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07/11/2016

= Wilderness Protocol
Due Tuesday @ 8am
Who Am I & Why Am I in this EMT Course?
o 1 page
o hand-written if legible
o special needs or concerns, if any
Dry Background Stuff
The Ideal EMT
o Compassionate
o Calm
o Knowledgeable
o Good speller
o Authoritative
o Efficient
o Resourceful
o Cooperative
o Confident
o Decisive
o Adaptive
o Fit
o Funny
o Communicative
o Professional
o Organized
o Servant
o Learner
o Educator
o Disciplined
o Motivated
o Experienced
o Unbiased
o Non-judgmental
o Humble
o Observant
Phone Numbers for the College
Tristan (or Roy)
o 530-938-5211
Ty
o 530-938-5237
Mail
o NOLS WMI WEMT, and Name 800 College Avenue, Weed,
California, 96094
History of EMTs
Baron Dominique-Jean Larrey
o The Surgeon General of Napoleons Empire
o More or less the beginning of EMS
o Instituted policy in Napoleons government to facilitate
emergency medicine practices on the battlefields
Flying ambulances (horse-drawn carriages)
Field hospitals with increased mobility, and better
organization
Developed and used the concept of triage, treated
members of the enemy army
World War I
o Great wealth of knowledge
o Thomas D-Ring traction splint
Brought mortality down for femur fractures from 80%
to 7%
World War II
o The use of penicillin
o Anti-malarial drugs
o Field hospitals are improved
o Tetanus immunizations
o Blood transfusions
EMS Today:
o 1966, paper published: The White Paper
National Academies of Science Research Council
Traffic collision death statistics
More people dying each year than the number
killed during the entire Korean War
Showed severe deficiencies in pre-hospital care in the
United States
Slower than in military medicine in Vietnam
Recommended provisions for pre-hospital care
o NHSA (National Highway Safety Act)
A number of standards were set
Motor vehicles had certain requirements added
Seat belts
Roadway standards
Edge and center line on the highways
Authorized the Department of Transportation to
fund communication and education of Emergency
Medical Services and Responders
o 1970
The National Registry of EMTs was created to
standardize and establish national testing standards for
EMTs
o 1973
The Emergency Medical Services Act
Establish EMS systems throughout the country
Scope of Practice
Federal Level
o Provides a model/guidelines for what skills EMS practitioners
should have
State Level
o Laws and scope of practice vary from state to state
o Standards for training vary from state to state
o Variety in standards for recertification
Local Level
o You will have a regional director
Most likely a physician that oversees a county
Wilderness Environment (p. 5)
Components of a Wilderness Setting
o Time
Extended transport time to advanced care facilities
Time can actually be a benefit, you have time to make
decisions in many cases
More patient contact time as well (Prolonged
Patient Care)
i.e. Infections, nursing (long-term patient
care)
o Environment
Lack of complete temperature control
Lack of protection from environmental factors
May even be the cause of injury in a patient
Creates logistical obstacles for an EMT
o Resources
Greater level of improvisation with a lack of resources
o Communication/Decision Making
Long range communication devices that may not always
work
More independent decision-making as a result of lacking
oversight from medical control
o Prevention
Ensuring that participants dont become patients
Initial Assessment

o Scene Size Up

o ABCDE Life Threats

Head to toe
Vitals
History

Scene Size Up
o Ensure that the scene is safe for the EMTs first
Second check for the safety of bystanders
Last check for the patient
o What was the reason for the accident, the mechanism of
injury (MOI)
Helps to determine routes for treatment based on
possible injuries
Consider the possibility of a spinal cord injury present in
the patient
o Begin applying Body Substance Isolation (BSI)
At the very least you should have gloves
Possibly glasses, other pieces of clothing to prevent the
mucus membranes of your body, maybe a mask
o Determine the number of patients (pts)
Helps to determine if you need additional resources or
assistance
o Upon approaching the patient, look to gain a General
Impression
Also worth note, approach from line of sight
o Rhyme
One, Im Number One,
Two, What Happened to You,
Three, Dont Get it On Me,
Four, Are There Any More,
Five, Dead or Alive
Approaching Patient
o I
Introduce yourself
o C
Get consent
o P
Protect the spine
Initial Assessment of the Patient
o Look for life threats first
o A
Airway
Open
Clear
Stop assessment if obstruction is found, fix
the airway
Adjunct for airway
o B
Breathing
Is it happening?
CHEST RISE AND FALL
Does it hurt?
Look for possible cause
Deliver oxygen if it seems necessary
Stop and fix if there are any issues
If someone is not breathing, but have a
pulse, do rescue breathing
o C
Circulation
Radial pulse
Leaking anywhere? BLOOD SWEEP
Skin pallor
o D
Decision
Decide whether or not to continue holding the
head
Decision based on MOI
o E
Expose
Check the concern area
Environment
Secondary consideration
Secondary Survey/Secondary Assessment
o Physical Exam/Head-to-Toe, Front-to-Back
o LAF
Look/Listen
Ask
Feel
Creepy touch
Smell!!!
o CSMs
Circulation
Is there warm blood flowing to his toes?
Check for circulation
Both radial pulses
Sensation
n+
Motion
Assess patient in whatever position you find them
Vital Signs (p. 11, ch. 13)
o Two sets of vital signs improve accuracy of assessment and
aid in the decision-making process
o Early-changing vital signs
Heart rate
Pulse changes before blood pressure changes
Respiratory rate
Skin
o Level of responsiveness (LOR)
A
Awake
Oriented
Name 1
Place 2
Time 3
Events 4
A&Ox4
Down to A&O x 0
Unconscious
V(erbal)
Responsive to Verbal
Reaction, but not waking up
P(ain)
Responsive to Pain
Reaction, but not waking up
U(nresponsive)
Unresponsive
o Heart rate(HR)/Pulse
Rate, Rhythm, and Quality
50-100 bpm
Steady rhythm (regular)
Certain pulse qualities are associated with certain forms
of trauma
Normal qualitystrong
o Respiratory rate
12-20 at rest for a healthy adult
Rhythm, regular, effort
Effort should be unlabored
Vital Signs (cont.)
Earlyvital signs (ALWAYS ADULT AT REST)
o LOR, LOC, or mental status
o Heart Rate
o Respiratory Rate
o Skin
Color, temperature, and moisture
Pink
Check mucus membranes
Warm
Dry
Cardiac patient
Pale, Cool, Wet
Blue
Hypoxia or hypothermia
Yellow
Liver
Red
Taking vital signs
o Always take a minimum of two
o (QUICK EXAMPLE)
Low respiratory rate, high heart rate, responsive to pain
stimuli
Opioid overdose
Time 8:23 833
LOR AO4 AO4
HR 64 112 strong, reg
RR 12 10
Skin Warm and dry Warm and dry
SpO2 98% 99%
Early vital signs (cont.
o Oxygen Saturation
96%-100%
94% is slightly hypoxic
Vital Signs (secondary/late changing)
o Blood pressure (p. 317 for age chart)
Pressure blood is exerting on the arterial walls
Important for perfusion
Oxygen is being pushed through the body
Once pressure drops too low, the patient is no
longer perfusing
Too high
Pressure on the arterial wall
Aneurysm
Also an indicator of a great deal of resistance in
the arteries
Heart is put under greater strain in order to
pump blood
Systolic
When the system is under load
Left ventricle is contracted
Diastolic
System is unloaded
Measuring
Stethoscope and cuff (Oscultation
You get a diastolic here
Palpation and cuff
ie 118/P
Range for a young adult at rest is roughly between 90-
120 but you should ask the patient to find out if it is
normal for them
Widening systolic and diastolic gap can be an indicator
of a head injury, a diastolic near 130 can be an indicator
of an imminent stroke
o Pupils
Check for
P
Pupils
E
Equal
o
R
Round
R
Reactive
L
To light
Hole made by the iris
Lets in light or takes away light
Dilate in dark, constrict in bright conditionsf
Eyes are PERRL or not PERRL, and then explain what is
wrong with it, ensure that this is an abnormality for the
patient
May not react to light when
Head injury has occurred
May also be unequal
After head injury
Extremely constricted pupils that arent very reactive to
light
Most likely heroin
Extremely dilated pupils that do not respond to light
Usually a dead person
o Temperature
Different than skin temperature
Looking for the core temperature
Must use a thermometer
Normal is 98.6/37
o --Why vitals?
Start with time always
LOR
HR
RR
SCTM
BP
P
TEMP
Looking for change, but it is also a good way to see
medications doing their work. Must have a baseline
before any drugs are delivered
Documentation (p. 14-16)
S
o Subjective (or Summary)
Age, Sex, Chief Complaint, MOI, LOR
Not the most serious injury that you find, or the
totality of injuries, but simply the Chief Complaint
Scene size up, ABCDE
O
o Objective
Head to toe, vitals, SAMPLE history
Findings from our head to toe exam,
Observations?
Pertinent negatives
MOIno spinal pain reported, good
CSMsX4, AO4, seatbelt, helmet
Vital Signs
Most Recent
First and Last
SAMPLE History + Relevant history
A
o Assessment (Problem List)
Possible wrist
Possible (L) Rib Fx
Anticipated problems as well
P
o Plan
Treatment Plan and Transport/Evac Plan
Treatment
Tx
o Splint and immobilize wrist,
monitor CSMs
o Maybe ACE wrap ribs
Evac
Straightforward for an ambulance, without it
becomes more complex and difficult
Pulmonary respiration
Internal respiration
What controls are breathing?
Chemoreceptors
o Detect increases in CO2 and decreases in O2
Detects in the brain and blood vessels
Primarily detects CO2
Ventilation
Air going in and out of the lungs
Tidal volume
Amount of air that is inhaled and exhaled in one single breath
Minute volume
The tidal volume multiplied by the number of respirations in a
minute
Average adult tidal volume is ~500 ml of volume
o ~350 ml reach the alveoli, the other 150 remains dead in the
trachea
Anatomy of the lung
Parietal pleura
o Coats and covers the inside of the rib cage
Visceral pleura
o Attached to and covers your lungs
Between the two pleura there is the potential for empty space

