[
    {
        "Welcome and Introduction": "hello class and welcome to chapter 7 lifespan development of the emergency care and transportation of the sick and injured 12th edition do you complete this",
        "National EMS Education Standard Competencies": "chapter in the related coursework you will have a fundamental understanding of the physiological and psychosocial differences of each phase of human development you will be able to discuss adaptations and strategies that might work to better assess and manage patients okay so let's get started so humans",
        "Introduction to Lifespan Development": "develop throughout their lives and emts must be aware of the physical changes a person undergoes of various stages because they may alter the approach to patient care",
        "Neonates and Infants - Physical Development": "so neonates and infants and remember neonates is birth to one month okay so and it's covered in chapter 33 obstetrics and neonatal care and infants that is one month to a year in the develop at a startling rate the weight so a neonate usually weighs between six to eight pounds at birth the head accounts for 25 of its body weight after week two infants grow at a rate of about one ounce per day so they double their weight by four to six months and triple it by the end of the first year the cardiovascular system of a neonate in an infant so at birth the neonate becomes makes the transition from fetal circulation to independent circulation okay so the pulmonary system prior to birth a neonates lungs have never been inflated the first breath is facilitated in part of the chest passage through the birth canal and it increases that inner thoracic pressure so infants younger than about six months are particularly prone to nasal congestions infants have proportionately larger tongues and proportionately shorter narrow airways and some airway obstructions are more common in infants okay so the rib cage is less rigid and the ribs sit horizontally for bag valve mass ventilation remember that the infant's lungs are very fragile so forceful ventilations can result in trauma from pressure or barotrauma so respiratory muscles are immature and they there are fewer alveoli in the lungs and respiratory problems can quickly become life-threatening in neonates and infants okay so the nervous system of neonates and infants the nervous system continues to evolve after birth and neonate is born with certain reflexes so that the neonate is born with a moro reflex and that's basically a startle reflex when a neonate is caught off guard it opens its arms wide and spreads its fingers and seems to grab at things then they are born with the palmer grasp and that occurs when an object is placed into the neonate's palms then there's a rooting reflex and when something touches the neonic's cheeks it will turn its head towards that touch then there's the succulent reflex and that occurs when the neonates lips are stroked and neonates fontanelles are the spaces between the bones that will eventually fuse to form the skull the posterior fontanelle fuses at about three months the anterior fontanelle fuses at nine to 18 months of age a depressed fontanel may indicate dehydration and a bulging fontanelle is indicative of inner increased intracranial pressure this figure shows a great picture of the fontanelles of infants okay so a little bit more about neonates and infants nervous system by two months of age infants can track objects with their eyes and recognize familiar faces in that six months they can sit upright and they begin to make cooing and babbling sounds by 12 months of age an infant can walk with minimal assistance and knows his or her name and their immune system so infants and neonates immune system maintains some of the mother's immunities infants can also receive antibodies via breast and this fosters further boosters their immune system okay so the psychosocial changes of",
        "Neonates and Infants - Psychosocial Development": "infants and neonates and they begin at birth and evolve as the infant interacts with and reacts to the environment and there's a slide of the noticeable characteristics of the various ages okay so crying is the main method of communicating distress of infants and neonates they bond is in its based on a secure attachment so anxious avoidant attachment is found in infants who are repeatedly eject rejected and children show little emotional response to their parents or caregivers and treat them as they would strangers also separation anxiety is common in older infants trust and mistrust refers to a stage of development from birth to about 18 months which involves an infant's needs being met by his or her parents or caregivers",
        "Toddlers and Preschoolers": "okay so let's move on now we're into the toddler in preschool and so their toddler in preschool uh toddlers remembers about one two three years and preschool is three to six years and the physical changes so the cardiovascular system of a toddler preschool is not dramatically different from an adult preschoolers ages three to six years the pulse rate is 80 to 140 beats per minute the respiratory rate is 20 to 25 breaths per minute and the systolic blood pressure is 80 to 100 milligrams of mercury toddlers and preschoolers have not well developed lung musculature and are unable to sustain deep or rapid respirations for an extended period of time weight gain should level off and the loss of passive immunity is one of the most impactful physiological changes at this stage of the human's life neuromuscular growth makes considerable progress at this age and toilet training is usually completed around 28 months of age okay so some psychosocial changes the challenge for this group is sometimes referred to as autonomy versus shame and doubt so at 36 months of age basic language is mastered interaction and playing games with other children begins and by 18 to 24 months this cause and effect begins to become understood so children learn to recognize gender differences by observing role models",
        "School-Age Children": "school age children this is going to be the next group and this is 6 to 12 years physical changes so from ages 6 to 12 a school-aged child's physical traits and functions continue to mature at a rapid rate growth of four pounds and two to five inches each year permanent teeth come in and brain activity increases in both hemispheres so some psychosocial changes so children learn various types of reasoning and we're going to talk about three of those types of reasoning pre-conventional reasoning conventional reasoning and post-conventional reasoning okay so pre-conventional reasoning is how children act almost purely to avoid punishment and get what they want conventional reasoning is when children look for approval from their peers in society and then post-conventional reasoning this is when children make decisions guided by their consequences okay so children begin to develop their self-concept and self-esteem at this age",
        "Adolescents": "now we're going to get into the adolescents and we call them teenagers sometimes this is from 12 to 18 years vital signs begin to level off within the adult ranges so the pulse rates you're going to notice are the same as the adults and this is 60 to 100 beats per minute respiratory rate is 12 to 20 and systolic blood pressure is between 90 and 110 millimeters of mercury adolescents experience a two to three year growth spurt an increase in muscle and bone growth and body changes girls generally finish their growth spurt at about 16 and boys at about 18 years of age the endocrine and reproductive system matures and secondary sexual development takes place so pubic hair and auxiliary axillary hair begin to appear voices start to change and menstruation begins okay so some psychosocial changes so adolescents and their families often deal with conflict as as i'll let adolescents try to gain control their lives from their parents so privacy becomes an issue and self-consciousness increases adolescents may struggle to create their own identity with multiple options for gender exists and many are fixated on their public image okay so they often want to be treated like adults yet cared for like younger children anti-social behavior and peer pressure tend to peak at age 14 to 16 so smoking illicit drug use and unprotected sex are problems that may arise and eating disorders can arise in adolescence from their attempt to gain self-control through what they eat a code of personal ethics develops based partially on parents ethics and values and partially by peers and personal experience adolescents have a high risk for suicide and depressant depression okay so the next group we're going to talk about 19",
        "Early Adults": "to 40 year olds are the early adults and that's the range 19 to 40 and their physical changes so their vital signs do not vary from those that we've seen that will be seen through adulthood and the pulse rate of course will average around 70 beats per minute and once again that range will be 60 to 100 beats per minute the respiratory rate will stay in the range of about 12 to 20 and the systolic blood pressure once again will be between 90 to 120 millimeters of mercury from age 19 to shortly after 23 the body should be functioning at its optimal level lifelong habits are solidified and the body is working at peak efficiency but in the late latter years of early adulthood the effects of aging gradually become evident so some psychosocial changes life centers on work family and stress and during this period adults strive to create a place for themselves in the world and many do everything they can to settle down despite the amount of stress and change this is one of the more stable periods of life",
        "Middle Adults": "now let's talk about middle age so middle age or middle adults are between 41 to 60 physical changes so the vital signs remain about the same middle adults are vulnerable to vision and hearing loss cardiovascular health becomes an issue and cancer the incidence of cancer increases so menopause takes place in the late 40s and early 50s diabetes hypertension and weight problems are common exercise and healthy diet can diminish the effects of aging so some psychosocial changes there's a focus on achieving the goal life's goals middle adult must readjust their lifestyle as children leave home finances can become a worrisome issue and generally people at this age have physical emotional and spiritual reserves to handle life's issues so middle adults can may find themselves caring for children leaving for college and caring for their aging parents as well",
        "Older Adults - Physical Changes": "then there's older adults so older adults include those ages 61 years and up so physical changes life expectancy is constantly changing now it's about 78 years old so it's determined in part by the birth year in the country of residents they are often able to overcome numerous medical conditions but may need multiple medications the cardiovascular system in older adults so cardiac function declines with age largely due to atherosclerosis heart rate in cardiac output decreases cardiac output can no longer meet the demands of the body and the vascular system becomes stiff the heart must work harder to overcome that vascular resistance okay and the ability to prove to provide replacement blood cells decline as as does the blood volume the respiratory system in older adults so the size of the airways decrease or increase and the surface area of the alveoli decreases okay so the elasticity and the strength of the intercostal muscles and diaphragm decreases and breathing becomes more labor intensive by age 75 the vital capacity may amount to only 50 of the vital capacity of a young adult so the chest becomes more rigid and fragile and the cough and gag reflexes diminish along with the ability to clear secretions so older adults are at a greater risk of aspiration and airway obstruction smooth muscles of the lower airway weaken causing airway collapse on inhalation this produces inspiratory wheezing lower flow rates and air trapping in the alveoli older adults are more susceptible to lung infections the endocrine system in the older adults so insulin produces drops off and metabolism decreases the product the reproductive system changes to some extent as well and so you have hormone reproduction for both sexes is going to gradually decrease as they age okay and sexual desire may diminish with age but does not cease then the digestive system in older adults so there's some changes in the gastric and intentional intestinal function and it may inhibit natural intake in utilization in older adults okay so tooth loss may makes chewing difficult and tastes and sensations decrease saliva secretion decreases and this reduces the body's ability to produce complex carbohydrates the ability of the intestines to contract and move food through diminishes in gastric acid acid secretion diminishes diminishes gallstones become increasingly common and decrease elasticity of the anal sphincter causes fecal incontinence the renal systems in the older adults so the filtration function declines by 50 from age 20 to 90. kidney mass decreases 20 over the same span and there is a blood supply reduction in the kidneys okay so there is decrease ability to remove waste and to conserve fluids when needed the nervous system in the older adult so the brain weight may shrink from about 10 to 20 percent by the age of uh 80. motor and sensory neutral networks become slower and neurons are lost but that does not mean that there is a loss of knowledge or skill and then sleep patterns change okay age-related shrinkage creates a void between the brain and the outermost layer of the meninges which provides room for the brain to move when stressed okay then the peripheral nerves slow with age in the older adults so sensations become diminished and may be misinterpreted immerse interpreted increased reaction time causes longer delays between stimulation and motion and prolonged reaction times and slower reflexes contribute to a higher incidence of falls then you have sensory changes so pupillary reaction and ocular movements become restricted visual distortions are common peripheral fields of their a vision narrow hearing loss is four times more common than vision loss and loss of high frequency hearing or deafness occurs then the psychosocial changes until about five years before death most people retain high brain function statistics may indicate that 95 percent of the elderly live at home and they may need assistance from family friends or home health care increased need for assisted living facilities and financial limits may restrict the access to health care or medications today more than 50 percent of all single women in the united states who are 60 years or age or older are living at or below the poverty level one of the important issues that an elderly needs to face is their own mortality isolation and depression changes can be challenges",
        "Review and Conclusion": "okay so we that concludes chapter seven um so we're going to go through these uh review questions and see how much we learned okay so number one when providing bag valve mask ventilations to an infant what is the most important thing to remember and i think that it's b and the infant's lungs are fragile yep that's it you see an infant capable of reaching out to people and drooling she is most likely what do we think see she's most likely four months of age okay an infant who is repeatedly rejected experiences what type of attachment and it's going to be the anxious avoided attachment and this is observed in infants who are repeatedly rejected so it's b why do colds develop so easily in toddlers and preschoolers i think it's d yeah all of the above so toddlers experience that loss of passive immunity they do not have well-developed lung musculature and they are spending a lot of time around their playmates and classmates so all of the above all right the pulse rate of a toddler is slightly higher than the adults right so b the pulse rate is 90 to 150 beats per minute a school-aged child looking for approval from his peers and society is demonstrating what type of reason okay so is it pre-convention convention or post and we think that this is going to be conventional thinking right so conventional punishment that's that pre and guided by their decisions that's post self-concept what a self-concept self-concept is how we perceive ourselves and why should you be concerned about a 16 year old patient who seems depressed and i would say if c adolescents are at a higher rate for suicide okay they're they're struggling to create their own identity but are caught between two worlds so c and why do finances become an issue during middle adulthood what do you think i would think it would be a because we're supporting or they're supporting the children and their parents yes and it's a um the parents of adults in this group are getting older and now need care so let's say okay and why is breathing more labor-intensive for the elderly and i think it's going to be all of the above and that's correct all three of the factors make breathing more labor-intensive for the elderly so this concludes chapter seven lifespan development of the new um the new edition of the emt book and thank you for joining me today and if you like this lecture uh go ahead and look around and listen to some more thanks"
    },
    {
        "Chapter Introduction": "hello and welcome to the emergency care and transportation of the sick and injured chapter 10 patient assessment after you complete this chapter in the related coursework you will understand the scope and sequence of patient assessment from medical and trauma patients and all the phases and components of the patient assessment please note that this chapter is divided into five sections scene size up primary assessment history taking secondary assessment and reassessment these divisions will help facilitate the instructor's approach for teaching this skill as a whole concept okay so let's begin as an introduction",
        "Importance of Patient Assessment": "the importance of a patient assessment cannot be overemphasized the assessment process is divided into five main parts as stated earlier and that's the scene size up the primary assessment history taking the secondary assessment and then the reassessment the order in which these steps are performed depends on the patient's condition and the environment in which the patient is found it may be necessary to change the order of some of these steps after scene size up based on your findings and the need to prioritize the care of certain conditions rarely does one sign or symptom show you the patient status and underlying problem a symptom is a subjective condition the patient feels and tells you about and a sign is the objective condition you can observe or measure about the patient",
        "Scene Size-up": "so let's begin with the scene size up the scene size up refers to your evaluation of the conditions in which you will be operating situational awareness is necessary throughout the entire call to ensure safety dispatch provides basic information about the request for assistance okay so the scene size up combines information and observations to help observe ensure safe and effective operations an understanding of the situation conditions prior to responding the dispatcher's information and then an observation of the scene you must ensure scene safety and this cannot be stressed enough issues that you may encounter in a pre-hospital setting can range from minor difficulties to major dangers if the scene is not safe for you and your team to enter the scene and approach and manage the patient do what you can to make it safe or call for additional resources consider traffic safety issues and issues related to scene safety if you must approach a patient on a working roadway consider environmental conditions at the same at the scene as well if appropriate help protect bystanders from becoming patients as well some forms of hazards include environmental physical chemical electrical water fire explosions physical violence also be aware of scenes that have the potential for violence such as violent patients or distraught family members angry bystanders or gangs or unruly crowds an emergency seen as a dynamic changing environment determine the mechanism of injury or moi or the nature of illness so calls for assistant to which you may respond can be categorized as either medical conditions trauma conditions or both so traumatic injuries are a result of physical force that's applied to the outside of the body usually from an object striking the body or the body striking an object for patients who've experienced traumatic injuries determine the mechanism of injury and you're going to hear that as moi terms commonly associated with moi include blunt trauma and penetrating trauma medical patients determine the nature of illness and this there are some similarities between the mechanism of injury and natural illness and sometimes you might have to talk to the patient family or bystanders to get it or use your senses to check for clues be aware of the scenes with multiple patients who are exhibiting similar signs and symptoms such as carbon monoxide and this could indicate an unsafe scene for emts the importance of mechanism of injury or nature of illness is valuable in preparing you to care for the patient so consider this next we need to take standard precautions standard precautions and personal protective equipment need to be considered and adapted to the pre-hospital task at hand standard precautions are protective measures that are traditionally been recommended by centers for disease control and prevention for use in dealing with so objects body or blood bodily fluids or other potential exposures risks of communicable diseases the concept of standard precautions assumes that all blood body fluids non-intact skin and mucous membranes may pose a substantial risk of infection when you step out of the ems vehicle and before actual patient contact standard precautions must have been taken or initiated at minimum gloves must be in place before any patient contact also consider glasses and a masks and determine the number of patients that is our next in the scene safety scene size up okay so during the scene size up it's important to accurately identify the total number of patients when there are multiple patients you should use the instant command system identify the number of patients and begin triage so let's talk about triage a little bit triage is the process of sorting patients based on the severity of the patient's condition and consider additional resources so maybe more ambulances or maybe we need police officers or a helicopter or perhaps maybe more fire trucks and then it or it could be advanced life support or air medical also as i stated fire departments may handle hazmat management technical rescue services and perhaps might include extrication from automobile accidents or wilderness search and rescue okay rope rescue or water rescue and then you might also need as an additional resource law enforcement personnel so questions to ask when determining the need for additional resources so you could does the scene pose a threat to you or the patient how many patients are there and do we have the resources to respond to their conditions",
        "Primary Assessment": "after you do the scene survey scene size up now we're doing the primary assessment okay so this is when we actually are about to meet the patient so the patient assessment begins when you greet your patient the single all-important goal of a primary assessment is to identify and begin the treat of immediate or imminent life threats okay so you must physically examine the patient and assess the level of consciousness and airway breathing and circulation the very first thing we do when we walk in is we're going to form that general impression and so this is to determine the priority of care and what is the first part of the primary assessment it includes making a note of the person's age sex race level distress and overall appearance as we approach we want to make sure the patient sees us coming okay so note the patient's position and whether the patient is moving or still avoid standing over the patient if possible address the patient by name introduce yourself to the patient ask about the chief complaint the patient's response can give you insight to the level of consciousness air patency respiratory status and overall circulatory status life-threatening problems should be treated immediately and define whether your patient's condition is stable stable but potentially unstable or unstable to direct further assistance and treatment and next we're going to scan for signs of uncontrolled external bleeding so uncontrolled external bleeding takes priority over other assessments now we're going to assess the level of consciousness so the level of consciousness can tell you a great deal about the patient's neurologic and physiologic status we're going to assess uh assessment of an unconscious patient focuses on the abcs and so sustained unconsciousness should warn you that a critical respiratory circulatory or central nervous system problem there is a problem and some type of deficit might exist conscious with altered level of consciousness may be due to inadequate perfusion medication drugs alcohol or poisoning to assess for responsiveness we're going to use that mnemonic avu and choose one description so we're going to test to determine whether the patient who resp who does not respond to verbal stimuli um will respond to painful stimulus these tests include we could pinch the back of the patient's arm uh pinch the the patient's skin or trap area apply upward pressure along the ridge of the orbital ring along the underside of the eyebrow or the patient who moans or withdraws is responding to the stimulus all right next we want to orient and test the mental status by checking the patient's memory and thinking ability so we're going to evaluate if the patient's ability if he has ability to remember so person does the person does he remember his or her name place can he identify the current location time that's the current year month and appropriate approximate date an event can he describe what is happening he or she okay and if they could answer all those questions that is being alert and oriented times for for and that's person place time and event any deviation from alert and oriented to person place time in an event or from the patient's normal baseline is considered an altered mental status next we're going to identify and treat life threats okay so conditions that cause sudden death are considered life threats and this could be for an example an airway obstruction or respiratory failure or respiratory arrest or shock severe bleeding or prime or cardiac rest in most cases identifying correcting life-threatening issues begins with the airway followed by breathing and then circulation and we say abc in some cases it is more appropriate to address life threats with circulation first so following a sequence of c a b cap okay now we're going to just go right down through into the abcs okay so in the primary assessment we're in the abcs as we move through that primary assessment we're going to stay alert for signs of an airway obstruction we need to ensure the airway remains patent and adequate responsive patients so patients of any age who are talking or crying have an open airway a conscious patient who cannot speak or cry most likely will have a severe airway obstruction and if you identify an airway problem we need to stop the assessment process and work to clear the patient's airway because if the patient has signs of difficulty breathing and is not breathing at it immediately take corrective actions all right so in unresponsive patients we know that they have um unresponsive patients we need to assess the airway patency okay so if there is a potential for trauma we know we're using that jaw thrust maneuver to open the airway if you cannot obtain a patent airway using the jaw thrust maneuver or if it is it can be confirmed that the patient did not experience any trauma we could use that head tilt chin lift maneuver to open the airway signs of obstruction for an unconscious patient so any obvious trauma blood or any other obstruction noisy breathing such as snoring bubbling gurgling cro crowing strouder or other abnormal sounds or extremely shallow or absent breathing these are all signs of an obstruction in an unconscious patient all right so after we have assessed um if the patient is breathing now we need to assess the breathing so once you have um make sure that there is a patent airway make sure that the patient's breathing is present and adequate so as you assess that we're going to ask the following questions so is the patient breathing is the patient breathing adequately and is the patient hypoxic positive pressure ventilation should be performed for patients who are not breathing or whose breathing is too slow or too shallow if the patient is breathing adequately but remains hypoxic administer oxygen so the goal of oxygenation for most patients is a saturation of approximately 94 to 99 percent if the patient seems to develop difficulty breathing after your primary assessment you should immediately re-evaluate the airway consider providing positive pressure ventilations with an airway adjunct when the respirations exceed 28 respirations are fewer than 8 and respirations are too shallow to provide adequate air exchange or shallow respirations can be defined by little movement of the chest wall okay so poor chest exertion observe how much effort is required to make that patient breathe so are there presence of retractions use of accessory muscles are they nasal flaring two to three word dipsnia meaning they get short of breath just talking tripod position that's when they're sitting up and it looks like they're actually in a triangle in the sniffing position or labored breathing respiratory distress is an increased effort and rate okay and then respiratory failure occurs when the blood is inadequately oxygenated or ventilation is inadequate to meet the oxygen demands of the body the ultimate result of respiratory failure could result in respiratory failure if not corrected assess circulation so now we're into the c's so evaluate by assessing the patient's mental status pulse and skin condition so there's three different parts of the circulation that is the mental status pulse and skin condition okay so assess the pulse the pulse if there is a pulse present you will need to palpate it so responsive patients who are older than one year we're going to palpate the radial pulse and that's at the wrist unresponsive patient older than one year we're going to palpate the carotid and that's at the neck and then we're going to palpate the brachial pulse located in the middle area medial area inside the upper arm and children under 1 h okay if you cannot palpate a pulse we're in an unresponsive patient we're going to start cpr skin condition so perfusion is assessed by evaluating the patient's skin color temp and condition and cap refill so skin color which is the description so we're going to talk about poor peripheral circulation will cause the skin to appear pale white ashen or gray high blood pressure can also cause the skin to be abnormally flushed or red and when the blood pressure is not properly saturated with oxygen it'll look blue okay so this might be a little bit hard to see but this little baby's uh face area is bluish it's cyanotic okay so skin color poor peripheral circulation once again causes that skin color to be pale white ashen or gray okay skin temp so normal skin temp will be warm to the touch abnormal skin temperatures are hot cold cool or clammy and then moisture normal moisture is dry and if the skin is wet moist or excessively dry and hot that suggests a problem and then there's cap refills so cap refill is often evaluated in pediatric patients by assessing the ability of the circulatory system to perfuse the capillary system in the fingers and toes okay and so this is a great photo of the skill drill cap refill should be restored within two seconds and it to test it you're going to gently push down on the fingertip until it blanches or turns white okay and then we're releasing it and then we're going to count to see when the normal pink color returns should be less than two seconds all right then we're going to assess and control any external bleeding so should occur before addressing airway or breathing bleeding from a large vein is going to be a steady flow of blood but bleeding from an artery is characterized by spurting okay so that's how you know the difference if it's a flow or if it's spurting venus versus arterial controlling external bleeding is very simple we're just applying direct pressure and then if direct pressure is not quickly successful or if there is an obvious arterial hemorrhage of an extremity we're putting on a tourniquet okay then we're going to perform a rapid scan to identify any life threats so identifying injuries that must be managed or protected before the patient is transported and this is a 60 to 90 seconds to perform a rapid scan it is not a systematic or focused physical exam and to see that you could see skill drill 10-1 in your book okay then after the abc we're going to do the d this is how i remember it and that it stands for determined priority of patient care and transport abcd and the priority of patient include those with any of the following conditions so high priority so if anybody's unresponsive difficulty breathing or uncontrolled bleeding we're going to do it as a high priority patient okay any altered level of consciousness severe chest pain pale skin or other signs of poor perfusion maybe a complicated childbirth or severe pain in any area of the body that's going to be a high priority patient so we're going to load and go okay the golden hour so let's let's talk about the golden hour some people call it the golden period and this is from the time of injury to definitive care during which treatment of shock and traumatic injuries must occur in order to maximize the patient's chance of survival so immediate transport is one of the keys to a survival of the patient who needs immediate care that the emt cannot provide and this is a great slide and it shows the golden hour also called the golden period okay and so discovery of the accident and activation of ems the first 20 minutes then the platinum 10 minutes and that's the initial assessment intervention and packaging of the patient getting that patient off the scene and then you have the ems transport and initial hospital stabilization okay transport decisions should be made at this point transport decisions are based on the patient's condition ability availability of advanced care distance of transport and local protocols all right so next we're going to move into the history taking part and this is the next part of the patient assessment and this includes the history of the patient and the history of the present illness okay so history taking this provides details about the patient's chief complaint and an account of the patient's signs and symptoms so we want to be sure to document all of the following so we want to talk about the date of the incident the patient's age gender patients race medical history and the current uh patient's current health status okay now we're going to investigate the chief complaint and so the chief complaint often is the opqrt questions but we're going to investigate the history of the present illness and we're going to begin by making introductions make the patient feel comfortable and obtain permission to treat we're going to ask few simple and direct questions refer to the patient as mr miss or mrs using the patient's last name ask open-ended questions and they're going to help determine the chief complaint and use eye contact to encourage the patient to continue speaking and repeat statements back to show understanding if the patient's unresponsive of course we're gonna where are we gonna get the information from the patient we're gonna get it from the family all right so we're gonna try and get the the past pertinent medical history and clues about the incident um may be obtained from and that the family a person who may witness or bystanders and see if there's any medical alert jewelry or other patient medical history documentation like a card okay next we're going to use that opqrst mnemonic and this is the mnemonic we use to gather information on the present illness okay so opqrst and uh we're going to gather additional information about the patient's present illness and current symptoms all right so identify pertinent negatives so pertinent negatives are negative findings that weren't no care or intervention okay so let's talk about the op qrst a little bit more the o stands for onset and that is when the um when the problem started p stands for provocation and that's if anything makes the problem better or does anything make the problem worse okay q stands for quality and that's how would you describe the the feeling like the pain is it a stabbing or shooting a pressure r stands for region or radiation so where the actual problem is and does it radiate anywhere severity stands for uh how severe it is so on a scale of zero to ten what does the pain or discomfort feel like and then timing when did it start okay is it uh constant or um does it come and go okay then we're gonna obtain sample and sample stein stands for the s stands for signs and symptoms the a stands for the allergies of the patient m stands for medications p is the past pertinent medical history l is the last oral intake and e is the events leading up to the illness or injury and so sample is the history of the patient whereas opqrsd is the history of the present illness and this is all in the history section of the patient assessment",
        "Critical Thinking in Assessment": "critical thinking and assessment okay so let's talk about critical thinking and this is an essential component in assessing a patient and it involves gathering so we're seeking the facts to help our clinical decision making and scene management we're evaluating so we're considering what the information gathered means and then we're synthetic sizing putting together the information that you have gathered and validated and synthesized into a plan to manage the scene and or care for the patient taking history on sensitive topics okay so these could include alcohol or drugs signs may be confused and hidden or disguised so many patients may deny having any problems the history gathered from a clinically or chemically dependent patient may be unreliable do not judge the patient and be professional in your approach also a sensitive topic include physical or abuse or violence so we have to report all physical abuse or domestic violence to the appropriate authorities you need to follow state laws and local protocols do not accuse instead immediately involve law enforcement it's a mandatory reporting and sexual history it may be a sensitive topic consider all female patients of child bearing age who repeat report lower abdominal pain to be pregnant unless ruled out by history or other information ask about the patient's last menstrual period inquire about urinary symptoms with male patients and when appropriate ask about the fam the potential for sexually transmitted disease in all patients another special challenge is going to be a silence so patience um inextremely is extremely important in dealing with patients and their emergency crisis using close-ended questions that require a simple yes or no may work best so consider whether the silence is a cue or a clue to the patient's chief complaint then you have overly talkative patients and reasons why a patient may be overly talkative include excessive caffeine consumption they might have nervousness or they might have taken crack or cocaine or other methamphetamines and there might be an underlying physiological issue then another special challenge is a patient could have multiple symptoms so you need to prioritize the patient's complaints as you would in a triage so stop with start with the most serious and then end with the least serious another special challenge in obtaining a patient history could be anxiety so consider the context of the situation and recognize that the observed anxiety may be a sign of a serious underlying medical condition frequently anxious patients can be observed in emergency scenes that involve a large number of patients such as a disaster some anxious patients show signs of physiological shock such as polar diaphoresis shortness of breath numbness and tingling in the hands and the feet dizziness or lightheadedness or loss of consciousness anxiety can be an early indicator of low blood sugar levels or shock or hypoxia all right anger and hostility could be a challenge when you're trying to obtain that patient history friends family or bystanders may direct their anger and rage towards you but remain calm reassuring and gentle if the scene is not safe or secured treat retreat until it is secured also if the patient is intoxicated so this is going to be a special challenge do not put an intoxicated patient in a position where he or she feels threatens and has no way out okay the potential for violence and physical confrontation is high when the patient's intoxicated alcohol dolls dulls the patient's senses and then another special challenge could be crying a patient who cries may be sad in pain or emotionally overwhelmed remain calm and be patient reassuring and confident and maintain a soft voice and then there's depression okay so depression is among the leading cause of disability worldwide the symptoms include sadness a feeling of hopelessness restlessness irritability sleeping and eating disorders and a decreased energy level the most effective treatment in handling a patient's depression is being a good listener limited cognitive abilities is also going to be a special challenge in obtaining patient history and so keep your symp keep your questions simple and limit the use of medical terms be alert for partial answers and keep asking questions in cases of patients with severely limited cognitive function rely on the presence of family caregivers and friends to supply answers to your questions and then there will be cultural challenges so don't use medical language patients from some cultures may prefer to speak only with a healthcare provider of the same gender so gain the assistance of a patient's friends or family member too and enlist the health help of health care providers of the same culture or background if possible then there might be language barriers and so you if you can find an interpreter if if possible and if not determine whether the patient understands who you are keep questions straightforward and brief and use hand signals or gestures if needed okay be aware of the language diversity in your community also hearing problems so ask patients slowly and clearly and you can use a stethoscope to function as a hearing aid for the patients you could also learn simple sign language during your career and it will help communicate right or you could use a pencil and a piece of paper then visual impairments so identify yourself verbally when entering the scene it is important that you put any items that have been moved back into the previous position and during the assessment and history taking process explain each step in your assessment of vital signs notify the patient before preparing to lift the patient or move the patient or him or her onto the stretcher all right so we've just concluded the history taking of the of the patient that's the third section now the four section of the patient care report or assessment patient care assessment is the secondary assessment okay so the secondary assessment is the fourth the fourth section so if the patient is stable condition and has an isolated complaint you may choose to perform the secondary assessment at scene but if the secondary assessment is not performed at the scene it is performed in the back of the ambulance and route to the hospital however there are situations where you may not have time to perform the secondary assessment you may have to continue to manage life threats identified during the primary assessment and route to the hospital the purpose is to perform a systemic or systematic physical exam of the patient an assessment that focuses on a certain area or system of the body often determined through the chief complaint or a focused assessment okay and so how and what you assess during your physical exam we're going to inspect paul payton oscar tape and i always say it's look listen and feel so inspection that's the look at the patient for abnormalities palpate that's the feel for abnormalities and the auscultate that's listening with the stethoscope auscultation the mnemonic d-cap btls reminds you what to look for when you're inspecting and palpating various body regions for trauma okay so compare findings on one side of the body with the other side okay so d cap btls it stands for deformities contusions abrasions punctures or penetrations burns tenderness laceration and swelling",
        "Secondary Assessment": "so systematically assess the patient is the secondary assessment and like we mentioned the goal is to identify hidden injuries or causes that may have been identified during your 60 to 90 second exam during your primary assessment okay so you're going to see the skill drill on 10-2",
        "Focused Assessment": "and then um it's we also do a focus assessment so for the medical and we're going to perform this on patients who sustained non-significant mois or response to medical patients okay so typically based on our chief complaint and the goal of this focused assessment is to focus your attention on the body part or system that is affected okay and so when we talk about this focused assessment we're going to um explain uh different areas so we're going to start with a respiratory system first and so if a patient's having difficulty breathing this is what we're going to focus our focus assessment on we're going to look at the patient's chest we need to expose it we're looking for any signs of airway obstruction or maybe some trauma to the neck of the chest we're inspecting the chest for overall symmetry okay so both sides are rising and falling we're listening we're going to auscultate and listen to breath sounds noting abnormalities and we're going to measure the respiratory rate chest rise and fall for tidal volume and effort we're looking for retractions and we're looking for increased work of breathing when assessing for breathing obtain the following of course we're going to do the rrq and that stands for respiratory rate rhythm quality of breathing and depth of breathing all right so continuing with the respiratory system a normal rate in adults range from 12 to 20 breaths a minute children breathe at an even faster rate so what we're going to do and how we're going to do this is we're going to count the number of breaths in a 30 second period and then we're going to multiply them by 2. the respiratory rhythm should be regular or irregular and so regular is the time from one peak chest rise to the next and it should be consistent irregular respirations can vary and it could mean a underlying medical condition or trauma condition serious trauma condition and then the cue the quality of breathing okay so um normal breathing is silent and breathing accompanied by other sounds may indicate a significant respiratory problem we call these advantageous breath sounds and then we're going to look at the depth of breathing so that's the amount of there the patient can exchange and it depends on the title rate and title volume all right and here we go this is a good demonstration and it shows the locations for auscultating breath sounds and you're going to do it on both sides of the chest and multiple lung fields all right and then we're going to listen for breath sounds okay so what are we listening for normal snoring remember snoring that's an upper respiratory that could be from croup or from the tongue then there's wheezing is wheezing upper lower well wheezing is lower right wheezing is lower crackles rhonchi strider so crackles and bronchi are going to be lower and strider could be upper okay so during the focus exam we just talked about the respiratory system if you have some type of respiratory problem now we're going to talk about the focus exam of the cardiovascular system and so what we're going to do if they have some type of chest area pain or chest area complaint okay so we're going to look for trauma to the chest and listen for breast sounds once again and then we're going to consider the pulse and respiratory rate and blood pressure we want to pay particular attention to rate and quality and rhythm of the pulse we need to consider our findings when assessing the skin okay so check and compare distal pulses to determine any right or left-sided differences and then consider auscultation for abnormal heart tones and then the pulse okay so normal resting poles for an adult is between 60 to 100 the younger the patient the faster the pulse rate is what we usually say and this slide is going to show you the normal ranges for the pulse rate and then we're going to do the quality so the rrq once again except for this time it's going to be for the pulse so the rate rhythm and quality so pulse quality where you want to just um they're they could be described as strong or bounding and a pulse that is weak or difficulty of field is is usually described as weak or thready and the pulse rhythm so is it regular or irregular the interval between each contraction should feel the same the pulse should occur over constant regular rhythm the rhythm is irregular it could be because the heart periodically has an early or late beat and if the pulse beat is missed it could create an irregular rhythm and then we're going to take the blood pressure so the pressure of the blood against the walls of the artery is the blood pressure and a drop in blood pressure may indicate a loss of blood or fluid components or a loss of vascular tone and arterial construction and a cardiac pumping problem it could indicate decreased blood pressure is a late sign of shock and abnormally high blood pressure may result in a rupture or other critical damage in the arterial system so when we take the blood pressure the cuff the gauge is a signal and it contains of the following components so the the blood pressure cuff has a wide upper cuff an inflatable wide bladder which is sewn into the cuff it has a ball pump or a one-way valve and a pressure gauge which is calibrated in millimeters of mercury auscultation is one of the most common means of measuring the blood pressure and so you could see the skill drill on 10-3 and also there's palpation so that's feeling and that just depends on the ability to hear sounds and should be used in certain cases to obtain a blood pressure measurement we call that blood pressure by palp and that's on skill drill 10-4 okay all right and so normal blood pressures uh are showing on the screen if it's a low blood pressure meaning lower than normal that's hypo tension and higher than normal is hypertension okay so we've covered respiratory and um cardiovascular and now we're going to get into the neurologic system so when we're doing this focus assessment on the neurological system we are going to assess um anytime we're confronted with a patient who has any changes in mental status or some type of head injury or stupor dizziness drowsiness or syncope we're going to do this neurological assessment okay and so we're going to evaluate the level of consciousness and orientation uh determined the by the patient's ability to talk and once again we're going to use that to have poo scale and if appropriate to determine that mental status also we're going to use the glass calcoma scales and this is a score which can be helpful in providing additional information on patients with mental status changes okay pupils so and during the neurologic assessment we're going to do pupils we're going to look at those and we want them to be normally round and approximately equal size and they should adjust their size depending on the light so the diameter and reactivity to the light of the patient's pupils can reflect the status of the person's brain perfusion oxygenation and condition if the absence of light the pupils will become fully relaxed and they'll be dilated okay so this is a good photo of on this slide and it shows some examples so the up one the top one there's light being shown in the eyes those are constricted then dilated is big and wide open and dark and then there's unequal in slide c unequal pupils okay so a small number of the population exhibit unequal pupils and abnormal pupillary response can indicate an altered brain function so we use this mnemonic and it's pearl and it's useful assessment guide to to um to talk about the pupils so pupils pearl stands for pupils equal and round regular in size and reactive to light",
