f, 520–521 Stimulants, 365, 373t, 375, 379
Soft tissue injuries. See also Burns; Open wounds Stingray, 408, 409t
closed wounds as, 466–467, 466f Stings. See Bites and stings
types of, 466 Stoma, 145, 153–154, 153f, 184f, 239, 239f
Soft tissues, 464, 465 Stomach, 492
752 | Emergency Medical Response
Strains, 498, 502–503, 503f definition of, 282
Stress delivery devices for, 285–287, 285f–287f, 285t
as cause of behavioral emergency, 425 fixed-flow-rate, 283–284, 283f, 288
definition of, 17, 34 Food and Drug Administration requirements for
of EMR, 32, 34, 35, 42 oxygen units, 283
at multiple- (or mass-) casualty incident, indications for, 282–283
670–671 for newborn, 568f
Stress management, 35–36, 42 oxygen cylinders for, 284, 284f, 288, 289f
Stretcher, 85, 87, 96–97, 97f. See also Litter safety precautions for, 288, 289f
Stridor, 187, 227, 233, 252 for shock, 442, 442f
Stroke Skill Sheet, 290–292
assessment scales for, 350–351 variable-flow-rate, 283, 287
care for, 351 Surrogate decision maker, 45, 55
causes of, 349, 349f Swathe, 498, 507
definition of, 340, 349 Sympathetic nervous system, 78
signs and symptoms of, 350, 350f Symptoms, 145, 148, 179
Structures, unsafe, 140 Syncope, 340, 342–343
Subconjunctival hemorrhage, 484, 487 Synergistic effect, 365, 372
Subcutaneous emphysema, 484 Systolic blood pressure, 173, 190, 191f
Substance abuse and misuse
in adolescents, 379 Technical Assistance Team (TAT), 6
care for, 379–380 Teeth injury, 538, 539f
consent of patient involved with, 49 Tendons, 68, 498, 499, 500
definitions of, 365, 371 Tension pneumothorax, 484, 490, 490f
by EMR, 43 Terrorism, 674
forms of, 372 Tertiary effects, 673, 686
in older adults, 378 Tetanus, 389, 410
overview of, 371–372 Thermal burns, 477–478, 479f
prevention of, 380 Thoracic cavity, 64, 65f, 485, 485f
signs and symptoms of, 379 Thoracic muscles, 74
substances and, 372, 373–374t, 375–378 Thoracic region, 484
Sucking (open) chest wound, 484, 491, 491f Thorax, 69, 69f
Suctioning Thready pulse, 580, 585
definition of, 227 Throat, 228
overview of, 259–261 Thrombus, 340, 349
purpose of, 234 Throwing assist, 695, 698–699, 698f
Skill Sheets, 268–271 Thyroid gland, 80, 80f
Sudden cardiac arrest, 296, 302 Tibia, splinting of, 512, 512f
Sudden death, 17, 33 Ticks, 404, 404f, 404t
Sudden infant death syndrome (SIDS), 580, Tidal volume, 227, 237
595–596 Tissue, 61, 66
Suicidal person, 143, 427–429, 429f Toddlers, 582, 583f
Suicide, 143, 423 Tolerance, 365, 372
Sundowning, 600, 606 Tonic phase, 340, 344
Sun safety, for EMR, 41 Tourniquet, 445, 453–454, 454f, 458
Sunscreen, 41 Toxemia, 558, 570
Superficial, 64 Toxicity, 647, 648
Superficial burn, 464, 473, 473f, 477 Toxicology, 365, 366
Superior, 63, 63f Toxin, 365, 366
Supine position Trachea
definition of, 64, 65f, 85 in child vs. adult, 581, 581f
indications for, 99 description of, 228
log roll for placing patient in, 100, 100f deviated, 236
Supplemental oxygen Traction splint, 498, 508, 508f
administration of, 287–288 Traffic control, 122–123, 123f, 138–139, 139f, 639
for children, 590, 590f Transdermal medication patch, 296, 314, 314f
Index | 753
Transfer of care, documentation in, 222–223 personal safety at scene of, 637–638
Transferring, 616, 619–620, 620f positioning of emergency vehicles at, 639, 639f
Transient ischemic attack (TIA), 340, 349 scene size-up in, 629–630
Transverse plane, 63 seat belts and air bags in, 130–131
Trauma traffic control in, 639
in children, 593 undeployed air bags in, 640
definition of, 446 unstable vehicles after, 129–130
multi-system, 447 See also Extrication