Chest trauma
Fx of rib/clavicle
o S/sx
Sharp pain
Pain on inspiration
Shallow breathing
Swelling/deformity
Tenderness to palpation
Presenting
Self splinting with hand
o Tx
LOOK AT THE CHEST!
AT SKIN LEVEL
O2?
Position of Comfort
Apply a sling and swath
Tape midline to midline
Ace wrap
Pain medications
NSAIDs, but nothing like aspirin that will thin the
blood
Continue to monitor the patients vital signs
Flail chest
o S/Sx
Paradoxical movement
Shallow breathing/dyspnea
Cyanotic
S/Sx of shock
o Tx
O2 + BVM
Position of Comfort
Is there a need for a backboard?
RAPID evac
Lung trauma
o Hole in the visceral pleura
Can create a space between the parietal pleura and the
visceral pleura
Collapses the lung
Called a pneumothorax
o Pneumothorax
S/Sx
Increased dyspnea
Lung sounds will be diminished on affected side
Cyanosis
Asymmetrical chest rise
Because there is no way for the air to escape the chest,
because the skin is intact, this is called a closed
pneumothorax
Tx
EVAC RAPIDLY
O2
BVM?? (PROBABLY NOT)
Could actually worsen the issue
EVAC to hospital
o Open Pneumothorax
S/Sx
Same as pneumothorax
Differences
o Open wound to the outside that will
increase rate of pneumothorax
WILL MOST LIKELY PRESENT AS A SUCKING CHEST
WOUND
Tx
O2
EVAC
Occlusive dressing
3 sided occlusive dressing
4 sided occlusive dressing
o Hemopneumothorax
S/Sx
Same as pneumothorax
Tx
o Tension pneumothorax
Complete lung collapse
Continues leaking air, so you will actually get tension
and pressure within the thoracic cage
S/Sx
Dyspnea is going to get even worse
Effort of breathing is going to be much worse
Lung sounds are extremely diminished or absent
Jugular veins distended
Tracheal deviation
Tx
O2
P.O.C.
EVAC
BVM?
o Spontaneous pneumothorax
S/Sx
Same as pneumothorax, but typically much
slower
o To listen to lungs
Sub-clavicular
Check both lungs
Under armpit, nipple level
Directly below scapula
If clear, clear bilateral
Always check both lungs, listen for differences
Cardiac Tampenade
o Pericardial membrane
o Typically with penetrating trauma
o Nicks pericardial membrane and heart
o Same deal as pneumothorax
o S/Sx
JVD
Shock
Narrowing pulse pressure
o Tx
Evac
Commotio Cordis
o Typically the result of blunt trauma, hits the heart at the
right time and damages the hearts electrical system,
destroys rhythm
o Almost always fatal
Hypoperfusion (SHOCK)
Inadequate PERFUSION of oxygenated blood to the brain and body
tissues due to a problem with the cardiovascular system of the
supply of oxygen
o Gas and nutrient exchange
Pump problems
o Heart attack
o Chest trauma
Cardiac tampendae
o Cardiac dysrhythmia
o Congestive heart failure
o Valve problem
Mitral valve prolapse
o ODs/Meds
o These can all lead to CARDIOGENIC SHOCK
Fluid problems
o Hemorrhaging
Internal
External
o Dehydration
o Burns
o These can all lead to HYPOVOLEMIC SHOCK
Pressure/Vascular problems
o Typically seen with a head injury/spinal injury
Brain injury alone cannot cause it
o You may see flushed skin from the point of injury down
o Anaphylaxis
Anaphylactic shock
o Sepsis
Septic shock
o Psychogenic shock
Pain, stress
Blood vessels rapidly dilate
Vasovagal shock
o These can lead to NEUROGENIC SHOCK
S/Sx
o Early (Compensated Shock)
Check early vitals
LOR
Restless, anxious, irritable
HR
Increased heart rate
Radial pulse is still strong
RR
Increased respiratory rate
Shallow breathing?
Should not be difficulty breathing or
shortness of breath
SCTM
Skin becomes paler
Cool
Clammy or moist
SpO2
BP
Unchanged, maybe slightly higher
Pupils
No change
Temp
No change
Lungs
Others
Nauseous
Fainting
Dizzy
Overall feeling of lack of wellness
Thirst
o Late (Decompensated Shock)
LOR
Confusion
Not alert
Overall decreases in total LOR
HR
Increase
Absent radial
RR
Shallow, irregular
SCTM
Cyanosis
Cool to cold
Diaphoretic
SpO2
Lower
BP
Falling
Pupils
Sluggish
Poor light response
Temp
Lungs
o Irreversible Shock (Pre-Death)
LOR
Gone
HR
Decreasing
RR
Dropping
SCTM
Cold
Cyanotic
SpO2
Dropping
BP
Undetectable
Pupils
Unresponsive and dilated