        "Neurovascular Status": "all right so neurovascular status and so we perform a hands-on assessment to determine sensory and motor response when we're doing the neuro exam focus examine so we want to look for bilateral muscle strength and weakness so we're going to complete a thorough sensory assessment test for pain sensations and position and compare distal and proximal sensories and motor responses on one side to the other we we're going to look at skill drill 10-5 okay in order to get a better understanding for that now once we've done let's say we've done the neuro exam we've done these focus exams now let's say that the patient has a trauma it's a trauma situation and so we're going to do that dcap btls right and so we're going to look at all the atomic regions and we're going to look at the head neck and cervical spine and we're going to palpate check the eyes check the color um assess the cheekbones we're going to check the patient's ears and we're going to look for fluid okay well then we're going to move into the head and neck and cervical spine and we're going to check um all those things related so the max cell maxilla and the mandible we're going to look in the mouth to see if there's any broken teeth and also notice any unusual odors in the mouth okay then we're going to move down to the chest and we're going to look listen and feel in the chest area we're going to move down into the abdomen okay so we're going to palpate for tenderness rigidity and patient gardening guarding not gardening so and then we're going to move into the four quadrants so we're going to move to the um and palpate the fourth quadrants the left upper left lower right upper and right lower quadrant then we're going to move into the pelvis and we're going to inspect the pelvis for symmetry and then we're going to look for the extremities for the d-cap btls in all the extremities we're going to check for pulses motor and sensory functioning okay then we're going to roll the patient usually when we roll them we're putting them on the backboard at that point and we're going to inspect the back for any decap btls symmetry and open wounds we're going to palpate the spine from the neck to the pelvis and and see if we can feel any tenderness or deformity all right now finally we're in the vital sign section okay so now we're going to move into the vital sign section that's the next area of the medical assessment or trauma assessment okay so we're going to assess the vital signs and we're going to use appropriate monitoring devices all right so these devices should need never be used to replace our comprehensive assessment of our patient but let's talk about the pulse ox okay so it's used to evaluate the oxygenation's effectiveness and so it measures the oxygen saturation of the hemoglobin on those capillary beds and so patients with difficulty breathing they should receive oxygen regardless of their pulse ox though okay so even if it says 99 if they have difficulty breathing we're going to give them oxygen all right next we're going to talk about capnography and that can quickly provide information on the patient's ventilation circulatory and metabolism then you're going to do um blood glucose or blood glucometry and this measures the level of glucose or sugar in the bloodstream and that's on skill drill 10-6 okay then we're going to do the nbp measurement and that's non-evasive blood pressure measurement okay and then finally the very last thing we're going to reassess the patient all right so we're going to reassess the patient we're going to perform that reassessment at regular intervals during the assessment process the first purpose of that reassessment is to identify and treat changes in the patient's condition so repeat the primary assessment we're reassessing vital signs and we're going to compare the baseline vitals obtained during the primary assessment with any and all of the subsequent vital signs okay so we're looking for trends did the blood pressure go up did the blood pressure go down did the heart rate go up we're looking for trends and then we're reassessing the chief complaint then we're going to recheck our interventions okay and we're going to identify and treat the patient's condition so any we're going to document any changes and whether it was positive and negative and then we're reassessing so when we have when we talk about unstable patients we're going to reassess them every five minutes it's just a continuous reassessment continuous okay and as i said the reassessment is the last part of the patient assessment so this concludes chapter 10 patient assessment lecture now we're going to go to the review questions to see how much we've learned okay all right here we go",
        "Review": "so during the scene size up you should routinely determine all of the following except all right so accept i think it's going to be the ratio of pediatric patients to adults right we're just looking for the number of patients all right b is the answer you arrive at the scene of an injured person as you exit the ambulance you see a man laying on the front porch of his house he appears to have been shot in the head and is laying in a pool of blood what should we do okay i think it's going to be a retreat to a safe place and wait for law enforcement to arrive of course because we can't enter an unsafe scene right we don't want to become part of the problem okay number three findings such as inadequate breathing or an altered level of consciousness should be identified in the oh goodness all right so not breathing good or altered that's the primary the primary very fast and we need to try and fix those okay we're going to identify those life threats which of the following would not detect would we not detect while determining our initial general impression all right so we're going to see the cyanosis we'll probably hear gurgling severe breathing ah rapid heart rate maybe that's not the initial general we need to check the abcs to do that all right yep indeed the general impression we're not going to be um palpating that for the pulse yet okay your primary assessment of an elderly woman who fell reveals an altered loc and a large hematoma on our forehead uh-oh after protecting her c-spine and giving her oxygen what are we gonna do what are we gonna do so let's see i think they want us to do a rapid exam right or are we going to do a focus assessment on her head i think we're doing a rapid exam to see if there's any life threats perfect so be rapid exam okay a semi-conscious patient pushes our hand away when you pinch his earlobe you should describe this level of responsive to pain right see so they are responsive to pain it puts you away assessment of an unconscious patient breathing begins by how does it begin it's going to begin when we open the airway so if it's trauma remember trauma we're going to do that jaw thrust non-trauma it's head tilt chin lift opening the airway is going to begin our assessment okay your 12 year old patient can speak only two or three words without pausing to take a breath this is two to three word dipstine yup b two to three word dipsneh all right you should determine a pulse and an unresponsive eight-year-old how are we going to do that remember anybody one year or above we're doing the an unresponsive we're doing the carotid pulse in the neck right one year or above one year and under it's going to be that brachial okay so d one year and above when assessing your patient's pain you say it started in his chest but it has spread to his lungs oops spread to his legs sorry this is an example of which part of the opqrst pneumonic so this is region or radiation all right so the opq st all right so this concludes chapter 10 of the patient assessment if you like this chapter go ahead and subscribe to the channel because we're going to be going through the whole book all right thanks have a great night"
    },
    {
        "Introduction to Lifespan Development": "hello and then welcome to emergency care in the streets chapter 10 lifespan development lecture after you complete this chapter in the",
        "National EMS Education Standard Competencies": "related coursework you will have a fundamental understanding of the physiologic and psychosocial differences of each phase of human development",
        "Introduction to Human Development": "okay so let's get started humans evolve as people over their lifespans and paramedics must be aware of the changes that humans undergo at each stage of their life changes will be obvious and sometimes physical and mental these changes may affect the approach to patient care",
        "Infants": "so let's start with infants an infant is a person aged one month to one year babies younger than one month are called newborns or neonates depending on their age and so infants both grow and develop the growth is defined as an increase in size and development represents increased function or mastery of skills so physical changes with vital signs the younger a person the faster their pulse rate and respirations so in children blood pressures often correspond with the weight typically increasing with age weight of full term newborn usually weighs about 7.5 pounds at birth due to fluid loss infants lose 5 to 10 of their birth weight in the first week so infants begin gaining weight again during their second week growth at a rate of one ounce per day their weight doubles by six months and triples by one year cardiovascular systems prior to birth fetal circulation occurs through placenta post birth infants experience physical changes to enable independent circulation through their own vasculature the pulmonary system so a newborn's first forceful breath results from chemical mechanical thermal and sensory triggers young infants who are nose breathers for the first several months of their lives those under six months are prone to nasal congestion so they can cause viral upper respiratory infections so check to ensure nasal passages are clear if called for choking infant when compared to adult infants have the following characteristics they have less rigid red cages diaphragm in a newborn major respiratory muscle intercostal muscles are not well developed yet immature accessory muscles which may cause fatigue and proportionately larger tongue and proportionately shorter narrow airways which may cause occlusion more easily than an adult they have fewer alveoli which decreases surface area for gas exchange and fragile lungs that are easily damaged by excessive force or volume when providing bag valve mass ventilations so bearer trauma is trauma from pressure and it's imperative to use the correct size bag mask device for the patient the renal systems so newborns and infants can be easily dehydrated the ability of the newborn's kidneys to concentrate urine and excrete water may also cause dehydration the high percentage of water in infant urine may cause electrolyte imbalances also their immune system so infants have a passive immunity acquired from their moms that continues during their first year of life breast fed infants receive additional antibodies via milk and when it comes to their nervous system infant's nervous system continues to evolve following birth so newborns cannot localize and isolate a particular response to sensation an infant's brain stem and spinal are present and functioning but memory and fine motor coordination are not yet fully developed an infant's ability to control body temperature is very limited and the motor and sensory develop are most developed by cranial nerves which control blinking sucking and gag reflexes infants are born with the following four reflexes they have the moro reflex and that's when the infant is startled here she opens her arms wide and spreads their fingers grabbing at things they have the palmer grasp and that's when infant grabs an object that is placed in their hand they have a rooting reflex when touched on one cheek the infant turns the head towards that touch and they have the sucking reflex that's when infants start to suck when their lips are touched many of these reflexes are tested when feeding and they're fontanelles so it allows the head to be molded for example when passing through the birth canal three or four bones of the skull eventually they bind together and form suture joints by the age two a sunken anterior fontanelle may indicate dehydrations and sleep pattern is developed through a combination of nervous system development and parental efforts most infants develop the ability to sleep for five hours by age three months some do not develop this until one year a concern related to infant sleep is sudden infant death syndrome or sids muscular system so growth plates often called ephesus plates are located on either end of the infant's long bones and are the centers where longitudinal bone growth occurs growth charts they track the growth and of infants and children they provide percentages comparing to child's growth to growth expected for the age of the child and then teeth teeth um teething generally begins between ages four to seven months teeth erupt in a predetermined order and most children have all of their teeth by age three permanent teeth start to come in around age six psychosocial changes so an infant's psychosocial development begins at birth and involves as the infants interact with and react to their environment infants typically have their own timetable for becoming attached to their family and bonding formation of close personal friendship or relationship it usually is based on a secure attachment which occurs when an infant understands that parents or caregivers will be responsive to their needs an anxious avoidance attachment is observant infants who are repeatedly rejected these children become isolated most infants use crying as the primary method of communicating distress an infants will cry to express anything parents can usually tell what an infant needs by the tone of the infant's cry for infants a reaction to a situational crisis follows three phases there is the protest phase and it can start immediately usually lasts about a week it includes loud crying irritability restlessness and rejection of other caregivers efforts then there's the despair phase and this involves um monotonous whaling because the infant believes the situation is not going to change and then there's a withdrawal this occurs when the infant becomes almost apathetic and appears bored by his or her surroundings developing infants need a predictable environment to feel secure if an infant's environment is too unpredictable he or she may withdraw trust and mistrust so stage of development from birth to about 18 months infants gains trust when caregivers provide a planned organized and stable environment infants respond well to scaffolding and this is instructional technique in which the person builds on what has already been learned so temperament easy children have normal body function have low intensity reactions and adjust readily to their surroundings you should adjust your approach to an infant based on the patient's developmental age allow caregivers to hold the infant allow caregivers to hold the infant during a physical assessment and distract the child save the hardest part of the assessment for treatment and treatment for last",
        "Toddlers and Preschoolers": "okay so the next group we're going to talk about is toddlers and preschoolers and there are physical changes and those a toddler is a child age one to two years a preschooler is a child aged three to five years and as compared to an infant vital signs in this group are as followed so pulse and respiratory rate are slower than infants systolic blood pressure is higher than infants approximately 100 millimeters mercury and weight gain levels off a toddler's cardiovascular system is similar to that of an adult toddlers lose their passive immunity and begin to develop colds so this exposure to others helped them acquire their own immunity toddlers and preschoolers experienced numerous types of musculature growth including the development of gross motor skills and grabbing objects with the full palm and they develop fine motor skills such as picking up a crayon muscle mass and bone density increase and become more like those of an adult renal system changes including bladder control so the average age for toilet training is about 18 months baby teeth will emerge through the teething process and may include pain and fever and sensory development makes tickling fun psychosocial changes so separation anxiety peaks between ages 8 10 to 18 months language acquisition occurs in phases beginning with the ability to speak at one of one to two words at age one year most children master basic language by uh three age three to four years understanding that and using complete sentences and toddlers begin interacting with peers which results in learning about control obedience and competitiveness through game playing paramedics should consider the following when caring for toddler and preschool patients so always include the parent and caregiver position yourself at the child's level and explain what you plan to do ahead of time giving the child choices whenever possible and then save the hardest part of the assessment for last other factors also affect the psychosocial development of the toddlers and preschoolers so there are three approaches to parenting affects a child's development so there's the authoritarian style and this expects complete obedience disregards a child's personal freedom and may lead to a child having self-esteem issues there's the authoritative style and this sets and reinforces rules balancing parental authority with the child's personal freedom and allows children to develop an independent well socialized easy going adults then there's a per permissive style that does not impose any rules if any on the child and tolerates all behaviors including socially unacceptable ones and it may be divided into an indifferent parent who doesn't care or an indulgent parent who's excessively lenient giving the impression of spoiled children although not uncommon in the united states divorce has a profound effect on the child's self-esteem and sense of well-being so children question if divorce has their was their fault and experienced pain from the changing environment most children adopt easy if both parents maintain their children as their priority",
        "School-Age Children": "okay so the next um age we're going to talk about is the school age children this is age 6 to 12 years and the following physical changes often affect patients in this group so vital signs and physical body approach those of an adult children at this age grow approximately 5.5 to 7.7 pounds and 2 inches each year brain function develops in both hemispheres permanent teeth arrive and puberty may begin at age 10 or younger children develop three stages of reasonable reasoning so there's pre-conventional conventional and post-conventional so pre-conventional is reasoning involving acting to avoid punishment conventional is reasoning involving acting to obtain approval from peers in society and then post-conventional is reasoning involving making decisions guided by consequence children develop self-concept and self-esteem so self-concept definition is a person's perception of him or herself and self-esteem is how a person feels about him or herself paramedics should use the same techniques employed for preschoolers note that gaining or losing trust is the biggest issue with this age group so be direct assertive and open",
        "Adolescents": "then we're going to talk about adolescents these are teenagers age 3 to 18 years vital signs level off to that about adult ranges so systolic blood pressure is between 110 and 131 millimeters mercury pulse rates are between 60 to 100 and respirations are in the range of about 12 to 20. this age group undergoes rapid two to three year growth spurt as muscle and bone grows and blood chemistry changes patients in this age group undergo reproductive system changes so secondary sexual characteristics develop in both males and females including enlargement of external sexual organs and pubic and accelerary hair changes in range and depth of voice and girls breasts and thighs increase in size and they begin menstruation although the first period which is called monarch may occur in some school-aged girls both sexes secrete hormones associated with reproduction and conflict often marks the relationship between teenagers and their family privacy becomes more important self consciousness increases as teenagers struggle to fit in rebelliousness may increase as a part of finding their identity and peer pressure is a major factor some teens show more interest in sexual relations and teams begin to develop their own code of personal ethics based on their parents and influences of their environment paramedics should provide discretion respect and privacy to this age group and speak to the patient in an area that is separate from the parents and caregivers if possible",
        "Early Adults": "and then there's early adults that's the next group we're going to talk about and they are ages 19 to 40. vital signs do not vary throughout adulthood and pulse rates will stay around 70. respiratory rates 12 to 20 and blood pressure will be approximately 12 120 over 80 millimeters of mercury and the human body functions at the most optimal level between these ages of 19 to 25 and the following physical changes occur after this group so the spinal discs begin shrinking and fatty tissue increases and leads to weight gain work family and stress define the age group early adults do everything they can to settle down this group tends to seek and find romantic love and have babies this is considered to be the most stable periods of life with fewer physical changes and problems related to well-being",
        "Middle Adults": "and then you have middle adults these middle adults are between 41 to 60. despite the body's high level function patients in this group are vulnerable to the following physical changes so vision and hearing loss cardiovascular disease weight gain due to lower metabolism and cancer rates increase women begin middle menopause between 40 to 50 and this causes bone density loss and cardiac conditions people in this group focus on meeting their life's goal so some must adjust to living with grown-up children and some have financial worries as they face retirement and people now see crisis as a challenge to be overcome rather than a threat",
        "Late Adults": "and then you have late adults so this is people in the group that are 61 or older and vital signs depend on the person's overall health medical conditions and medications the cardiovascular system so atherosclerosis is caused by the buildup of cholesterol and calcium within the walls of the vessels and this can lead to particular partial or complete blockage of blood flow in the vessel in general people in this age group have hearts that are less able to deal with exercise and disease as a result of the following so decreased pulse rate declining cardiac output and an inability to elevate the cardiac output to match the body's demands overall the vascular system becomes stiff resulting in the following changes so there's an increased diastolic blood pressure decreased cardiac output and reduced elasticity of the peripheral vessels of up to 70 percent reduced ability to compensate for blood pressure changes fatty tissues begin to replace bone marrow resulting in the production of fluer fewer blood cells the respiratory system so the following structural changes make breathing more difficult for patients in this age group so the size of the airway increases well while surface area of the alveoli decreases and lungs become less elastic forcing people to use intercostal muscles to breathe muscle strength of those intercostal muscles and diaphragm decreases so changes in mouth and nose leave the airway less protected and the chances of aspiration and obstruction are more likely so it's more difficult to clear secretions and cough and gag reflexes decline weakening of smooth muscles of the upper airway leads to collapse in respiratory wheezing and low flow rates in older adults the vital capacity is significantly decreased because of loss of respiratory muscle mass increased stiffness of the thoracic cage and decreased surface area available for air exchange while vital capacity decreases residual volume increases and causes stagnant air to hamper gas exchange in the alveoli in the endocrine system so reduced physical activity and declining endocrine system leads to weight gain and changes in reproductive system occur in both men and women so males still produce sperm but they lose penis rigidity and females experience atrophy of uterus and vagin the vagina related to menopause decreasing hormone production and then the renal system so structural and functional changes occur in the kidneys filtration declines significantly between ages 20 and 90 and aging kidneys respond less effectively to hemodynamic stress and to fluid and electrolyte imbalances which means the body has decreased ability to eliminate waste and decrease ability to conserve fluids and then gastrointestinal system so functional changes may inhibit nutritional intake and utilization resulting in vitamin and mineral deficiencies and um so there is decreased intense taste decreased saliva production slower gastric mobility diminishing acid secretion decreased ability to excrete nutrients and fecal incontinence then the nervous system so central nervous system changes may include a brain weight loss of 10 to 20 percent by age 80 loss of between 5 to 50 percent of neurons and loss of a much as much of 20 percent of the frontal lobe synapsis slower motor and sensory neuron networks and note the brain's metabolic rate remains the same as does the oxygen consumption so sleep patterns of older adopts adults will change and become biphasic so two phased so peripheral nervous system changes may include overall diminished sensation and deteriorated nerve endings which cause the skin's sense sensitivity to heat cold sharpness and wetness so this can lead to injury and then there's sensory changes so while the senses are affected by aging many patients in this group see and hear well general eye and vision changes though include pupillary reaction um in the pupils will become smaller and sluggish in response to light and increase visual distortions decrease ability to focus at close range related to lens thickening and narrow peripheral fields of vision with greater sensitivity to glare hearing loss related to structural changes is four times more common than the loss of vision in this population so eating becomes less pleasurable due to loss of both taste buds sensation and olfactory perception paramedics should value the chance to learn from wisdom of late adults five years before death most maintain a high level of brain function so general statistics related to this population include many live at home and most are active healthy and independent many have financial concerns relating to paying for health care and basic necessities and late adults must come to terms with their own mortality which may prove difficult as family members and friends die so many older people are happy and actively participating in life okay so this concludes chapter 10 development lecture i hope that you've enjoyed it thank you"
    },
    {
        "Introduction": "hello and welcome to the emergency care in the streets chapter 11 patient assessment lecture upon completion of this chapter and the related coursework you will be able to form a field impression using scene and patient assessment findings you will be able to identify the components of a",
        "Patient Assessment": "patient assessment process and describe the essential actions or steps within each okay so let's get started one of the most important skills you will develop as a paramedic is the ability to assess a patient combines a number of steps including assessing the scene obtaining the chief complaint and medical history and performing a secondary assessment the process should seem seamless to the patient and it leads to a differential diagnosis which is a list of possible diagnoses based on assessment findings and a working diagnosis which is one diagnosis on which you base your treatment",
        "Assessment Process": "the assessment process should be organized and systematic but flexible as well after the primary survey and identification and treatment of life threats the sequencing of the history gathering and secondary assessment can be tailored to each patient so your job is to quickly identify your patient's problems set your care priorities and develop a patient care plan then execute that plan so let's talk about sick versus not sick",
        "Sick versus Not Sick": "an important assessment skill is determining whether the patient is sick or not sick and this could be based on the chief complaint respirations pulse mental status skin color temperature and condition for trauma patients it includes the mechanism of injury and obvious signs and symptoms of trauma it provides you with the basis for determining whether the patient is stable or unstable and if the patient's sick the next step is to determine how sick minor illness versus life-threatening events so every time you assess a patient you have to qualify if your patient is sick or not sick and quantify how sick the patient is so let's talk about establishing the",
        "Establishing the Field Impression": "field impression based on your patient's history and chief complaint a determination of what you think is the patient's current problem you must be able to communicate with the patient and ask the right questions to make the best decisions you must be a good detective shift through information gain to ask increasingly relevant questions develop a patient assessment style that works for you but is based on sound medical practice is the medical or trauma so is this medical trauma medical patients identify the chief complaint and shift through medical history whereas trauma patients the patient's medical history may be less impact on your care plan the destination may be very important and remember that medical events can cause trauma and trauma events can produce medical problems so keep an open mind so you are ready to respond to your patients needs this flow chart explains the scene size up the first steps of the patient assessment",
        "Scene Size Up": "so the scene size up the scene size up involves looking around and evaluating the overall safety and stability of the scene before initiating any patient care so make sure you have safe and secure access to the scene make sure you are ready to egress out of the scene and consider any specialty resources you need and get them in route the sooner you call for help the sooner it arrives your main focus is to ensure the safety of the well-being of the ems team and any other emergency responders if the scene does not appear safe do what is necessary to make it safe or request additional resources to secure the scene before beginning patient care it requires constant reassessment crash and rescue scenes often in include multiple risk and extrication hazards the threat of another motorist disrupting the scene is always a possibility where an american national standards institute 107 or 207 certified high visibility public safety vest and consider also wearing specialty reflective gloves coats and boots assured that your team can safely gain access to the scene and the patient and then safely exit with the patient if the scene cannot be stabilized consider a snatching grab do not do the absolute least you have to do for the patient to be moved to safety that's what a snatching grab is and establish a safe parameter to keep bystanders out of harm's way formulating a basic plan and visually scanning the scene should take place before you and your team exit the vehicle request additional resources if necessary and be wary of toxic substances and toxic environments proper body and respiratory protection is a must so be wary of potential crime scenes law enforcement should enter and secure the scene first if the ems team unknowingly enters the scene first request law enforcement immediately and if the scene is unstable consider retreating to your rig so formulate an escape plan and park your vehicle away from the scene refrain from entering until law enforcement personnel have secured the scene be aware of the potential for violence from bystanders patients who abuse methamphetamines can have a much larger threat than the average person they're often paranoid and emotionally unstable and um arms sometimes so they may experience delirium never hesitate to call for law enforcement assistance risk related to physical environment include unstable surfaces snow and ice rain consider the stability of the structures around you if you have any doubts leave the area establish a safe perimeter request additional resources and once the safety of the ems team has been insured the safety of the patient is the next priority if you are unable to minimize a hazard consider moving the patient to a safe area and ensure safety of bystanders next establish a perimeter or barrier around the scene okay next we're going to talk about the",
        "Mechanism of Injury": "mechanism of injury or the nature of illness so that's written as the moi and mechanism of injury is the way the traumatic injury occurred the forces that act on the body to cause the damage and it can help you predict the likelihood of certain injuries having occurred and estimate their severity",
        "Nature of Illness": "and then there's the nature of illness that's the general type of illness a patient is experiencing if there is more than one patient or if the patient is obese you may need to request additional resources if multiple patients are present and have similar problems or complaint consider carbon monoxide poisoning or contact with other noxious agent or possibly food poisoning the presence of multiple patients means they must be a must be triaged so listen for clues in the dispatch information and activating law enforcement or the incident man incident command system so ics may be necessary be familiar with the various specialized resources available to you and only specially trained responses responders should participate in rescue operations assess the need for manual stabilization and spinal motion restriction your first priority is your own safety and the safety of your ems team members all patients should be treated as potentially infectious wear properly sized gloves on all calls and wear eye protection if blood or fluids may potentially splash or spray wear a hippa or an 95 mask if inhaled particles are a risk factor and wear a gla a gown if indicated better to err on the side of caution",
        "Personal Protective Equipment": "personal protective equipment or ppe includes clothing or specialized equipment that provides protection to the wearer from substances that may pose a health or safety risk such as steel toed boots or helmets or heat resistant outerwear also maybe self-contained breathing apparatus or leather gloves okay so now we're flowing down the patient assessment",
        "Primary Survey": "and we're into the primary survey it's the second step in the patient assessment so you have the primary survey and there's an examination techniques and you may use three exam techniques during your primary survey or the secondary assessment depending on the urgency of the patient's condition",
        "Inspection": "so inspection you want to look over the patient and noting any abnormalities or asymmetry that may indicate soft tissue emergencies",
        "Palpation": "there's palpation you want to touch to feel for abnormal abnormalities and at times palpation is gentle but a firm touch will help you identify areas of pain and tenderness fingertips are good for detecting texture and consistency while the back of your hand is better for noting skin temperature and then there's auscultation and that's listening to sounds within the body with the stethoscope so next and the primary survey you're going to form a general impression and based on your initial presentation and chief complaint the primary survey is the most time intensive portion of this process you should be able to form a general impression within 60 to 90 seconds as you look at talk to and touch the",
        "General Impression": "patient the general impression is your overall initial impression that determines your priority of patient care it's based on the surroundings the mechanism of injury signs and symptoms and chief complaint it enables you to identify threats to the abcs but you have to avoid tunnel vision and you make conscious objective and systematic observations answer two questions is the patient in stable or unstable condition and is the patient sick or not sick the level of consciousness may provide the first clue to the alteration in the patient's condition decide whether to implement spinal immobilization and restricted procedures and determine your patient's priorities so identify the mechanisms of injury or the nature of illness and identify the age and sex of the patient treat the life threats as you would find them and decide what additional care is needed and what needs to be done on scene or when it when to initiate transport and which facility is the most appropriate okay so assess the mental",
        "Assess the Mental Status": "status by using afu and also the um whether they're alert to person place time or event and that's alert in oriented times four now are they responsive to verbal stimuli are the response of the pain or are they unresponsive and that's the app to score and then assess the airway is the airway open and patent and then the responsive patients who are talking or crying provide a clue about the airway patency so snoring respirations indicates a position problem and gurgling or bubbling indicates a need for suctioning and when considering airway options move from simple to complex the possibility of a spinal injury determines which technique to use to open the airway so of course we know it's the head tilt chin lift maneuver if there's medical and jaw thrust maneuver for trauma if you're going to use a mechanical means to like bag valve mask the patient you need to use an airway adjunct so an oropharyngeal or nasopharyngeal but remember it takes considerable time to prepare so if the patient cannot maintain their airway use a more invasive techniques and this includes an endotracheal tube innovation or a rescue airway such as a king or a laryngeal mask or a surgical airway",
        "Assess the Breathing": "now assess the breathing so is the patient breathing if not you have to breathe for them and if they are breathing is it adequate expose the chest and inspect for injuries and consider the minute volume so respiratory rate multiple by the tidal volume inspired with each breath also consider consider the breathing rate the work of breathing and assess for chest rise and fall note the symmetry of the chest wall in the depth and rhythm of the respirations and then auscultate lung sounds note the presence clarity and any abnormal sounds and then of course it's the sea and that's circulation so perform that full body scan look for any major bleeding or life-threatening injury and check for the pulse and evaluate the skin",
        "Assess and Control External Bleeding": "assess and control external bleeding so perform a rapid exam to identify any major external bleeding venous bleeding is characterized by steady flow arterial bleeding is characterized by spurting and evaluate unresponsive patients by doing a sweep for blood by quickly and lightly running your gloved hands from head to toe palpate the pawls and of course we're doing the radial if they're responsive and the carotid if they're unresponsive adults or children and then the brachial artery and infants count the number of beats in 30 seconds and multiply them by two the quality so a normal pulse is easy to feel a weak one is difficult to feel and with hyper tension the pulse should it can feel bounding and then check the rhythm of it and is it normal and that will be regular irregular if some beads come earlier late or are skipped and that can indicate a serious condition and then report your findings by describing the rate quality and rhythm and we talked about the skin color so color people of color mucous membranes can be assessed normal skin color and light skin is pink and dry and temperature so rises as peripheral blood vessels dilate a fever high environmental temperatures and then it falls as blood vessels constrict so shock the table on this slide shows the results for inspection and palpation of the skin",
        "Restoring Circulation": "so restoring circulation if a patient has inadequate circulation you must restore it control severe bleeding and improve oxygen delivery to the tissues if you cannot feel a pulse and an unresponsive adult begin cpr until the aed in the manual defibrillation is available defibrillator remember the follow standard precautions and you must evaluate the cardiac rhythm of any patient in cardiac arrest with a manual cardiac monitor defibrillator regardless of the trauma or age oxygen delivery is improved through the administration of oxygen and then you want to assess for the patient's disability so a b c d",
        "Neurologic Exam": "perform a neurologic exam or evaluation a mini neurologic exam includes afu and pupils a quick assessment for neurologic deficits so the glass calcoma score most commonly employed reliable and consistent method of assessing mental status and neurologic function it it assigns a point value for opening eye verbal response and motor response and these values are added for a total score",
        "Gross Neurologic Deficits": "assess for gross neurologic deficits so move the patient um have the patient move through all the extremities assess for motor strength and weaknesses and grip strengths and assess for loss of sensation and then you have the e so a b c d e exposing then cover visually inspect areas being examined to make an accurate and thorough assessment you cannot assess what you cannot see and then make the transport decision so you have to identify priority patients",
        "Priority Patients": "typically deemed to be in either an unstable or potentially unstable condition and need definitive care that cannot be accomplished in the field expedite transport by doing only what is necessary on scene and handling everything else in route so there's a list of priority patients on the slide and they include cpr hyper perfusion some complicated birth and i'll let you guys read through those priority patients okay now in the patient assessment we're down to",
        "History Taking": "the history taking and this is the third step in the patient assessment so the purpose of the history taking is to gain information about the patient and learn about the events surrounding the incident history of the immediate event and the pertinent past medical so you want to ask open-ended questions close-ended questions can be useful but generally or usually garner limited info so avoid asking leading questions and ask age-appropriate and education appropriate questions so be patient and use opportunities for patient teaching",
        "Patient Information": "so the patient information so name and chief complaint are the most important pieces to obtain obtain other info in whatever order is most conducive to good patient care and the most convenient",
        "Techniques for the History": "so techniques for the history taking your appearance and demeanor you should be clean neat and look professional and project a good attitude",
        "Note Taking": "note taking let the patient know that you will be asking a number of questions and writing info so position yourself at eye level and maintain good contact and pay attention okay so when you're doing the history taking you want to have some good communication techniques and you want to always introduce yourself and address the patient ask the patient his or her name and how he or she would like to be addressed so avoid catch-all nicknames be familiar with the cultural groups in your area and with any issues that could lead to misunderstanding and asking about feelings so you will need to ask the patient if they're tired or depressed or any number of feelings that are most easily dealt with by denial so try to keep unpleasant sights sounds and smells from the patient who is feeling badly validate the patient's feelings be empathetic but effective with your questioning communicate with empathy so put yourself in the patient's shoes do not hesitate to communicate your feelings and address the emotional impact of what has been said and offering reassurance so be cautious about what you tell your your patients and inappropriate reassurance harms your credibility",
        "Nonverbal Cues": "reading nonverbal cues is what we're going to talk about next so changes in body movements and facial expressions may suggest pain or psychological distress or fear so being a good listener involves patient listening encourage dialogue so care decisions are based on answers to your questions combined with data from your diagnosis avoid medical jargon so use layperson terminology and match your terminology to the patient's level of knowledge and understanding social history is not typically gathered in the pre-hospital setting however it provides valuable info regarding the patient's overall health status and helps to identify risk factors for various disease processes all right so obtaining a history of",
        "Obtaining a History of Alcohol and Drug Abuse": "alcohol and drug abuse so alcohol is often involved in motor vehicle crashes alcohol can mass a number of signs and symptoms including pain so be alert for the smell of alcohol on the patient's breath patients may give an unreliable history and if asked how much alcohol or drug has been consumed the amount is routinely understated right so intoxicated patients can be impatient aggressive and non-compliant the fear of punishment for legal drugs use may lead to denial and keep a professional attitude okay don't judge the patients by appearance or attitude and then taking the sexual history so talk to the patient in a setting that is as private as possible keep your questions focused and do not interject any opinions or biases about sexual choices or behaviors every patient you care for deserves to be treated with compassion and respect okay so when it comes to domestic",