during pregnancy, 571 Vehicle stabilization, 129–130, 636, 641
Trauma alert criteria, 616, 622 Veins, 76, 76f, 446
Trauma dressing, 445, 449, 449f Venomous snakes, 406–408, 407f
Trauma system, 445, 447 Venous bleeding, 448, 449f
Traumatic asphyxia, 484, 487 Venous system, 76, 76f
Traumatic brain injury (TBI) Vented chest seal, 491, 491f
causes of, 530–531, 531f Ventilation, 72, 74, 227, 235–236, 585. See also
definition of, 530 Artificial ventilation; Respiration
overview of, 610 Ventricles, 74, 75f
“Trench box,” 701 Ventricular fibrillation (V-fib), 296, 311
Triage Ventricular tachycardia (V-tach), 296, 311
assessment in, 666 Vial of Life, 173, 175, 605f
definition of, 658, 662 Violence
primary and secondary, 663 against oneself, 427–430
SALT Mass Casualty system of, 667, 667f against others, 430–432
START system of, 665–666, 665f at scene, 135–136
tagging systems in, 663, 663f–665f, 664–665 Virus, 17, 19, 19t
triage officer and, 662 Visual impairment, 602, 609
Triage tags, 658, 663, 663f Visual warning devices, 616, 628
Triangular bandage, 446, 450, 450f Vital organs, 61, 66
Trimesters, 558, 559–560 Vital signs
Tripod position, 121, 134, 134f by age, 194t
Tuberculosis (TB), 17, 24 definition of, 145, 161
Twisting force, 498, 500, 501f obtaining baseline, 186–194
Two-person seat carry, 85, 94, 94f, 114 Skill Sheet, 202–203
Type 1 diabetes, 340, 346 Voluntary muscles, 68, 498, 499, 500f
Type 2 diabetes, 340, 346 Voluntary nervous system, 78
Vomiting
Umbilical cord, 558, 560, 565, 565f, 571, 572f during artificial ventilation, 238–239
Universal precautions, 17, 26, 27 in drowning, 414
Upper arm, splinting of, 509, 509f for ingested poisoning, 368–369
Urinary system, 82, 82f
Uterus, 558, 559f, 577, 577f Wading assist, 695, 699
Walking assist, 85, 93, 93f, 113
Vacuum splint, 498, 508 Walking wounded (green), 658, 665
Vagina, 558, 559, 559f Warm zone, 647, 653, 653f
Variable-flow-rate oxygen, 283, 287 Water-related emergencies, 410–414
Vector-borne transmission, 17, 22, 22f Water rescue, 140, 411–413, 413f, 696–699
Vehicle crashes Weapons of mass destruction. See WMD
all-terrain vehicles and, 131, 461 Wheezing, 187, 227, 230, 252
alternative-fueled cars in, 639–640 White blood cells, 74
appropriate behavior specific to, 136t Wind chill effect, 396, 397f
as cause of traumatic brain injury, 531, 531f Windpipe, 228
children and, 593, 593f Withdrawal, 365, 372
kinematics of trauma in, 127–129, 459–461, WMD
459f biological weapons, 683–684
mechanism of injury in, 630 blister agents, 682
motorcycles and, 131, 460–461, 461f blood agents, 682
754 | Emergency Medical Response
chemical weapons, 681 Women
classifications, 681 heart attacks and, 300
definition, 673, 680–681 pregnancy in, 558–560, 559f
explosives and incendiary weapons, See also Labor and delivery
685–686 Work practice controls, 17, 29
incapacitating agents, 683 Wounds
nerve agents, 673, 682, 689–690 closed, 466–467, 466f
pulmonary agents, 682 definition of, 464
radiological/nuclear weapons, 684–685, 685f See also Chest injuries
WMD incident Wrist, splinting of, 509–510
arrival at, 687
equipment and supplies for, 687 Xyphoid process, 306f
preparation for, 686–687
providing care in, 688 Yeasts, conditions caused by, 19t
scene safety in, 688 Youth. See Child(ren)
Index | 755
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Care steps outlined within this manual are consistent with:
• 2015 International Consensus on CPR and Emergency Cardiovascular Care (ECC)
Science with Treatment Recommendations
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