Tx
o Consider spine
o Ensure patent airway
o Ensure adequate breathing
BVM if too fast or too slow
o O2
NRB mask because you can always turn it down, move
to nasal cannula later on if they are unable to tolerate
o Control external bleeding
o POC
o CPR? AED?
o Maintain body temperature
o Calming and reassuring the patient
Do not lie to the patient
o Transport
o Good physical exam
o Ask for a solid SAMPLE history
Orthostatic vital signs (p 24 in spiral)
Pulse and BP with patient supine
Then patient standing pulse and BP
If the body cannot adjust to the change in positioning, they may
still be in shock
Common Wilderness problem (p. 93) Bloody Nose (Epistaxis)

CPR
When to stop CPR (p. 62)
o Successful resuscitation
Return of Spontaneous Circulation
o Dangerous occurrence on scene
o Fatigue/30 minutes
o Pronounced dead
Coroner, doctor, medical examiner
o Transferred to equal or greater care
o DNR is presented
Well-defined DNR
Continue until presented with the physical paper
o Avalanche victims
MOI for airway
Airway
Snow plug
CPR is done on people who have survived an avalanche
When not to start
o When the patient is alive
o Dangerous scene
o DNR is presented and is well defined
o Obvious lethal injury
o Dependent lividity
o Rigor mortis
Assessment for scenario
Based on MOI, there is a possible spinal cord injury
o 2x2 contusion on lumbar spine
o Lack of good CSMs
Shock is a definite possibility
o High heart rate
o Pale, cool, clammy
o What type of shock
Hypovolemic, maybe neurogenic
Possible fractured rib or ribs
Spine and Spinal Cord Injuries (788, 18 in spiral)
MOI is one of the key components that may indicate a spinal cord
injury
Index of Suspicion
o MOI should give you a high level of suspicion of a spinal cord
injury
MOI
o Fall
Significant enough to cause change in LOR
o High velocity impact
o Fall thats greater than 1M where impact is directly on the
spinal column including the spinal column and pelvic cradle
First 7
o Cervical
Next 7
o Thoracic
Next 5
o Lumbar
C4
o Breathe no more
Body Brain
o Sensory
Brain Body
o Motor
S/Sx
o Pain, tendernesson Spinal column
o Altered distalCSMs
o Paralysis or weakness in extremities
o Respiratory arrest
o Neurogenic shock
Clinical Observation
Dress code
o Providence
Scrubs, Name Badge
Verification form
SOAP reports
Sterility
Fainting
Confidentiality
Good Guest Behavior

Head Injuries
The skull
o Encases the brain
Covered by the meninges
The dura mater
The arachnoid membrane
Cerebrospinal fluid
Pia mater
Internal layer, actually covering the brain
The Brain
o Connected to the spinal cord by the medulla oblongata
o Next up is the cerebellum
Trauma
o Superficial
Goose Egg
Superficial scalp injuries can cause a great deal of
bleeding although not realistically dangerous
o Mild
Concussion