        "Domestic Violence and Sexual Assault or Rape": "violence and sexual assault or rape you are required to report a case if you suspect physical abuse or domestic violence look for clues to indicate and emergency scenes involving domestic violence are some of the most dangerous for ems and law enforcement so maintain evidence per protocol in situations involving sexual abuse or rape be supportive caring and non-judgmental handling physical attraction to patients so it's never appropriate for a clinician to act on feelings of attraction to the patient if a patient becomes seductive or makes sexual advances firmly make it clear that your relationship is professional and keep someone else in the room with you at all times",
        "Ensuring Confidentiality": "and then ensuring confidentiality so it is your duty to maintain confidentiality of a patient information be familiar with relevant laws such as hipaa and state laws and then protecting the patient's privacy you need to interview the pri the patients in a private setting and be persistent enough to obtain information that patient may be reluctant to share but do not hesitate to ask non-essential personnel to leave the room when you gather information from third parties if patients can't provide info other sources on scene may be used the further away the further you go from the primary source the greater the chance of information will contain inaccuracies though family and friends often function as filters for information okay so they may be able to describe the patient's chief complaint history and past pertinent and possibly other current health statuses but remember you cannot reveal medical info about your patients to their family law enforcement personnel and bystanders can also provide info if emergency care responders are already on scene find out what info they already have obtained and the results of any care they've provided for routine transfers take a few minutes to review the transfer paperwork all right so you must strive to understand the differences inherent in all people most common barriers are in communication of breath race authenticity age gender language education religion geography and economic status beliefs can affect many medical decisions and treatment plans dietary practices and family relationships need to be considered during transport and some cultures have identified an identified leader of the household so establish good relationships with the person to enhance that patient care always obtain consent before administering any medicine you must provide the best possible care for all patients regardless of their socioeconomic status and remember the importance of manners like using phrases such as yes sir or ma'am or possible would you facilitating cross-cultural communication so identify an interpreter so consider using a close-ended questions to avoid enact translations right so remind interpreter that information is confidential and use a certified medical interpreter if possible it ensures confidentiality and it understands medical terminology speaking louder will not always overcome a language barrier",
        "Special Challenges and History Taking Dealing with Talkative or Reserved Patients": "so special challenges and history taking dealing with talkative or reserved patients so overly talkative patients determine whether they use uh they it's from some type of medical problem and keep your patient and patients who do not offer enough information ask open-ended questions to encourage that there's also patients who are going to have anxiety so expect your patient to initially be somewhat anxious okay so if your patient remains anxious consider why because high anxiety is an early sign of shock",
        "Patients with Depression": "talking to patients with depression so consider the patient might be depressed if he or she seems sad hopeless restlessness or irritable and then there's situational depression and that's a reaction to a stressful event in the person's life but then there's chronic depression and you must ask about the patient's feelings to assess for risk of suicide also follow your local protocols dealing safely with anger and hostility so anger and hostility at unfairness or and harsh realities are normal but be attentive to changes in body language so establish a safe and secure scene call for law enforcement if necessary and also retreat if necessary",
        "Clarify a Confusing History or Unusual Behaviors": "clarify a confusing history or unusual behaviors so the patients may give you information to the physician that he or she doesn't did not provide to you consider the possible reasons for that confusing behavior might be lack of oxygen or toxic environment or stroke or some type of mental illness manage patients with",
        "Manage Patients with Sensory or Development Challenges": "sensory or development challenges so limited education or intelligence and a skillful question answer approach often yields adequate information so be alert for partial answers or omissions and you may need to get some information from family members or caregivers when it comes to hearing loss low vision or blindness so hearing loss for some patients speaking slowly and slightly louder may be all that's necessary low vision be careful to announce yourself and your reason for being there",
        "Managing Age Related Considerations Pediatric Patients": "alright so managing age related considerations pediatric patients so initial approach should be similar to that of the adult you want to obtain an accurate history but it could be difficult so listen to the parents and be sensitive to the fears of the parents as well pay attention to the relationship between the parent and child tailor your questions to the age of the child right in neonates and infants maternal history and birth history is going to be important gather an accurate family history and travel history and renew of the system should pay special attention to skin ears nose and teeth geriatric patients so can be challenging due to a variety of medical and traumatic conditions not seen in other patients so accommodate sensory losses and patients tend to have multiple chronic conditions and it might complicate the history taking process so they may have multiple complaints or multiple medications gather all accurate medical history along with current dosages signs may be less dramatic in older patients so consider including a functional assessment during systems review alright so responsive medical patients the chief complaint the most serious thing that the patient is concerned about the reason the patient called you or or someone else called you and it should be recorded in the patient's own words okay so don't determine the patient's alertness ask about the events and look for clues on scene or in the home to better understand the patient's condition vague complaints challenge you to ask the right questions and be a patient listener all right and so we know with the history of the present illness we this information should provide a clear sequential and chronologic account of the patient's signs and symptoms so signs of course are what we observe and then symptoms are subjective information that the patient gives us the history of the present illness is the opqrst and then the history of the patient is ample or sample begin with what is going on today and why did you call 9-1-1 if the patient's behavior is inappropriate consider a medical problem such as hypoxia or low blood glucose and then the current health status so it's made up of many unrelated pieces of information it often ties together some of the past history with the history of the current event questions that will be most helpful are what prescription medications are you taking and do you take any over-the-counter meds or are you allergic to anything do you smoke do you take illicit drugs what did you eat today or yesterday do you exercise and what kind of hazards are present in the household so the use of safety belts or protective wear or bike helmets gun locks medication lock boxes and do you have any specific disease in your family or where do you live perhaps how do you spend your time during the day have you had any important experiences lately are you optimistic or decide which items you want to explore and which you do not okay so for family history it helps to",
        "Family History": "establish patterns and risk factors for potential diseases not every aspect of family history is necessary and information should be related to the patient's current medical condition so social history occupational identification may provide information about possible toxic exposures and the environment provides information about lifestyle and chronic exposures travel history is relevant long plane rides may cause pulmonary embolisms and questions regarding diet may be appropriate and then the patient's medical history so the opportunity to learn about any pertinent and chronic underlying conditions frequently linked to the patient's current medical problem and it should include current medications and dosages and also allergies and childhood illnesses and adult illnesses maybe past surgeries and past hospitalizations disabilities",
        "Patient's Emotional Effect": "a patient's emotional effect provides insight into the overall mental health of the patient determine whether the patient has ever experienced the current problem before and a new problem in condition is best considered serious until you prove it otherwise when it comes to unresponsive patients you're going to have to rely on a thorough head to toe plus the normal diagnostics tools to acquire information needed to care for your patient with trauma patients revisit information from that primary survey consider the mechanism of injury and also mechanisms that may be life-threatening include falls so an adult that's greater than 20 feet children it's greater than 10. also high-risk motor vehicle crashes and those are any intrusion ejection death of the other patient person in the vehicle or vehicle telemetry data consistent with the high risk of injury or vehicle pedestrian collision also motorcycle and atv crashes okay so this slide shows significant mechanisms of injury such as ejections um or death of another patient in the pasture compartment also um falls of greater than 20 feet and high speed mechanisms of injuries and motor vehicle crashes of greater than 20 miles an hour or penetrating injuries to the head neck or chest torso or extremities okay if the patient is an infant or child mechanisms that indicate a high priority include falls more than 10 feet falls of less than 10 feet with lots of consciousness or medium to high speed vehicle crashes or bike crashes so multiple mois often come into play during a traumatic event so in motor vehicle crash determine whether seat belt or air bags were involved improperly installed child safety seats can be rendered useless and if the patient shows any systemic involvement with what appears to be a minor nmoi continue the assessment to find the more serious problem so let's talk about a review of the body",
        "Review of the Body Systems": "systems and um pertinent negatives may be way to gain information so some general symptoms so vague non-specific signs and symptoms make it difficult to differentiate between various field diagnoses but ask questions like um are do you have a fever or chills or night sweats or some type of weight variations hair skin or nails so ask questions about a rash or itching in multi-skeletal so ask about joint pain or loss of range of motion or swelling redness or some type of localized heat or deformity with the head and neck pay particular attention to complaints of headaches or loss of consciousness and so eyes and ears with the eyes ask about visual acuity and the ears ask about hearing throat and mouth so for the nose ask about the smell throat and mouth focus on complaints of a sore throat or bleeding or pain or any like dental issues",
        "Endocrine System": "when it comes to the endocrine system ask the patient has enlarged enlargement of the thyroid gland or ask about temperature intolerance chest and lungs you want to screen for dips knee on chest pain focus on any coughing or wheezing ask the patient if they've had pretty previous cardiac events or um pain or discomfort so hematology in lymph nodes so ask about the history of anemia or bruising and then ask about tender or enlarged lymph nodes gi you want to ask about appetite or general digestion pay attention to signs and symptoms that point towards gi bleeding and ask about urinary habits or changes jenna tayuria ask about a current or history of sexually transmitted disease and for women reporting acute abdominal pain um ask about their menstruation cycle or when was the last period or if they've had sexual um intercourse question men about erectile dysfunction and for men who report pain on urination discharge when was their most recent sexual encounter and if they use condoms for the neurologic ask about the history of seizures or syncope loss of sensation or weakness in the extremities or paralysis look for signs of facial symmetry and if you suspect a stroke use the cincinnati scale stroke or the los angeles pre-hospital stroke screen or another tool used in your region okay so now we're going to talk about",
        "Critical Thinking": "critical thinking the goal of assessment is to figure out the most likely reason for the patient's chief complaint and how best to address it so recognize that there are five aspects of critical thinking there's concept formation data interpretation application of principles reflection in action and reflection in action so basically there's two reflection in actions the first one being willing to change course as you interpret the patient's condition and then the second is doing honest and thorough post-run fatigue to benefit learning you must be able to think and perform well under pressure and you must be a great listener and a patient listener okay so clinical reasoning we're going",
        "Clinical Reasoning": "to talk about next and this combines knowledge of anatomy physiology pathophysiology and the patient's complaints to help direct questioning when you are obtaining history so note any abnormal symptoms of physical findings as well as their anatomic location pay attention to signs and symptoms that are inconsistent with your working diagnosis and then your differential diagnosis and that's a working hypothesis of the nature of the problem start with broad possibilities and consider the patient's chief complaint and once you have determined your working diagnosis continue to question the patient to help confirm the diagnosis all right so now we're moving into the fourth step which is the secondary assessment",
        "Secondary Assessment": "the secondary assessment is the process by which quantifiable objective information is obtained from a patient about his or her overall state of health compared to subjective historic information that is obtained from the patient together these types of information can give you a comprehensive field impression and a differential diagnosis",
        "Secondary Assessments": "secondary assessments consist of two elements obtaining vital signs and performing a systemic physical exam such as a full body exam a focused exam on a specific injury or an exam that is based on the body system of the chief complaint the appropriate abnormalities on ex on examination so you must understand the wide variety of normal as you approach the patient consider body systems and anatomic locations and the start of the exam is determined by factors such as the stability the chief complaint the history and the ability to communicate not every aspect of the secondary assessment will be completed in every patient",
        "Factors To Consider When Beginning an Exam": "so factors to consider when beginning an exam include the location or the position the patient's point of view maintaining professionalism so always protect the patient's privacy the physical exam of priority patients so the physical exam performed depends on the patient's need if traditional physical exam isn't possible a full rapid full body scan may be required a 60 to 90 second non-systematic review and palpation of the patient's body inspect the soft tissue and look for open wounds and palpate for pain and tenderness okay and so to perform a rapid full body scan",
        "Rapid Full Body Scan": "see skill drill 11-1 assessment techniques include you're inspecting and so you're just looking at the patient palpation and palpation is you're touching for the purpose of obtaining information and then percussion so this entails gently striking the surface of the body typically where it underlies various cavities it detects changes in the denseness of the underlying structures so normal lung is medium to loud with low pitched sounds muscle and bone is soft high pitch and hollow organs are loud high pitched and tympanic it requires a lot of practice so to perform percussion c skill drill 11-2 and then auscultation then that involves listening with a stethoscope and it requires keen attention to thorough understanding of what normal sounds like and a lot of practice and so this table shows normal vital signs at every age in different ages",
        "Vital Signs": "so vital signs their baseline is the first set and then serial vital signs are additional sets you want to do the pulse of course the rate rhythm and quality and then palpate the pulse so um several several points including the following areas so radial brachial femoral and carotid count 30 seconds and multiply by two these photos show the location of common pulse points in the body and then the respirations so the rate",
        "Rate Rhythm and Quality": "rhythm and quality and then um",
        "Respiratory Rate": "so the respiratory rate typically assessed by inspecting the patient's chest the quality so you can learn um to recognize the pathologic respiratory patterns or rhythms such as tachypnea or acoustimal respirations and the rate should be measured for 30 seconds and multiplied by 2 in pediatric patients and the table on this slide shows pathologic respiratory patterns then you want to do the blood pressure",
        "Blood Pressure": "and that's the measurement of force exerted on the walls of the blood vessels it's commonly measured in the peripheral artery it's a product of the cardiac output and peripheral vascular resistance it's measured using a cuff that is appropriate to the patient's size and i ideally should be auscultated",
        "Blood Pressure Cuff": "blood pressure cuff gauge should be inspected periodically because it can lose accuracy and require recalibration then the temperature so when using a device for measuring the tympanic membrane's temperature make sure that the external auditory canal is free of serum and position the probe in the canal so that the infrared beam is aimed at the tympanic membrane wait two to three seconds until the digital temperature reading appears then use your pulse ox so you should never be used as an absolute indicator of the need for oxygen it requires the percentage of hemoglobin saturation it measures that and it can provide inaccurate information for a variety of reasons so equipment used in the secondary it includes the stethoscope blood pressure cuff reflex hammer sometimes gloves and sheets and blankets capnography or glucometry and then you have your stethoscope so the acoustic it does not amplify sounds it blocks out ambient sounds and then your electronic it converts sound waves into electronic signals and amplifies your cuff is used to measure the blood pressure it consists of an inflatable cuff and a nanometer which is the pressure meter okay so the physical exam",
        "Physical Exam": "we're going to talk about next and that's the most important skill a healthcare provider can master you will begin to gain information regarding the patient's overall presentation as you approach the scene so look for signs of significant distress such as mental status changes or labored breathing obvious pain or deformity other aspects that may be worth noting is the dress and hygiene expression and overall size or posture and also odors in overall state of health so there are terms that describe the degree of distress such as mild moderator acute severe and there's other terms that describe the general state of the patient's health such as chronic or frail robust robust or vigorous the secondary assessment is driven by the information you gathered during your primary and the history taking",
        "Full Body Exam": "when it comes to the full body exam it's a systematic head-to-toe exam the goal is to identify hidden injuries or identify causes that may not be found during the rapid exam so to correctly perform a full body exam see skill drill 11-3",
        "Focus Exam": "so a focus exam it's performed on patients who have sustained non-specific mois and are responsive it's based on the chief complaint and the most common complaints involve the head heart lungs and abdomen mental status so for any patient who has had a head related problem such as a concussion or headache you should assess and palpate the head for trauma so look for facial symmetry and look at the pupils and assess the cognitive function and that is the ability to use reasoning so you could use the avpu score and assess whether the patient is alert and oriented in four areas so person place time day of event day of the weekend event and use the glass calcoma score and once the basic mental status has been assessed conduct a thorough",
        "Mental Status Exam": "mental status exam so you're looking for general appearance speech and language mood and thoughts and perceptions information relevant to the thought content insight and judgment and then of course cognitive function and that's the attention and you want to pay attention to memory such as remote memory or recent and then you want to look at the skin so",
        "Skin": "the hair and nails the skin is perhaps the quickest and most reliable way of assessing a patient's overall distress and that's to look at the skin there are several uh the skin serves as three major functions and we remember it is uh transmits information protects the body and regulates the temperature in cold environments a constriction of the blood vessels shunt split away from the skin and in hot environments the vessels in the skin dilate you want to examine the skin and inspect and palpate the color temp condition and look for evidence of diminished perfusion such as polar cyanosis diaphoresis and vasodilation or flushing okay so you look also look at the fingernails and lips for perfusion and that's where the epidermis is the thinnest okay so vasoconstriction may indicate pale skin um and it correlates with low arterial oxygen saturation so that's cyanosis also modeling is found in severe protracted hypoperfusion and shock so skin turgor relates to hydration and lesions may only be the only external evidence of a serious internal injury okay",
        "Hair": "hair so examine the hair by inspection and palpation and note the quality texture and distribution all right recent changes in growth and hair loss may indicate an underlying endocrine disorder also look at the nails so the color texture or shape normal nail may be firm and smooth and overly thick nails or nails with lines running parallel to the fingers suggest a fungal infection so this table shows abnormal findings in the nails so eyes ears nose and throat so h e e n t",
        "Head": "so the head so you're going to examine the head for it by feeling and inspecting looking for asymmetry or deformity or tenderness evaluate the face the color moisture symmetry and contour and to correctly assess the head c skill",
        "11-5 the Eyes": "drill 11-5 the eyes you want to look they're the examiner to focus you focus on the because of the central nervous system looking in the anterior chamber posterior chamber inspect and palpate the under in upper and lower orbits you could also assess for visual acuity and um look to see you could do use finger counting and it's done from a noted distance and then look at the pupils so normally round and appropriately equal size in light pupils dilate and in high light or when the light is bright it suddenly introduces pupils inconsistency can constrict okay so evaluate whether the eyes move in harmony and uh can con track in all fields so up down left and right to currently or correctly examine the eyes c skill drill 11-6",
        "Ears": "then the ears so involved with hearing sound perception and balance so they consist of the outer middle and inner so you want to assess for changes in the hearing wound swelling or drainage when it comes to the nose it's divided in the two chambers by the nasal septum each chamber consists of three layers the superior middle and inferior ss anterior and inferiorly and look for symmetry in foreign bodies discharge and tenderness and note any evidence of respiratory disease the throat is evaluate the mouth and pharynx the neck as part of the overall hydration status pay attention to the teeth lips oral mucosa and the mouth so the lips and um the symmetry and gums should be pink with no lesions or edema inspect airway for instructions when it comes to the throat the size color and moisture the oral pharynx discolorations usually odors of the patient's breath and also fluids that might need suctioned when it comes to the neck look for symmetry or masses palpate the carotid pulses and to examine the neck look at skill drill 11-17 okay so the cervical spine that of",
        "Cervical Spine": "course is the pathway by which the spinal cord makes its way out of the brain and into the torso so consider the mechanism and evaluate for any pain or altered mental status indications for spinal immobilization of course are tenderness on palpation complaint of pain in the spine altered mental status a glass count of less than 15 and evidence of a distracting injury or paralysis inspect and palpate so for tenderness and deformity and continue assessment of",
        "Range of Motion": "the patient's range of motion should take place only when there is no potential for serious injury when you're going to the chest inspect of the superior aspect of the torso and then the anterior and posterior portions remember it contains the heart lungs and great vessels and so to examine the chest c skill drill 11-8 you're looking for symmetry and respiratory effort in the general shape of the chest wall or for any deformities or crepitus and then of course you're going to",
        "Breath Sounds": "auscultate for breath sounds remember normal breast sounds are clear and quiet tracheal sounds are loud and harsh brachial are low and high pitched brachial vascular sounds are soft and breezy vascular sounds are fine and somewhat fainter advantageous breath sounds are abnormal breath sounds and they include wheezing which is high piss pitch whistling crackles also called rails and that's wet wrong guy that's congested breast sounds with a higher pitch and rattling strider that's a crowing sound and plural friction rubs that's squeaking or grating the figure shows locations for auscultating those breath sounds and this one shows locations and descriptions of abnormal versions of normal breast sounds it may be helpful to describe the sounds rather than attempt to immediately classify him so are the sounds dry or moist continuous or coarser fine determine if the breast sounds are diminished or absent and localize assess transmitted voice sounds so the cardiovascular system it circulates the blood through the body and blood flows in two currents you have the systemic it carries oxygen rich blood and then the pulmonary circulation it carries oxygen poor blood okay so you",
        "Cardiac Cycles": "have the cardiac cycles and they involve cardiac relaxation and that's diastole filling and then contraction of that left ventricle that's systole the contraction and relaxation of the heart combined with flow of blood generates characteristic heart sounds through auscultation with the stethoscope you have s1 s2 s3 and s4 heart sounds can be heard at the chest wall in a parasternal areas superiorly and inferiorly as well as in the region superior to the left nipple okay the sounds related to the patient's blood pressure and as i mentioned there are five but only the first and the fifth are clinically significant so phase one is clear faint tapping sound that gradually increases in intensity and correlates with the systolic contraction and then phase five it's when all sounds disappear and it correlates with diastolic pressure feel the chest wall to locate the point at maximum impulse and appreciate the a apical pulse palpate for any lifts in the chest wall suggesting hydroperf hypertrophy and be prepared or be aware of any thrills which is humming vibrations also a murmur and that's abnormal whoosh like sound heard over the heart that indicates turbulent flow around the cardiac valve and it could be graded by a range of intense intensity one through six",
        "Arterial Pulses": "arterial pulses are a physical expression of the systolic blood pressure and the venous pressure tends to be low assess the extremities for signs of venous obstruction or insufficiency okay jugular vein distension and if the patient has a penetrating left chest trauma jvd may indicate cardiac tamponade and if the patient has petal edema it could be heart failure in older patients the ability to compensate for cardiovascular insult may be compromised arterial sclerosis or atherosclerosis and diabetes medications for high blood pressure as well cause that pay attention to arterial pulses so the location rate rhythm and quality and obtain an accurate blood pressure and repeat periodically palpatine auscultate the carotid arteries and you're assessing for bruits for a suspected heart problem assess the pulses regularity and strength and signs look for the skin for hypoperfusion breast sounds baseline vitals and extremities for peripheral edema the abdomen can be divided into imaginary quadrants so you have the left upper right upper left lower right lower the ninth so you could also divide them into nine areas and you could see those on the slide contains almost all of the organs of digestion and the peritoneum is a well-defined layer of fascia made up of the parental and visceral peritoneum okay there are three basic mechanisms which produce abdominal pain you have visceral pain this results when hollow organs are obstructed you have inflammation and that's an irritation of sonomic pain fibers located in the skin and then you have",
        "Referred Pain": "referred pain and this has origins in a particular organ but is described by the patient as pain in different locations you want to look for and obtain baseline vitals and orthostatic vitals and then you have in the abdomen generally considered positive if the blood pressure shows a decrease in systolic of 20 and the blood pressure shows an increase in the diastolic of 10 an increase in pulse rate by 20. so documentation whether the patient was pulse was regular if the patient was being monitored and whether the patient was experiencing any other symptoms",
        "Examining the Abdomen": "when examining the abdomen make the patient as comfortable as possible and always proceed with abdominal",
        "Abdominal Assessment": "assessment in the systemic fashion so routinely performed by inspection auscultation percussion and palpation and in the order quadrant by quadrant so you want to refer to skill drill 11-9",
        "Ascites": "ascites so that's fluid within the peritoneal cavity abdominal may appear markedly distended okay so and then bluish discoloration in the periumbilical area that's a colon sign or along the flanks that's a gray turner sign and it's indicative of a ruptured atopic pregnancy or acute peritonitis pancreatitis pancreatitis sorry and then",
        "Auscultation": "auscultation so it may be limited um but setting must be quiet for you to hear bowel sounds so practice on healthy people and note presence or absence of vowel sounds okay so there's hyperactive which is increased or hypoactive is decreased or you know absent palpation so that yields to tenderness palpate each quadrant gently but firmly and a normal abdomen should clear soft without tenderness or masses the patient's responses are going to be the indicate pain or distress and also guarding that's a voluntary or involuntary contraction of the abdominal muscles",
        "The Liver": "palpate the liver so you want to place your left hand behind the patients parallel to and supporting the 11th and 12th rib and place your right hand on the right abdomen just below the ribcage ask the patient to take a deep breath and try and feel the liver edge as it comes down to meet your fingertips also palpate the gallbladder and use the same technique as you palpate for the liver and generally you cannot feel the gallbladder but a patient's response indicating pain may mean possible inflammation you could also palpate the spleen and",
        "Spleen": "you may be able to palpate it if it's inflamed with your left hand under reach reach over and around the patients of support and press forward with the forward the lower left rib cage and adjacent soft tissues with your right hand below the costal margin press in towards the spleen when it comes to an aortic aneurysm it may be seen as a pulsating mass in the upper midline of the abdomen don't palpate it okay if you suspect an aortic aneurysm you want to minimize manipulation",
        "Hernias": "there's also hernias so that's a locate localized weakening of the abdominal wall it's not always visible but place the patient in a supine position and ask him or her to raise their head and shoulders you'll see it when it comes to the female genitalia of",
        "Female Genitalia": "course we're just it's the external genitalia ovaries fallopian tubes uterus and vagina assessment should only be performed it's very limited and reasons to exam would be any type of life threatening hemorrhage right or immediate childbirth clinical reasons for pain and palpation of the fallopian tube and ovary region include etopic pregnancies and pelvic infections make note of any bleeding inflammation discharge swelling or lesions and then the male genitalia of course consists of the things on the slide so the reproductive ducts testes urethra prostate gland and penis an examination is limited with your partner present so assess for bleeding injury or underlying fractures  and a priapism so that's a prolonged direction usually the result of a spinal cord injury and look for evidence of urinary incompetence and then the anus that's the distal orifice of the canal and often evaluated in the same time as the genitalia and assess the need for bleeding control or any other intervention when it comes to the muscular skeletal system you have the joints skeletal muscles principal joints of the upper extremities and then the principal joints of the lower extremities joints become more vulnerable to injury stress and trauma as we age",
        "Common Types of Muscular Skeletal and Soft Tissue Injuries": "common types of muscular skeletal and soft tissue injuries include fractures and sprains dislocations contusions and hematomas and open wounds in a fracture you could have a physiological fracture or a pathogenological fracture when examining the skeletal and joints so pay close attention to their structure and function consider how the joint and extremity look and how well they work okay and then refer to skill drill 11-10 you can have problems with the shoulders or related structures often determined by noting the patient's pulse posture so you want to look for tenderness swelling crepitus deformity rotation and echomosis and assess the range of motion so raise their arms above their head have them demonstrate rotation and perform in internal rotation as well also inspect the elbows you want to palpate between and see if there's pain or tenderness or swelling and the range of motion as well so have them flex and extend pronate the forearms while they the elbows are flexed and then look at the hands so palpate the hands palpate the carpal bones and range of motion of all so make the fists and extend and flex move the hands laterally and medially and then inspect the knees the range of motion as well palpate the hips and palpate the pelvis observe the ankles palpate the feet and ankles assess the range of motion so you want to have the patient inert and exert the ankles and feet and inspect palpate and check the foot and toes",
        "Peripheral Vascular System": "the peripheral vascular system so of course it compromises aspects of the circulatory system and you have the lymphatic system and it's a network of lymph nodes and ducts so the lymph nodes are large accumulations of lymphatic tissue they manage a key function in the body's immune system so perfusion occurs in the peripheral circulation and disease of the peripheral vascular system are often seen in patients with underlying medical conditions such as diabetes or hypertension or obesity or tobacco use during the assessment pay attention to both upper and lower extremities look for signs of that indicate acute or chronic problems and refer the skill drill 11-11 inspect the upper extremities from fingertips to shoulders and the five ps of the acute arterial insufficiency include pain poller and pulselessness inspect the lower extremities from the groin to the buttocks to the feet and palpate the pulses in the lower extremities and note the temperature of the feet and legs and palpate the superficial lymph nodes we know that the spine is can it consists of 33 vertebrae inspect the back from both the posterior and lateral aspects okay so you have this cervical thoracic and lumbar spine and just understand kyphosis is the outward curvature of the thoracic spine scoliosis and that's the curvature of the spine and so this figure shows abnormalities of the spine so lordosis kyphosis and scoliosis the spine using the thumb to touch four spinal processes and check the rest of the back for any significant findings on palpations range of motion so check passively first then actively and if the pain or tingling um stop the exam and mobilize the spine so exam the spine examine you could see the skill drill on 11-12. next we're going to talk about the nervous system so the structure and function of the nervous system the brain is an extraordinary complex structure with enormous perfusion requirement all nerves are channeled to the brain via the spinal cord and the nervous system is divided into the voluntary and the involuntary so you have reflexes involuntary motor response is specific sensory stimuli and you have like primitive reflexes and then you have the babinski reflex test that may be used to check for that neurogenic or neural okay so the neurologic exam it's to determine the patient's mental status and functions and reflexes mental status exam that's that coast map you can see it on the slide it's consciousness orientation activity speech thought memory effect and perception",
        "Cranial Nerve Exam": "cranial nerve exam so it determines the presence and degree of disability and it can be performed in less than three minutes",
        "Evaluation of the Motor System": "so evaluation of the motor system you're going to evaluate and observe the posture and body position watch for involuntary movements evaluate muscle strength check for coordination and also with the finger to the nose and the heel to the shin check sensory function and that's tested bilaterally so assess primary sensory function so the response to stimuli or assess cortical sensory function and that's the perception of gross various light touches to evaluate deep tendon reflexes refer to skill drill 11-13 all right so there are results of the",
        "Results of the Neurologic Exam": "neurologic exam and so you um so there could be delirium and that's um uh consists of an acute sun change in the mental status there's dementia and that's representative of a gradual deterioration of the cognitive cognitive functions and then common encountered abnormalities so you have the facial and extremity strength of symmetry so you could have aphasia or dystonia or seizures vertigo visual changes or tremors",
        "Secondary Assessment of Unresponsive": "secondary assessment of unresponsive so when you're ruling out trauma or after you have positioned unresponsive patients in the recovery position if there's trauma position the patient in a neutral alignment place a properly sized and fitted cervical collar and implement spinal motion restriction look for signs of illness perform at least two set of vitals and always assess the posture of an unresponsive patient so always consider unresponsive patients to be unstable transport rapidly and reassess so when you do the the secondary of the",
        "Secondary of the Trauma": "trauma there's two classifications there's isolated and then there's multi system okay so a high visibility factor so don't become distracted by obvious non-life-threatening injuries any trauma patient who's unresponsive or has an altered mental status is considered high risk before examining a trauma patient make sure that the patient's cervical spine is manually immobilized in the neutral position",
        "Recording Secondary Assessments": "when it comes to recording secondary assessments it should be done in an orderly and concise manner and documentation requires and ensures that an accurate history accounting of the patient's problems prior to entering the hospital will exist in a formal medical record so remember that not everything can be discovered in the secondary keep total time in the field a minimum an evaluation by a trained physician coupled with lab and radiographic studies may be needed for that diagnosis",
        "Monitoring Devices Continuous Ecg Monitoring": "when it comes to monitoring devices continuous ecg monitoring the purpose is to establish a baseline and so patients who present with any cardiac related signs and symptoms with a cardiac input should have continuous cardiac monitoring the electrodes must be placed on the patient properly",
        "Bipolar Leads": "bipolar leads are used for monitoring purposes and those consist of two electrodes positive and negative and they're placed on two different limbs right so there are times when the ecg looks normal but the heart is not functioning properly and we know that's pea 12 lead allows you to look at the heart from several angles to localize that site of injury to the heart muscle it's indicated in any patient who might have a cardiac related condition it's appropriate for older patients in many situations and the only way to learn to take a 12 lead is to practice with the equipment okay so this flow chart explains",
        "Reassessment": "reassessment and that's the final step in the patient assessment and reassessment so stable patients should be reassessed every 15 minutes in the unstable every five reassessment of medical or mental status and abcs so compare the patient's level of consciousness with your baseline assessment review the airway the breathing and circulation and reassess the pulse reassessment of the patient care and transport priorities so have you addressed all life threats do priorities need to be revised and is your initial transport decision still appropriate obtain another complete set of vitals and compare with expected outcomes of your therapies and also look for trends so remember with cushing's reflex or cardiac tamponade you're gonna start to see changes either with cushing's reflex it's going to be slowing up the pulse or raising of the blood pressure and then erratic respiratory patterns but with cardiac tamponade you're going to have muffled pulse pressures or narrow pulse pressures muffled heart tones and jvd and so document all your findings with each reassessment okay so we have reached the end of chapter 11 patient assessment lecture if you've liked this lecture go ahead and subscribe to our channel because we're going to be putting out the rest of the screencasts from um the 8th edition of the paramedic book oh great and thank you have a great night"
    },
    {
        "Introduction to Lifespan Development": "chapter nine lifespan development human beings undergo various changes throughout their lifespans these changes can significantly affect how Medical Care is provided and received it's important for aemts to understand these developmental stages to adapt their approach to Patient Care effectively providers need to be aware of the different changes that a person experiences at various stages of life for instance the physiological and psychological needs of an infant differ greatly from those of an elderly person recognizing these differences ensures that aemts can provide the most appropriate and effective care for each individual the awareness of lifespan changes may lead aemts to alter their approach to Patient Care this could involve adjusting communication Styles being mindful of different medical conditions that are prevalent at different ages or modifying treatment protocols to suit the specific needs of the patient",
        "Neonates and Infants Development": "neonates and infants represent the earliest stages of human development these stages are characterized by rapid growth and significant changes both physically and cognitively neonates from birth to one month undergo initial adjustments to life outside the womb during this period basic functions such as feeding sleeping and responding to sensory stimuli are established understanding these basic needs are important for providers when providing care to ensure the well-being and safety of the patient infants are defined as children from 1 month to one year where the development rate becomes quite startling infants develop at a rapid Pace acquiring new skills and abilities almost weekly they begin to gain motor skills such as rolling over sitting up and eventually crawling cognitive and sensory development also progresses quickly with infants starting to recognize familiar faces respond to sounds and explore their surroundings ings",
        "Physiological Changes in Infants": "at Birth a neonate typically has a pulse rate ranging from 90 to 205 beats per minute accompanied by a respiratory rate of 30 to 60 breaths per minute however within the first half hour after birth it is common for a neonate's pulse rate to decrease to around 120 beats per minute while the respiratory rate adjusts to a approximately 30 to 40 breaths as the infant grows these rates continue to evolve by the time the child reaches one year of age the respiratory rate usually slows to 20 to 30 breaths per minute Additionally the tital volume which measures the amount of air displaced between normal inhalation and exhalation starts at 6 to 8 mm per kilogram in neonates but increases to 10 to 15 milliliters per kilogram by the end of the first year blood pressure also changes in relation to the patient's weight for a neonate birth the average systolic blood pressure ranges between 67 to 84 mm of mercury this range increases as the child grows reaching 85 to 104 mm of Mercury by the age of 1 year temperature regulation is another important aspect of physical development a neonate's normal body temperature typically Falls between 98\u00b0 F and 100\u00b0 fahrenheit as the child transitions into empy the normal temperature range slightly adjusts to between 96.8 and 99.6 de f",
        "Growth and Development in Infants": "at Birth a neonate typically weighs between 6 to 8 pounds or 3 to 3 and 1 12 kg the head accounts for approximately 25% of the infant body weight reflecting rapid brain growth in the first week neonates commonly lose about 5% to 10% of their birth weight due to fluid loss but start gaining approximately 1 o per day by the second week this rapid growth allows them to double their birth weight by four to 6 months and then triple it by the end of the first year at Birth neonates undergo a significant transition from fetal to Independent circulation this shift requires the infant to adapt to breathing air and using its own circulatory system for oxygenation marking a critical change necessary for sustaining independent life this topic will be covered in Greater detail in the Pediatrics chapter",
        "Respiratory and Anatomical Considerations in Infants": "neonates are primarily nose breathers which makes them more susceptible to nasal congestion infants younger than 6 months are particularly prone to this condition which can lead to upper respiratory infections it's important to ensure that it infants nasal passages are clear and unobstructed by mucus to facilitate proper breathing the structure of an infant's rib cage also differs from that of an adult the ribs sit horizontally and the rib cage is less rigid causing infants to be belly breathers due to the immaturity of their accessory muscles infants can fatigue quickly when breathing becomes labored infants have a proportionally large tongue and a shorter narrower and less stable Airway compared to older children or adults this anatomical difference makes their airways more prone to obstruction additionally infants have fewer Alvi in their lungs which decreases the surface area available for gas exchange it's important to remember that an infant's lungs are fragile when performing bag Mass ventilation excessive force can lead to barot trauma so care must be taken to provide gentle controlled ventilations to avoid causing harm",