LOR
Constantly monitor LOR even on concussion
patients
AO3-4
HR
Elevated, normal ranges though
RR
Elevated, normal ranges though
SCTM
Within normal ranges
BP
Elevated, normal ranges though
Pupils
Symptoms
Most patients will have a headache
Nausea
Dizziness
Visual symptoms
Stars
Light sensitivity
Personality changes
o Severe
LOR
AO<3, 2 or less
The D.I.C.C.-head Phenomenon
Disoriented
o Not coherent or reacting to their
surroundings coherently
o Still going to be AO0
Irritable
o Not very friendly
Combative
o Physically aggressive
Comatose
o Unresponsive
Consent not necessarily needed
Needs immediate evac
HR
Maybe seeing a decrease in heart rate,
compensating for ICP
RR
Erratic breathing
SCTM
Potentially looks warm and flushed
BP
Systolic will initially go up in a significant way
Pulse pressure will be widening
Pupils
Unequal pupils possibly
Symptoms
Seizures may be observed
Electrical storm essentially, in the brain
All symptoms of mild head injuries may get much
worse
Vomiting
Projectile vomiting
The real concern sets in
Bleeding or ICP will create increased BP in
the brain, so what you may see is a
decrease in the amount of blood being sent
to the brain
o You will see a strong, maybe even
bounding, pulse
Mild can progress to severe
Advancing ICP can cause this
Can restrict the medulla
Bleeding
Below the dura mater, subdural
Bleeding between the brain and the dural
mater
Epidural
Between the dura mater and the skull
Glasgow Coma Scale
Eye Opening
Spontaneous Eye Opening4
Verbal command3
Pain2
Dont open--1
Verbal Response
No response--1
Motor Response
Obeys verbal6
Localizes pain5
Responds to pain4
Abnormal flection in response to pain3
Extension in response to pain2
o Posturingvery, very bad sign
No response1
Total is 15, lowest is 3
8 is intubate, so they are in a coma
Open head injury
Skull fracture
We could also see some other specific
physical signs that indicate that someone
has an open head injury
Obvious injury to the skull
o Deformity crack, etc
o Echimosis
Bruising
Behind the ears or around the
eyes
Raccoon eyes, Battles
sign
o Leaking of CSF and/or blood from the
ears or nose
Treatment
Urban
ABCDE
o Airway
Concerned about puking
Suction and rolling them
into the recovery position
Calling ALS for advanced airway
options
o Breathing
They are going to be put on a
high flow NRB
Bag anyone who is in
respiratory failure or respiratory
arrest
o C
Diffuse pressure around the
wound
No direct pressure on a skull
fracture
o Decision
They are probably going on a
backboard
o Evaluate
LORMonitor
Constant contact
Probably on a backboard
Wilderness
Mild or severe?
o Mild
Doesnt necessitate evacuation
Monitor for 24-48 hours
If signs and symptoms are
gone, they can stay in the
backcountry
Sleeping
Let them sleep, definitely
let them sleep
You dont want them to be
overs-timulated
Wake them up every two
hours to continue
monitoring their LOR
o Severe
EVAC
Elevate the head slightly to help
possibly alleviate the ICP
Homework
Work on vital signs
o Piece of paper containing five sets of vital signs from five
people
Open book quiz
o Marked as quiz #2
Half the weight of a closed book in-class quiz
National Registry Account!!!
Bring one written SOAP report to class
o Bring verbal report from spiral notebook
Gear practice!
Wild Wound (BRADY CH.26) (SPIRAL P.34)
Control Bleeding
o Direct Pressure (& Elevation)
Pressure Dressing
o Tourniquets
Improvising a tourniquet
Hopefully done in conjunction with direct pressure
Prevent Infection
o If there is a risk of tetanus, you need to evacuate the person
o Pressure irrigation to prevent infection
W/ copious amounts of water that is clean enough to
drink
o When we feel confident that we have cleaned out all of the
possible infection vectors
Promote Healing
o 1
Gauze dressing and bandage
o Or 2
Semi-permeable transparent dressing
Benzoine tincture
Butterfly bandages
Put transparent bandage on and peel edges off
Keep an eye on it. Also it will tear off skin?
Closed Soft-Tissue Injury (Epidermis intact)
o Contusion
The bruise itself is typically not the problem, but instead
an indicator of a possible underlying issue
o Hematoma
Swollen
Indicator of bigger blunt trauma
Open Soft-Tissue Injury (Epidermis not intact)
o Abrasion
Superficial wound on the surface of the skin
No risk of death, risk of infection (high)
o Avulsion The Flapper
Peeling away of skin
Great deal of damage in tissue, nerves and veins and
arteries
o Amputation
Try to recover the limb
Keep it with the patient, cool and safe
o Puncture
Can have greater levels of internal bleeding and organ
damage inside the wound
On the extremity
We would like to encourage it to bleed a little bit
Let wound bleed out some of the bacteria
first
o Impaled Object
Leave it in place
Stabilize with bulky dressings
Remove if
Interfering with the airway (through the cheek)
Inhibits transport
o (Evisceration)
Internal organs protruding from the body
Typically the intestines
Warm moist bandage
Treat for shock
Burns
Skin Anatomy and Physiology
o Epidermis
Most upper layer
o Dermis
Largest part of the skin
Location of skin organs
Hair follicles
Sweat glands
Sensory receptors
o Subcutaneous tissue
o Functions
Provides protection from the environment
Protects the body from bacteria
Provides sensory input
Pressure
Hot, cold
Provides water balance
Keeps water in, keeps water out
Provides temperature regulation
Dilating and constricting blood vessels
Grows hair and makes oil
Salt and H2O excretion
Sweat
Shock absorption
Burn classification
o Agent
Thermal
Fire, boiling water, touch
Chemical
Lye, HCl, battery acid
Electrical
Lightning, power line
Radiation
Sunburn, radioactive substance
o Body part
Face
Groin
Hands
Feet
Circumferential
Airway
o Depth
Superficial (1st)
Burned your epidermis
(i.e. sunburn)
S/Sx
Pain
Redness
Swelling
Peeling
Partial Thickness (2nd)
Burned down to dermis
A lot of pain
Blisters
Full Thickness (3rd)
Maybe charred
Maybe white/pale
All the way past the three layers down to muscle
or bone
No pain in actual burn area
o Extent
Must pay attention to
Measure with the Rule of Palms
Your palm with fingers=1% of your total body
surface area
Rule of Nines
Head is 9%
One arm is 9%
Front of chest is 9%
Abdomen is 9%
Backside is 18%
Legs front and back, each 18%
Groin is 1%
Child
o Head is 18%
o Groin is 1%
o Front of the belly 18%
o Backside 18%
o Arm is 9%
o Legs are 14%
Tx
o Cool the burn
You want a lot of water
o Remove the patient from the source of the burn (part of
scene safety)
o Airway burn inspection
R
Remove constrictions
Belts, necklaces, rings
A
Airway
Look for singed hair
Soot near airway
B
Breathing
Dry cough
Vocal changes
C
Cool?
Cannot cool an airway burn down
Consider the possibility of shock? Watch for
hypothermia
Evacuation/Transport?
o Evac rapidly any full thickness burns or partial thickness that
is over 10% of the total body surface area
o Evac rapidly any burns to the airway and any circumferential
burns
o
Wound
Infections
o Tender
o Swollen
o Red
o Warmth
o Pus
o Tx
Reopen wound and pressure irrigate
Use soap and water
Hot soaks also work very well
2 minutes long
Pack and open with moist gauze progressing to
dry gauze
You should be doing 3 or 4 hot soaks a day
Advancing infection
o Pain all of the time
o Redness area increases
o Swelling increases
o Warmth will become just general heat
o RED STREAKS
The infection has traveled to the blood
They will be going towards your lymph nodes
o Lymph node swelling
o Look for an abscess
Further Advanced infection
o Fever
Final stage
o Septic shock
Fever
Decrease in LOR
Musculoskeletal injuries
S/Sx
o Pain
o Swelling
o Bruising
o Reduced range of motion
o Reduced CSMs
o Crepitus
o Other sounds
Maybe a broken ligament?
o Deformity
Tx
o RICE
R
Rest
I
Ice or cool down, probably cool down
Decreases pain and inflammation
C
Compression
Provides support, decreases swelling
E
Elevation
Reduces swelling
After RICE-ing
o Can they use it?
Assess
Start with CSM
Next to ROM
Does patient have active and passive range
of motion
Weight bearing?
o DECIDE
Usable
Tx
Continue to RICE
PAS
Support the injurynot splint
Musculoskeletal Injuries
Bones
o Fracture
Muscles/Tendons
o Strains
Ligaments
o Sprains
Assess injury
o CSM check
o Open Fx?
Bone is exposed
Open wound and an angulated fracture
High risks to the bone because it is outside of its
normal environment
Wilderness
Try to reduce an open fracture if
#1 You can clean the wound and the bone
o Pressure irrigation
#2 If you can successfully reduce it
#3 You can then make it with a moist
dressing
o Potentially an antibiotic cream as well
Get an open fracture immobilized!!!
o Angulated fracture
Traction and realign
o Splinting
Padded (avoid bulk)
Rigid
Adjustable
CSM Access
Immobilize
Joints and bones, above and below injury
RICE and pain meds
Process
Direct manual stabilization
Assess CSMs for injured extremity
Measures the splint
Begins to immobilize
Upper arms are very good with use of the
trunk
Lower Body/Lower Leg
o Long bone
Immobilize
Femur fractures
Watch for femoral artery
Force is probably significant enough to cause
positive MOI
Full leg splint
Dislocations (p. 32 spiral)
Evacuating all first time dislocations
Reducing
o Fingers/Toes
Traction and replace
Stop for resistance or pain
RICE until usable
o Patella
o Shoulder
Kocher method
o Jaw
Environmental Threats
Hypothermia
o Lowering of core temperature
o Mechanisms of Heat Loss and Heat Gain
Heat Loss
Conduction
Contact
Convection
Moving contact
Radiation
Evaporation
Respiration
Heat Gain
Basal Metabolism
Exercise
External Heat Sources
o Stages of Hypothermia
Early signs
Cold and Unhappy
Shivering
Hunched over
Apathy
Middle stages
Decrease in fine motor skills
Umbles
Mumble
Stumble
Grumble
Middle-late
Umbles get worse
Decrease in gross motor skills
Shivering that is uncontrollable
Altered mental status
Later stages
Stop shivering
Starting to look dead
Muscular rigidity
Your previously high HR and RR begins to
plummet
Difficult to find pulse
LOR
Movement to a ventricular fibrillation
o Tx
Treat the cause
Look at mechanism
Change wet to dry
Change the environment
Put them in a heated ambulance
Find shelter, prevent exposure
Feed the shiver
Warm/Sweet fluids
CarbsFats
Fatty foods
Exercise
Hyporap
You must make sure that the individual does not
get TOO hot inside the hyporap
o Tx (Severe)
Check pulse for 30-45 seconds
No pulse, do CPR, give them O2
Always treat them very gentaly
Active rewarming
Be sure that you are warm and have good feeling in
your extremities
Wilderness
Treat them gently
Dont do CPR if you cant detect a pulse
Provide rescue breathing for 5-15 minutes
WetDry
EVAC
Frostbite and Non-Freezing Cold Injury
o Frostbite
Local freezing injury
First step
Vasoconstriction
Causes
Cold temperatures
Wind chill
Reduced circulation
Tight clothing
Dehydration
Touching cold metal
Individual susceptibility
Classification
Superficial
Only outer layer of skin is frozen
Partial thickness
The injury has progressed into the
underlying tissues
Full thickness
The injury extends into the underlying
tissues and muscles
What does it look like
While frozen the skin is gray, white, waxy or
mottled, cold and numb
Tx
If not frozen
Skin to skin
If frozen
Ideally: Immerse in water bath 99-102
degrees Fahrenheit
Practical: warm skin
Both
Protect from refreezing
Never massage or use radiant heat
Manage pain
Prevent a second freezing if you thawed
Protect the thawed tissue from injury
Ibuprofen may be helpful for pain
o Non-Freezing Cold Injury
AKA Immersion Foot
Constricted blood vessels reduce heat, oxygen and
nutrients to cells
Injury ranges from a few weeks of sore feet to
permanent muscle and nerve damage
S/Sx
Cold, mottled toes or feet
Foot feels wooden, numb, or pins and needles
After warming, itch and pain are often prominent
symptoms
After warming may be red, swollen and numb
Tx
Warm affected area
Air dry
Elevate
Ibuprofen may be helpful with pain management
Avoid constriction and further injury
Protect blisters or damaged tissue
Healing takes weeks. Pain and temperature
sensitivity may last years
Chillblains
Another local non-freezing cold injury
Cause
Cold blood vessels dilate when warmed,
capillaries leak proteins which cause a local
inflammatory reaction and the red itching
bumps
S/Sx
Swollen, tender, itches, reddish
Tx
Isolated small blisters can be kept in the
field if infection and subsequent freezing
can be prevented
In general, evac larger blisters, blood filled
blisters, partial or full thickness cold injuries
The pain from non-freezing cold injuries
usually necessitates evac
Heat Illnesses/Hydration
o Heat Exhaustion
LOR
Normal
HR
Elevated
RR
Elevated
SCTM
Pale, Cool, Clammy/Flushed
S
Nausea, reduced appetite, vomiting, headache
A

M
Alcohol, Antidepressants, Amphetamines,
Antihistamines, Cocaine
P

L
Hx of Inadequate H2O, Decrease in urine
frequency, darker urine
Tx
Shade, rest, cool, increase H2O to quench thirst
o Heat Stroke
LOR
DICC, ataxia, possible seizures, possible
hallucinations
Essentially, heat stroke is defined by the change
in LOR
HR
Serious increase
RR
Serious increase
SCTM
HOT
Tx
Transport and aggressively cool
o Hyponatremia
Same Sx as heat exhaustion, but caused by excessive
water

Rehydration mix
1 tbsp salt, 8 tbsp sugar, 1 liter of water

How long would it take for you to go unresponsive if you fell into
freezing water?
Approximately 12 minutes?
o Actually 1-2 hours

Bites and Stings


North American Bites and Stings
o Snakebites
Over 3000 species of snakes, 375 known as venomous
120 species
20 known as venomous
Pit viper
Has a cytotoxin, causes necrosis, localized effects
Coral snakes elapidae
Carries a neurotoxin
Who is at risk?
Rural inhabitants
Agricultural workers
People hassling snakes
Accidental encounters
Prevention
Leave snakes alone
Learn local snake habitat and habits
Wear boots and long pants
Dont step or reach blindly
Use caution at night
Close doors and tents at night
Snakebites
Primarily defensive
Strike fast from any position
Hand, forearm and lower leg most common bite
sites
Venom release varies
S/Sx
Pit Vipers and Vipers
Primarily hemotoxic
Fang marks
Swelling and Pain
Bruising and Blisters
Weakness, sweating, chills
Nausea, vomiting
Elapids
Primarily neurotoxic
Local swelling
Nausea, vomiting
Weakness, dizzy
Drooping tongue, facial muscles, eyelids
Ineffective Tx
Cut and suck
Suction
Ice
Topical medications
Tourniquets/constriction bandages
Electroshock
Effective Tx
Scene Safety
Immobilize the limb
Transport to a physician/hospital
Monitor for S/Sx of envenomation
No unproven or discretied treatments that may
harm
Clean bite if not in Australia
Elapids
Consider pressure immobilization
Evacuation Guidelines
Any snakebite
Rapidly S/Sx of envenomation
North American Snakes of Medical Importance
Elapids
Coral snakes (Micruroides)
Rattlesnakes (Crotalidae)
Rattlesnakes (Crotalus, Sistrurus)
Cottonmouth Water Moccasins and
Copperheads (Agkistrodon)
o Gila Monsters
S/Sx
Bleeding, throbbing pain
Weakness, nausea, sweating, dizzy, rapid HR
Tx
Same as rattlesnake bite
o Insects and Arachnids
Important vectors for pathogens
Annoying
Some have toxins that poison
Some cause non-healing wounds
Some have allergens that trigger allergic responses
o Bee, wasp, ant stings
Mild/Moderate Reactions
Local swelling (sting)
Flushed and itchy skin
Hives and/or welts
No respiratory difficulty
Severe Reactions
Large areas of swelling
Respiratory distress
Shock
o Necrotic Spider Bite
S/Sx
Initially painless bite
Red blister appears 1-5 hours later
Bulls eye lesion
Chills, fever, generalized rash, weakness
Tx
Clean bite wound
Evac if necrosis develops
o Widow Spider Bites
S/Sx
Red, itchy area
Initially painless bite site
Pain and anxiety 10-60 minutes after bite
Muscle cramping in the back and abdomen
Burning and numb feet
Headache, nausea, vomiting, dizziness
Tx
Clean and ice the bite
Pain medications
Evacuation
o Insects as Disease Vectors
Mosquito borne diseases include
Dengue
West Nile
Malaria
Yellow Fever
Rift Valley Fever
Field Protective measures include
Wear long sleeve shirts and pants
Sleep under mosquito netting or in tents
Avoid exposure at dawn and dusk
Avoid mosquito prone areas
Use repellent
o Scorpion Stings
S/Sx
Mild
Local pain, swelling
Serious
Increased pain, numbness, tingling
Nausea, vomiting, sweating, blurred vision
Tx
Clean wound
Ice or cool water
Evacuate
o Ticks
Ticks are vectors for:
Spotted fever
Tick fevers
Lyme disease
Lots of other illness
Tick Bite Prevention
Poison Ivy, Oak and Sumac
o Urushiol
o About 10% dont react
o Tx
Wash with cold water and soap ASAP
Creams, lotions etc.
Marine
o Jellyfish
Remove, saltwater rinse, removing further
o Stingray
Clean, then hot water soak
Submersion Incidents (Drowning) Brady Ch.31
Panic! Voluntary breath-holding
Hypoxiadecreased LORunresponsivenessrespiratory arrest
o Point of Rescue: Unresponsive
Recovery position
o POR: Respiratory arrest
PPV, monitor pulse
Cardiac arrestbiological death
o POR: Cardiac arrest
CPR
AED
Ensure that they are drive
Very, very young children: Mammalian Dive Reflex
Vagal response, parasympathetic response, slows
down all processes
o POR: Biological death
You have 4 to 6 minutes
You basically have an hour until you are unresponsive
Drowning
o Changing definition
o Preferred term is submersion
Tx
o Scene safe?
Reach, throw, and go
o Spine precautions
o Managing their airway
o Managing their breathing
o Managing/checking their circulation
o Thinking again about their spine
o Thinking about their environment
Note
o White foam coming from upper airway?
o Ventilate straight through, its just surfactant
Dive injuries (p. 110 spiral)
o Its all about gas pressure
o Every 33 seawater/34 freshwater descended = +1 atm
o Barotrauma of descent
Middle ear blocked
Eardrum rupture
Sinus squeeze
Mask squeeze
Dental barotrauma
Cavities
Typically no life threats
o Barotrauma of ascent
POPS
Pulmonary Over-Pressurization Syndrome
AGE
Arterial Gas Embolism
Threat of stroke
Heart attack?
Could block blood supply to the spinal cord
Decompression Sickness
The Bends
Nitrogen in the blood bubbles up
High Altitude Injuries
PPV by patient, crackling in the lungs
HAPE
o S/Sx
Shortness of breath at rest