        "Reflexes and Development in Infants": "the nervous system continues to develop after birth however neonates are born with certain innate reflexes that are crucial for their initial survival and interaction with the environment one such reflex is the Moro reflex also known as the startle reflex this occurs when a neonate is surprised by a sudden stimulus causing them to fling their arms open wide spread their fingers and appear to grab at things another reflex is the palar grasp which is triggered when an object is placed into a neonate's palm proning them to close their hand around it Additionally the Roo reflex is observed when something touches a neonate's cheek causing the neonate to instinctively turn their head toward the touch this reflex helps the neonate find the nipple or bottle to begin feeding in a similar fashion the sucking reflex is activated when an infant's lips are stroked which is vital for feeding",
        "Fontanels and Musculoskeletal Development": "fontanels are soft areas on a baby's head head where the bones of the skull have not yet fused these areas allow the head to be molded during birth and provide space for brain growth during early development in the early months of Life the posterior fontel typically fuses by 3 months of age while the anterior fontel fuses between 9 and 18 months these font nails are crucial for the baby's development and their condition can indicate various health issues for instance a depressed Fontanel often suggests dehydration while a bulging fontel May indicate increased interial pressure in the muscular skeletal system growth plates which are also known as epithelial plates are situated at the ends of long bones and infants and play a pivotal role in bone elongation during childhood these plates facilitate the increase in bone length additionally bones undergo a process of AP positional growth wherein they increase in thickness by depositing new bone tissue on their surfaces",
        "Renal and Immune System in Infants": "in the renal system infants are at a higher risk of dehydration as their kidneys are typically unable to produce concentrated urine leading to urine that is predominantly composed of water this can result in the development of electrolyte imbalances in the immune system during the first 6 months of Life infants retain some of their mother's immunities providing them with something known as passive immunity additionally breastfeeding offers an extra source of antibodies further support the infant's immune defense",
        "Psychosocial Development in Infants": "psychosocial changes commence at Birth and evolve as the infant interacts with and adapts to their surroundings the first year of life is marked by particularly rapid developmental changes across various domains during this formative period crying emerges as the principal mechanism for communicating distress this vocalization serves multiple functions such as signaling needs related to hunger discomfort or emotional upset as infants grow and develop their cries become more nuanced allowing caregivers to better interpret and respond to their specific needs this communication function of crying plays a role in fostering the infant caregiver Bond and in facilitating the infants adjustment to their social environment bonding in infancy is underpinned by secure attachment which is established when infants perceive that their parents or caregivers will consistently respond to their needs secure attachment Fosters a sense of safety and Trust conversely anxious avoidant attachment develops infants who experience repeated rejection leading them to exhibit minimal emotional response to their parents and caregivers and interact with them in a manner similar to how they would with strangers separation anxiety commonly emerges in older infants between 10 to 18 months during which they may display clingy behavior and exhibit fear towards UNF amiliar places and individuals the stage of trust versus mistrust spending from birth to approximately 18 months is characterized by an infant's need for a structured and predictable routine during this developmental phase infants either establish trust in their caregivers or develop a sense of mistrust based on the consistency and reliability of the care they receive",
        "Toddler Development": "during the toddler years or 1 to three several notable physical changes occur the average pulse rate ranges from 80 to 140 beats per minute while the respiratory rate is between 22 and 37 breasts per minute systolic blood pressure typically Falls between 86 to 106 mm of Mercury the average body temperature ranges from 96.8 to 99.6 generally stabilizing around 98.6 de F by the time the child reaches preschool age Additionally the lungs of toddlers continue to mature with the development of more terminal bronchioles and Alvi which are needed for efficient gas exchange",
        "Preschool Development": "in preschoolers Age 3 to 6 years the pulse rate ranges from 65 to0 beats per minute and the respiratory rate Falls between 20 to 28 breaths per minute systolic blood pressure typically ranges from 89 to 112 mm of mercury weight gain during this period should stabilize and preschoolers do not possess well-developed lung musculature which in turn limits their ability to sustain deep or rapid respirations over extended periods in the transition from infancy to the preschool years several significant physiological and developmental changes occur the loss of passive immunity happens as the infant's immune systems become more self-reliant neuromuscular grp growth is characterized by the child's extensive exploration and use of their nervous system and muscles by the end of this developmental stage the preschooler's brain will have reached approximately 90% of its final adult weight engaging in play activities exerts stress on muscles and Bones increasing muscle mass and bone density concurrently the renal system and elimination patterns continue to develop toddlers typically gain the neuromuscular control necessary for bladder control by 12 to 15 months of age with the average age for toilet training being around 28 months teething also occurs during this period which can be painful and sometimes accompanied by fever the leading cause of death in this age group remains un unintentional injuries",
        "Psychosocial Changes in Toddlers and Preschoolers": "during the preschool years psychosocial changes are notable as children continue to develop their language and self-expression toddler's exhibit strong attachment to their parents this provides them with a sense of security separation anxiety typically Peaks between 10 and 18 months of age by 36 months children generally Master basic language skills though refinement of these abilities continues throughout childhood by ages 3 to 4 years most children are capable of using and comprehending full sentences and begin to transition from using language to communicate immediate needs to employing it creatively and playfully interact with peers and participation in games commence teaching children about control rule following and competitiveness additionally by 18 to 24 months toddlers start to grasp the concept of cause and effect observing their role models children also begin to recognize and understand sexual differences",
        "School Age Development": "during the school AG years which last from 6 to 12 years of age a child's vital organs and body metrics progressively align with those typical of adulthood the pulse rate averages between 58 and8 beats per minute while the respiratory rate ranges from 18 to 25 breaths per minute systolic pressure generally Falls between 97 to 120 mm Mercury these changes reflect the ongoing maturation of the child's physiological systems as they approach adult levels during the school age years most children experience an annual weight gain of approximately 4 lbs and a height increase of about 2 and a half Ines brain function continues to mature in both hemispheres supporting cognitive and motor development additionally permanent teeth begin to replace primary teeth during this period that being said despite these advancements unintentional injuries Remain the leading cause of death among School aged children",
        "Psychosocial Development in School Age Children": "during the school age years children undergo significant psychosocial development learning VAR ious forms of reasoning initially they engage in preconventional reasoning where their actions are primarily motivated by the desire to avoid punishment and fulfill personal needs as they progress to Conventional reasoning children seek approval from their peers in society aligning their behavior with social norms eventually they reach postconventional reasoning where decisions are Guided by personal conscience this period is also critical for the development of self-concept and self-esteem self-concept refers to an individual's perception of themselves while self-esteem encompasses how they feel about themselves and their sense of belonging within their peer group",
        "Adolescent Development": "during adolescence which spans from 12 to 18 years Vital Signs start to stabilize within the ranges typical of adulthood the original pulse rate generally Falls between 80 to 100 beats per minute while the respiratory rate is between 12 to 20 breasts per minute systolic blood pressure typically ranges from 110 to1 mm of mercury during adolescence individuals experience a rapid growth spurt lasting approximately 2 to 3 years and characterized by significant increases in muscle and bone development growth typically progresses from the hands and feet to the long bones of the extremities and then finally the Torso girls usually complete their growth by around 16 years of age while boys continue to grow until approximately 18 years reaching muscle mass and bone density Levels Close to those of adults concurrently the reproductive system matures with the onset of secondary sexual characteristics despite these developmental advances unintentional injuries still remain the leading cause of death among this demographic",
        "Psychosocial Changes in Adolescents": "during adolescence individuals seek to assert control over their lives and achieve independence from their parents leading to increased concerns about privacy and heightened self-consciousness this developmental stage often involves a struggle to establish a personal identity with adolescents using feedback from family and peers to shape their adult self-image they made desire to be treated with the autonomy afforded to adults while still seeking the care and support typically associated with younger children rebellious behavior Can emerge as part of the process of identity formation peer pressure plays a significant role during this period strongly influencing adolescent decisions and behaviors antisocial Behavior often Peaks during the 8th or 9th grade with adolescents potentially developing eating disorders due to an obsession with body image this period may also see the emergence of self-destructive behaviors including smoking alcohol consumption risky sexual activities and other high-risk behaviors increased interest in sexual relations is common and adolescents begin to form a personal code of ethics which is influenced both by their parents values and their environmental experiences additionally adolescents are at a heightened risk for suicide and depression compared to other groups",
        "Early Adulthood Development": "early adults aged 19 to 40 years experience physical changes that reflect continuation of adult physiological Norms during this stage Vital Signs generally remain stable with a pulse rate typically around 70 beats per minute the respiratory rate is expected to be within the range of 12 to 20 breasts per minute with systolic blood pressure usually falling between 90 and 140 mm of mercury from ages 19 to 25 years the body typically functions at its optimal level marking a period of Peak physical health during this time individuals establish lifelong habits and routines however the natural process of wear and tear begins to take effect on the body leading to changes in Bones tissues and muscles the intert vertible discs in the spine may start to settle potentially resulting in a slight decrease in height additionally there's an increase in fatty tissue contributing to weight gain while muscle strength begins to decline and reflexes may slow unintentional injuries remain a leading cause of death within this age group",
        "Psychosocial Changes in Early Adulthood": "during early adulthood life primarily revolves around work family and managing stress individuals strive to establish their place in the world often focusing on settling down and achieving stability this period is characterized by high levels of job stress as many people prioritize career advancement and work life balance marriage and child birth are prevalent while child birth being particular L common within this age group despite the challenges early adulthood is considered one of the more stable periods in life with generally fewer psychological issues related to well-being compared to other stages of life",
        "Middle Adulthood Development": "during middle adulthood which spans from 41 to 60 years Vital Signs generally remain consistent with those observed in earlier adulthood the average pulse rate stays around 70 beats per minute the respiratory rate continues from 12 to 20 and systolic blood pressure remains between 90 and 140 mm of mercury while the body continues to function at a high level individuals in this age group may become increasingly susceptible to vision and hearing loss along with other varying degrees of physical degradation additionally cardiovascular health often becomes a significant concern for many people during the stage of life during middle adulthood the incidence of cancer increases and individuals may begin to experience medical symptoms or simply be unaware of conditions such as diabetes and hypertension for women menopause typically occurs in the the late 40s or early 50s despite these changes maintaining regular exercise and a healthy diet can help mitigate many effects of Aging in terms of mortality unintentional injuries are still the leading cause of death for those aged 41 to 44 years while cancer becomes the primary cause of death in individuals between the ages of 45 and 60",
        "Psychosocial Changes in Middle Adulthood": "during middle adulthood individuals focus on achieving their life goals often reassessing and adjusting their lifestyle as their children leave home financial concerns frequently become more prominent during this stage however middle adults typically have developed physical emotional and spiritual reserves to help them manage life's many challenges additionally they may face the Dual responsibility of supporting children who are leaving for college while simultaneously caring for aging parents",
        "Leading Causes of Death Across Lifespan": "according to the siners for Disease Control and prevention unintentional injuries commonly referred to as accidents are the leading cause of death for several age groups including toddlers preschoolers schoolage children adolescents and adults aged 41 to 44 years these injuries can result from various incidents such as Falls vehicle accidents drowning and poisoning and they highlight the need for preventative measures and safety interventions tailored to each age group for individuals aged 4 5 to 60 years cancer emerges as the leading cause of death this shift reflects the increased susceptibility to malignancies as individuals age influenced by factors such as genetic predisposition lifestyle choices and environmental exposures the transition from unintentional injuries to cancer as the primary leading cause of death underscores the changing health risks that are associated with a Aging in older adults age 65 and older heart disease and cancer become the predominant causes of death heart disease including conditions such as coronary artery disease heart failure and stroke is often linked to age related changes in cardiovascular health lifestyle factors and comorbid conditions cancer with its various forms also remains a significant concern due to the increased risk associated with aging and accumulated exposure to carcinogens over a lifetime the progression of leading causes of death from unintentional injuries to cancer and then to heart disease and cancer in older adults illustrates the evolving health challenges throughout the lifespan emphasizing the importance of targeted prevention early detection and management strategies to address these age specific risks",
        "Older Adults Development": "older adults are defined as individuals aged 61 years and older physical changes during the stage of Life are influenced by evolving life expectancy statistics currently the average life expectancy is approximately 78 years with a maximum life expectancy estimated to be around 120 years these estimates vary based on several factors including the year of birth and the country in which that person resides life expectancy is influenced by advancements in health care living conditions and socioeconomic factors all of which can contribute to the length and quality of life in older adults in older adults age 65 years and older heart disease and cancer are the leading causes of death vital signs in this age group can vary significantly depending on the individual's overall health medical conditions and the medications they are taking despite the prevalence of chronic conditions many older adults are capable of managing and overcoming various medical issues they may require multiple medications to address these conditions effectively highlighting the need for comprehensive and individualized medical care to optimize Health outcomes and quality of life in later years",
        "Cardiovascular Changes in Older Adults": "in older adults the cardiovascular system undergo significant changes cardiac function generally declines with age primarily due to atherosclerosis which leads to the buildup of plaque in the arteries this condition results in a decrease in heart rate and cardiac output with the heart's ability to meet the body's demands becoming increasingly compromised the vascular system also becomes stiffer with age causing diastolic blood pressure to rise as a result the heart must work harder to pump blood and blood flow to organs is often reduced Additionally the ability to produce replacement blood cells diminishes with age accompanied by a decrease in blood volume this is partly due to the replacement of active bone maror with fatty tissue further affecting hematopoesis these changes collectively impact the efficiency of the cardiovascular system and the overall health of older adults",
        "Respiratory Changes in Older Adults": "in older adults the respiratory system experiences several age related changes the size of the Airways increases as a smooth muscle weakens and the surface area of the avvi decreases leading to diminished gas exchange efficiency the natural elasticity of the lungs also declines necessitating increased use of the intercostal muscles for breathing the chest becomes more rigid due to the calcification of the ribs to the sternum and both the intercostal muscles and diaphragm begin to lose strength consequently breathing becomes more labor intensive and the chest structure becomes more Fragile with overall weakening of the bone structure in older adults the smooth muscles of the lower airway weaken with age leading to potential Airway collapse during strong inhalation and causing inspiratory wheezing this weakening can result in reduced flow rates and air trapping within the lungs Additionally the overall decrease in metabolic activity associated with aging increases the risk of lung infections by the age of 75 vital capacity may be reduced to about 50% of what was observed in young adulthood this decline is influenced by several factors including the loss of respiratory muscle mass increased stiffness of the thoracic cage and decreased surface area available for gas exchange as a result vital capacity decreases while residual volume increases with ag stagnant air in the Alvi can impede effective gas exchange potentially leading to hypercarbia and acidosis",
        "Endocrine and Reproductive Changes in Older Adults": "in older adults the endocrine system undergoes notable changes as physical activity tends to slow down while food intake often remains unchanged insulin production decreases and Metabolism slows leading to an increased susceptibility to diabetes metis changes in mental status May sometimes be attributed to fluctuations in blood glucose levels the reproductive system also experiences age related changes men can continue to produce sperm into their 80s although penile rigidity generally diminishes over time women experience a reduction in the size of the uterus and vagina alongside a gradual decrease in hormone production for both sexes that being said although sexual desire may diminish with age it typically does not disappear entirely",
        "Renal and Gastrointestinal Changes in Older Adults": "in older adults the renal and gastrointestinal systems undergo significant changes the filtration function of the kidneys declines by approximately 50% from age 20 to 90 years and kidney Mass decreases by around 20% over the same period this decline in renal function impairs the body's ability to effectively clear wastes and conserve fluids when necessary additionally GI function changes with age can affect nutritional intake and utilization these changes can lead to deficiencies in vitamins and minerals which impacts overall health and well-being in older adults several additional changes affect the renal and GI systems taste bud sensitivity decreases which can impact appetite and food enjoyment teeth become weaker and saliva secretion diminishes impairing the ability to process complex carbohydrates effectively gastric motility slows due to the loss of intestinal tract neurons this may result in constipation or reduced appetite gastric acid secretion also diminishes affecting digestion reduced blood flow in the mesenteric vessels decreases the intestine ability to extract nutrients from digested food gallstones become increasingly common with age and changes in the anal sphincter reduce its elasticity potentially leading to fecal incontinence these alterations collectively influence the efficiency of the digestive system and the overall nutritional status in the older adult",
        "Nervous System Changes in Older Adults": "in older adults the nervous system experiences several changes by age 80 brain weight May decrease by 10 to 20% leading to slower and less responsive motor and sensory neural networks despite this reduction the metabolic rate and oxygen consumption in the brain remain relatively constant there is a diminished number of brain cells with aging however the interconnections between remaining brain cells continue to develop providing redundancy and supporting cognitive function although there is a loss of neurons this does not necessarily equate to a loss of knowledge or skill additionally sleep patterns often change with age which can affect overall rest and cognitive function with age the brain undergo age related shrinkage creating a void between the brain and the outermost layer of the meninges this void provides space for the the brain to move when subjected to stress or trauma peripheral nerve sensation also diminishes leading to misinterpretations of sensory input this results in slower reaction times and a reduction in reflexes contributing to an increased risk of Falls and Trauma Additionally the deterioration of nerve endings impairs the skin 's ability to sense its surroundings further affecting balance and coordination",
        "Sensory Changes in Older Adults": "in older adults sensory changes are often observed though many retain good vision and hearing some individuals may require eyeglasses or hearing aids but it's important not to assume that all older patients are nearly deaf or blind pupilary reaction and ocular movements become more restricted with age pupils generally become smaller and the opacity of the eyes lens can diminish visual Acuity causing pupils to respond sluggishly to light visual distortions such as blurred vision or difficulty focusing are also common hearing loss is significantly more prevalent than vision loss being four times more common among among older adults this disparity highlights the importance of addressing hearing health and ensuring appropriate interventions for those with sensory impairments",
        "Challenges in Assisted Living for Older Adults": "the surge in the older adult population in the United States resulting from the baby boom between the 40s and 60s has significantly increased the demand for assisted living facilities these facilities cater to the growing need for long-term care offering support with daily activities health care and even social engagement however the close living quarters and communal settings in many of these assisted living facilities can exacerbate the spread of infectious diseases especially during pandemics such as influenza and covid-19 the transmission of viruses in such environments poses a heightened risk due to the higher likelihood of person-to-person contact and shared spaces outbreaks of chlamydia and ganara are even known to occur furthermore Financial limitations can present substantial barriers to accessing adequate healthc care and medications many of these patients are on fixed or limited incomes and they may struggle to afford necessary treatments medications or health care services this of course can affect their health outcomes and significantly decrease their quality of life these economic challenges underscore the need for policies and programs that address the affordability of Health Care and support for aging populations",
        "Quality of Life in Older Adults": "older adults bring a well of wisdom and experience and it is essential to acknowledge and affirm their sense of self-worth most individuals in the late stages of Life maintain High cognitive function up until approximately 5 years before death after which mental function is thought to decline this phenomenon is known as the terminal drop hypothesis facing mortality is a significant issue for older adults and some may grapple with feelings of uselessness or concern about being a burden to their families these emotional challenges are often compounded by isolation and depression however with adequate financial resources and a strong support system of friends and family older adults in their 80s and Beyond can still lead fulfilling lives and maintain a sense of productivity and enjoyment my paternal grandfather traveled the country well into his late 80s and continued working part-time on his farm for my aunt well into his mid90s my maternal grandfather who is currently 88 years old as of this recording currently flies one day a week in his private airplane and spends time traveling around the state visiting friends that he's known for years a supportive environment and Good Financial stability play crucial roles in enhancing the quality of life and overall well-being of older adults",
        "Conclusion": "this lecture highlights the various physical psychological and social changes that occur across the lifespan from early adulthood to late adulthood it begins with the developmental Milestones of infants and toddlers including key physical and psychosocial changes such as the development of motor skills and language as well as the emergence of secure attachment and separation anxiety it then transitions to the physical and psychosocial development of preschoolers schoolage children and adult adolescence noting significant growth spurts the maturation of the reproductive system and the impacts of peer pressure and identity formation as individuals reach early adulthood they experience optimal physical functioning but face potential health concerns such as unintentional injuries and lifestyle changes that impact their metabolism middle adulthood brings about physical changes such as as decreased cardiovascular health an increased risk of cancer and adjustments in lifestyle as children leave the home psychosocial challenges during this period include dealing with job stress Financial concerns and the need to balance personal and familial responsibilities lastly in older adults physical and sensory changes become more pronounced including declines in cardiovascular function respiratory capacity and sensory perception the psychosocial aspects involve facing mortality dealing with feelings of worthlessness or feeling as there are a burden and managing isolation and depression despite these challenges with adequate financial resources and strong social support older adults can continue to lead fulfilling lives enjoying productivity and meaning meaningful connections with others"
    },
    {
        "Introduction to Patient Assessment": "chapter 10 patient assessment to effectively manage patient care it's important to master and be proficient with the patient assessment process which is applied to every patient en counter this assessment process is divided into five key components the size up primary survey history taking secondary assessment and reassessment the sequence in which the steps are executed is determined by the patient's condition and the surrounding environment the components used to evaluate a medical patient are also applicable when assessing a trauma patient though the findings in management may vary a sign refers to an objective condition that can be observed by the health care provider while a symptom is a subjective condition reported by the patient the chief complaint is the primary reason for which the EMS professional was summoned effective clinical decision-making relies on your ability to gather evaluate and synthesize patient information to develop a comprehensive understanding of the patient's condition and formulate a field impression throughout the assessment apply critical thinking skills by first gathering information through observation of the scene and questioning the patient and bystanders next evaluate this information by determining its significance and prioritizing it appropriately synthesize the data to create a management plan for the scene and or the patient integrate the information obtained with knowledge from similar past situations and experiences clearly articulate your assessment-based decisions and construct well supported arguments justify your actions and decisions based on the assessment be aware that factors which may hinder emergency medical care may not be present in other medical settings always base treatment or transport decisions on the assessment of the patient.",
        "Scene Size-Up and Safety": "the scene size up involves evaluating the conditions in which you will be operating and represents the information gathering phase of the patient assessment process continuous situational awareness is essential throughout the call requiring constant attention to the conditions and individuals around you as well as an assessment of environmental factors prepare for the specific scenario based on the initial dispatch information and consider various factors that will influence your operations in patient care including road and traffic hazards instant specific dangers and potential scenes of violence the scene size up should integrate the dispatcher provided information with your direct observations of the scene ensuring scene safety is a fundamental aspect of prehospital care as every scene carries the potential for injury prioritize safety by first protecting yourself and your partner followed by other responders and bystanders and lastly the patient as you approach the scene and before exiting the vehicle assess for potential hazards including traffic chemical and biological agents down power lines or lightning secondary collapse fire and explosions carbon monoxide and unstable surfaces when assessing the patient plan to exit via the same route which will often involve maneuvering a heavy stretcher working in adverse conditions and on unstable surfaces is a common challenge in prehospital settings ensure that measures taken to protect yourself are also considered for the patient maintain focus and take your time to address the situation ation effectively additionally Safeguard bystanders from becoming patients and be vigilant for signs of potential violence if necessary request law enforcement assistance relocate to a safe area and call for additional resources.",
        "Mechanism of Injury and Nature of Illness": "when determining the mechanism of injury or the nature of illness avoid immediately categor izing the patient solely as trauma or medical as some patients may fall into both categories early consideration of the Moi or illness helps in preparing for the remainder of the assessment as it allows you to identify all relevant aspects of the emergency four traumatic injuries which result from physical forces applied to the body classification is based on factors such as the type type and magnitude of the force the duration of its application and its location on the body understanding the Moi provides essential clues that will guide the focus of your assessment and Aid in formulating an appropriate management plan in cases of blunt trauma the force is applied over a broad area resulting in injury without bricking the skin conversely penetrating trauma involves Force applied to a specific point of contact between the skin and an object this carries a higher risk of infection to determine the nature of illness make an effort to identify the general type of illness such as a seizure heart attack diabetic condition or poisoning the noi is often best described through the patients Chief complaint and medical history to quickly identify the noi engage with the patient their family and even bystanders to gather information about the emergency Additionally you can also use your senses to inspect the scene for potential Clues regarding the cause of illness.",
        "Standard Precautions and PPE": "standard precautions and PPE must be adapted to the specific prehospital task at hand PPE encompasses both clothing and specialized equipment with the type required varying according to the duties performed special precautions are protective measures that are designed to mitigate exposure risks to communicable diseases assuming that all blood body fluids excluding sweat non- intact skin and mucous membranes May pose a substantial infection risk this would include dried potentially infectious materials to effectively reduce exposure risk adhere to standard precautions before exiting the EMS vehicle and making patient contact this includes hand washing before and after patient care wearing gloves prior to any patient interaction using eye protection if necessary and wearing a mask for protection against some Airborne diseases ensure that you are properly educated in the use of standard precautions and adjust your protective measures as needed if exposure is suspected follow your agency guidelines for post exposure reporting testing and prophylaxis.",
        "Determining Number of Patients and Resources": "determining the number of patients is crucial for assessing the need for additional resources if there are multiple patients are more than the responding unit can manage activate the mass casualty plan which typically involves establishing an instant command system requesting additional units and initiating triage the IC is a flexible framework that's used to manage disasters and mass casualty incidents triage is the process of sorting patients based on the severity of their conditions to allocate Personnel equipment and resources effectively consider additional or specialized resources such as a paramedic backup for severe injuries or complex medical conditions air support for advanced life support and the local fire department services for needs Beyond fire suppression including technical rescue vehicle extrication high angle rope rescue Hazmat management and swiftwater rescue search and rescue teams are valuable for locating packaging and transporting patients over long distances and rough terrain law enforcement may be required to manage traffic or address potential violence so position yourself and your vehicle at a safe distance until the scene is secured evaluate the situation by asking how many patients are present are sufficient resources available for their conditions does the scene pose any risks to yourself your patient or others it is advisable to call for backup when necessary even even if additional units are later instructed to stand down.",
        "Primary Survey and Life Threats": "the goal of the primary survey is to identify and address immediate or imminent life threats this involves a physical examination of the patient to assess the level of Consciousness Airway breathing circulation disability and exposure the primary survey is not intended to be an in-depth physical exam or a detailed assessment of Vital Signs life threats should always be prioritized during this process we Define a life threat as anything that is a threat to profusion as the inability to peruse is the only thing which causes loss of life and limb forming a general impression involves rapidly identifying potential life-threatening issues and is the initial step in the primary survey that determines the priority of Emergency Medical Care Begin by observing the patient age sex weight level of distress overall appearance and any visible bleeding this overall visual assessment provides critical information as you approach the patient note the patient position and whether they are moving or still and ensure that you are at eye level rather than standing over the patient check that they are breathing assess skin color and condition and detect any odors that suggest chemical hazards smoke or alcohol if the patient is responsive introduce yourself and inquire about their Chief complaint as their response can offer in sight into their level of Consciousness Airway patency respiratory status and overall circulatory status before proceeding with the examination treat any life-threatening conditions immediately upon identification address the following questions to form your general impression does the patient appear to have a life-threatening condition were they injured and if so what was the mechanism of injury is the patient coherent and able to answer questions assess whether the patient's condition is stable stable but potentially unstable or unstable and remain vigilant for any changes in their condition maintain a high index of Suspicion and begin treatment if a traumatic issue appears to be the primary problem while also being alert to potential medical Origins.",
        "Assessing Level of Consciousness": "assess the level of Consciousness by categorizing the patient into one of three groups unresponsive responsive with an altered level of Consciousness or responsive with an unaltered level of Consciousness sustained unresponsiveness suggests a significant issue with the respiratory circulatory or central nervous system for unresponsive patients prly package and transport them to the hospital for further evaluation and treatment further assessment is necessary for any patient with an altered level of Consciousness an altered loc in a responsive patient may suggest inadequate profusion and oxygenation affecting brain function it can also result from medication ations drugs alcohol poisoning hypoglycemia chemical imbalances or neurological conditions test for responsiveness by using verbal tactile and painful stimuli to gauge the patient's reaction assess their orientation to determine their awareness of time place and identity if there is any indication of a spinal injury ensure the patient's cervical spine is manually stabilized either by you or another provider in order to establish spinal mobile restriction indicators for spinal motion restriction include blunt trauma with any of the following findings an Moi that suggests potential spinal injury pain or tenderness upon palpation of the neck or spine patient reported neck or back pain paralysis or neurological complaints such as numbness or tingling parismatch.com spine pain reports and difficulty or even the inability to communicate with the patient to assess the patient's responsiveness use the avpo scale first check if they are awake and alert meaning they are fully conscious and aware of their surroundings if not determine if they are responsive to verbal stimuli responding to verbal cues or commands if there is no response to verbal stimuli assess whether the patient is responsive to painful stimuli reacting only to painful stimuli if the patient does not respond to any form of stimuli they are considered unresponsive this figure shows the appropriate methods of gauging a patient's responsiveness to pressure stimuli gently but firmly pinch the patient's earlobe or press on the bone above the eye or gently but firmly pinch the muscles of the neck besides the methods we just reviewed alternatively you could rub your knuckles against the patient's sternum though this method is much less referred due to concerns about causing injury as it is led to multiple lawsuits if a patient does not respond to stimuli on one side attempt to elicit response on the other.",
        "Airway and Breathing Assessment": "always be vigilant for signs of Airway obstruction as both mild and severe obstructions can result in inadequate air flow into and out of the lungs leading to insufficient profusion of the entire body determine whether the airway is open and adequate and continually reassess it throughout the assessment for responsive patients observe if they are talking or crying which indicates they are moving air pay attention to their speech as it can provide important clues about the adequacy of their Airway and breathing a responsive patient who cannot speak or cry likely has a severe Airway obstruction if an airway problem is detected halt the assessment process and focus on clearing the patient's Airway take note that signs and symptoms of Airway and breathing issues often overlap for unresponsive patients immediately assess the patency of their Airway and consider that they may have experienced a traumatic event if there is a potential for trauma use the jaw thrust maneuver to open the airway if you can confirm that no traumatic event occurred you may use the head tilt chin lift maneuver instead in an unresponsive patient relaxation of the tongue muscles can also obstruct the airway address this by positioning the airway way and then placing an oral or nasal Airway be aware that Dentures blood clots vomitus mucus food and other foreign objects can cause Airway obstruction and should be cleared using manual techniques or suction signs of Airway obstruction in an unresponsive patient include obvious trauma blood or other visible obstructions noisy breathing such as snoring or bubbling and extremely shallow or absent breathing Airway positioning should be adjusted based on the patient's age and size for trauma patients or those with an unknown illness manually stabilize the cervical spine while performing the jaw thrust maneuver once the patient's Airway is confirmed to be open assess the adequacy of their breathing determine if the patient has spontaneous respirations meaning they breathe without assistance check if the patient appears to be choking if their respiratory rate is abnormally fast or slow and if their respirations are shallow or deep observe for cyanosis listen for abnormal breath sounds when osculating the lungs and ensure that the patient is moving air effectively into and out of the lungs rapidly assess respirations to determine if the rate is normal fast or slow the depth is normal or shallow and if the chest rise is equal or unequal use a stethoscope to listen to breath sounds over each lung ensuring that each chest rise and breath sounds are equal on both sides when assessing breathing obtain the respiratory rate evaluate the quality and character of breathing gauge the degree of distress and note the use of accessory muscles in the neck or chest you should never withhold oxygen from a patient who is having difficulty breathing provide positive pressure ventilations for patients who are apnic or whose breathing is either too slow too fast or too shallow administer oxygen if the patient is breathing adequately but remains hypoxic with the goal of achieving oxygen saturation levels between 94 and 99% if the difficulty breathing develops after the primary survey immediately re-evaluate the airway remember the primary concern is effective air exchange not just the number of breaths observe the effort required for the patient to breathe shallow respirations are indicated by minimal chest wall movement or poor chest Excursion while deep respirations result in significant rise and fall of the chest document whether the patient P's respirations are shallow or deep labored breathing is characterized by the patient posture focus on breathing and increased effort and depth of each breath signs of inadequate breathing include the presence of retractions nasal flaring seesaw breathing and supraclavicular and intercostal retractions in pediatric patients additionally if a patient can only speak two or three words before pausing to breathe this indicates inadequate breathing two common postures indicating that a patient is trying to increase air flow are the tripod position and the sniffing position the tripod involves the patient sitting and leaning forward on outstretched arms with the head and Chin slightly thrust forward the sniffing position often seen in children involves the patient sitting upright or lying on their back with the head and Chin thrust forward respiratory distress occurs when a patient's having difficulty breathing while respiratory failure happens when the blood is inadequately oxygenated or ventilation is insufficient to meet the body's oxygen demands.",
        "Circulation Assessment": "assessing circulation involves evaluating how effectively blood is circulating to the major organs by examining the patient's mental status pulse and skin condition to assess the pulse which is the pressure wave created by each ventricular contraction which causes a surge of blood through the arteries palpate the pulse point where a major artery is close to the surface for responsive patients older than one year palpate the radial pulse at the wrist for unresponsive patients older than one year palpate the kateed pulse in the neck make sure to avoid your thumb when palpating the pulse to avoid feeling your own a normal pulse rate for and adult should range between 60 to 100 beats per minute during the primary survey assess the pulse to determine if it is present or absent normal fast or slow and weak in thready or strong in bounding evaluate the adequacy of the pulse in Greater detail during the secondary re assessment if you cannot palpate a pulse on an unresponsive patient you should begin CPR immediately if they have a pulse but are not breathing then provide ventilations at a rate of 10 to 12 breasts per minute for adults and 12 to 20 breasts per minute for infants or children if the pulse is lost at any point start CPR and apply the AED never begin CPR or use an AED on a responsive patient assess the skin to evaluate circulation perfusion oxygen blood level and body temperature perfusion is determined by examining the patient's skin color temperature moisture and capillary refill skin color reflects the blood circulating through the vessels and the amount and type of pigment in the skin blood appears red when adequately oxygenated resulting in pink skin and lightly pigmented individuals in those with deeply pigmented skin color changes may be noticeable in specific areas such as fingernail beds mucous membranes lips the underside of the arm palms and the conjunctiva for infants and children also assess the palms of the hands and soles of the feet inadequate peripheral circulation may cause the skin to appear pale white Ashen or gray potentially with a waxy or translucent appearance cyanosis which is characterized by a blue or gray discoloration of the skin over blood vessels indicates low oxygen levels in the blood high blood pressure may lead to abnormal flush or redness of the skin jaundice or yellowing of the skin is typically a sign of liver disease or dysfunction skin temperature should be assessed to determine abnormality normal skin is warm to the touch while abnormal temperatures can be hot cool cold or clammy skin that feels hot May indicate significant fever sunburn or hypothermia skin will feel cool in the early stages of shock with mild hypothermia or inadequate profusion coold skin is associated with profound shock hypothermia or frostbite to assess the skin temperature feel the patient torso underneath clothing with the back of your hand skin moisture should also be evaluated with dry skin being normal while wet or moist skin from sweat or excessively dry and hot skin suggest potential issues because skin color temperature and moisture are often interrelated consider these signs together when recording are reporting describe the skin color first followed by temperature and then note whether the skin is dry moist or wet capillary refill time is commonly evaluated in pediatric patients in order to assess the circulatory system's ability to restore blood to or profuse the capillary system in the fingers and toes while this can provide an indication of a pediatric patient's level of profusion it's not considered an adequate measure in adults factors such as body temperature position pre-existing medical conditions smoking history and medications can all affect capillary refill time to test it place your thumb on the patient's fingernail and your fingers on the underside of the finger then gently compress capillary refill time should be prompt with nail bed color returning to Pink poor peripheral circulation is suspected if capillary refill time takes more than 2 seconds or if the nail bed simply remains blanched when assessing and controlling external bleeding first identify and immediately control any major external bleeding prioritizing this over Airway or breathing concerns signs of significant bleeding include active bleeding from wounds or other evidence of blood loss serious bleeding from a large vein typically involves steady blood flow while arterial bleeding is characterized by a spurting blood flow perform a blood sweep by running your gloved hands from head to toe checking for blood on your gloves apply direct pressure with a gloved hand and then a sterile bandage to control most cases of bleeding if direct pressure is ineffective or if you encounter obvious arterial Hemorrhage of an extremity use a tourniquet to restore a circulation act immediately to improve it the absence of a palpable pulse in a responsive patient suggests low cardiac output if a pulse cannot be felt in an unresponsive patient and an AED or manual defibrillator is not available begin CPR once an AED or defibrillator is available assess the need for defibrillation.",
        "Disability and Neurological Assessment": "to assess the patient for disability conduct a brief neurologic evaluation to determine their mental status check if the patient is alert and oriented to person place time and event any deviation from this level of awareness or from the patient's usual Baseline mental status is considered altered orientation assesses a patient's mental status by evaluating their memory and cognitive function a common test involves checking the patient's ability to recall four key aspects person place time and event Additionally the glass galcom scale assigns a score based on eye opening verbal response and motor response this does provide an objective measure for the patient level of Consciousness but remember this was invented specifically for head injuries start by visually inspecting each area of the patient to ensure a thorough and accurate assessment after completing the assessment cover the patient to respect their privacy and to maintain body heat conducting a rapid full body scan which shouldn't take more than 60 to 90 seconds helps identify other injuries that may need to be managed or protected before transporting this involves inspection to look for Visible abnormalities palpation to feel for any abnormalities and oscilation to listen for abnormal body sounds to guide your exam D use the memonic Decap btls which as you should know stands for deformities contusions abrasions punctures or penetrations Burns tenderness lacerations and swelling this should help you to remember what to look for during inspection and palpation identify any immediate life threats and address them swiftly recognize signs and symptoms that could indicate a life-threatening condition including anxiety loss of meaningful communication loss of consciousness unresponsiveness to external stimuli and slack muscles with the tongue sagging against the posterior throat only a few General conditions can lead to sudden death including Airway obstruction respiratory arrest respiratory failure primary Cardiac Arrest shock and severe bleeding these conditions are often manageable or reversible but quick recognition and immediate action are crucial identifying and addressing life-threatening issues starts with the assessment of the ABCs in cases of cardiac arrest you should be assessing the ABC simultaneously remember controlling life-threatening bleeding takes precedence over concerns about Airway and breathing as if we don't have red stuff on the inside of the body putting oxygen in the body is meaningless.",
        "Rapid Full Body Scan and Transport Decision": "the rapid full body scan helps to determine the priority of patient care and transport high priority patients should be transported immediately if they exhibit difficulty breathing have a serious mechanism of injury present a poor general impression show any alteration in mental status experience severe chest pain display pale skin or other signs of poor profusion are undergoing complicated childbirth have uncontrolled bleeding are responsive but unable to follow commands report severe pain in any area of the body or are unable to move any part of their body protecting the patient's spine and identifying fractured extremities are also essential for a safe and effective transport if you suspect a spinal injury or if the mechanism of injury suggests a significant risk of such an injury consider final motion restriction early the golden hour refers to the crucial time from injury to definitive care during which the potential for survival is the highest you should spend as little time as possible on the scene with patients who have sustained significant trauma aim to complete the assessment stabilization packaging and the initiation of transport to the appropriate facility within 10 minutes of arrival on scene this is known as the Platinum 10 in some cases patients May benefit from remaining on the scene for Continued Care call for additional support from paramedics if they are not already in route and if necessary a paramedic unit can be met during transport for the critical patient correctly identifying high priority patients is a essential during the primary survey and Rapid transport is critical for survival initiate this transport as soon as practical and then reassess Vital Signs every 15 minutes if the patient's condition is stable or every 15 minutes if unstable remember don't be falsely reassured by normal vital signs reevaluate them often as well as re-evaluating the mechanism of injury to ensure all critical information has been considered.",
        "History Taking": "history taking provides critical details about the patients Chief complaint and an account of their signs and symptoms providers should gather as much information as possible from family friends and bystanders on the scene check for medical identification tags and paperwork in order to obtain this additional information that being said don't delay transport for a patient's unstable conditions as their immediate care is your priority document all gathered information thoroughly including their demographic details past medical history current health status pertinent family history and recent travel history to investigate the chief complaint effectively start by introducing yourself and ensuring the patient feels comfortable obtain permission to treat and then ask a few simple open-ended questions to gather information use eye contact appropriate body language and empathetic language to show concern and encourage the patient to share more details avoid interrupting and be empathetic towards the patient situation collect information about the chief complaint from observable Clues at any details provided in the original dispatch additionally utilize family members friends bystanders other public safety personnel and medical identification tags in order to gather essential information to investigate the history of present ill using the opqrst method start by assessing the onset of the patient's problem determine when the issue began what the patient was doing at that time and how long ago they first noticed the problem next address provocation and pation by identifying factors that exacerbate or alleviate the issue understanding what provokes the problem can be important to determine its cause and severity while identifying palliating factors helps in understanding what might provide some relief to assess the quality of the patient's pain ask the patient to describe it in their own words try to avoid leading questions and take the time to listen patiently to their description document their description carefully including any specific terms they use additionally ask them to point to the area of pain describe its location and then mention any other Associated pain this could include focal pain which would be localized to one area or diffuse pain which spreads over a broader region to evaluate the region and radiation of the pain ask if the pain or discomfort travels from its origin to other parts of the body radiating pain moves from the source to another area while referred pain occurs in locations other than the origin for assessing severity gauge the patient's perception of the Pain's intensity compared to past experiences ask the patient how bad is this episode compared to previous ones how would you rate this problem on a scale of 1 to 10 10 or zero is normal and 10 is the worst pain imaginable to understand timing ask when the problem began and how its Nature has changed over time remember opqrst works best for medically induced pain such as non-traumatic abdominal pain back pain chest pain and so on and so forth some patients might self-treat or self-medicate before calling 911 so the provider should inquire about any prior treatments to avoid potential overdoses identifying pertinent negatives involves noting any expected findings based on the patient's complaint that are not present this can help in forming a more accurate diagnosis and treatment plan to investigate a patient's past medical history use the memonic sample to guide your inquiry seeing as how everyone who's taken this course has been through EMT I'm not going to spend a lot of time on Sample history just understand that this form of History taking is used by virtually every health care provider in the profession today it should be asked on every every single patient you come in contact with.",
        "Sensitive Topics and Communication Challenges": "when addressing sensitive topics such as alcohol and drug use or even physical abuse approach the patient with care and empathy for alcohol and drug use be aware that signs and symptoms may be misleading or even concealed and patients may deny substance abuse and their history could be unreliable especially if they have a chemical dependency take the time to establish a strong Rapport assuring the patients that their information will be kept confidential for physical abuse or violence it is crucial to report any suspected cases to the appropriate authorities and involve law enforcement if abuse or domestic violence is suspected look for hidden Clues and inconsistencies in the information provided by the p patient or even others at the scene recognize that the patient may not be able to answer questions due to fear of further violence and the physical aggressor may even be present potentially influencing responses in domestic violence cases your involvement can be dangerous so maintain a high index of Suspicion be observant open-minded and non-judgmental accurate thorough and objective documentation is essential for all cases of abuse and domestic violence and remember it's a mandatory reporter in any state in the US it is your responsibility your responsibility to make sure that this information gets passed on to the appropriate authorities not simply the Receiving Hospital when discussing sexual history be sensitive as many patients find this topic uncomfortable for female patients consider any woman of childbearing age with lower abdominal pain to be pregnant unless ruled out by further history or other information ask about the timing of their last menstrual period the regularity of periods any unusual vaginal discharge or bleeding urinary symptoms such as frequency or burning severity of cramping any unpleasant odors the possibility of pregnancy use of birth control number of sexual partners and any recent sexual activity for male patients inquire about urinary symptoms such as pain upon urination discharge sores increased urination burning itching difficult ulty voiding any trauma number of sexual partners and recent sexual encounters also ask about the potential for any sexually transmitted diseases and ensure that all information will be kept confidential when faced with Silence from a patient it's important to be patient and use close-ended questions that require simple yes or no answers this should encourage communication silence itself may be a clue to the patient's Chief complaint so observe the patient's environment for any visual signs that could explain their lack of communication additionally pay attention to non-verbal cues such as facial expressions which may indicate pain or fear when dealing de with an overly talkative patient consider that causes might include excessive caffeine consumption nervousness or the ingestion of stimulants like cocaine or methamphetamines allow the patient to express themselves but guide them to focus on the thoughts by frequently summarizing their statements and clarifying information to ensure accuracy for patients presenting with multiple symptoms invest invest extra time in addressing them and prioritize their complaints as you would during triage always ask for additional information to try to understand why you were called and maintain an open mind avoiding fixation on any single complaint or detail anxiety is commonly observed in emergency scenes involving numerous patients or during routine EMS calls where individuals are struggling to cope anxious patients might show signs of psychological shock and anxiety could indicate underlying issues such as low blood glucose levels shock or hypoxia reassure the patient that their nervous or anxious responses are normal and can be managed maintaining confidence and a positive demeanor be cautious as emergency situations with anxious or hysterical patients could escalate into violence in a similar fashion encounters with angry or hostile patients carry the risk of violence anger can be directed at you by patients their friends their family or even bystanders who aren't involved it's important not to take such Behavior personally and avoid avoid responding with anger instead remain calm reassuring and gentle and be attentive to non-verbal cues like posture and facial expressions if the scene is unsafe contact law enforcement for assistance and ensure that potentially violent or hostile patients do not leave the room alone you are allowed to leave if you feel that you were in an unsafe situation and as always if you're attacked you have every right to defend yourself when dealing with intoxicated patients be aware that the information they provide may be difficult to obtain and potentially unreliable intoxicated individuals may become impatient or defensive so it's important not to put them in a position where they feel threatened or trapped approach them with acceptance diplomacy and objectivity this should be done to avoid making judgments never assume that a patient's condition is solely due to alcohol or drug consumption patients who are crying may be experiencing sadness pain or emotional overwhelm remain calm patient and reassuring using a soft voice show empathy and treat them with respect and dignity depression is a leading cause of disability worldwide and can manifest a sadness hopelessness restlessness and irritability be non-judgmental and compassionate sympathetic and provide a listening ear and support as often patients need someone to talk to and understand their feelings when countering patients with confusing Behavior or history be aware that medical conditions such as hypoxia stroke diabetes trauma and drug or medication use can contribute to confusing symptoms hypoxia in particular is a common cause of confusion additionally older patients may suffer from dementia delirium or Alzheimer's disease verify each patient's Baseline mental status as confused behavior is not considered a normal response for patients with limited cognitive abilities keep questions simple and avoid using complex medical terminology be attentive to partial answers and continue asking questions as needed for those with severely limited cognitive function rely on information from from family members caregivers and friends to provide or supplement answers for patients with language barriers consider utilizing interpreters translation resources and even mobile apps to facilitate communication first you should ascertain if the patient speaks or understands any English and ensure they know who you are keep your questions straightforward and brief and hand gestures May Aid in understanding inform the hospital in advance if a non-english-speaking patient will be arriving for patients with hearing impairments which can range from slight to Total deafness ask questions slowly and clearly you can even use the stethoscope as a hearing aid and changing the pitch of your voice could improve prove their ability to hear some patients May read lips so communicate face to face and even consider learning basic sign language if you are required to wear a mask due to disease transmission communicate Outdoors where physical distancing can be maintained in the end pencil and paper can also be useful for visually impaired patients verbally identify yourself when you enter their space return any moved items to their original positions and explain what is happening maintaining contact by keeping a hand on their arm or shoulder notify them before lifting or moving and remember that EMS environment is unfamiliar to them.",
        "Secondary Assessment and Vital Signs": "the secondary assessment aims to obtain Vital Signs and conduct a thorough physical exam of the patient if they are stable and have a single complaint this assessment can be performed on scene however if the patient is unstable or has multiple issues it should be carried out in the back of the ambulance while in route to the hospital at a minimum document the following levels of consciousness respirations pulse blood pressure skin condition blood glucose and pulso symmetry the physical exam can either be a comprehensive head-to-toe assessment or focused on a specific area or region it's important to compare findings on one side of the body with the other and in some cases noting any odors during the exam as odors can reveal infections certain medical conditions or potential seen safety threats when assessing vital signs it's important to use the appropriate monitoring devices while keeping in mind that these devices do have limitations and can experience mechanical failures they should never replace a thorough and comprehensive assessment of the patient for pulse oxymetry this tool evaluates the effectiveness of oxygenation and is useful in determining how well oxygen therapy Broncho dilator therapy and artificial ventilations are working pulse oxymetry should not be used in cases of hypo profusion or if you know the patient has anemia it should also be avoided with any exposion to carbon monoxide or other toxic inhal or if the patient has cold extremities these conditions can affect the accuracy of the device's readings non-invasive blood pressure measurement typically involves the use of a blood pressure cuff and can be performed using various methods such as oscor palpation or electronic it is important to note that electronic devices May provide inaccurate readings if used in moving Vehicles noisy environments or if the cup is not properly sized or placed you should always take the first set of vital sides manually regardless of the availability of the electronic device to assess oxygen consumption carbon dioxide levels are measured since CO2 is a byproduct of aerobic cellular metabolism and reflect the amount of oxygen being consumed in tile carbon dioxide or etco2 can be detected using various methods such as color metry capnometry and capnography capnometry employs a disposable or electronic device to measure CO2 output while capnography provides a detailed measurement of CO2 levels along with a waveform that represents serial measurements over time in title CO2 specifically refers to the partial pressure or maximal concentration of CO2 at the end of an exhaled breath offering critical information about the effectiveness of ventilation and the patient's metabolic status the use of an entitle CO2 2 detector is used for confirming and monitoring Advanced Airway placement the absence of C2 could indicate that the endot trical tube is misplaced or that there is a significant reduction or absence of CO2 in the lungs conversely an increase in cardiac output will be reflected in the entitle CO2 measurement providing insights into the adequacy of both ventilation and circulation this monitoring helps ensure proper placement and function of the advanced Airway as well as effective overall patient management blood glucometry measures glucose levels in the bloodstream and is particularly indicated for patients with known diabetes Who present with a decreased level of consciousness patients with an unexplained decreased loc General Mala weakness or simply a poor general impression.",
        "Full Body and Focused Assessments": "the goal of a full body exam is to identify hidden injuries or underlying causes that may not be immediately apparent for any patient who has experienced a significant mechanism of injury is unresponsive Ive or is in critical condition a comprehensive full body exam should be conducted after addressing and managing any immediate life threats this thorough examination ensures that no critical injuries are overlooked and that the patient's condition is fully assessed a focused assessment is generally performed on patients who have sustained minor mechanisms of injury or are unresponsive medical patients presenting with a specific complaint this type of assessment concentrates on the chief complaint and involves directing attention to the immediate problem at Hand by focusing on the particular issue you can more efficiently identify and address the patient primary concerns without expending resources on a full body exam that may be unnecessary for Less CR critical cases in the focused assessment of the respiratory system Begin by examining for signs of Airway obstruction and Trauma to the neck and chest expose the patient's chest and inspect for overall symmetry ensuring that both sides of the chest move equally carefully listen to breath sounds noting any abnormalities such as wheezing crackles or decreased breath sounds observe for protractions which can indicate difficulty breathing palpate the area from the clavicles to the shoulders and down to the abdomen and reassess the breath sounds as you go additionally look for the presence of subcutaneous osma which can suggest underlying trauma or injury for assessing the respiratory rate the normal resting range for adults is 12 to 20 breaths per minute it is best to check the patient's respirations discreetly especially in a responsive and alert patient without drawing attention to what you're evaluating additionally observe the respiratory Rhythm and note whether the patient's breathing is regular or irregular assessing the quality of breathing involves listening to breath sounds on each side of the patient's chest during the primary survey decreased or absent breath sounds on one side and reduced movement in the rise and fall of the chest on that side may suggest inadequate breathing normal breathing is typically silent if there is a mild obstruction in the upper Airway such as from a farm body or swelling Strider may be heard bubbling or gurgling sounds indicate the presence of fluid in the airway to assess breathing it's often most effective to listen the breast SS from the patient's back begin oscilation over the upper lungs approximately 1 inch below the clavicle at the midclavicular line then move to the midlung Fe fields and finally the lower lungs at the mid axillary line ensure that you lift the patient's clothing or simply Slide the stethoscope under it place the diaphragm of the stethoscope firmly against the skin to clearly hear the breath sounds breath sounds can be described in several ways normal breath sounds are clear and relatively quiet wheezing is characterized by a high-pitch whistling sound which suggests obstruction or narrowing of the lower Airways crackles are moist crackling sounds that are typically heard on both inspiration and expiration they indicate pulmonary edema ronai are continuous lower pitched rattling sounds indicative of mucus in the the larger ear ways of the lungs Strider is a brassy crowing sound caused by the narrowing swelling or obstruction of the upper Airway plural friction rubs produce a squeaking or grading sound when the plural Linings rub together additionally if a patient coughs up thick yellow or green sputum it most likely indicates an advanced respiratory infection coughing up blood or frothy white or pink sputum may be associated with a chest injury suggesting a mix of blood and fluid with air in the lungs froy sputum can also be a sign of heart failure the depth of breathing reflects the volume of air exchanged by the patient which depends on both the rate and tital volume tidal volume refers to the amount of air measured in millimeters moved into or out of the lungs during a single breath shallow respirations are indicative of a decreased tidal volume meaning the patient is taking in less air with each breath in contrast deep respirations suggest an increased tidal volume with more air being moved in in and out of the lungs with each breath when evaluating a patient with chest pain or discomfort it's essential to examine the cardiovascular system thoroughly start by checking for abnormalities in the thoracic region including listening for breath sounds and inspecting the chest for trauma assess the pulse and respiratory rate focusing on the rate quality and Rhythm of the pulse additionally monitor the patient's blood pressure and re-evaluate the skin condition compare distal pulses and listen for abnormal heart tones during oscilation for adults the normal resting pulse rate ranges from 60 to 100 beats per minute rates exceeding 100 beats per minute indicate teoc cardia while rates below 60 per minute are in indicative of braic cardia when assessing pulse quality describe a normal pulse as strong a pulse that is stronger than usual should be noted as bounding conversely a pulse that is weak and difficult to detect is referred to as weak or threy regarding pulse Rhythm determine whether it's regular or irregular an irregular rhythm is characterized by an occasional early or late beats or simply missed pulse beats blood pressure refers to the force exerted by circulating blood against the walls of the arteries a decrease in blood pressure May indicate several issues such as a loss of blood or its fluid components diminished vascular tone in arterial constriction problems with cardiac pumping or an overdose of beta blockers or other anti-hypertensive medication as shock progresses blood pressure will decrease any patient exhibiting markedly low blood pressure has insufficient pressure to ensure adequate profusion of vital organs olic pressure represents the peak pressure exerted in the arteries during ventricular contraction and the subsequent pulse wave diastolic pressure refers to the residual pressure in the arteries during the heart's relaxation phase blood pressure is measured in millimeters of mercury and is reported as a fraction with systolic pressure over the diastolic pressure when measuring blood pressure avoid using an arm with an IV site central line catheter or Port also stay away from dialysis fistulas or shunts patients who have a history of myectomy on that side or simply an injury to that arm most EMS agencies carry at least four sizes of blood pressure cuffs OB adult Pediatric and infant using a cuff that is too small may result in an inaccurately high reading while a cuff that is too large may lead to an inaccurately low reading a neurologic assessment is crucial when a patient exhibits changes in their mental status Begin by evaluating the level of Consciousness and orientation to gauge the patient's cognitive function using the avpo scale to assess their mental status consider their activity level mood and thought content observe facial expressions to infer emotional states such as anger fear depression anxiety or restlessness and then determine if the patient seems uncomfortable evaluate the coherence of of their statements and their memory including recognition of family members and perception of current events inspect the head for trauma and monitor Vital Signs like pulse blood pressure and skin changes as these can indicate hypo profusion of the brain assess the mental status by checking if the patient is alert and oriented to person place time and event and the determine their glass galoma score check for any gross neurologic deficits and quickly assess for loss of sensation by touching the distal portions of their extremities pupils provide important clues about a patient's neurological status as their diameter in reactivity to light can reflect the brain's perfusion oxygenation an overall condition normally pupils are round of roughly equal size and adjust accordingly to light levels meaning they constrict in bright light and dilate in dim light bilateral dilated pupils that do not respond to light often indicate severe conditions such as death if the pupils are fixed dilate in response to light but do not constrict when the light is removed react sluggishly or are of unequal size this could suggest a depressed brain function this may be due to a brain or brain stem injury trauma stroke brain tumor inadequate oxygenation or perfusion or the influence of CNS depressants like drugs or toxins the memonic Pea is a useful guide for assessing the pupils and stands for pupils that are equal round and reactive to light and with accommodation this means you should check that the pupils are of equal size round and responsive to light additionally assess their ability to adjust the changes in light and focus when evaluating neurovascular status we should check to see for bilateral muscle strength and any weakness as well as to conduct a thorough sensory assessment to determine the patient's response to touch temperature and pain when assessing the head neck and cervical spine start by inspecting these areas for any abnormalities gently palpate the scalp and skull looking for pain deformities tenderness crepitus or any signs of bleeding additionally examine the patient's face for the presence of a rash or ptii which are small red or purple spots that are caused by bleeding under the skin when assessing the patient's eyes start by checking the color of the Scara to ensure it's normal examine the eyes for any foreign objects or blood and look for bruising or discoloration around the eyes and behind the ears inspect the patient's ears and nose for any fluids before opening the mouth examine the upper and lower Jaws for any issues once the mouth is open look for broken or missing teeth take note of any odors such as strong alcohol or fruity smells which may indicate the need to check the blood glucose level additionally check the neck for swelling or bleeding palpating for signs of trauma be alert for subcutaneous osma which is a crackling sound produced by air bubbles Under the Skin and inspect for a pronounced or distended jugular vein when assessing the chest start by inspecting visualizing and palpating the area for any injury or signs of trauma look for signs of abnormal breathing such as retractions or paradoxical motion which often indicates rib fractures during palpation note any crepitus as this can suggest fractured ribs additionally check for subcutaneous empyema particularly in cases of severe blunt chest trauma finally osculate the chest to assess breath sounds when assessing the abdomen look for signs of trauma and distension palpate the abdomen to detect tenderness rigidity and any signs of patient guarding visually inspect the area for bruising or abnormalities bruising over the flank area May indicate blood collecting in the retrop paranal space when assessing the abdomen a symmetry May indicate a swollen organ beneath that area severe distension could result from fluid accumulation in the paranal space known as aides blood due to a slow leak from a rupture obstruction like a bowel blockage or an infection such as sepsis palpate the abdomen to evaluate for symmetry masses tenderness and signs of bleeding of course we always want to begin palpation in the quadrant farthest from the patient's pain or obvious injury and then check for Rebound tenderness inspect the pelvis for symmetry instability pain tenderness crepitus bleeding deformity and any obvious signs of injury if the patient reports no pain gently press downward and inward on the iliac crests of the pelvis bones but avoid rocking the pelvis inspection of the pelvis area is typically not performed in medical emergencies unless pain and bleeding are present in female patients assess whether the bleeding originates from the vaginal opening the urethra external genitalia or the rectum for male patients determine whether the bleeding comes from the urethra or the rectum assessment of the muscular skeletal system is typically performed due to achieve complaint associated with trauma or the mechanism of injury never force a painful joint to move compare the right side with the left side looking for weakness or atrophy and assess the quality of grip strength inspect each extremity for Decap btls check for pulses motor function and sensory function by assessing distal pulses at the foot and wrist asking patients to wiggle their fingers and toes and evaluating sensory function by asking patients to close their eyes and identify Sensations like squeezing or pinching with a finger or toe palpate each extremity individually to check for edema paying close attention to the color of the hands and arms in comparison and of course noting the color of the fingers and nail beds for the posterior body assessment inspect the back for Decap btls as well as symmetry bleeding and open wounds check the back as you log roll the patient ensuring the spine remains in line at all times do not remove the hand that is supporting the shoulder and carefully palpate the spine from the neck to the pelvis with the other hand if time permits during transport you may choose to perform a focused assessment of each body system to determine whether to conduct additional exams ask yourself two questions what additional problems can be identified through this exam and how will these findings change my treatment choices based on the findings you may need to address potentially life-threatening conditions establish spinal motion restriction if neck or back pain or other abnormalities in sensation or movement are identified in relation to trauma modify ongoing treatments based on new information initiate treatment for additional issues found during the focus exams or adjust transport decisions to a more suitable facility.",
        "Reassessment and Ongoing Care": "reassessment is carried out at regular intervals throughout the assessment process in order to identify and address any changes in the patient's condition the purpose of reassessment is to ensure continuous monitoring and adjustment of care is needed during the reassessment repeat the primary survey and compare the patient level of Consciousness with your initial Baseline assessment additionally reassess the ABCs to monitor any alterations in the patient status reassess Vital Signs by comparing the Baseline values obtained during the primary survey with subsequent measurements look for Trends in the vital signs to detect any changes in the patient's condition continuously monitor the patient's mental status and the ABCs keep an eye on skin color and temperature and reassess the blood pressure and pulse to ensure they are within expected ranges reassessing the chief complaint involves evaluating the effectiveness of the treatments administered up to that point this includes asking whether the current treatment is improving the patient's Condition it's important to determine if any previously identified problems have improved or worsened additionally assess any new issues that may have emerged since the last evaluation this approach helps to ensure that the patient's condition is continuously monitored and managed effectively rechecking interventions involves a thorough evaluation of all actions taken during the patient assessment process the primary focus should be on the management of the patient's Airway breathing and circulation ensuring these are adequately addressed verify that bleeding is controlled effectively and confirm that other interventions are performing as intended addition add Al consider whether new interventions might be necessary based on the patient's evolving condition identifying and treating changes in the patient's condition is a critical aspect of reassessment this process is necessary to monitor any fluctuations in the patient status if the patient's condition improves maintain the current treatment approach however if deterioration occurs adjust your treatments as needed it is important to document all changes both positive and negative remember unstable patients should be reassessed every 5 minutes while stable patients should be reassessed every 15 minutes to ensure appropriate ongoing care.",
        "Conclusion and Summary": "the primary assessment is crucial because it quickly identifies and addresses immediate life-threatening conditions it prioritizes the evaluation of the air we breathing and circulation or ABCs which are essential for ensuring the patient's Survival by focusing on these critical aspects first the primary assessment helps stabilize the patient and lays the foundation for a more detailed evaluation and treatment in the patient assessment process the secondary assessment involves obtaining Vital Signs and performing a systematic physical exam to identify and address issues beyond the initial life-threatening conditions this includes evaluating levels of consciousness respirations pulse blood pressure skin condition blood glucose and pulse oximetry depending on the patient's condition and the complaint this assessment might be conducted at the scene or in route to the hospital reassessment is a critical component of ongoing patient evaluation and involves repeating the primary survey comparing current findings with Baseline assessments and noting any changes in the patient's condition regular monitoring helps in identifying any new or worsening issues and ensures the treatments are effective if necessary interventions should be adjusted based on the patient's evolving condition for a more thorough evaluation focus on specific body systems and conditions such as the respiratory cardiovascular neurologic and abdominal systems this includes inspecting for abnormalities assessing breath sounds evaluating pulse quality and Rhythm and palpating for tenderness or swelling additionally check pupils for responsive and symmetry to gauge neurological status recheck all interventions to confirm their effectiveness and document any changes unstable patients require assessment every 5 minutes while stable patients need to be reassessed every 15 to ensure timely adjustments to their care"
    },
    {
        "Introduction to Patient Assessment": "chapter five patient assessment introduction patient assessment in the critical care environment deviates notably from the conventional Emergency Medical Services field assessment in two fundamental ways firstly Critical Care patients frequently undergo extensive treatment and stabilization procedures before the arrival of the critical care transport professional this prior intervention can introduce complexities and nuances that demand astute evaluation and adjustment of the patient care plan secondly the critical care transport environment often avails itself to Advanced Diagnostic information that is not typically accessible during field assessments these Diagnostic Resources Encompass a range of data including laboratory results Imaging studies and realtime monitoring parameters all of which furnish inv aable insights into the patient's condition enabling more precise clinical decisions the core assessment framework employed in the hospital's ICU remains consistent with the approach applied in the field however within the context of critical care transport several distinctive features emerge firstly patient Acuity levels in the critical care transport setting are are substantially elevated necessitating a heightened vigilance for subtle changes and the potential for Rapid deterioration secondly Critical Care patients within this environment often rely on Advanced technological support which may not be routinely employed in prehospital settings these Technologies Encompass mechanical ventilators continuous renal replacement therapy machines and Complex infusion pumps among others consequently the critical care transport professional must possess a comprehensive understanding of these devices as well as the capability to troubleshoot and respond to device related issues swiftly and",
        "Arrival and Planning": "competently arrival in planning upon arrival at the referring fac facility the critical care transport professional must adhere to a systematic introduction protocol to ensure seamless patient care continuity firstly the provider should initiate introductions with the patient's care team fostering effective communication and establishing a collaborative care environment this introduction is essential as it sets up the stage for the exchange of vital patient information following this it is imperative that the provider requests access to the patient's chart and all available diagnostic Data before acquiring a handoff report this introduction process serves a dual purpose that is similar in function to a prehospital Scene It signals to the health care providers that the critical care transport paramedic has arrived on site and is fully prepared to commence patient care promptly in the context of critical care transport the significance of reviewing the patient's chart before obtaining a handoff report cannot be overstated this initial step provides the provider with a foundational understanding of the patient's medical condition enabling them to tailor their assessment and interventions accordingly moreover it mitigates the risk of redundancy preventing the hospital care team from reiterating information already documented in the chart the handoff report provided by the treating nurse or physician Bridges the information gap between the written patient care report and the pre-arrival notification this report often delivered verbally encapsulates critical details regarding the patient's medical history current condition ongoing treatment and their anticipated care plan it acts as a dynamic supplement to the static patient chart offering real-time insights into the patient status notably it's important to recognize that the individual delivering the handoff report may not necessarily be the primary caregiver who has administered the majority of the patient care upon initial assessment it is imperative to promptly assertain whether the individual is afflicted by traumatic injury medical illness or both this differentiation serves as a critical pivot point in directing subsequent evaluation and therapeutic interventions to achieve this the assessment process must be conducted with precision and questions should be tailored to elicit specific information pertinent to the patient's condition in cases where a traumatic injury is suspected the paramedic should inquire about the mechanism of injury including a details of about the event the force involved and any anatomical regions of concern additionally questions should be focused on pain localization Mobility limitations and any sensory or motor deficits this targeted approach AIDS in identifying traumatic injuries such as fractures dislocations or soft tissue injuries conversely when a medical illness is suspected the line of questioning should Encompass the patient's medical history presenting symptoms and any underlying chronic conditions particular attention should be paid to signs and symptoms indicative of medical illnesses such as chest pain shortness of breath altered mental status or systemic symptoms such as fever or nausea obtaining a comprehensive medical history including medication use and previous medical interventions can further refine the assessment and assist in differentiating between potential medical eies when preparing for the transport of injured patients it's essential to gather specific information through a comprehensive line of questioning these inquiries aim to provide a thorough understanding of the circumstances surrounding the injury and the patient's condition thereby guiding appropriate care during transport inquiring about the time of injury helps establish the duration since the traumatic event occurred aiding in the assessment of potential complications or changes in the patient's condition over time understanding the mechanism of injury including details about how the injury occurred and the speeds involved he evaluates the extent and nature of the traumatic injury this information assists in identifying high impact mechanisms that may result in severe trauma determining whether the injury was accidental or deliberate is essential for assessing the potential presence of associated injuries such as self-inflicted wounds and may also have legal implications inquiry regarding the use of safety equipment such as seat belts or helmets can provide insight into the likelihood of specific types of injuries especially in cases involving motor vehicle accidents or Falls gathering information about diagnosed injuries from healthc care providers or diagnostic tests conducted at the scene or referring facility AIDS in tailoring the care plan and ensuring continuity of care during transport inquiring about diagnostic tests that have been performed and their results such as x-rays CT scans or laboratory studies helps in understanding the patient's current condition and any potential complications or comorbidities identifying diagnostic tests that are indicated but have not yet been carried out is also essential for planning further evaluation and interventions during transport it ensures that appropriate tests are conducted to assess the full extent of injuries or medical conditions when transporting patients presenting with a medical complaint a meticulous approach to Gathering essential information is vital for ensuring appropriate care during transport to this end several critical details should be obtained inquiring about the time of symptom onset is vital to establish the temporal context of the patient's condition assisting in the identification of potential causes and guiding the assessment knowing the precise time of the patient's arrival at the referring facility helps to track the duration of symptoms and any changes in their clinical status during the stay understanding whether the patient symptoms have improved worsened or remained stable over time is important for assessing the severity of the medical condition and the urgency of further interventions inquiring of about the diagnostic test conducted at the referring facility and the associated results offers valuable insights into the patient's current medical status and AIDS in the continuity of care gathering information about the potential differential diagnosis considered by healthc care providers helps paramedics understand the range of possible underlying medical conditions facilitating targeted assessment and management identifying any complications or adverse events related to the patient's medical complaint is critical for determining the patient's overall clinical stability and any necessary interventions during transport documenting the interventions administered at the referring facility and the patient's response to these treatments informs the ongoing care plan ensuring that any necessary follow-up measures are taken during transport the hospital patient care record or PCR is a viable repository of information providing critical insights into the patient's medical history care and current condition when reviewing the PCR it's important for the provider to adeptly discern between pertinent and extraneous information to optimize patient care and decision making one variable in this differentiation process is the anticipated transport time as it directly influences the level of detail required anticipated transport time serves as a vital determinant in sifting through the information obtained within the PCR for shorter transport durations a concise summary of the patients demographics transfer orders and essential clinical data May suffice however for longer transport times a more comprehensive review of the PCR becomes imperative this thorough examination ensures that the critical care transport professional has all the necessary information at their disposal to provide appropriate assessment and intervention during the extended Journey items of significance within the hospital PCR Encompass a broad spectrum of patient related data demographics basic patient information such as name age and medical record number transfer order including details about sending and accepting Physicians the destination Hospital specific care unit and contact information for each involved party as needed in standing orders for transport these are vital for understanding the patient's prescribed medical interventions history and physical examination findings or the hmp a comprehensive overview of the patient medical history and current physical condition physician notes records of the healthc care providers assessments diagnosis and treatment plans nursing notes information on nursing care Vital Signs and Trends in the patient condition medication administration record a log of medications administered to the patient lab values and results of diagnostic studies includes copies of Imaging studies stored on digital media offering insight into the patient's clinical status physiologic scoring method results objective assessments that gauge the patients severity of illness Advanced directives documents specifying the patient's wishes regarding medical treatment and family and caregiver names and contact information vital communication and support a careful examination of the PCR with particular emphasis on the h&p physician notes nursing notes and the medication administration record serves as an indispensable step in the critical care transport professionals preparation for patient care this comprehensive review not only furnishes valuable insights into the patient's clinical history but also furnishes critical Clues regarding the patient's current condition and ongoing management the hmp report offers a comprehensive overview of the patient's medical history including pertinent Det details about pre-existing conditions surgical history allergies and medications physician notes provide critical information on the patient's diagnosis treatment plan and any changes in the clinical course nursing notes on the other hand offer real-time documentation of the patient's Vital Signs Trends and responses to treatment the medication administration record provides a chronological record of prescribed medications dosages and the patients adherence collectively this information constitutes a wealth of data that can unveil critical insights into the patient's current condition potential complications and any evolving issues that may require immediate attention during transport armed with the knowledge from the hospital PCR the provider is better equipped to conduct a focused and efficient bedside assessment upon arrival this information AIDS in directing the providers attention to specific areas of concern facilitating a targeted evaluation of the patient's Vital Signs physical findings and neurologic Status additionally it informs the provider about any medications administered and their potential impact on the patient's clinical presentation the PCR derived insights also enable the provider to anticipate and respond to changes or complications that may arise during the critical care transport thereby enhancing the quality of care",