The Medical Patient
Begin with standard assessment, but begin with SAMPLE at last row
and go to vital signs, then head to toe
Sx of Pain/Discomfort
o Requires further explanation
OPQRST
Onset
What were you doing?
Sudden or gradual?
o Maybe a combination of both?
Provokes/Palliates
What makes it feel worse?
What makes it feel better?
Quality
Describe?
Sharp or dull?
Region/Radiation/Referred
Where is the pain?
Can you point to it with one finger?
Does it travel anywhere?
Severity
What is your pain on a 0-10 scale?
What is the worst pain youve ever felt?
Trend in pain level?
Time
How long ago did it start?
How long have you been feeling this way?
Constant or intermittent?
Cardiac Emergencies (ch. 18)
Myocardium
o The heart
SA node sends electrical impulses to the AV node, which
sends it to the bundle branches
AV can send its own pulses at about 60 a minute
Atherosclerosis

Arteriosclerosis
Ischemia
Decreased blood flow to the tissue, typically the
heart
Infarction
Tissue death
4-6 hours, most tissue will be dead
Acute coronary syndrome
Angina or Angina Pectoris
(Acute) Myocardial Infarction
Tissue death of the heart
Really, a heart attack
o Before allowing a patient to refuse treatment, you must
inform them of the risks of refusal up to and including death
Heart Attack
o S/Sx
All could be true for angina as well
Chest pain
OPQRST
Sudden
Provoked by stress or exercise, sometimes
nothing
Palliated by calming down, resting, oxygen,
nitroglycerin
Quality is typically squeezing, pressure,
or tightness, or heavy/uncomfortable
Region is substernal, may radiate to L jaw,
arm, back, or epigastric system
Severity is always more than 0
Typically 15-20 minutes or more
People will feel anxious
Denial/Feeling of impending doom
Dyspnea
If someone is having trouble breathing, ask them
how their chest feels, and vice versa
Lung sounds
Could be clear
Could be wheezing (Cardiac wheezing)
Wet/Rales
o CONGESTIVE HEART FAILURE
Pulse could be high, or it could be low
Heartbeat could be irregular
Respiration will be high
Skin
Pale
Ashen or gray maybe?
Cyanotic?
Moist
Diaphoretic?
Blood pressure could be high or it could be low
Nausea and vomiting
Lightheaded
Dizzy
Fainting?
Fatigued
Weakness
o Tx
ABCsO2
Give O2 if SpO2 is less than 94%
Calm and rest the patient
Reassure the patient and put them in a position of
comfort
Assist with patients meds
Aspirin
Anti-coagulant
4 81 mg tablets
o OR
1 325 mg tablet
You cannot give an aspirin to someone who
is allergic to it
o Find this out in the SAMPLE history,
ask specifically
Nitroglycerin
Vasodilator
1 tablet/spray sublingual
1 dose every 5 minutes
You need to ensure that the patients
BP>100 systolic to administer nitroglycerin
Do you have any erectile dysfunction
medications on board?
You can repeat this process up to 3 doses
o Beyond, theyre going to need
something else
Transport and monitor
Abdominal emergencies/illnesses
MOI
o Ruptures
Blunt trauma
o Perforation
o Hemorrhage
o Infection
o Obstruction
o Torsion
o Evisceration
o You need to know if there WAS an MOI or just an HPI
When doing your head to toe
o CC will be pain
Is the pain always there or is it pain on palpation?
Does it hurt when I press or when I let go?
Pain on rebound? = rebound pain
Pain on palpation? Pain on rebound? Pain on foot strike?
o Rigid/Distended is bad
o Bruising is bad
o Scars are bad
o Do you hear any bowel sounds?
You should hear them
o Any obvious wounds?
What to look for during your sample history?
o Hx: Quality
Visceral pain
Its coming from the organs themselves
Solid organs feel like a dull and diffused pain
Parietal pain
The peritoneum can be irritated or inflamed
Referred pain
Pain occurs in another place
Tearing pain
It will be almost an irritated pain
BORNFSH
Blood
Anywhere in feces, vomit, urine etc.
Other people with similar S/Sx
Recent changes to your diet?
Nausea/Vomiting/Constipation/Diarrhea
Fever
Shock? Stress
History of this pain?