        "Primary Assessment": "provided primary assessment a critical component of the initial patient assessment during Critical Care transport involves obtaining a brief yet comprehensive glimpse into the patient's condition to facilitate this process the provider should be positioned at the patient's head ensuring optimal visibility to assess Vital Information this assessment aims to swiftly identify any acute life-threatening issues while also enabling a systematic and Rapid evaluation of the patient organ systems and Anatomy the provider's positioning at the patient's head allows for immediate assessment of the patient's overall condition with a primary focus on identifying acute life-threatening issues this entails evaluating the patient's level of Consciousness assessing for signs of sever bleeding and detecting any immediate threats to the airway breathing or circulation with the patient's head as the vantage point the provider can systematically perform a rapid evaluation of the patient's organ systems and Anatomy this includes not only the ABCs but also the neurological status and exposure to potential injuries or environmental factors most providers use the March or ABCDE method starting with March we have massive Hemorrhage which would be the assessment of any massive bleeding sources and immediate steps to control Hemorrhage if identified Airway ensuring patency of the patient's Airway and addressing any obstructions respirations evaluation of breathing patterns lung sounds and oxygenation status circulation the assessment of the patient's circulatory status including pulse quality blood pressure and signs of shock or profusion deficits and hypothermia recognizing and addressing any signs of hypothermia as well as taking measures to maintain the patient's core temperature however AB CDE is preferred Airway ensuring the patient's patent Airway Remains the top priority as any Airway compromise can rapidly deteriorate the patient condition breathing assessment of breathing adequacy including rate depth and oxygenation is essential for maintaining oxygen delivery to tissues circulation evaluation of circulatory status focuses on assessing profusion and addressing any signs of shock or hemodynamic instability disability neurological assessment including a level of Consciousness and pupilary reactions helps to detect any neurological deficit and lastly exposure ensuring the patient is adequately exposed enables a thorough Examination for injury and allows for the initiation of appropriate interventions when it comes to determining the need for Airway intervention the critical care paramedic undertakes a thorough evaluation to establish whether the patient's current Airway status is safe or requires immediate intervention to secure or maintain it this assessment includes an anatomic examination of the airway to identify any potential issues such as pathologies diseases are anatomical factors that might pose challenges during intubation if it becomes necessary Additionally the provider customizes the examination based on the patient's level of Consciousness and cooperation adapting to it accordingly in considering Airway intervention a conservative and safety first approach is advocated providers are encouraged to air on the side of caution potentially opting to intubate the patient at the hospital or emergency scene before transfer especially when faced with indications of potential Airway difficulties for intubated patients the focus shifts to ensuring the safety of the artificial Airway in place this entails a visual inspection of the interrical tube verifying its size and depth to ensure proper positioning furthermore waveform capnography is employed to definitively confirm the ET tube's accurate placement thereby preventing complications like a sophal intubation the securing device holding the tube in place should also be examined to ensure it is effectively preventing tube dislodgment with an additional check to ensure the securing strap is correctly routed to maintain stability during transport as a preventative measure aimed at minimizing Airway obstructions the provider conducts a suction maneuver during the initial assessment to clear any secretions or potential debris that could compromise the Airways patency conducting a comprehensive respiratory assessment is an integral part of a critical care transport professional's initial evaluation with the primary objective of detecting any injury or illness directly impacting the respiratory system this multifaceted assessment encompasses various factors and aims to provide a holistic understanding of the patient's respiratory status the primary focus during this assessment is to identify any injuries or illnesses that directly affect the respiratory system which includes Discerning whether the patient's breathing difficulties are a result of pulmonary issues or if there is evidence of underlying non-pulmonary pathology that might indirectly affect respiration such factors such as respiratory rate effort and breathing patterns are considered to provide insights into the patient respiratory distress or stability it's important to emphasize the significance of trending over time as this approach helps identify changes in the patient's condition and response to interventions rather than relying solely on isolated respiratory value values moreover the respiratory assessment includes the recognition of indications for specific injuries or pathology even involving organs beyond the respiratory system providers must be vigilant in identifying patterns such as inspiratory or expiratory resistance as these can provide valuable clues about the patient's underlying condition palpation of the chest wall is another valuable aspect of the assessment enabling the provider to gather additional information about the burden of in injury which may not be readily apparent through other means for patients receiving mechanical ventilation additional considerations come into play the provider should confirm the adequacy and safety of mechanical ventilation ensuring that the delivered title volume is appropriate for the patient's needs and evaluating Peak inspiratory pressure levels to prevent complications like barot trauma furthermore the provider should screen for patients at risk of hyperoxia as oxygen toxicity can have adverse effects the circulatory assessment is a component of evaluating a patient's clinical status during Critical Care transport as it offers insights into the patient circulatory function and AIDS in determining the level of Acuity this comprehensive assessment involves several key aspects that are vital in assessing the patient circulatory Health firstly a rapid assessment of patient Acuity can be achieved through a concise bedside examination this includes an evaluation of the patient's skin including color temperature and overall condition any abnormalities such as power coolness or modeling May indicate poor profusion and oxygenation additionally capillary refill time is assessed with a prolonged time of 2 seconds signifying compromised peripheral profusion vital signs are continuously monitored as part of the circulatory assessment this ongoing measurement of Vital Signs including heart rate blood pressure respiratory rate and oxygen saturation is fundament Al to document Trends and assess the patient responses to interventions the mean arterial pressure is especially valuable as it provides a more physiologic representation of blood flow than isolated systolic blood pressure values however it's important to bear in mind that Vital Signs have limitations and their interpretation should be context specific considering factors such as medication effects or underlying medical conditions moreover when assessing a patient with suspected Hemorrhage the provider actively seeks potential sources of bleeding external wounds particularly those affecting the extremities require immediate attention including packing dressing and splinting furthermore the provider must remain vigilant for signs of internal hemorrhage which may not be readily apparent specific indicators such as gray Turner sign or a seat belt sign warrant close examination finally assessing the pelvis is important as pelvic fractures can lead to significant internal bleeding proper mobilization and stabilization of the pelvis may be necessary to minimize further Hemorrhage the GI assessment is a vital as aspect of evaluating a patient's overall health and detecting potential GI problems during the transport process this assessment encompasses three main components inspection oscilation and palpation during the inspection phase a general overview of the oral mucosa in abdominal areas is performed to initially assess the patient's GI status any unusual findings observed during the inspection should be promptly reported these findings might include dry mucus membranes suggestive of dehydration or pale mucus membranes indicating possible hypovolemia the presence of a large abdomen may be indicative of aites and visible hernas or masses warrant further examination Additionally the assessment involves inspecting the stools for characteristics such as color consistency and odor as these can provide valuable information about potential GI issues with dark Molina stools indicating upper GI bleeding and stools mixed with bright red blood suggesting lower GI bleeding oscilation of the abdomen predes palpation and percussion and involves listening for bowel sounds in all four quadrants of the abdomen bow sounds should be present in all quads though they may vary in intensity and characteristics potentially reflecting different disease States it's important to recognize variations such as hypoactive or hyperactive bow sounds as they can provide clues about the patient's GI function some clinical conditions like an ilas can significantly affect bow sounds causing them to be diminished or absent the palpation phase of the GI assessment is critical for documenting tenderness and evaluating the abdominal area simple palpation helps assess tenderness while rebound tenderness characterized by pain upon the release of pressure may suggest perianal inflammation special attention should be paid to patients with suspected pelvic fractures as palpation must be conducted cautiously to prevent further injury the Murphy sign indicative of kystis involves applying firm pressure to the right upper quadrant of the abdomen often eliciting severe pain exacerbated by Deep inspiration nodules in the liver which may be related to malignancy should be carefully noted additionally palpation of the spleen is generally not feasible while palpation of the right kidney although possible offers limited clinical value and should be avoided in patients with a history of polycystic kidney disease the Geno urinary assessment encompasses an evaluation of the mamory testicular and prostate glands although this assessment is typically limited to patients with specific needs such as those with spinal cord injuries or trauma that may have resulted in gu issues it's a component of the overall patient assessment as it helps identify potential gu conditions or complications that require attention and intervention during transport in cases of inst stage renal disease patients may have complex gu needs due to their compromised renal function two common renal replacement therapies include paranal dialysis and hemodialysis each with its own set of of considerations for patients undergoing peronal dialysis there is a heightened risk of peritonitis therefore it's imperative to use aseptic technique when handling peronal dialysis equipment and Performing exchanges to minimize the risk of infection and peritonitis development hemodialysis involves the use of an AV shunt typically located in the forearm or thigh or a tunnel dialysis catheter inserted into the chest during the assessment of a patient with an AV shunt providers should assess for the presence of a thrill which is a palpable vibration indicating that the shunt is functioning normally however these assessments should only be conducted in dire emergencies and require a sterile technique to prevent infection and complications in cases where patients have Central lines it is Essen enal to exercise caution and adhere to strict protocols flushing lines that contain heprin before aspirating a significant amount of waste typically a minimum of 10 MLS per Port helps prevent complications and ensures that the lines remain functional and safe for use during transport the disability assessment evaluates and monitors the patients's neurological status during transport it involves a comprehensive neurologic examination that extends beyond the initial survey and continues throughout the transport process to monitor for any evolving Trends or changes in the patient's neurologic condition this continuous monitoring is of utmost importance because neurologic conditions can be dynamic And Timely detection of any alterations in neurologic function allows for prompt intervention the neurologic IC examination during Critical Care transport can be approached in a tiered manner the initial examination focuses on swiftly identifying major neurologic pathology and providing an initial assessment of the patient's neurologic status this initial assessment typically includes evaluating the patient's level of Consciousness pupilary reactions gross motor responses and basic sensory responses these fundamental elements allow for an immediate understanding of the patient's neurologic condition guiding the initial steps of care subsequently a more thorough neurologic examination can be conducted delving into more subtle neurologic findings this comprehensive assessment involves an in-depth evaluation of various aspects of neurologic function such as cranial nerve function motor string R reflexes coordination sensory perception and mental status this detailed examination provides a nuanced understanding of the patient's neurologic status which is particularly valuable in cases where the initial assessment raises concerns or where the patient has a pre-existing neurologic condition neurologic scoring AIDS in quantifying the patient level of Consciousness and cognitive function to assess the patient's level of Consciousness effectively the AVP scale is often employed this scale categorizes patients into four categories alert verbal response to stimuli painful response to stimuli or unresponsive this straightforward classification system allows providers to quickly gauge the patient respons iess and mental status the glass galoma skill or GCS is another vital tool for measuring a patient's health status particularly their level of Consciousness it provides a more detailed and comprehensive assessment of neurological function than the AVP scale the GCS evaluates the patients's eye verbal and motor responses assigning numeric IAL scores for each component these scores are then summed to provide an overall GCS score which ranges from three to 15 however it is important to apply the GCS with a reference guide to ensure accurate and consistent scoring as it requires precise evaluation of specific criteria in addition to assessing consciousness the neuro exam may also involve the use of the Richmond agitation sedation scale or the r for evaluating agitation and sedation levels in patients this scale is particularly useful when monitoring patients who may require sedation or those at risk of becoming agitated during transport it provides a standardized assessment of the patient's level of agitation or sedation helping Healthcare providers make informed decisions about appropriate interventions and medications to maintain the patient's comfort and safety the neuro assessment incorporates a systematic approach that involves evaluating both direct neurological signs and indirect indicators that may provide valuable insights into the patient neurological status this process is divided into several phases of care ensuring a thorough evaluation the assessment by proxy involves considering not only the immediate neurological signs but also indirect clues that might point to neurological issues this comprehensive approach is essential to avoid missing potential neurological abnormalities and provides a more holistic view of the patient neurologic status within the focus neurologic assessment specific components are examined closely visual fields are assessed to determine the patient's ability to perceive objects within their field division and any nagus which signifies involuntary IE movements is observed as it may offer neurologic Insight pupil assessment involves the evaluation of pupil size reactivity to light and shape bilaterally deviations from the expected responses can be early indicators of neuro issues and timely recognition is fundamental for patient care cranial nerve assessment is another critical component aiming to evaluate the function of the 12 cranial nerves each serving specific functions changes in extraocular movements and papillary responses controlled by cranial nerve 3 can be among the the earliest signs of increased intracranial pressure detecting these changes prly is vital for managing potential neurological emergencies exposure assessment is an essential component of the critical care transport process facilitating a thorough and systematic head totoe evaluation of the patients's entire body this comprehensive assessment encompassing both anterior and and posterior views enables the critical care transport professional to make vital observations that can significantly impact the patient care and safety during the exposure assessment the provider should pay close attention to specific details including the presence of scars pressure injuries or any items that may have shifted or become lodged under the patient these observations provide valuable insights into the patient's medical history past injuries or potential sources of discomfort or pain one key aspect of exposure assessment is the removal of wet clothing this step is imperative for several reasons wet clothing can contribute to hypothermia by significantly impacting the patient's temperature regulation moreover it creates an environment conductive to skin breakdown increasing the risk of pressure injuries and other Dermatological issues when applying medical devices like pelvic binders direct contact with the skin is optimal for proper placement and Effectiveness in certain cases the provider's primary responsibility may involve ensuring the continuity of wound management initiated before their arrival this is particularly relevant for Hemorrhage control measures like tourniquet or pressure dressings the provider should assess the effectiveness of these measures and make necessary adjustments to maintain proper Hemorrhage control during transport another critical aspect is assessing the efficacy of existing splints or immobilization devices if these devices do not adequately stabilize fractured limbs or provide the necessary support they should be replaced or adjusted as needed to ensure the patient safety and comfort during transport in the context of critical care transport the exposure assessment also highlights concerns related to edema and pressure injuries timely identification of these issues during the assessment is vital for implementing appropriate interventions and preventing further complications throughout the",
        "Secondary Assessment": "transport secondary assessment the secondary assessment is a critical phase of patient evaluation during Critical Care transport designed to provide a more in-depth and comprehensive understanding of the patient's condition this assessment comprises several key components each aimed at Gathering essential information and data to guide appropriate interventions and ensure the patient's well-being during transport the detailed head-to-toe exam is an integral part of the secondary assessment during this phase the provider conducts a systematic and thorough examination of the entire patient's body including a close evaluation of each body region such as the head neck chest abdomen pelvis extremities and back the purpose of this exam is to identify any subtle inuries abnormalities or changes in the patient's physical condition that may not have been immediately apparent during the primary assessment it allows for a more precise assessment of injuries the identification of additional medical issues and a better understanding of the overall clinical picture the secondary assessment also involves a systems-based approach to evaluating specific diseases or medical conditions that may be relevant to the patient clinical presentation depending on the patient's history symptoms or known medical conditions the provider May focus on assessing particular organ systems or disease processes for example in a patient with a known history of cardiovascular disease a detailed cardiovascular assessment may be warranted in cases of respiratory distress a thorough examination of the Respiratory System including lung sounds and oxygen saturation would be essential this tailored approach ensures that potential issues are addressed promptly and interventions are appropriately directed one of the primary functions of the secondary assessment is to assist providers in mastering their understanding of what is considered normal for each patient by conducting a meticulous head-to-toe exam providers become intimately familiar with each patient's unique physical characteristics medical history history and Baseline condition this profound understanding enables them to recognize subtle variations from the patient's Norm aiding in the early detection of deviations and potential issues another critical role in the secondary assessment is the detection of any changes in the patient's condition that may have occurred since the initial primary assessment patients in critical care settings often experience Dynamic medical conditions that necessitate continuous monitoring the secondary assessment empowers providers to identify even the most subtle or significant alterations in the patient's clinical status allowing for timely interventions and adjustments to the care plan furthermore the secondary assessment involves a thorough evaluation of invasive equipment in use and the administration of fluids to the patient this comprehensive assessment highlights the proper functioning and positioning of various medical devices such as Central lines arterial lines chest tubes and urinary catheters additionally providers review the type and rate of fluids or medications being administered ensuring that they align with the patients specific condition and that there are no indications of complications or fluid leaks within the domain of vital signs the secondary assessment includes a comprehensive evaluation of key physiological parameters that hold Paramount importance in assessing the patient's overall health and stability these Vital Signs Encompass the patient pulse rate blood pressure respiratory rate pulse oximetry readings mental state and Body temp in specific clinical scenarios where continuous cardiac monitoring is deemed appropriate providers may choose to place the patient on a cardiac monitor continuous monitoring offers the advantage of real-time assessment of the patient's heart rhythm enabling the timely detection of arrhythmias are alterations in cardiac status the determination of an appropriate interval for Vital Signs assessments by the critical care transport professional is a dynamic process influenced by multiple factors firstly clinical findings guide the frequency of Vital sign monitoring the provider must consider the patient's current condition the severity of their illness or injury and any changes that may have occurred during transport anticipated outcomes also shape the interval for vital signs reassessment as patients with unstable or rapidly evolving conditions May necessitate more frequent monitoring to promptly identify deviations from normal parameters local practice protocols further inform the provider's decision regarding the interval for Vital Signs assessments as these guidelines may vary among Health Care Facilities in transport agencies however as a general guideline reassessments typically occur every 5 to 15 minutes during Critical Care transport as this interval strikes a balance between the need for continuous monitoring in unstable patients and the efficient use of resources during transport during the secondary assessment the comprehensive evaluation of Vital Signs extends beyond the conventional parameters to several additional critical measurements capnography for instance provides essential insights into into the patient's respiratory status by continuously monitoring the concentration of carbon dioxide in their exhaled breath this measurement AIDS in assessing the adequacy of ventilation the patient's respiratory rate and the potential presence of Airway obstructions or other respiratory issues Central Venus pressures are indicators of the patient circulatory and fluid status often monitored in critically ill patients with Central Venus catheters these measurements assist engaging the effectiveness of fluid resuscitation and guiding therapeutic interventions intracranial pressure monitoring is particularly relevant for patients with neurological conditions or traumatic brain injuries elevated ICP can indicate neurological deterioration and may necessitate specific interventions to mitigate potential cerebral damage for intubated patients Airway pressures provide critical information about the Integrity of the patient's mechanical ventilation and Airway management monitoring these pressures helps detect issues such as ET tube displacement Airway obstruction or pneuma thorax lastly assessing pulses in injured or canulated extremities is important for ensuring adequate profusion distal to the injury or catheter insertion site changes in peripheral pulses can alert the provider to potential vascular compromise or complications entitle CO2 is acquired by mainstream or sidestream sampling of exhaled gases whether the patient is undergoing mechanical ventilation or simply breathing spontaneously entitle monitoring serves several critical purposes during Critical Care transport firstly it facilitates detection of changes in the patient's condition such as alterations in respiratory rate and depth a sudden increase or decrease in entitle CO2 levels May signify respiratory distress or Improvement respectively secondly monitoring is essential in identifying metabolic acidosis in critically ill patients at as elevated entitle CO2 levels can indicate an accumulation of CO2 due to inadequate ventilation lastly during CPR entitle CO2 monitoring allows for the assessment of the effectiveness of chest compressions partial pressure of carbon dioxide or pco2 is determined Through Blood gas sampling typically obtained from an arterial or venous blood sample it's important to distinguish that PC2 measurement is different from capnography as it serves a different purpose pco2 monitoring is primarily employed to evaluate the effectiveness of a patient's ventilation strategy it is particularly valuable in patients with conditions such as ards or other scenarios where precise ventilation management is critical continuous monitoring of pco2 allows providers to make necessary adjustments to ventilation parameters ensuring that appropriate levels of CO2 elimination are maintained vital signs are important in any patient care scenario but several groupings of Vital Signs can provide viable evidence for specific underlying conditions pulses paradoxus is a phenomenon observed when the patient's blood pressure declines by greater than 10 mm of mercury during inspiration this abnormality may be associated with the loss of peripheral pulses and can indicate various underlying conditions it is commonly seen in cardiac tampeno it can also be observed in advanced obstructive lung diseases like copi and Asthma as well as in cases of croo the Beck Triad comprises three specific findings hypotension or narrowed pulse pressure muffled heart tones and jbd while it is essential to note that not all cases of pericardial tono present with be Triad its presence can be indicative of this serious condition pericardial tonot occurs when fluid accumulates in the pericardial sack back compressing the heart and impairing its ability to pump blood effectively the Cushing Triad is a set of Vital sign changes that are highly suggestive of an increased intracranial pressure it initially presents with hypertension and tacac cardia serving as early indicators of rising ICP If left untreated this Triad progresses to more severe manifestations including hypertension with a widened pulse pressure Broc cardia and an abnormal respiratory pattern such as biots or Shane Stokes respirations these changes in vital SS are concerning signs of worsening neurological status and may necessitate immediate intervention to reduce ICP and prevent neurological deterioration aortic dissections are a critical medical emergency characterized by the separation of the layers of the aortic wall which can lead to life-threatening consequences one important clinical feature associated with aortic dissections is disparity in blood pressure readings between the patients's right and left arms typically the left arm exhibits a higher systolic pressure compared to the right this discrepancy can be clinically significant with a different of greater than 20 mm of mercury in systolic blood pressure between the two arms being highly suggestive of an aortic dissection this discrepancy is due to the compromised Integrity of the aorta leading to uneven distribution of blood pressure throughout the arterial system recognizing this difference in arm blood pressures can Aid in the early suspicion and diagnosis of aoic dissections prompting surgical intervention in appropriate management to mitigate the risks associated with this condition hemorrhagic shock is a severe condition that occurs when there's significant blood loss leading to inadequate tissue profusion and oxygen delivery to vital organs in the context of hemorrhagic shock specific Vital sign changes are observed the patient pulse rate and respiratory rate continuously increase as the body attempts to compensate for the reduced circulating blood volume and maintain oxygen delivery importantly the systolic blood pressure May initially remain within the normal range or even slightly elevated however as the compensatory mechanisms become overwhelmed the patient urine output decreases and skin profusion worsens these findings are indicative of a critical state where the body's compensatory mechanisms are struggling to maintain adequate profusion highlighting the urgency for prompt intervention and resuscitation to address the underlying cause of hemorrhagic shock decompensated shock represents a progression of shock where both blood pressure and mental state begin to deteriorate in the initial stages of shock compensatory mechanisms attempt to maintain blood pressure and organ profusion however as shock advances is these mechanisms may become overwhelmed the systolic blood pressure declines reflecting the body's inability to maintain profusion to vital organs simultaneously the patient's mental state deteriorates with signs of altered Consciousness or confusion becoming apparent these changes signify the transition from compensated to decompensated shock indicating a critical point in the patient's clinical course assessment of severity demands Proficiency in selecting administering and interpreting the appropriate assessment tool for each patient this proficiency ensures that the provider evaluates the patient's condition and Acuity level selecting the correct assessment tool is important as it depends on the patient's specific medical condition such as using scoring systems like GCS for neurological assessment or the sequential organ failure assessment or sofa score for assessing organ dysfunction in critically ill patients administering the assessment involves conducting a thorough examination obtaining Vital Signs and recording relevant clinical data once collected the results of these assessments are interpreted to gauge the patient severity guide treatment decisions and determine the level of care required during transport assessment tools Aid healthc care providers in making informed decisions regarding their management and treatment two and notable assessment tools are the sequential organ failure assessment score and the quick sofa which deserve distinct yet complimentary purposes the sofa score is employed to compr R hensively assess and quantify the severity of organ dysfunction in patients with suspected or confirmed infection especially in the context of sepsis it evaluates various organ systems including respiratory cardiovascular hepatic coagulation renal and neurological assigning scores based on the degree of dysfunction conversely the quick so sofa or Q sofa score is designed for Rapid identification of patients at risk for life-threatening organ dysfunction related directly to infection it consists of three components altered mental status a systolic blood pressure of equal to or less than 100 mm of mercury and a respiratory rate of greater than or equal to 22 breaths per minute a q sofa score of greater than or equal to two suggests a higher risk of adverse outcomes Additionally the shock index calculated by dividing heart rate by systolic blood pressure serves as a predictive tool for post-intubation hypotension and Cardiac Arrest A score exceeding 0.8 indicates an increased risk for post-intubation hypotension while a score exceeding 0.9 signifies a heightened risk of cardiac arrest aiding clinicians in anticipating and managing potential complications during intubation procedures the assessment of sedation levels ensures that patients who are receiving ongoing sedation including medications like push those benzo aspenes are appropriately monitored and managed one of the widely adopted tools for assessing sedation in the ICU is the Richmond agitation sedation scale or the r this score provides a standardized and objective method for healthcare providers to assess the patient's level of sedation the scale ranges from -5 to four with each level representing a different level of agitation or sedation patients with r ass scores in the positive range typically exhibit varying degrees of agitation and restlessness suggesting the need for additional sedation to achieve a more optimal level of comfort and cooperation conversely patients with an R score of zero are considered calm and alert indicating that they are adequately sedated while maintaining weight fullness and appropriate responsiveness regularly assessing and documenting these scores in sedated patients allows Healthcare Providers to adjust sedative medications appropriately ensuring patient Comfort safety and effective care during transport pain assessment is an often underlooked and fundamental aspect of patient care and monitoring pain levels over time time using validated pain scales is essential to ensure appropriate pain management several pain assessment tools are available to healthcare providers catering to different age groups and patient populations one commonly used tool is the numeric Pain Scale which ranges from 0 to 10 where zero indicates the absence of pain and 10 represents the worst pain the patient has ever experienced this scale is typically employed for patients aged nine and above who can understand and use numerical values to express their pain intensity for patients including adults who may have difficulty with a numeric scale or those aged three and older the Wong Baker faces pain rating scale is a valuable alternative it utilizes a series of facial Expressions ranging from smiling to crying to help patients indicate their pain level making it particularly suitable for younger children or individuals who find it challenging to quantify their pain numerically keep in mind however patients diagnosed with autism may have difficulty utilizing this scale in Pediatric Health Care particularly when dealing with infants and non-verbal children the assessment of pain can be particularly challenging due to the limited ability of young patients to express their discomfort verbally to address this challenge healthc care providers utilized specialized pain assessment tools tailored to this population two widely recognized tools are the flak face legs activity cry consolability scale and the cries crying requires oxygen increase Vital Signs expression and sleeplessness scale the flax scale is designed to assess pain in infants and young children who may not have the communication skills to express their pain through words it evaluates Pain by considering five key behavioral indicators facial expression leg movement activity level cry and consolability each category is scored on a scale from 0 to two with a total score ranging from 0 to 10 higher scores indicate a higher level of pain or distress and this tool accounts for both facial expressions and physical movements providing a comprehensive assessment of pain in pediatric patients the cry scale is another valuable tool for assessing pain in infants particularly those in neonatal intensive care units the scale incorporates physiological and behavioral indicators to evaluate pain it assesses crying duration the need for oxygen changes in Vital Signs facial expressions and sleeplessness each component is assigned to score and the cumulative score AIDS in quantifying the level of pain or distress experienced by the infant the cry scale considers a range of clinical factors enabling providers to assess pain in a holistic manner in nonverbal and often clinically ill neonates in the context of critical care transport the management of IV access and fluid therapy is a multifaceted aspect of care to ensure the effective delivery of therapies and maintain the patients hemodynamic stability a well-coordinated plan of care must be established and communicated among the team members involved in the transport this collaborative approach begins with a comprehensive discussion of the plan of care which includes a review of anticipated medication administrations and any specific therapeutic interventions that may be required during transport one of the primary goals of the critical care transport team is to establish a to maintain appropriate IV access this involves not only securing existing lines but also assessing the patient needs for additional lines to facilitate the administration of various therapies the adequacy and patency of the IV access point are carefully evaluated to ensure uninterrupted delivery of essential treatments the review of IV fluids being administered to the patient is critical as it assists the provider in in maintaining the patient's fluid and electrolyte balance a meticulous assessment of the patient's hourly fluid input is conducted with the goal of ensuring that it is at least equal to the hourly output accounting for other volume losses such as vomiting or blood loss normal urine output ranges from 0.5 to 1 ml per kg per hour but this may vary in pediatric patients necessitating consideration of insensible fluid losses careful consideration of fluid selection is important in order to tailor the therapy to the patient specific clinical needs factors such as the patient's underlying medical condition electrolyte imbalances and hemodynamic Status must be taken into account when determining the type and volume of fluid to administer the team must exercise sound judgment and fluid management to optimize patient outcomes during",
        "Ongoing Assessment": "transport ongoing assessment ongoing assessment is a dynamic and integral aspect of patient care extending to the utilization of various Imaging modalities to support clinical decision-making the team engages in a comprehensive process to manage Imaging during patient transport firstly providers identify which Studies have been completed and the specific clinical indications that warranted these investigations this step is essential for understanding the patient diagnostic history and the context of the Imaging studies conducted thus far by doing so the team gains valuable insights into the patient medic medical journey and the evolving nature of their condition secondly the team assesses the actions taken based on the findings of the completed studies this should involve a careful review of the radiologic reports and interpretations as well as the subsequent interventions or treatment adjustments that were initiated as a result this allows the team to evaluate the effectiveness of Prior interventions ensuring that the patient's care plan is appr rately tailored to their evolving clinical status lastly the team considers whether additional Imaging studies are still needed to further evaluate and manage the patient's condition effectively 12 lead ECG serves as a versatile diagnostic tool that extends its utility beyond the conventional context of cardiac transport in critical care transport settings settings 12 lead ECG can provide valuable insights into various medical conditions that extend beyond primary cardiac concerns this diagnostic modality can reveal useful information for patients presenting with a spectrum of disorders including acute right ventricular failure pulmonary embolism metabolic disorders and toxicologic issues these conditions often manifest with ECG abnormalities that are indicative of the underlying pathophysiological processes to effectively integrate ECG into their practice providers must possess a deep understanding of not only the diagnostic criteria associated with these disorders but also their treatment recognizing ECG findings that warrant specific interventions or therapies is important for guiding patient care during transport furthermore ECG is an indispensable tool for monitoring patients during transport particularly when assessing for worsting conditions are changes in the patient's clinical status serial 12 leads should be obtained when other specific triggers are met such as the initial 12 lead containing abnormal findings or when there's a notable change in the patient's condition the serial assess ments provide critical information regarding the patient's response to interventions disease progression or evolving cardiac or non-cardiac complications by continuously monitoring ECG parameters providers can promptly identify emerging issues and adjust their management strategies accordingly ultimately contributing to the overall safety and well-being of the patient during the process Critical Care transport professionals are tasked with a crucial responsibility in the ongoing assessment of patients which extends to the Vigilant evaluation of invasive equipment such as tubes and lines these medical devices are instrumental in managing various aspects of patient care and must not only recognize their indications but also assess their patency effectiveness and monitor for potential complications one category of invasive equipment includes gastric tubes these tubes may serve to facilitate gastric decontamination administer medications or provide ongoing drainage of the upper gastrointestinal system in cases of bow obstructions in rare instances they may be inserted to investigate GI Hemorrhage or assess the possibility of an esophageal rupture nasogastric tubes are are the standard choice for these purposes although alternatives are considered when patients are unresponsive and intubated foldy catheters are another type of invasive device that warrants provids attention indicated for patients with ongoing incontinence are those requiring accurate fluid output monitoring foldy catheters are associated with an elevated risk of infection most Healthcare systems mandate a regular evaluation of the need for continued use every 24 hours feeding tubes although rarely placed in the emergency setting play a vital role in prolonged hospitalizations providing interal nourishment directly into the GI tract providers May encounter these patients with feeding tubes during transfers between icus or when transporting chronically ill patients the experiencing decompensation or acute illnesses additionally providers must be proficient in the assessment of external ventricular drains or evds these devices are used for monitoring and managing intracranial pressure in patients with neurologic conditions the assessment of EVD functionality and the patient respond to it is a critical component of secondary assessments providers are expected to conduct these assessments upon patient contact and following any major patient movements such as bed-to-bed transfers or loading and unloading during transport by evaluating the patency and effectiveness of these invasive devices providers ensure the safe and effective management of their patients ultimately contributing to improved patient",
        "Assembling the Assessed Information": "outcomes assembling the assessed information assembling and organizing assessed information is a fundamental aspect of ensuring comprehensive patient care the critical care transport professional is tasked with developing a problem list which essentially functions as a differential diagnosis comprising Associated symptoms or concerns that may necessitate management during the transport process this list is an AM alation of various sources of information including written data from the referring facility the provider's own patient examination findings current lab values the patient response to therapeutic interventions and an assessment of the patency and functionality of any invasive equipment the problem list serves as a dynamic road map that guides the provider in addressing the multi faceted aspects of patient care during transport it not only provides a structured framework for addressing the patients primary condition but also accounts for potential secondary issues that may arise during Transit by effectively reorganizing this information the provider can prioritize interventions and anticipate challenges thereby optimizing the quality and safety of patient care before initiating transport the provider must manage life threats or potential life threats emergency transport becomes imperative when these critical conditions cannot be effectively stabilized by the referring facility or the transport team underscoring the urgency of the situation conditions with anticipated complications that may arise during transport such as an open fracture that carries a risk of infection require ProActive Management strategies during the on scene phase the provider exercises clinical judgment to determine the most appropriate interventions these should be limited to addressing severe pain major life threats or situations where the patient's condition deviates significantly from their Baseline the provider May opt to defer new interventions until transport has been initiated and uring that the patient immediate and pressing needs are addressed first by adhering to these principles the provider ensures that the patient is in the best possible condition for transport while effectively managing emergent and anticipated challenges throughout the critical care transport  process"
    },
    {
        "Introduction": "chapter nine laboratory analysis and diagnostic studies introduction laboratory tests Encompass a spectrum of diagnostic evaluations involving the analysis of diverse body fluids including blood urine cerebral spinal fluid and others colloquially referred to as Labs within the realm of critical care",
        "Principles of Analysis": "transport these laboratory examinations serve mirrored function necessitating the critical care treat transport professionals possess a comprehensive grasp of the typical reference ranges of each laboratory value and the inherent physiological significance associated with each test the execution of these tests is fundamentally grounded in the support of an evidence-based approach to Patient Care Proficiency in comprehending these diagnostic tests and concurrent Imaging studies proves to be of Paramount importance particularly in preparing for potential unforeseen medical incidents and for properly responding to alterations in a patient's clinical condition during the transportation process as well as ensuring the seamless transfer of patient care between the originating and receiving Health Care Facilities principles of analysis Critical Care transport professionals must consistently uphold the principles governing the analysis of all laboratory values an indispensable facet of this adherence lies in their profound appreciation of the Precision and accuracy associated with these diagnostic tests Precision denoting the consistent similarity of values upon repeated testing ensures reliability and repeatability conversely accuracy signifies a degree to which a value or its average aligns with a recognized standard or the True Value in the realm of medical Diagnostics precision and accuracy or Paramount scientists Endeavor to develop tests that exhibit both precision and accuracy to guarantee the trustworthiness of results thus providers should remain acutely aware of these principles as they underpin the proper and dependable utilization of laboratory tests and critical care scenarios an awareness that providers must possess pertains to the variability and sensitivity and specificity among different laboratory tests sensitivity characterizes a Test's capability to accurately identify whether an individual has a specific medical condition or not in essence a highly sensitive test is one where most individuals who truly have the condition will yield a positive result conversely a test with low sensitivity tends to produce negative results in many individuals who indeed have the condition this metric essentially gauges the proportion of individuals and the target disorder who exhibit a positive test result on the other hand specificity pertains to the portion of individuals without the target disorder who obtain a negative result when subjected to the same test a highly specific test typically ensures that the majority of individuals who do not have the condition will return a negative test result thus minimizing false positives let's look at an example the D dier test which is employed to assess hypercoaguability and scream for dvts serves as a prime example illustrating the concepts of sensitivity and specificity in medical Diagnostics sensitivity in this context is determined by dividing the number of patients who exhibit a positive test result by the total number of patients with the actual disorder in the case of the D dier test sensitivity stands at about 93% implying that this test correctly identifies DVT and 93% of individuals who genuinely have the condition specificity is computed by dividing the number of patients who receive a negative test result by the total number of patients without the disorder for the dier the specificity rate is about 79% indicating that it correctly identifies individuals without a DVT in about 79% of cases this means that while the dher test is highly sensitive in detecting DVT when it's present it may produce false positive results in a proportion of cases as reflected by its lower specificity these values underscore the essential balance that must be struck When selecting and interpreting diagnostic tests as they can significantly impact patient care decisions and outcomes especially in critical care settings healthc care providers strategically combine tests with varying sensitivity and specificity profiles to optimize decision- making and resource utilization highly sensitive tests commonly employed as screening tools help identify potential cases of a particular condition subsequently individuals with positive results undergo highly specific tests to confirm a diagnosis with greater Precision it is important to exercise caution against unnecessary or misused tests as they can lead to complex interpretations and flaw clinical decisions qualitative assessments yield results without specifying a precise level as exemplified by serologic blood tests checking for the presence or absence of the Hepatitis B virus quantitative tests provide an exact measurement while semi-quantitative assessments indicate the degree of severity such as none mild moderate or severe providers should refrain from fixating on the notion of normal versus abnormal lab values normal ranges empirically derived are based on values that 95% of healthy individuals exibit for any particular test critically ill patients often deviate from this Norm as 5% of healthy individuals fall outside the healthy range Additionally the interpretation of normal ranges can be subjective in the context of emergency departments or icus and abnormal results May even reflect the desired effect of a specific treatment while abnormal lab values should not be ignored they must be assessed within the broader clinical context of the patient's condition errors in specimen collection identification labing or laboratory analysis can occasionally result in erroneous values underscoring the need for careful consideration furthermore it is essential to recognize that different Laboratories May establish distinct normal ranges for the same tests for instance one lab might provide three different sets of normal ranges for each test they perform as providers review lab reports they should pay meticulous attention to the indicated normal values and approach the interpretation of patient results the critical mindset considering potential variations between Laboratories this holistic approach ensures that laboratory data is effectively applied to inform patient care decisions in a critical care",
        "Specimen Cultures": "context specimen cultures specimen cultures such as blood urine sputum and other bodily fluids serve as invaluable Tools in clinical medicine enabling the identification of microorganisms and the precise treatment of infections culture tests are tailored to specific clinical scenarios with the sputum culture being a pivotal diagnostic tool when a respiratory infection is suspected in contrast the blood culture stands as as one of the most common types utilizing a blood sample to test for the growth of various pathogens including aerobic bacteria anerobic bacteria or fungi this investigation is instrumental in detecting bacteremia which signifies the presence of a bacterial infection within the bloodstream sensitivity tests help to determine the most appropriate antibiotic therapy by assessing the susceptibility of the ident identified microorganism to various antimicrobial agents the process of culture insensitivity typically spans 3 days to yield a comprehensive report the initial culture report is usually available within 24 hours providing preliminary information about the growth of microorganisms however it is the complete and final report obtainable within 72 hours that that furnishes the essential details required to guide clinicians in selecting the most effective antibiotics for targeted treatment this diligent approach to specimen cultures sensitivity testing and Reporting is essential in delivering optimal patient care and ensuring the appropriate management of",
        "Chemistry Review": "infections chemistry review physiology forms the foundation of medical understanding rooted in the fundamental principles of chemistry and cellular biology Critical Care transport professionals must possess a solid grasp of these principles as they are indispensable for insightful test interpretation and comprehensive Patient Care Central to this understanding are ions which are atoms that have undergone electron gain or loss each electron carries a single negative charge with the loss of electrons rendering an atom more positively charged or less negative and their gain making it more negatively charged or less positive ions can be categorized as cat ions carrying a positive charge or an ions bearing a negative charge the alteration of electron count results in varying degrees of charge charge such as plus one or plus two for losses and minus1 or minus two for gains the concept of ionic bonding is pivotal where ions of opposite charges join to form compounds exemplified by sodium chloride or NAC which we commonly know as table salt quantities of ions are expressed in moles or equivalents also known as EQ a mole represents a unit consisting of 6.02 * 10^ 23rd power atoms and equivalents measure amounts of charged particles for instance one equivalent is the equivalent to one mole of ionic charge so we'll use an illustration one sodium atom which we would denote as n na+ carries one charge and thus one mole of na+ atoms equates to one mole of charges which we would then denote as one equivalent one mole of calcium also known as CA + 2 corresponds to two moles of charges equating to two equivalents it's essential to note that this concept pertains exclusively to charge particles as uncharged molecules such as proteins remain electrically neutral overall an intimate comprehension of these chemical and cellular principles is integral to the role of critical care transport providers in order to critically assess and manage the physiological aspects of patient care osmolarity relates to the osmotic pressure generated by various body fluids including blood ccal spinal fluid or urine osmotic pressure arises within a confined space eliminated by semi-permeable membranes and is contingent upon disparities in solute concentrations within the solutions on either side of this membrane in essence osmolarity in osmol liity signify the pressure elicited by the particles present in a fluid offering a means to gauge osmotic pressure in humans osmol liity quantifies the amount of dissolved substance in 1 kilogram of water which we often mistakenly refer to as osmolarity while osmolarity itself evaluates the quantity of dissolved substance in one liter of water the osmo denoted as osm serves as the fundamental unit of measurement representing the pressure generated by one mole of particles in a solution it's imperative to recognize that osmotic pressure hinges solely on the number of particles within the fluid irrespective of their size for instance a single protein or sugar molecule induces an equivalent osmotic pressure as a single sodium ion concentration another vital aspect denotes the quantity of a substance present within a given volume of fluid in the context of laboratory measurements most concentrations are notably minuscule these include Min moles many equivalence and many Osmos all of which underscore the Precision and involved in the analysis of osmolarity and its implications for patient care and critical care settings reporting laboratory values can vary in terms of units of measurement used conventional units such as Mill equivalence per liter are commonly employed for reporting however SI units like mill moles per liter are also utilized in certain context many Labs provide results in both conventional and SI units to accommodate different preferences and clinical practices variations in normal reference ranges can exist among different labs and even from one instrument manufacturer to another providers must be well versed in the normal reference ranges for the specific tests they utilize in critical care settings additionally they should be aware of the normal ranges applicable to the individual patient they're caring for especially when comparing results obtained from various Health Care Facilities this awareness ensures accurate interpretation of laboratory values and supports a sound clinical decision-making in the dynamic environment of critical",
        "Biochemistry Review": "care biochemistry review the examination of proteins and enzymes in serum samples plays a role in Discerning the condition of the patient the human body Harbors an extensive array of diverse proteins each serving distinct functions required for various physiological processes among these proteins enzymes emerge as notable catalysts for biochemical reactions enzymes fa facilitate the transformation of one biologic substance into another a process that may proceed at a slug Pace when only the reactants are present however the addition of an appropriate enzyme can significantly accelerate the reaction rate this fundamental catalytic principle forms the basis for methods employed to measure enzyme levels in clinical Diagnostics the calculation of the Quant qu of enzyme present hinges on several key factors including the knowledge of the initial amount of substrate awareness of the amount of product generated and the Assumption of normal enzyme function enzyme function is typically Quantified in units per liter representing the amount of enzyme capable of catalyzing the conversion of one micromo of substrate per minute this unit of measurement provides a standard ardized means to evaluate enzyme activity and is instrumental in assessing various clinical conditions allowing for healthcare providers to glean essential insights into the patient's health",
        "Lab Profiles": "status lab profiles groups of related tests Consolidated into a single unit known as a panel or profile are indispensable Tools in clinical Di Diagnostics such panels are often named for the common link among the tests they comprise for instance a liver panel is a set of tests specifically designed to assess liver function and is documented as a matrix in a patient's Hospital chart offering a convenient overview of the patient's health status one of the most fundamental assessments performed in emergency departments or icus is the evaluation of lab values and blood samples the basic metabolic panel referred to as a kim7 is a prime example of a comprehensive panel used for this purpose Within These panels the measurement of serum sodium levels assumes particular importance sodium a major extracellular ion plays a vital role in maintaining the body's fluid balance in a healthy individual the the serum sodium concentration typically Falls within the range of 136 to 142 mil equivalents per liter while intracellular concentrations differ spanning from 3 to 20 mil equivalents per liter serum sodium levels can undergo dramatic changes primarily due to shifts in extracellular water concentrations making them a convenient marker for assessing a patient's fluid status sodium levels also constitute a key component in the calculation of serum osmol which helps to understanding of patients overall fluid and electrolyte balance elevated serum sodium levels known as hypernia are not uncommon in patients undergoing Critical Care transport in such cases treatment may involve the administration of hypertonic Saline manitol or diuretics to reduce cerebral edema hypernia is particularly prevalent in patients with traumatic brain injuries where excessively high levels exceeding 155 mil equivalents per liter can significantly increase mortality rates conversely abnormally low levels of sodium in the blood often result from an excess of free water or excessive sodium depletion conditions such as heart failure renal failure liver disease or diuretic therapy can contribute to hyponatremia correcting this requires a gradual approach typically targeting an increase of 4 to six mil equivalents per liter per 24-hour period to avoid potential complications monitoring intake and output including oral and intravenous IV input is vital in managing patients with sodium imbalances severe cases of low sodium levels below 125 mil equivalence per liter can lead to a range of symptoms including behavioral changes confusion delirium respiratory changes muscle twitching increased intracranial pressure and cardiac abnormalities convert firstly elevated sodium levels can cause fluid retention and cardiac irregularities thus maintaining sodium balance is an essential component of patient care potassium is a major intracellular cation with its extracellular concentration typically ranging from 3.5 to 5 m equivalent per liter hyperemia can lead to cardiac arhythmia making it a critical concern in patient care notable ECG changes associated with hyperemia include Peak T waves with flattened p waves occurring when the potassium level exceeds 7 mil equivalents per liter hyperemia can be exacerbated by derangements in other electrolytes and may result from various factors such as excessive potassium supplementation shifts of potassium from intracellular to extracellular fluid due to Cellular Lis Drug Administration metabolic acidosis or decreased potassium excretion as seen in acute renal failure it's important to note that some abnormally high potassium levels may be reported in error so the first consideration is often to redraw the specimen hyperemia due to massive tissue breakdown can escalate rapidly and does require aggressive treatment in cases of chronic hyperia with levels less than seven mow equivalent per liter and no symptoms or ECG changes immediate or aggressive treatment may not be necessary hypoa characterized by abnormally low potassium levels can also pose significant risks it can result from cellular shifts or increase potassium excretion in older patients hypokalemia may lead to arrhythmias and ECG changes additionally it can manifest with symptoms such as muscle pain hypo reflexia nausea vomiting and orthostatic hypotension severe hypokalemia can even cause cardiac abnormalities including at ventricular and intraventricular blocks and may lead to atrial arrest if the potassium level drops to around 9 mil equivalents per liter the management of potassium imbalances whether hyper K or hypo necessitates close monitoring and appropriate interventions to mitigate potential complications chloride is a major extracellular annion within the body and maintains electrical neutrality alongside the positive charges of sodium and pottassium its single negative electrical charge helps offset the positive charges of these cat ions contributing to the overall balance of electrolytes and body fluids the normal healthy range for chloride in the blood typically Falls within 96 to 106 M equivalents per liter hypochlor characterized by abnormally low chloride level may be indicative of impending renal dysfunction or may be observed in patients who are undergoing diuretic therapy in these cases the provider should monitor chloride levels and assess renal function and the impact of diuretic therapy on electrolyte balance conversely high levels of chloride can occur in patients who experience excessive diuresis providers must recognize and address hyperchloremia as it may have implications for a patient's fluid and electrolyte status chloride levels often mirror sodium levels in the blood and thus play a role in helping differentiate between various types of metabolic acidosis bicarbonate and carbon dioxide levels are vital indicators in acidbase status the Venus bicarbonate level which measures the concentration of bicarbonate ions in the Venus sample serves as one of the most fundamental indicators of acidbase status carbon dioxide and bicarbonate exist in a dynamic equilibrium within the body carbon dioxide is a gas and is typically expressed as partial pressure bicarbonate is an ion and is typically expressed as a concentration in the blood low bicarbonate levels can be indicative of metabolic acidosis or respiratory alkalosis metabolic acidosis results from an accumulation of acids or a loss of bicarbonate whereas respiratory alkalosis is characterized by excessive exhalation of carbon dioxide leading to a decrease of bicarbonate ions conversely elevated by carbonate levels could point to metabolic alkalosis or respiratory acidosis metabolic alkalosis results from an excess of bicarbonate ions while respiratory acidosis is characterized by inadequate removal of carbon dioxide which in turn raises bicarbonate levels normal bicarbonate ranges typically fall between 21 to 28 mil equivalents per liter while the normal range for carbon dioxide is generally between 22 to 28 mil equivalents per liter these ranges provide a basis for assessing the patient's acidbase status and are indispensable tools for healthcare providers blood Ura nitrogen or bu is a valuable laboratory parameter that reflects the metabolic status of the body particularly related to protein catabolism it is influenced by factors such as protein intake protein metabolism and the rate of excretion bun serves as a useful marker for assessing kidney function as it reflects the ability of the kidneys to filter and excrete Ura the normal range for bu typically Falls between 8 to 23 mg per deciliter however it is important to note that bu levels May naturally increase with age and values within the range of 28 to 35 are not uncommon in older individuals elevated bu levels particularly those exceeding 40 milligrams per deciliter may be indicative of decreased renal function a high protein diet or the presence of conditions that lead to increased protein catabolism such as Burns or Crush injuries creatinine on the other hand is a metabolite that plays a significant role in muscle energy metabolism it is continuously produced and degraded at a relatively stable rate by muscle tissues with individual variations in this rate being minimal it is commonly used as a marker to assess kidney function as it is filtered by the kidneys and excreted in urine normal serum creatinine levels typically range from 0.6 to 1.2 MGR per deciliter an abnormal creatinine level does not necessarily indicate a specific disease or its cause but it does suggest some degree of decreased renal function in the case of geriatric patients when creatinine levels are slightly higher than the upper normal value essentially approaching 1.5 millgram per deciliter it may signify greater kidney dysfunction compared to the same level of a younger patient identifying and correcting the cause of acute elevated levels is essential as prolonged kidney dysfunction can lead to permanent damage and necessitate interventions like lifetime dialysis or kidney transplantation additionally creatinine clearance which is the most accurate measurement of glomular filtration rate is used to assess kidney function more precisely speaking of glomular filtration rate also known as GFR this is a critical parameter used in nefrology to assess the overall efficiency of the filtration process within all the functioning nephrons in the kidneys it provides valuable insights into the kidney's ability to filter waste products and maintain essential electrolyte and fluid balance the exact GFR can vary significantly depending on factors such as age sex and body size in general a normal range typically Falls between 90 and 120 milliliters per minute per 1.73 Square met which is a standardized unit used to account for variations in body surface area providers must monitor changes in GFR over time as alterations in this rate can signal either Improvement or decline in kidney function it's important to note that GFR tends to naturally decline with age even in individuals without chronic kidney disease therefore providers use GFR values as a reference to detect renal impairment a value below 60 milliliters per minute is generally considered indicative of renal impairment suggesting a decreased ability of the kidneys to effectively filter and excrete waste products glucose which we often refer to as blood sugar is the most vital carbohydrate in the human body and serves as a primary source of energy for cells monitoring glucose levels is of Paramount importance in health care including prehospital and critical care settings poter care testing devices are frequently used to assess glucose levels the normal range for glucose in the bloodstream typically Falls between 70 to 110 milligram per de maintaining glucose within this range is essential for optimal cellular function hypoglycemia characterized by elevated blood glucose levels can have severe consequences if left un addressed it may lead to complications such as coma and in extreme cases can be life-threatening conversely hypoglycemia is typically easier to detect due to the associated symptoms with can include dizziness nausea and confusion severe hypoglycemia can lead to Syncopy and even seizures if not promtly treated total calcium is considered an essential electrolyte calcium's functions span a wide range from its involvement in muscle contraction to its role in intracellular signal transduction it exists in the bloodstream in three primary States free calcium ions approximately 47% colleted meaning bound to organic molecules and bound to proteins which are about 43% of the total calcium these fractions collectively contribute to the total calcium level the normal reference range for total calcium typically Falls between 8.5 to 10.2 mg per deciliter elevated levels may be indicative of underlying conditions such as hyper parathyroidism or tumors that secrete parathyroid hormone conversely low levels may occur in cases of renal insufficiency hypom magnesia hyperphosphatemia massive blood transfusion or conditions characterized by decreased parathyroid hormone secretion these conditions can disrupt the balance of calcium within the body and have widespread clinical implications potentially affecting muscle function nerve signaling and bone health ionized calcium represents the physiologically active form of calcium in the bloodstream as it is not bound or CED to other molecules assessing the concentration of ionized calcium is particularly key in clinical scenarios where there are alterations in the fractions of bound or CED calcium this can occur in conditions such as Reno failure or nephrotic syndrome where hypo Almia leads to changes in The Binding capaum of calcium additionally acid-based Arrangements specifically aetos can influence ionized calcium levels as can variations in cing compounds like citrate bicarbonate lactate phosphate and sulfate the normal reference range typically Falls within 8.8 to 10.3 mg per deciliter deviations from this range can have significant clinical implications low levels of ionized calcium may result in decreased cardiac output and hypotension making it critical for healthc Care Professionals to Monitor and address such abnormalities properly arrhythmias especially during prolonged Cardiac Arrest can also be associated with decreased ionized calcium levels in certain clinical scenarios calcium Administration may be warranted to address specific medical conditions for instance calcium Administration is often indicated in cases of hyperemia where it can help stabilize cardiac cell membranes and mitigate the risk of life-threatening arrhythmias calcium Administration may also be necessary in cases of hypocalcemia or calcium channel blocker overdose to restore ionized calcium levels to within the normal range and support proper cardiac and neuromuscular function magnesium is an essential mineral with a broad spectrum of physiological functions making it sensitive to disruptions in various body systems particularly the GI tract and endocrine systems the normal reference range for magnesium in the bloodstream typically Falls between 1.3 to 2.1 mil equivalent per liter elevated levels are relative ATIV L rare but can result from renal defects severe dehydration the over administration of magnesium containing medications or supplements untreated diabetic Comas or the aspiration of seawater these situations can lead to excessive magnesium absorption or retention causing an elevation in blood levels low levels of magnesium are more common and can be associated with the range of clinical conditions GI distress characterized by vomiting and diarrhea can lead to magnesium loss from the body contributing to hypom magnesia additionally conditions such as hepatic curosis and pancreatitis may result from impaired magnesium absorption or increased renal loss further exacerbating low magnesium levels hypom magnesia can have various Clin iCal manifestations including neuromuscular symptoms cardiac arrhythmias and metabolic disturbances phosphate is a vital electrolyte primarily regulated by the parathyroid glands and the kidneys it plays a significant role in various physiological processes with a particular focus on bone and dental health the normal range in the blood stream typically Falls within 2.3 to 4.7 mg per deciliter hyperphosphatemia which is characterized by abnormal high phosphate levels in the blood can result from conditions such as hypoparathyroidism and kidney failure in such cases the regulatory mechanisms that maintained phosphate balance may be impaired elevated phosphate level s can lead to calcium disorders as excessive phosphate combined to calcium reducing the concentration of ionized calcium in the blood this in turn can result in muscle spasms and other clinical manifestations low phosphate levels can be caused by nutritional disorders and conditions like hyperparathyroidism low levels can have several clinical consequences including altered mental status seizures and a weakening of the bones hypo phosphatemia can be particularly concerning in cases where phosphate deficiency affects the function of ATP blood components are an integral part of assessing a patient's overall health and the complete blood count or CBC test provides valuable information about these components the CBC includes several key parameters such as red blood cells white blood cells platelet hematocrit and hemoglobin levels among others abnormal values in any of these parameters should prompt the provider to consult the patient's complete medical record for context hematocrit is a measurement that indicates the percentage of formed elements in a Venus blood sample for example hematocrite value of 45% signifies that 45% of the sample consists of cells or cellular debris while the remaining 55% is plasma the normal reference range for hematocrit typically Falls between 41 and 50% deviations from this range May provide insights into various health conditions such as anemia or dehydration hemoglobin is a protein that transport oxygen to cells and carbon dioxide back to the lungs these levels can vary by sex with males typically having a reference range of 135 to 175 gam per liter and females having a range of 120 to 160 G per liter elevated levels may be seen in individuals experiencing hemo concentration due to factors like hydration Burns or excessive vomiting conversely low levels are of Greater concern and are often associated with various types of anemia including microcytic normocytic and macrocytic anemas the red blood cell count is a critical component of the CBC test providing information about the number of arthy present per microliter of blood the normal reference range for the RBC count typically Falls within 3.9 to 5.5 million cells per microliter it is important to note that an abnormal RBC count does not always indicate the presence of a disease and it may be influenced by various factors elevated RBC levels can occur in patients with elevated white blood cell counts which can skew the RBC count and lead to erroneously High values on the other hand low levels are more concerning and are often associated with various types of anemia including microcytic normocytic and macrocytic anemias the white blood cell count is a fundamental component of a CBC test that measures the total number of lucaites present per microliter the normal reference range for a white blood cell count typically Falls between 4500 to 11,000 microl deviations from this range can provide essential diagnostic insights into the patient's Health low WBC levels known as lucenia can be associated with various conditions including anemias such as a plastic anemia vitamin deficiencies the side effects of chemotherapy and severe infections such as sepsis conversely elevated WBC levels termed lucyisanerd infarction and deep vein thrombosis steroid Administration in stress from trauma can also lead to an increase in WBC count a more detailed analysis of the WBC count can be obtained through a white blood cell count differential which provides counts of specific types of white blood cells including neutrophils lymphocytes monocytes asops and basophils neutropenia which is characterized by an abnormally low nutrifil count is a common finding in patients undergoing chemotherapy or radiation therapy the WBC differential may also include a band cell count where elevated band cell counts representing immature granula sites would be indicative of an acute inflammatory response which we would often associate with active infections the platelet count is a key component of a CBC that assesses the number of circulating platelets in the patient's blood platelets are essential for blood clotting and wound healing and the normal reference range typically Falls between 150,000 to 350,000 platelets per microl deviations from this range can provide valuable diagnostic information about the patient's overall health elevated platelet levels known as thrombocytosis can be associated with Milano prolative disorders such as polycythemia and chronic myogenous leukemia these conditions can lead to an overproduction of platelets in the bone marrow resulting in increased platelet counts low platelet levels termed thrombos cytopenia can be caused by various factors including an enlarged spleen disseminated intravascular coagulation and the presence of high circulating levels of platelet antibodies thrombocytopenia can lead to an increased risk of bleeding and bruising due to impaired blood clotting proteins are essential components of the blood and they're assessment provides valuable insights into the patient's Health total protein testing examines the overall quantity of proteins present in a blood sample with a normal reference range falling between 6 to 8 gram per deciliter fluctuations in serum albumin levels can influence total protein levels albumin is a specific protein in the blood that serves multiple vital functions it acts as a transport protein for various substances including free fatty acids B Rubin hormones and Other Drugs additionally albumin functions as a free radical scavenger maintaining oncotic pressure and is responsible for maintaining the balance of fluids between the bloodstream and surrounding tissues the normal reference range for alumin levels is generally 3.5 to 5 G per deciliter low albumin levels can result from increased catabolism of proteins decrease production liver disease or damage and other factors this can lead to the development of Edema and is associated with conditions like acute respiratory distress syndrome in contrast high abum levels are typically observed in cases of dehydration and are generally not indic of pathological conditions lactate is a critical marker used in medical assessment to evaluate a patient's tissue profusion and oxygenation elevated serum lactate levels exceeding 2 milles per liter May indicate inadequate profusion and oxygenation of cells tissues and end organs although non-specific these levels can provide valuable insights into the patient's clinical condition notably lactate levels May respond slowly to adequate resuscitation with fluids and oxygen making serial lactate measurements essential for monitoring Trends in end organ profusion over time lactate dehydrogenase or LDH is an enzyme found in various body tissues and is not specific to any particular disease the normal reference range is typically 100 to 200 UL however the analysis of LDH isoenzyme forms such as ld1 to ld5 can offer more specific diagnostic information in the clinical setting while it was once considered a useful tool in diagnosing acute myocardial infarctions it has been largely replaced by troponin analysis it Still Remains valuable in assisting with the diagnosis of conditions such as pumac syus pneumonia and determining the severity of pancreatitis in patients with implanted ventricular assist devices monitoring LDH levels can provide early warning signs of pump thrombosis creatine canacee or ck is another enzyme found in various tissues including muscle liver lung G GI brain kidney and spleen tissues when any of these tissues are damaged CK may be released into the vascular space it is used for diagnosing and monitoring the response to treatment of conditions like rabdom myolysis the normal range typically Falls between 40 to 150 UL ckmb a specific fraction of CK primarily represents CK found in heart muscle the normal reference range for CK MB levels is generally 0 to 7 NGS per ml monitoring CK MB levels can be instrumental in assessing cardiac muscle damage especially in the context of acute coronary syndromes troponin is a critical protein involved in muscle contraction and is composed of three subunits T C and I each having three separate isoforms one of these isoforms is exclusively found in cardiac muscle making it a highly specific marker for cardiac muscle damage the normal range for cardiac trapon and I is typically 0 to 0.04 MGS per ml elevated levels can be detected in a serum sample as soon as 4 hours after myocardial injury and continue to remain elevated for 5 to S days following an acute MI tronent testing is also a valuable tool for detecting severe unstable angina in recent developments High sensitivity cardiac tronin T tests have emerged allowing for a quicker rule out of Ami B type natural uretic peptide or BNP is another important biomarker in cardiology the normal BMP value is generally less than 167 pgs per ml elevated BMP levels are indicative of abnormal ventricular function particularly heart failure when they fall outside the expected reference ranges BMP measurement assists in diagnosing and monitoring heart failure and can provide valuable insights into a patient's cardiac status inflammatory markers help assess and diagnose various medical conditions the PCT is one such marker and its levels significantly increase in response to a serious bacterial infection making it particularly useful in identifying conditions like sepsis your CRP is another inflammatory marker that exhibits a rapid rise in response to inflammation aiding in the diagnosis and monitoring of inflammatory processes the ESR is a classic marker for the acute phase reaction of inflammation with values Rising as part of the body's inflammatory response ESR is often used to gauge the extent of the inflammatory reaction liver function tests are essential in evaluating Liver Health and detecting liver damage or injury these tests measure the activity of enzymes typically present in liver cells some common liver function tests include the a the alt total bow Rubin direct bow Rubin and the alkaline phosphatase by assessing the levels of of these enzymes and other liver function parameters providers can gain insights into the functioning of the liver and identify potential liver Related Disorders or diseases the as which formerly was known as the sgot is an enzyme present in various body tissues including the liver skeletal muscle brain rbcs and heart in healthy individuals as levels are typically low and fall within the normal range of 10 to 30 UL elevated levels are indicative of liver damage with conditions such as acute hepatitis biliary tract obstruction alcoholic curosis hepatitis and liver cancer often associated with these levels additionally elevation in a may occur in the context of right heart failure hypoxia or extensive trauma reflecting tissue injury or damage in these situations alt previously known as sgpt is another enzyme found in various tissues including the liver kidney skeletal muscle and heart alt levels and healthy individuals are typically low in the normal range Falls between 1 to 40 UL like a elevated ALT levels are also associated with liver damage and are found in similar conditions such as hepatitis biliary tract obstruction sorosis and liver cancer total Bill Rubin is a metabolic byproduct of the breakdown of rbcs and exists in two forms indirect B Rubin which is not water soluble and direct B Rubin which is conjugated in the liver and excreted into the bile the normal range for total B Rubin levels in the blood typically fall between 0.3 to 1.2 mg per deciliter elevated levels can be indicative of various medical conditions including liver disease biliary tract obstructive or increased RBC hemalis direct B Rubin on the other hand represents the fraction of B Rubin that has been conjugated in the liver and is water soluble normal values for direct bow Rubin levels are usually within the range of 0.1 to 0.3 milligrams per deciliter while indirect B Rubin levels range from 0.2 to 0.9 milligrams per deciliter by fractionating B Rubin into direct and indirect components Healthcare Providers can gain more specific information about the underlying cause of B Rubin abnormalities Alp is an enzyme found in nearly all body tissues with significant production occurring in the bone liver intestine and placenta it plays a vital role digestion and the absorption of nutrients through the mucous membrane of the GI tract in clinical practice aop is valuable for assessing liver function and diagnosing common B duct obstructions the normal range is typically 30 to 120 UL the elevated liver function test or lft can manifest an either a hepat cellular pattern which would be indicative of of conditions like viral or alcoholic hepatitis or a chastic pattern which would be suggestive of bilary obstructions such as gallstones or masses amas is an enzyme produced by various tissues including the salivary glands pancreas ovaries small and large bowels and skeletal muscle it involves an important role in digesting carbohydrates the normal range typically Falls within 27 to 131 UL amales testing is viable for detecting pancreatic insufficiency or damage and B duct obstructions as well as assessing for head trauma in patients with cystic fibrosis low amales levels are commonly observed lipase is another enzyme involved in the digestive process and is produced by the liver intestine and stomach lipas breaks down diary fats and the normal range for lipase levels is usually within 31 to 186 UL although lipase levels may not be highly sensitive for identifying chronic pancreatitis or pancreatic cancer they tend to elevate in individuals with these conditions a additionally elevated lipas levels can be seen in cases of B duct obstruction or biliary disease coagulation assessment involves the intrinsic and extrinsic Pathways of the coagulation Cascade the intrinsic pathway is initiated by the activation of factor 7 followed by factors 6 and Factor 4 culminating in the activation of factor x which initiates the common pathway of coagulation conversely the extrinsic pathway is triggered by tissue injury and begins with tissue factor and Factor 7 leading to the activation of factor 10 and the initiation of the common coagulation pathway ultimately this Cascade results in the formation of fibrin leading to clot formation coagulation assessment are vital for evaluating the body's ability to both form and prevent clots especially when abnormal clotting is suspected these coagulation enzymes are primarily synthesized in the liver making them essential components of liver function tests the results of these assessments are typically reported in units of seconds one significant coagulation parameter is prothombin time or PT which measures the the rate of conversion of prothombin to thrombin in the blood sample PT predominantly reflects the function of the extrinsic pathway the normal PT range Falls within 10 to 13 seconds an increased PT can be indicative of liver disease or therapy with werin conversely PT May decrease in cases of low vitamin K levels disseminated intravascular coagulation or massive transfusions potentially indicating a disrupted coagulation balance activated partial thromboplastin time or aptt is a vital coagulation parameter used to assess the health of the intrinsic and common Pathways of the coagulation system elevated apt levels can be indicative of bleeding disorders such as hemophilia a hemophilia b or Von willbrand disease additionally apt levels are grossly elevated in cases of disseminated intravascular coagulation highlighting its utility and diagnosing this condition the normal range typically Falls within 25 to 40 seconds apt is also a valuable tool for monitoring the therapeutic effects of Hein International normalized ratio or the INR serves as a normalizing index that is based on the international sensitivity index with a normal range of 0.9 to 1.3 an elevated INR indicates various conditions including those where prothombin time is increased and in individuals receiving anti-coagulants INR is commonly used to Target anti-coagulant therapy with typical anti-coagulation targets ranging from 2 to three however in cases involving mechanical heart valves or certain circulatory support devices a target of 2.5 to 3.5 may be preferred an INR greater than five in conjunction with bleeding often necessitates prompt medical intervention and treat to restore homeostasis Factor XA is a valuable tool for guiding the dosing of anti-coagulation therapy allowing clinicians to measure the activity of heprin and low molecular weight heprin by assessing Factor XA levels providers can tailor anti-coagulant treatments to optimize their efficacy and reduce the risk of bleeding or thrombos otic events TEEG offers realtime insight into clot formation by quantifying the interplay between platelets and the coagulation Cascade it provides five key measures reaction time or R time clot formation time or k time Alpha angle maximum amplitude and Lis time also known as ly30 these parameters collectively provide a comprehensive assessment of clot strength which depends on the overall health of the coagulation Cascade a calculated G value typically ranging from 5.3 to 12.4 serves as a summary indicator of clot strength aiding in the evaluation of hematic function D dier on the other hand is a a fiin degradation product that serves as a valuable indicator of fibron linis it plays Central role in assessing clotting when a hypercoagulability state is suspected such as in the diagnosis of DVT the reference level for dher is typically less than 500 NG per ml although higher thresholds may be more appropriate in older individuals elevated D dier levels can can provide important clinical insights helping providers diagnose and manage thrombotic conditions effectively osmol is a critical parameter used to measure the concentration of solute particles in a solution the normal range in human Serum is typically between 275 to 295 this measurement is valuable in clinical practice especially for rotating hyperosmolar infusions like manitol which are commonly employed in the management of patients with elevated ICP ethanol not a normal physiological product in the body is the result of alcohol consumption legal intoxication levels vary by state but are generally defined as having a blood ethanol concentration or BAC of more than 80 milligrams per deciliter lethal levels which would be those associated with the high risk of fatality typically range from 300 to 400 monitoring ethanol levels in the blood is critical in various clinical scenarios such as assessing alcohol intoxication and its Associated impairment as well as managing cases of alcohol overdose which can be lifethreatening calculated value use in medical Diagnostics are derived from mathematical formulas and are essential for understanding various aspects of a patient's Health Providers must be careful not to alter the order of the ratio variables in these calculations in order to ensure accurate interpretation creatinine ratio is a valuable parameter that helps determine the cause of increased levels of two metabolites that indicate renal pathology The Bu and the creatinine CR the normal ratio typically Falls within the range of 10:1 to 20:1 an increased creatinine ratio can indicate conditions such as dehydration GI bleeding or increased catabolism on the other hand a decreased ratio may be present in patients with conditions like acute tubular necrosis or autoimmune renal injury this ratio AIDS clinicians in assessing renal function and identifying potential underlying causes of kidney dysfunction the anion gap is another calculated value with a normal range of 8 to 16 M equivalents per liter an elevated annion Gap suggests the presence of unmeasured annion such as those seen in conditions like lactic acid osis this information is particularly helpful in diagnosing and managing states of acidosis including a diabetic keto acidosis as it provides insights into the nature and severity of the acidbase",