Aortic Abdominal Aneurysm
o Sharp tearing pain
o Aorta ruptures
o You are probably going to die and theres not much that an
EMT can really do
Abdominal Pain Evacuation Criteria
o Pain
More than 12 hours
Rebound pain
Footstrike pain
Specificrigid/distended/tender
o Blood
Blood in feces/urine/vomit etc.
Volume and colors
Vomit it will look like coffee grounds
S/Sx shock
o Miscellaneous
Fever above 102/39
S/Sx with pregnancy
Persistent problems with:
Vomit
Diarrhea
Anorexia
Diabetic Emergencies
Type I
o Pancreas does not produce insulin in the proper quantities
o Insulin dependent
Type II
o Caused by diet, medications
Hypoglycemic
o Onset
Sudden
o Why?
Took insulin
Ate their meal then,
Exercised
o Vitals
LOR
Sliding down AVPU
Altered mental status
Grumpy
DICC
Seizures
HR
Elevated
SCTM
PCC
Glucose
<80
60
Altered mental status
50
Unconscious
o Tx
Sugar
Glucagon
Hyperglycemic
o Onset
Slower
o Why?
o Vitals
LOR
Drunken
HR
Elevated
RR
Elevated
Glucose
>120-140
300
Dehydration
o S/Sx
Peeing a ton
Increased hunger
Increased thirst
o Breath
Smells fruity, smells like acetone maybe
We want to take their blood sugar ASAP if possible
Protocol: Standing Orders for Administration of Oral Glucose
o Altered Mental Status
o Hx of Diabetes
o Intact airway
o ADMINISTER GLUCOSE
Tx
o Ensure before you leave for the expedition that they have
their insulin, their glucometer, extra batteries, glucose, ketone
strips
Require that they bring twice as much as they usually
bring
o Give sugar
Continue to administer until there is a change in their
mental status
o Lateral recovery
Wilderness Px
o Experience managing in stressful condition
o Hx = no emergencies in a year
o Well fed and hydrated
o Carry double
o Insulin, syringes, glucometers, strips, spare batteries
o Pre-trip interview
o Blood sugar trip log
o Sick day plan
Neurological Emergencies
What is causing this persons brain To STOP
o To
Toxins
o S
Sugar/Stroke/Seizures
o T
Temperature
o O
Oxygen (Shock)
o P
Pressure
Stroke (CVACerebral Vascular Accident)
o Basically the neurological version of a heart attack
o Part of your brain stops receiving blood flow
o Occlusive stroke
Artery is simply blocked by a clot
o Hemorrhagic stroke
Caused by brain hemorrhaging
o S/Sx
Hemiparesis
Weakness/paralysis on one side of the body
Facial droop
Headache
Speech problems
Reaching for the information and delivering
improper information
Word salad sometimes
Vision problems or changes
Incontinence
Memory Problems
o Assessment
FAST Exam
F
Facial droop
o Ask them to smile
A
Arm drift
S
Speech problems
o Have them repeat a sentence
T
Time last seen normal
o Not when they were discovered to
have changes, the last time you
remember them being normal
You only have three hours for an
occlusive stroke to deliver clot
busting medication
(P)
Previous deficits
o Tx
ID that they are possibly suffering from a stroke
Provide emotional reassurance
O2, probably a nasal cannula
Transport them in a Fowlers position
You need to first and foremost EVAC ASAP
You will need to go to a stroke center
MAKE SURE YOU RECORD THE TIME LAST SEEN
NORMAL
o TIATransient Ischemia Attack
Like a stroke but it goes in and out
Still requires immediate transport because you are at
higher risk for a stroke
Seizure
o Causes
Overstimulation
Eclampsia
Pregnant women, usually in the third trimester
Group of symptoms
o High blood pressure
o Excess protein in your urine
Low sugar
Low oxygen
Head injury/HACE
Excess temperature
Fever
Alcohol withdrawal
Epilepsy
o One of the really big risks is a lack of breathing in a seizing
person
o S/Sx
Full body convulsions
Aura
Epileptics can know ahead of time when they are
about to have a seizure sometimes
Collapse
Postictal state
o Treatment
O2 via NRB
Let them seize
PROTECT!
Protect their airway
Protect the patient
Protect their dignity
Patient Assessment System
o Status Epilepticus
One seizure after another without regaining
consciousness
Tx
o MOI?
Spine control
o Do your ABCs, do the full patient assessment system
o Look for clues as to why the person is altered
o GIVE SUGAR
o Continually reassess their vitals
Respiratory Emergencies
Assessment of the Respiratory Patient
o LOR, SCTM, and RR and Quality
o Pediatric RR is (p. 312)
Infant 20-40 B/Minute
Child 15-30 B/Minute
o Check for posture
Tripod, supine
o Lung sounds
Wheezing, rales, crackling, coarseness
o Heart Rate
A&P
o Hypercarbic Drive, the reason we breathe
COPD
o Chronic Obstructive Pulmonary Disease/Disorder
Chronic Bronchitis
Emphysema
Can cause a switch over to the hypoxic drive
Hyperventilation
o You have too much oxygen and have blown off way too much
CO2
o Cyclical process
o Anxiety attacks often cause this
o Coach them out of the hyperventilation if possible
Pulmonary Embolism
o S/Sx
Dyspnea
Sharp, one-sided chest pain
Sudden onset
Clear lung sounds
o Hx
Sedentary
Prolonged bed rest
Long bone Fx
Marrow in the blood stream
Smoking + Birth control pills
o Tx
ABCs and O2
Rapid transport
Pneumonia
o Infection and/or inflammation of the lung tissue
o Hx
Upper respiratory infection
Bronchitis possibly
Gradual onset
o S/Sx
Dyspnea
Cough (productive)
Fever (not in geriatric)
o Tx
Antibiotics are the treatment, but from an EMT
perspective you should transport immediately
ABCsO2
(Humidified oxygen)
Antibiotics
Asthma
o Triggers
Stress
Exercise
Allergy
Dust, smoke, chemicals
Cold environment
o Reactive airway disease
o The bronchi, typically the smaller bronchioles, are spasming
and blocking the airway
o S/Sx
Dyspnea
Wheezing
Inspiratory or expiratory
Severe is the silent chest
Elevated heart rate and respiratory rate
Coughing sometimes
o Tx
Remove the trigger
ABCsO2
Maybe create a better breathing environment for the
patient
Put their mouth in their shirt
Albuterol inhaler (Rx)
2 puffs every 4 hours
Acute episodes may need more aggressive
treatment
Transport the patient
Rapidly evacuate anyone with signs of a SEVERE
asthma attack
Epinephrine?
Congestive Heart Failure
o S/Sx
Right sided heart failure can lead to pedel edema
Left sided heart failure the fluid is going to back up in
the lungs
Pulmonary edema
Rales and crackles
o Tx
ABCsO2
Positive Pressure Ventilation or CPAP
Continuous Positive Airway Pressure
Transport
Vitals Review
Time Taken
HR & RR: Rate, Rhythm, Quality
Sp02%
o On room air or on a nasal cannula, NRB, etc.
Poisons/Toxicology
Absorption
o Safety/BSI
o Dry Chemicals
Brush it off
o Wet Chemicals
Flush
o In eyes
Flush it out for a number of minutes
Inhalation
o Safety
o Carbon Monoxide
Binds more effectively than oxygen to hemoglobin
Cyanotic
S/Sx
Decreasing LOR
Cyanosis
Headache
Nausea
Ingestion
o Accidental or Intentional
o What substance?
If you dont know it, call medical control who will
probably put you through to poison control
o You want to know about your patient
Weight, age, sex
How much?
When?
o Activated charcoal
Dont use if there is no airway
Other contraindications
Injection
o Bites and Stings
o Drugs
Anaphylaxis
To be allergic to something you have to be exposed to the allergen
at least once in your life
Pt. Rights
o Patient
Ensure right patient, right drug
o Indication
Moderate to Severe Dyspnea
Large areas of swelling
Especially your airway
Tongue, face, lips, mouth
Hives/Cyanotic
Blood Pressure Drops
HR and RR increase
o Contraindication
No contraindication if used in an emergency
o Expiration Date
Should be current and you should check the color
o Dose
Adult
0.3 ccs, in a 1:1000 concentration
Child
.15 ccs, in a 1:1000
Anyone less than 66 pounds
o Route
Intramuscular
Tx
o Deliver oxygen
o Epi-Pen
o Monitor vitals
o Anti-histamines
Epinephrine
o Vasoconstrictor and bronchodilator
Behavioral/Psych/Mental Health Emergencies (Brady ch. 23)
If there is no organic or physical cause, there may be a mental
health or psychological explanation
Ask as part of SAMPLE just like any other disease
Depression
o ~10% of the U.S. population has been diagnosed with clinical
depression
o Suicidal patient
Are you thinking of killing yourself?
Do you have a plan to kill yourself?
Do you have the means at hand?
Do you have a history of suicide attempts?
Family Hx
Reflective listening
Breathe
Bipolar Disorder (Manic Depressive)
o ~2.5% of U.S. population
Schizophrenia
o ~1% of U.S. population
o False beliefs not grounded in reality
o Hallucinations and psychosis
o Psychotic break
Anxiety
o Anxiety Disorder, Panic Disorder, PTSD, OCD
o ~20% of U.S. population
o
Blisters

Obstetrics/Emergency
Emergencies: Trauma

Female Anatomy
o Uterus
Holds babies
o Eggs come from
Ovaries
o Fallopian Tubes connect the ovaries and the uterus
o Vagina and uterus connected by cervix
o Pregnant
Placenta
Nutrient exchange
Umbilical cord
Blood vessel connection
Amniotic sac
Protection and temperature regulation
Change in Cardiovascular system
Increased blood volume
Increased heart rate
Some women may become hypotensive
Change in GI system
Nausea and vomiting
Menstrual Period
o Roughly a 28 day cycle
o Day 14 is ovulation
Pregnancy lasts for 40 weeks
o Count from last ovulation period
o 1st Trimester
Fetus is developing
Primagravata
o The first pregnancy
o Much more difficult
Teeth and Dental Emergencies

Med Legal
Good Stuff (Help you stay out of trouble)
o Consent
o Good Samaritan Laws
o Protocols
o Documentation
o Confidentiality
Bad Stuff (Things you might get sued for)
o Negligence
RPP standard
Geriatrics
Intro
Effects of Aging on Body Systems
o Cardiovascular
Heart muscle weakens
Irregular electrical dysrhythmia
Are you on a medication for that?
Digoxin/Lanoxin
o Respiratory
Decreased airflow
Less active cilia
o Musculoskeletal
Osteoporosis
Kyphosis
Arthritis
Loss of muscle mass
o Neurological

o Gastrointestinal
Constipation from codeine or vicodin
Concern about obstructions
Liver issues
o Renal
o Integumentary
Thin skin, more prone to tearing
o Vision/Hearing
Cataracts
Assessment
Special Geriatric Findings
o Cardiac Emergencies
o Dyspnea
o Altered Mental Status
o Trauma/Shock
o Environmental Emergencies
o Abuse
The Eye (p. 91 spiral)
Only cover one eye if only one is injured
Conjunctivitis
o S/Sx
Increased tears
Itching
Stickiness
Gunk
Snow Blindness
o S/Sx
Hot sand in your eyes
Photophobia/sensitivity
Redness
Pain
o Tx
Remove contacts
S/Sx go away on your own within about 24 hours
Rest in a dark place
Genitourinary Problems
Case studies
o Late Menstrual Period
S/Sx
Late
No pain
Hx
Sexually active with a male
Stress
Increased physical exertion
Questions
Menstrual cycle?
Birth control?
Morning sickness? (Probably not the best
question)
Breast tenderness?
S/Sx of pregnancy
Lightning (p. 56 spiral)
MOI
o Ground Current
o Splash
Jumping from object to object
o Direct Hit
o Blast injury
o Contact
S/Sx
o Cardiac Arrest
o Respiratory Arrest
o Burns
o Neurological Deficits
Vision
Hearing
CSMs
Tx
o ABCs
o CPR
o Tx Burns
o Evac?
o O2
Search and Rescue
Interview
o Last seen?
o Medical conditions?
o SAMPLE?
Basically a SOAP note history
o Gear + Clothing
o Place Last Seen
o Experience
o Weather
o Mental Health of the student
o Physical fitness
Search is considered an emergency
Containment
Communications?
o What do you have?
o What do they have?
o Whistle is good, signal mirror is also good
Evacuation
o 4 person team
Simple Triage & Rapid Transport
START Triage
o This is primary triage, not secondary triage
o You need a leader for each color group
Triage based on RPM
o Respirations
Not breathing
2 Tx steps
Position airway
o If breathes, red tag, if no breath,
deceased
Next question is rate?

o Perfusion
o Mental Status
Decision-Making (Spiral p. 102)
Medicine is a set of reasonable decisions that change over time.
o Matt diFrancesca
One of the most important decisions a group can make is how they
will make decisions.
Expertise
Heuristics
Analysis
Communicable Diseases
Pathogens
o Virus
o Bacteria
o Protozoa
o Fungi

CLOSED HEAD INJURY VS. BEHAVIORAL EMERGENCY


PUPILS
DRUGS, TBI, OR STROKE

HEART AND LUNGS CONNECTION

FIELD TREATMENT OF DRUGS ETC.



This is a differential cheat sheet. The way it works is pretty obvious.
Go through the symptoms presentthe problems listed are possible causes.
Through examination many can be ruled out quickly (i.e. Medulla
damagebrain trauma when no M.O.I. for trauma is present). It should
work by checking off what the realistically possible causes are, noting
duplicates across different symptoms and creating a differential. This list of
symptoms and their causes is in no way to be taken as exhaustive.

Indicates a symptom with only one cause

Low minute volume


Medulla damage
o Stroke
o Toxins
o Brain trauma
o ICP
Spinal cord damage
Thoracic cage damage
o Rupture of thoracic wall
o Flail chest
Lung damage
o Hole in lung
Hypoxia
Lung tissue damage
Congestive heart failure
Severe sepsis
Flail chest
Shock/hypoperfusion (p. 165)
Hypovolemic shock
o Blood loss
o Internal bleeding
GI bleeds
Distributive shock
o Loss of vascular tone (AKA low blood pressure)
Anaphylaxis
Sepsis
Cardiogenic shock
o Myocardial infarction
o Trauma
o Medical damage to heart tissue
o Cardiac tamponade
Obstructive shock
o Tension pneumothorax
o Pulmonary embolism
Pneumothorax
Edema
Infection
o Alters capillary permeability
Liver failure
o Inadequate proteins for transport
Trauma
o Destruction of capillaries
Altered mental status
Neurologic impairment
Seizures
Neurologic impairment
Inability to speak or difficulty speaking
Neurologic impairment
Visual or hearing disturbance
Neurologic impairment
Inability to walk or difficulty walking
Neurologic impairment
Trauma (obviously)
Paralysis (sometimes limited to one side)
Neurologic impairment
Weakness
Neurologic impairment
Loss of sensation (sometimes limited to one side or area of the body)
Neurologic impairment
Pupil changes
Neurologic impairment
Fast heart rate
Overactive thyroid
o Graves disease
Rectal bleeding
GI bleed
Nausea
Viral infection
Bacterial infection
Myocardial infarction (heart attack)
Vomiting
Myocardial infarction (heart attack)
Paradoxical thoracic motion
Flail chest
Gasping for air
Sucking chest wound
Reduction of breath sounds on one side of the chest
Pneumothorax
Uneven chest wall movement
Pneumothorax
Distended neck veins
Traumatic asphyxia
Cardiac tamponade
Tension pneumothorax
Head, neck AND shoulders appearing dark blue or purple
Traumatic asphyxia
Bloodshot and bulging eyes
Traumatic asphyxia
Swollen and blue tongue and lips
Traumatic asphyxia
Weak pulse
Cardiac tamponade
Low blood pressure
Cardiac tamponade
Steadily decreasing pulse pressure
Cardiac tamponade
Tearing chest pain radiating to the back
Aortic injury or dissection
Differences in pulse or blood pressire netweem the rogjt amd ;eft
extremities or between the arms and legs
Aortic injury or dissection
Palpable pulsating abdominal mass
Aortic injury or dissection
Cardiac arrest
Aortic injury or dissection
Cyanosis
Pneumothorax

Walking knee brace


Improvised C-Collar
Splinting a long bone
Splinting a joint
Above and below
Securing hands of a patient on a backboard that is unconscious
Secure the feet of the patient that is on a backboard
Glasgow Coma Scale
Eye Opening
o Spontaneous Eye Opening4
o Verbal command3
o Pain2
o Dont open--1
Verbal Response
o No response--1
Motor Response
o Obeys verbal6
o Localizes pain5
o Responds to pain4
o Abnormal flection in response to pain3
o Extension in response to pain2
Posturingvery, very bad sign
o No response1
Total is 15, lowest is 3
8 is intubate, so they are in a coma
What are the contraindications for activated charcoal?