        "Blood Gases": "disturbance blood gases the typical arterial blood gas or ABG panel is a critical diagnostic tool used in clinical settings to assess a patient's acid base and oxygenation status this panel provides essential information about the patient's physiological condition and evaluates the patient's acidbase status by measuring several key parameters the pH of the blood sample provides a direct indication of whether the patient is in an acidic alkaline or neutral state pac2 reflects the respiratory component of acidbase balance indicating how effectively the patient is eliminating carbon dioxide through respiration bicarbonate level and base excess represent the metabolic component of acidbase balance reflecting the body's ability to regulate and maintain the bicarbonate levels in response to metabolic changes these measurements collectively offer in sites into the patient's acid-based status which can help diagnose conditions like metabolic acidosis or respiratory alkalosis Additionally the ABG panel assesses the patient's oxygenation status pao2 represents the oxygen tension in the arterial blood providing crucial information about the patient's oxygen levels sao2 indicates the percentage of hemoglobin that is saturated with oxygen hydrogen ion concentration denoted as pH quantifies the amount of unbuffered hydrogen ions present in the blood serving as a direct indicator of the blood's aity or alkalinity the pH is intimately related to two other critical components of blood gas analysis the patients pco2 and their bicarbonate ion the pH level is highly sensitive to changes in pco2 in bicarbonate ion and increase in pco2 indicating elevated levels of carbon dioxide leads to a smaller fraction of bicarbonate ion in the equation resulting in a lower pH value this would indicate acidosis conversely an increase in the bicarbonate ion level will lead to a larger fraction in the equation causing an increase in PH which would indicate alkalosis both increased in decreased levels of both pco2 and bicarbonate ion have profound effects on the pH level for arterial blood the normal PH range Falls between 7.35 and 7.45 while for Venus blood it typically ranges from 7.31 to 7.41 one any significant deviations from these normal ranges can have critical implications for physiological processes in the body when assessing blood gases by carbonate levels offer insights into the metabolic aspect of acidosis or alkalosis related conditions the normal range for bicarbonate concentration in arterial blood typically Falls between 22 to 26 M equivalents per liter in conjunction with bicarbonate base xcess or be is another essential parameter measured during atrial blood gas analysis base XS quantifies the degree of metabolic derangement and is often referred to as base deficit when expressed as a negative value while healthy individuals generally have minimal base EX clinical interpretations may vary based on this value base excess is measured in units of mil equivalence per liter and typically fall within the range of -2 to posi3 negative value signify an excess amount of acid or lack of Base which would indicate metabolic acidosis conversely positive values indicate either a deficit of acid or an excess amount of Base suggesting metabolic alkalosis one clinical application of Base excess lies in its utility for assessing proper fluid resuscitation healthc Care Professionals can use base excess to gauge whether a patient's fluid balance is appropriate providing valuable information in the critical care setting it is important to note that the administration of intervenous bicarbonate to treat metabolic acidosis does remain a topic of controversy in clinical practice and its use is Guided by specific patient circumstances and clinical judgment pao2 quantifies the amount of oxygen dissolved in the bloodstream the normal range typically Falls between 80 and 100 mm of mercury serving as a vital indicator for maintaining adequate oxygenation deviations from this range such as levels below 80 signify hypoxia additionally sao2 plays a role in the evaluation sao2 represents the percentage of potential oxygen binding sites in the hemoglobin molecules that are occupied by oxygen this measurement can be conducted noninvasively through transcutaneous methods using specialized monitor and probes it is important to distinguish this from the oxygen saturation calculated from arterial or Venus blood samples which would be sao2 which can be reported in blood gas analysis reports a normal value for measured sao2 typically exceeds 93% though it is imperative to exercise caution when interpreting calculated saturation from blood gas values as certain abnormal hemoglobin variant such as carboxyhemoglobin and methogo can lead to falely elevated readings furthermore carboxyhemoglobin assessment is an integral part of blood gas analysis as levels within normal parameters should not exceed 0.02 or 2% based on the total hemoglobin concentration evaluating these levels are essential as it aids in confirming carbon monoxide poisoning and guides appropriate therapeutic interventions it is worth noting that Healthcare Providers should exercise discretion when assessing these levels at individuals who smoke as they may exhibit a higher Baseline due to prolonged exposure to cigarette smoke elevated carboxyhemoglobin levels can be observed in critically ill patients making its inclusion in most blood gas analysis imperative as part of a compreh ensive arterial or Venus blood gas report these parameters collectively provide clinicians with invaluable information regarding a patient's oxygenation status enabling the timely identification and management of oxygen related  issues"
    },
    {
        "Introduction": "Clinician-performed ultrasound has proven crucial for the evaluation of critical disease. Improvements in size, weight, cost, user-friendliness, and communications have allowed the enthusiasm for hospital ultrasound to migrate into the out-of-hospital arena. With increasing evidence that ultrasound can play a role in out-of-hospital emergency care, this diagnostic modality has been used in international explorations on all continents, in challenging high-altitude expeditions, on cruise ships, in hyperbaric chambers, and even in outer space on the International Space Station. Ultrasound-guided diagnosis of critical conditions in the field has the potential for improving triage decisions, hastening therapy prior to hospital arrival, avoiding unnecessary or harmful treatments, and expediting transport to correct facilities. Prehospital ultrasound has been described in advanced ground and flight EMS systems, in military medicine for both service personnel and civilians, in austere or underdeveloped environments, and in mass casualty situations. Non-physicians with limited medical backgrounds have demonstrated the ability to perform and interpret ultrasounds with adequate training. Despite the recognition of a need for field use of point-of-care ultrasound, its routine incorporation into prehospital algorithms has not yet been established.",
        "Why prehospital ultrasound?": "Bedside ultrasound performed by non-radiologists has been well described to accelerate diagnosis and patient management, ultimately decreasing hospital lengths of stay and reducing costs. Out-of-hospital ultrasound has facilitated improvements in diagnostic accuracy but outcomes research has not been performed within this setting. The potential for extrapolation of similar outcomes using prehospital ultrasound is intriguing. Prehospital diagnosis of a grave illness may lead to immediate procedural care, direct admission to relevant specialty centers, and prevention of secondary transfers. Ultrasound-assisted triage may allow more stable patients to be redistributed away from overwhelmed centers and visibly guide immediate resuscitative interventions in the field.",
        "Settings of field use": "In the United States, EMS crews are primarily staffed with non-physicians using a \u201cscoop and run\u201d transport philosophy, providing basic resuscitation while delivering patients to the nearest appropriate facilities. Some European countries, however, use physician personnel on board their EMS vehicles or mobilize specific physician units to direct medical management and allocate resources. EMS physicians are increasingly common in the US as well. These units may spend longer in the field providing treatment prior to transport. Therefore, the utility and feasibility of prehospital ultrasound may differ depending upon practice environment. The concept of ultrasound assistance enabling rapid, accurate care before hospital arrival remains the same regardless of which system is employed.",
        "Indications": "The 2008 American College of Emergency Physicians policy statement regarding emergency ultrasound lists the following examinations as core emergency ultrasound applications: trauma, intrauterine pregnancy, abdominal aortic aneurysm (AAA), cardiac and volume status, biliary, urinary tract, deep venous thrombosis (DVT), soft tissue and musculoskeletal, thoracic, ocular, and procedural guidance. Prehospital use in many of these areas is described in the following sections.",
        "Indications - Trauma": "The area of most extensive study regarding prehospital ultrasound is the Focused Assessment with Sonography in Trauma (FAST) examination to detect traumatic cardiac tamponade and intraperitoneal bleeding. The current standard is for the FAST exam to be performed immediately upon arrival to the trauma center during advanced trauma life support physical examination surveys. However, Walcher et al. demonstrated that performing prehospital FAST (PFAST) ultrasounds at the trauma scene changed management in 30% of patients with a 93% sensitivity and 99% specificity for detecting intraperitoneal free fluid. Identification of free fluid enabled providers to reduce patient blood loss by providing permissive hypotension, and non-essential therapies were avoided to shorten time to surgery. Advance notification of PFAST results was provided to receiving hospitals, which then activated surgical teams when needed. In 22% of patients, the choice of receiving hospital was changed based on the ultrasound findings. Due to the results of this study, one major German air rescue provider incorporated PFAST into its algorithm for trauma management. Other studies have demonstrated successful paramedic performance of the PFAST exam while en route, on ground or in air, without prolonging time to transport. Of note, ultrasound cannot distinguish blood from ascitic fluid or pinpoint exact areas of bleeding. It is not sensitive in the detection of retroperitoneal fluid, organ injury, or hollow viscus injury. These limitations of ultrasound may cause delayed or missed fluid detection on out-of-hospital or triage FAST exam. It remains to be seen whether positive findings on a PFAST exam in the United States would alter management as illustrated in the Walcher study, since many trauma centers in the US have immediate response by trauma teams and protocols in place to mobilize operating theaters quickly. The FAST detection of pericardial fluid may have more potential for prehospital intervention. A dramatic case report details the course of a 17-year-old 26-week pregnant female suffering from a stab injury. Despite field chest tube placement with evacuation of air and blood, the patient's vital signs declined. Ultrasound revealed a significant amount of pericardial fluid, which was immediately drained in the field and again in the emergency department. The patient ultimately survived, largely due to prehospital intervention. Similarly, another report describes how in-ambulance paramedic detection of traumatic pericardial effusion and subsequent alerting of the receiving team facilitated direct operative intervention. These cases highlight the potential for the PFAST exam to change prehospital practice and guide on-scene resuscitative therapies. ",
        "Indications - Pulmonary": "While the Extended FAST exam (eFAST), including evaluation of pleural sliding, has been imprinted into emergency department and trauma protocols, it has not become standard in the prehospital environment. Adoption of sonographic pneumothorax evaluation may be invaluable in the trauma setting, as physical exam findings and ancillary monitoring have proven insensitive or difficult to discern in a noisy ambulance or helicopter. Detection may facilitate prehospital needle thoracostomy and prevent development of tension pneumothorax. Additionally,Ruling out pneumothorax avoids unnecessary procedures and their sequelae, allowing focus on other resuscitative efforts. Equally, assessments of lung sliding and pleural effusion have become useful adjuncts in the management of acute dyspnea. Zechner et al. report a common scenario encountered by prehospital personnel: a patient with a history of both chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF) presenting in severe respiratory distress with wheezing. When pulmonary edema was discovered via on-ambulance sonographic B-lines, treatment was immediately altered to discontinue terbutaline and proceed with urapidil (an alpha,-antagonist), enabling rapid improvement in the patient's clinical status. Subsequently, a German group developed a prehospital chest protocol to evaluate undifferentiated dyspnea. Using the subxiphoid cardiac view, bilateral coronal views, and bilateral anterior intercostal views, this protocol investigates pericardial or pleural effusion, pneumothorax, and right heart distension for pulmonary embolus. Providing supportive information in 68% of their patients and most useful for finding pleural effusion in decompensated CHF, prehospital ultrasound guided emergency physician management at the hospital.",
        "Indications - Cardiac": "Dedicated prehospital cardiac examination is very amenable to ultrasound. Brun et al. illustrate prehospital use of transthoracic echo for evaluation of shock in a patient with prior cardiac surgery presenting with dyspnea, tachypnea, crackles on exam, and hypotension. Ultrasound revealed pericardial effusion with thrombus in contact with the right ventricular free wall causing diastolic collapse of the right heart from a vitamin K antagonist overdose. The prehospital team notified the receiving hospital to prepare prothrombin complex concentrates in advance of arrival, and shortened time to drainage by the cardiac surgeons. Out-of-hospital groups have also diagnosed pulmonary embolus from acute right heart strain and examined cardiac output using non-physicians with tele-ultrasonography. The same challenges that affect interpretation of in-hospital echocardiography exist, such as differentiating between acute versus chronic right heart strain, epicardial fatty tissue versus small pericardial effusion, and stable versus unstable pericardial effusion. These physiological processes may require a more in-depth level of training. The main area of prehospital cardiac research stems from literature suggesting that absence of cardiac activity on bedside echocardiography predicts unsuccessful resuscitation in cardiac arrest. Thus there has been some focus on prehospital echocardiography performed by non-physicians for field pronouncement of death and avoidance of costly resuscitative efforts or misdirected allocation of resources. This has been further supported by a prospective study showing only a 3.1% (one patient out of 32) survival to hospital admission of cardiac arrest patients who displayed cardiac standstill on prehospital echo. In situations where uncertainties in decision to stop resuscitation are influenced by downtime, presence of bystander CPR, duration of resuscitation, ECG rhythm, age, or persistence of pulseless electrical activity (PEA), having a visible and reproducible prognostic parameter is useful. Although this study supports the idea that prolonged resuscitative efforts in the field may be futile when cardiac standstill is seen, there appears to be a small subgroup of people who survive to hospital admission, and the authors recommend not basing prehospital resuscitation on one single initial scan.",
        "Indications - Abdominal": "Within the emergency department setting, bedside ultrasound has been a rapid and accurate adjunct for diagnosis of AAA, renal colic, and cholecystitis. There are few reports of ultrasound for these disease processes in out-of-hospital settings. Prehospital ultrasound as a tool for investigation of abdominal or flank pain in the suspected abdominal aortic aneurysm may enhance admission decisions and reduce the potential for secondary transfer. An Australian helicopter retrieval team describe use of in-flight ultrasound in a man with suspected inferior myocardial infarction (MI). He had already received aspirin and enoxaparin prior to ultrasound-guided discovery of AAA. His management was changed to administration of fresh frozen plasma (FFP) for reversal of these agents and arrangements were made for direct transfer to the vascular team through advance notification to the receiving hospital. Other groups have successfully trained medic crews to evaluate the abdomen for AAA but the incidence of prehospital discovery and subsequent changes in patient outcomes have not been demonstrated. Out-of-hospital physicians utilizing ultrasound have changed management plans in hurricane disaster relief and in expeditions to the Amazon jungle when evaluating causes of abdominal disease.",
        "Indications - Obstetrics": "Evaluation of obstetric emergency is an area that may significantly benefit from prehospital ultrasound. A case series demonstrated the utility of ultrasound during air medical transfer where ambient noise creates difficulties in auscultating fetal heart rate. One case in particular highlighted the appropriate prevention of air medical transport in a patient displaying fetal distress due to premature rupture of membranes with prolapsed cord. When the flight team discovered intermittent fetal bradycardia on ultrasound, the transport was aborted and the patient went straight to the operating theater, averting fetal demise in this initially unrecognized condition. Diagnosis of ruptured ectopic pregnancy was confirmed by sonographic right upper quadrant free fluid in a patient with a reportedly normal pregnancy. Presence of free fluid heightened the suspicion of the prehospital team, who arranged immediate laparotomy during which a uterine rupture from myometrial implantation was discovered.",
        "Indications - Musculoskeletal": "Emergency medical technicians have successfully detected the presence of simulated fractures, and ultrasound detection of fractures has been useful in combat environments. These suggest diagnostic and therapeutic ultrasound implications particularly in remote environments where traditional diagnostic imaging is not available. Unstudied prehospital ultrasound applications include detection and reduction of shoulder dislocations, hip dislocations, pediatric fractures, and muscle and tendon injuries, and in nerve block analgesia.",
        "Indications - Prehospital ultrasound protocols": "Prehospital ultrasound protocols have been developed for the evaluation of life-threatening conditions. The Prehospital Assessment with Ultrasound for Emergencies (PAUSE) protocol includes a heart and thorax examination for pericardial effusion, pneumothorax, and cardiac motion with systematic guidance of resuscitative efforts. An integrative sonographic trauma survey has been proposed to identify multi-injury pathologies in the setting of mass casualty or combat. The CAVEAT examination assesses the chest for pneumothorax, hemothorax, and pericardial tamponade, the abdomen for FAST detection of hemoperitoneum, the inferior vena cava for qualitative volume assessment, and targeted extremity evaluation for detection of fracture. As each of the components within this protocol has been demonstrated using non-physicians, it is presumed that this protocol may be incorporated into the medic skill set. Supplementation of EMS training programs with easy-to-follow algorithms using pictorial aids may enable the implementation of prehospital ultrasound evaluation for resuscitation.",
        "Indications - Other": "In addition to detection of fluid in pleural, pericardial, and peritoneal cavities, Lapostolle et al. evaluated DVT and vascular flow disruptions in an out-of-hospital setting. This study found that ultrasound examination improved diagnostic accuracy in 67% of cases. Ultrasound has been used to diagnose high-altitude pulmonary edema and high-altitude cerebral edema in the Himalayas using thoracic and ocular ultrasound respectively, although with experienced physicians and not with mountain medics. Groups have explored prehospital transcranial Doppler use for assessment of brain injury and neurological disease. Procedural applications like peripheral intravenous access and abscess evaluations may also be useful in out-of-hospital scenarios. Ultrasound-guided thoracentesis and paracentesis are anecdotally common in settings without other radiographic capabilities.",
        "Disaster and mass casualty triage": "Mass casualty incidents require fast, reliable triage of large numbers of patients using limited resources. The chaotic environment, relative lack of medical personnel, and destruction of existing infrastructure can prevent early treatment of injured patients. The ability of ultrasound to identify patients who would benefit most from intervention could lessen uncertainties of physical exam findings in these situations. Placing diagnostic capability into the hands of first responders may be useful in future disaster strategies to augment triage accuracy, enhance mobilization of resources, improve allocation of scarce resources, and facilitate destination decisions. The few studies that have examined the above are understandably retrospective. Chart analysis of trauma patients at a Level I trauma center found that 20 of 286 patients triaged as in the simple triage and rapid treatment (START) method had positive FAST findings, with possible delayed hemoperitoneum identified in 7% of total patients. However, only six patients received operative management within 24 hours, with both over- and undertriage as significant problems. Because it is unclear if positive FAST findings would alter management in this setting, the study did not support the use of routine FAST as a secondary triage tool. Others have illustrated the usefulness of the FAST exam as a diagnostic and triage adjunct. Ultrasound was used as a screening modality for free fluid in the 1998 Armenian earthquake. Renal Doppler ultrasound performed at triage guided management of severe acute crush injuries in the aftermath of a 1999 Turkish earthquake, and ultrasound proved crucial in the identification of hemoperitoneum, hemothorax, intimal tear of the femoral artery, DVT, and deep tissue hematoma in both triage and middle-late stage assessment of patients admitted during the 2010 Wenchuan earthquake. The most recent case illustration highlights the usefulness of emergency department triage by ultrasound during the 2013 Boston Marathon bombing. An emergency medicine resident went bed-to-bed performing ultrasound and tagging results to the patient. The authors note that both triage and acute care for these patients were by the results of bedside ultrasound and recommended its implementation in disaster planning.",
        "Military": "The potential for out-of-hospital ultrasound use by military medics in the field is considerable, especially in the recognition of occult blood loss occurring in conditioned soldiers to prevent late-stage shock and in possible sonographically guided coagulation of internal bleeding. Army National Guard medics (EMT-B level) have successfully performed limited echocardiography for detection of cardiac activity. Military non-physician medics have performed fracture evaluation, FAST with pneumothorax examination, ocular, renal, vascular, and obstetric examinations. In addition, ultrasound training has been incorporated into the curriculum for special operator medics.",
        "Role of non-physicians/EMS training": "Multiple studies have established that non-physician personnel are capable of quickly learning and demonstrating proficiency with ultrasound in a wide variety of applications, in diverse environmental settings, and in differing modes of EMS transport. Training has encompassed a number of different methods including lectures, proctored hands-on sessions, before and after examinations, refresher sessions, OSCE assessments, web-based modules, flashcards, and tele-ultrasound guidance. Course times vary from as little as 2 minutes for fracture evaluation instruction to 1 day for FAST teaching, with cardiac and lung training reported from 10 minutes to 2 hours. Instruction for paramedics or ultrasound-naive physicians outside the United States appears longer, from 8-hour to 100-hour programs for the FAST exam and 2-day courses for the thoracic exam. Currently, there is no consensus on the optimal training time or method required to adequately train non-physician personnel, and no study to date has compared different training methods for EMS personnel.",
        "Tele-ultrasound": "Tele-ultrasound may become a valuable data transmission tool which takes advantage of a centralized expert's sonographic skills and disperses acquisition and interpretation of images to multiple unskilled providers. Tele-ultrasound has been described in remote locations and aboard the International Space Station. In an American study examining feasibility, 51 paramedics with no prior ultrasound experience received a 20-minute didactic session covering orientation and the FAST examination. With tele-ultrasound guidance, they performed complete FAST exams in a median time of 262 seconds. Although real-time clinical translation during EMS transport is required, this technology shows promise.",
        "Feasibility of ultrasound in the field": "Apart from operator skill and already known limitations of ultrasound as a diagnostic modality, several recurring limitations appear in field use which may prevent adequate completion of an ultrasound examination. Flight medics reported insufficient time to complete scanning. Screen visibility was hindered by bright ambient light, and physical restrictions arose from lack of space. Patient parameters such as obesity and combativeness prevented imaging, and battery or machine failure contributed to unsuccessful acquisition. Similar factors affect on-ground transport: difficult spatial arrangements, sunlight, battery problems, and a requirement for probe handling to be ambidextrous. In addition, harsh environmental conditions deprioritized ultrasound performance and optimal views were limited by presence of pacer pads, cervical collars, or splints. With ground transport, multiple examination completion times are longer and measurements may be less precise when completed in a moving vehicle, but these may not be statistically or clinically significant when compared with stationary performance. Other studies have shown that ultrasound can be completed without prolonging transport time. Despite these limitations, authors who have examined prehospital ultrasound feasibility have shown positive overall results and demonstrated the modality's utility in the field. Technological advances have allowed machinery to decrease in cost, weight, and bulk. Recent development of pocket-sized devices, wearable transducers, and in-clothing tele-ultrasound devices illustrates this, but perpetual improvements need to be made. Portable ultrasound devices need to be robust enough to operate in extremes of temperature while maintaining reasonable battery life, and inbuilt alternative power sources (e.g. solar energy) need to be considered. Displays that provide good visibility in bright light conditions with rapid boot-up time and simplified controls need to be incorporated. In addition, expanded image storage space and intrinsic capabilities for image transmission such as wireless internet or Bluetooth need to be included.",
        "Future directions": "European expert consensus groups have recognized prehospital ultrasound as one of their top research priorities. Recent literature has shown achievable diagnostic accuracy in non-physician hands and presented examples of patient care facilitation in treatment and transport decisions, thus supporting the use of prehospital ultrasound in varying EMS systems, in austere or impoverished settings, in combat and disaster environments, and in large recreational settings. Many of these studies involve small numbers of providers or small numbers of patients. The documented benefits of ultrasound in a hospital setting need to be reproduced in high-powered, larger-scale scenarios in the EMS literature. More permanent integration of ultrasound use within EMS systems, and development of longitudinal standardized curricula within EMS training, need to be established. Within this realm, questions surrounding the most efficacious way to teach first responders the most applicable ultrasound examination types to learn, and the optimal way to approach quality assurance of prehospital users, need to be answered. Ultimately, large-scale demonstration of the clinical improvement that prehospital ultrasound can produce in patient care needs to be established and patient-centered outcomes both within and outside the hospital need to be documented."
    },
    {
        "Introduction: the call-taking process": "When a patient calls 9-1-1 and speaks with a medical communications officer, the complex process of provision of care has been initiated. This first point of medical contact, the interaction between the patient and communication officer, can influence every subsequent experience of the patient during his or her prehospital and even in-hospital care. Consequently, it is essential for the communication officer to initiate and optimize the patient for the subsequent paramedic-patient contact; the paramedic in turn optimizes the patient for contact with the local emergency department (ED) or other destination. Although many consider that the 9-1-1 medical communications center is involved only in resource allocation such as dispatching ambulances, it also has a pivotal role in the provision of patient care. The accurate identification of the chief complaint by the communications officer serves as an adjunct to the field personnel by allowing them to incrementally build on the dispatch \u201cdiagnosis\u201d and initiate the appropriate therapy. If the communications officer incorrectly identifies the chief complaint, this may result in ineffective or inappropriate prehospital therapies, and even worse, it may introduce systematic biases that affect provision of patient care from the paramedic-patient contact onward. (For simplicity, the term paramedic will be used in this chapter, though the principles apply to all provider types including EMS physicians.) For example, during the initial steps in the communicator-patient interview, if the chief complaint includes scene safety (e.g. drowning or electrocution case), the dispatcher decides on the protocol that best addresses the issues. If the chief complaint involves trauma, then the dispatcher decides on the protocol that best addresses the mechanism of injury (e.g. fall, traffic accident). When the chief complaint appears to be medical in nature, the dispatcher chooses the protocol that best fits the patient\u2019s foremost symptom, with the priority symptoms taking precedence. Regardless of which call is assessed, the subsequent dispatch information can influence the thought processes of the responding paramedics and potentially influence how the paramedics approach the patient. For example, in the case of drowning or electrocution calls, the paramedics are preparing themselves for this type of call, essentially reviewing in their minds the protocols and procedures to use when approaching the patient. For all calls, the EMS personnel consider their previous experiences to determine how to proceed with the call when they initiate their own first medical contact.",
        "En route to the patient": "Just as emergency physicians do when they pick up a medical chart, view the chief complaint, and begin their approach to the patient with some element of preconceived notions based on the recorded chief complaint, so do field personnel when they are approaching the patient after being dispatched with some form of dispatch code. This can be beneficial to the paramedic in that it may immediately confer some sense that the patient has no high-priority symptoms, thereby requiring the paramedic to delve further into the reason for the EMS call. It can also be detrimental for the paramedic, in that it may mislead him or her into assuming that no priority symptoms are present when in reality one or more may be present. It may also be detrimental for the patient because it may mislead the paramedic into minimizing and/or underestimating the patient's symptoms, which could result in inaccurate or ineffective use of protocols. This may also pose an increased risk to the patient if the paramedic has a negative interaction with the patient, leading to mistrust, and in some cases, no transport to hospital. Emergency medical services personnel must compile a massive amount of information in a relatively short period of time. They must incorporate this information with their prehospital clinical skills and baseline knowledge in their clinical decision making, which is necessary to diagnose and treat patients effectively. Similar to emergency physicians, paramedics have become very fast in their decision-making processes, using strategies of both efficiency and thoroughness. Paramedics have also developed certain rules of thumb, shortcuts, and abbreviated thinking to make fast, efficient, and accurate decisions, or what clinical decision experts term heuristics. Various ethnographic and descriptive studies exploring medical errors, adverse events, and near misses in EMS have shown that paramedic decision making is a predominant factor influencing patient safety in EMS.\n\nWhen paramedics are interacting with a patient, there is clinical reasoning related to both the line of medical inquiry, such as the history, physical examination, and diagnostic tests, and the clinical decision making (i.e. the cognitive process of using data to evaluate, diagnose, and treat the patient). Clinical reasoning is a tremendously complex process and is under intense ongoing investigation. There is no single model of clinical decision making that adequately relates to the very complex environment that exists in the emergency setting. Rather, there are several models or strategies that individuals use in clinical decision making or cognitive performance including:\nPattern recognition or skill based (e.g. making a diagnosis immediately on entering the room, which is frequently unconscious, automatic, and based on years of experience)\nRule based (e.g. Advanced Cardiac Life Support algorithms)\nHypothetical deductive or knowledge based (considered the highest level of deduction; a clinician generates a hypothesis and uses existing and new knowledge to find an answer)\n\nSome experts describe a fourth model of a naturalistic or event-driven process of decision making (i.e. treating the patient first and then making the diagnosis). Interestingly, how and where paramedics make decisions and the density of decision making of paramedics in the patient journey are postulated to differ from those of other health care providers, and are under ongoing research.",
        "History taking": "It is essential that regardless of the dispatch determinant, the EMS crew approaches each patient in the same manner. Field personnel should acquire a history in an unbiased manner by using effective communication strategies. A balance of both subjective and open-ended questions (e.g. Can you describe your pain for me?) and objective and close-ended questions (e.g. Is the pain sharp?) should be used. In fact, throughout all disciplines of health care, traditional dictums state that effective history taking can lead to an accurate diagnosis in the majority of cases. Three possible outcomes can result from the history taking from a patient dispatched with an undifferentiated dispatch code. First, the paramedic may identify a prehospital diagnosis related to one of the 27 chief complaint conditions listed amongst the non-priority symptoms in the Medical Priority Dispatch System algorithms. It is important that the paramedic does not trivialize the patient's needs in the absence of priority symptoms, as each patient defines his or her own emergency. Second, the paramedic may establish a prehospital diagnosis that is accurate but not one of the 27 chief complaint conditions. In these situations, the crew members must coordinate their prehospital care knowledge to effectively care for the patient's needs. Third, perhaps the most frustrating for the crew, the paramedics may be unable to identify the specific chief complaint. This last outcome may be the first indication that the patient truly has an undifferentiated condition. At this point, it is important for the crew members to truly optimize the provider\u2013patient interaction, while minimizing the time to treatment and time to transport. The following strategies can be used to improve diagnostic accuracy during the history taking. Collect information to confirm or exclude life-threatening conditions first, then focus on the most likely diagnosis. Reaffirm that there are no high-priority symptoms present that could be affecting the patient's ability to render accurate answers, such as hypoglycemia or receptive and expressive aphasia with stroke. Ensure that the patient is oriented to person, place, and time, and that there is no underlying cognitive impairment due to drug ingestion, delirium, dementia, etc. When feasible, sit at the patient's bedside to collect a thorough history. Use adjuncts to facilitate the history taking (e.g. drawing diagrams or using other visual aids). Optimize communications so that the patient clearly understands the language and questions (e.g. asking simple questions). Obtain collateral information from the next of kin, friends, or bystanders. Allow a few moments of uninterrupted time to mentally process each patient. Generate \u201cmost life-threatening\u201d and \u201cmost likely\u201d diagnostic hypotheses. Mentally process one patient at a time. Avoid decision making when overly stressed or angry; take time out, regroup, and reevaluate the decision. Move on to physical examination to augment the history that has been elicited.",
        "Physical examination": "Sir William Osler taught that what was not found in a history was aided by completing an appropriate physical examination, and specifically that the history provided 90% of the diagnosis, that physical examination provided 9%, and that diagnostic tests contributed the remaining 1% of diagnostic certainty. In the situation of the patient who remains undifferentiated despite optimizing the history, it is paramount that the paramedic perform a thorough and complete physical examination. This begins with ensuring that a complete set of vital signs is taken and recorded. The following strategies can be used to improve the diagnostic accuracy during the physical examination process. Ensure a complete and uninterrupted physical examination or secondary survey. Clarify the history while conducting the physical examination. Perform an environmental scan of the patient's physical surroundings to complement the history (e.g. general surroundings, state of disarray, etc.). Have a structured and simple differential diagnosis or impression, based on the presenting history and physical information currently available (e.g. an altered level of consciousness can be broken down into structural, metabolic, and toxicological etiologies).",
        "Adjuncts to the history and physical examination: prehospital diagnostic tests": "In the case of the diagnostically undifferentiated patient, paramedics should use appropriate prehospital diagnostic tests to facilitate the working diagnosis. This would include such tests as the fingerstick glucose assessment and a prehospital 12-lead ECG. The following strategies can also be used to improve the clinical decision making for use of diagnostic tests. Employ any readily available decision-making algorithms or decision rules. A classic example is the Ottawa Ankle Rules that help emergency physicians in deciding on ordering ankle x-rays for injured patients. Although there are very few clinical guidelines in practice for the out-of-hospital setting, with the increasing body of evidence, these will increase in the future. Use existing prehospital protocols for specific therapeutic decisions whenever possible. Use only those tests that will affect the disposition or treatment of the patient by confirming or excluding the disease hypothesis at hand.",
        "The truly undifferentiated patient": "The patient who remains truly undifferentiated after the aforementioned maneuvers requires the same degree and level of care as those patients who have clear prehospital diagnoses. To further facilitate the care of the patient, it is important to advocate for the patient and relay the paramedic's concerns to the receiving facility. The hospital in turn can then continue to optimize the patient interaction to identify and meet patient needs.",
        "Transition of care to the receiving facility": "Just as the transition of care from the dispatcher to the paramedic occurs, there is also a transition of care between the paramedic and the hospital ED. It is of tremendous importance that this hand-off process maintains and facilitates the continuity of patient care and does not jeopardize patient safety. Many if not all EDs experience the difficult situation of ED overcrowding and long turnaround times for EMS staff. When a paramedic crew brings in a patient with no priority symptoms and no identifiable chief complaint, this may lead to confrontation between the charge nurse or physician and the paramedics. Moreover, this may lead to the receiving ED triaging the patient to the waiting room or to a lower triage score than is actually required. If the patient is truly deemed to be undifferentiated, then the paramedic must clearly state this to the receiving ED and elaborate on what has been done to optimize the history and physical exam, and provide insight and recommendations for next steps.",
        "Consequences of an undifferentiated patient": "There may be absolutely no significant consequences to either the patient or the EMS crew when the patient is undifferentiated. The patient may have an uneventful transport and ED stay. The main frustration is that both the paramedic crew and the patient are left with perhaps an unsatisfactory health care transaction. However, it is also possible that these patients may be subject to increased medical error and potentially compromised patient safety due to undifferentiated diagnoses. Error in all aspects of medicine has become an international issue with recent publications of the Institute of Medicine report To Err is Human, and several large retrospective studies (the Harvard Medical Practice Study, the Colorado-Utah Study, and the Quality in Australian Healthcare study). In the Institute of Medicine report, error is defined as the \u201cfailure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim.\u201d All these retrospective studies, which evaluated patients admitted from the ED, found surprisingly high rates of medical errors, many of them originating in the ED, and most of them preventable. There have been no large prospective studies describing error in the ED or the prehospital environment. Also there have been no reported associations between undifferentiated patients and the risk of medical error. There are several ways of classifying clinical errors, which in turn provide a means of reducing or preventing these errors. A common way is to have errors classified based on the models of cognitive performance or clinical decision making: skill-based errors (generally known as slips, or a failure in the execution of an action sequence, and lapses, or a failure of execution when the action was not the intended action), rule-based errors (mistakes such as the wrong rule is chosen due to misperception of situation or misapplication of rule), and knowledge-based errors (mistakes such as the lack or misapplication of knowledge or misinterpretation of knowledge). An alternative approach is to categorize errors into procedural errors (i.e. IV starts, intubations, and such), cognitive errors (any error in the course of diagnosis, management, and disposition of patients), and affective errors (emotional state of the medic unduly influences the clinical decision-making process). An alternative method of categorizing error is to overlay it on top of the clinical decision sequence of events that occurs when a patient is seen. For example, the progress of a patient through the ED or the ambulance is driven by multiple decisions underlying the sequence of patient assessment, diagnosis, treatment, and disposition. Many experts feel that the largest weighing or pivotal feature in this sequence is the diagnosis and its associate clinical decision making. There are three commonly described sources of diagnostic error: no-fault, system, and cognitive errors. No-fault errors can be related to a variety of factors focused mainly on the patient. This would include situations in which the history is atypical or undifferentiated; patients who are confusing, inaccurate, uncooperative, or non-compliant; and patients who misrepresent their conditions. System diagnostic errors result from a large variety of error-producing conditions (multiple interruptions, stress loads, busy shifts, etc.), equipment failure, and organizational failures. Cognitive diagnostic errors, as the preceding discussion reflects, are any of the errors related to line of medical inquiry. Diagnostic error, such as misdiagnosis, can thus result in an incorrect choice of therapy, failure to use an indicated diagnostic test, misinterpretation of test results, and failure to act on abnormal results, which in turn may lead to patient harm in the form of incorrect treatment protocols, incorrect destination choices, and risks of no transfer.",
        "Strategies for minimizing errors in clinical reasoning": "Paramedics can limit errors in their clinical reasoning by recognizing the potential biases that may be present and incorporating certain strategies or heuristics. The science and evidence around heuristics, clinical decision making, and reasoning are in relative infancy and require prehospital care providers to extrapolate from the current and evolving evidence regarding the heuristics of decision making in medicine and emergency medicine. These may include the following. Many experts will avoid using a previous diagnosis to influence their diagnosis \u2013 perform your own history, conduct a physical exam, employ strategic diagnostic tests, and with your clinical knowledge formulate your own diagnosis and management plan. Minimize the influence of personal or external biases (e.g. an overzealous partner or other health care provider) on your clinical decision making. Check for critical items in the past medical history and/or risk factors for serious disease. Pay particular attention to the vital signs of the patient. Avoid premature closure if the diagnosis is uncertain or undifferentiated. Be careful of high-risk environments and times, such as high-volume and high-acuity times of day, and personal and emotional fatigue. Be careful of high-risk patients \u2013 refusal of care, abusive/hostile/violent patients, confrontational and annoying patients, and those with drug etiology or psychiatric disease. Be careful of situations in which the presumptive diagnosis does not match the history, physical exam, or diagnostic test results. Go back to your assessment of the patient and reformulate a working plan.",
        "Conclusion": "Although some may consider the undifferentiated patient a difficult or frustrating patient to manage in the prehospital setting others may consider that they are a complex yet challenging patient population to manage. It is paramount that paramedics recognize the importance of clinical reasoning related to both the line of medical inquiry, such as conducting an effective and efficient history, physical examination, and diagnostic testing and tempering this with their clinical decision making (i.e. the cognitive process of using data to evaluate, diagnose, and treat the patient). Because there is no single model of clinical decision making that adequately relates to the very complex environment that exists in the ED or the out-of-hospital environment, paramedics must be familiar with the various ways in which they can cognitively evaluate, diagnose, and treat the patient. By recognizing effective strategies to optimize collecting a history, conducting a physical exam, and using diagnostic tests, they will reduce and prevent medical error, leading to improved patient safety."
    },
    {
        "Introduction": "Technology has evolved such that many laboratory-based analyses can now be performed on portable (sometimes handheld) devices, allowing testing at the point of care. Point-of-care testing (POC) is emerging across many settings in health care. Broadly addressing the setting of emergency care, the advantages may include reduction in time to treatment for emergency conditions, and improved flow through increasingly congested emergency departments. There is discussion of the potential benefits offered by introducing POC testing to the prehospital setting. Advantages may include earlier initiation of life-saving treatment, as well as enabling more informed destination choices. The wide variety of POC testing options may save money and make the practice of EMS more efficient and effective. However, it is a balance of costs and benefits. The discussion contains three subissues: what is the reliability of the emerging technology of POC, can that reliability translate to rugged prehospital conditions, and, most importantly, will it make a difference to patients? There may be a fourth issue in the subtext: what this means to the scope and education of EMS professionals.",
        "Is this particular test right for my service?": "Is the POC test valid and reliable? A good diagnostic test moves the clinician from diagnostic uncertainty to greater certainty. If the pretest probability of disease is low or high enough, there is no point in doing a test that costs money and may carry risk \u2013 at a minimum, the risk of false positive (or negative), at worst, a risk of harm by adverse reaction. For each test, there is a need to ascertain the sensitivity and specificity, and/or positive and negative predictive value. The issue of whether the result will change clinician actions is also important. The presence (or absence) of action may be on the basis of evidence-based criteria, local practice, and/or system design. For example, if field trauma triage protocols are not structured to incorporate the results of a lactate or cranial scanning for hemorrhage, there is no sense in putting these tools in the field. They are expensive, they need maintaining, and it will be frustrating for the field provider to produce data on which he or she cannot act.",
        "Is POC right for EMS?": "There are a number of advantages, at both patient and system level. POC may allow more targeted and earlier intervention. This may enable more appropriate regionalized destination strategies. It may even stretch to evidence-based non-transport, and the application of new therapies in the field. POC may have a particular role in community paramedicine.\n\nThere are some disadvantages as well. POC may carry medicolegal risk, with a need for development of a robust quality assurance/improvement plan. There is concern for scope creep, and that POC represents just another fancy toy. There is skepticism that POC testing will contribute to EMS being used as doctor or nurse replacement in the reform of health care.\n\nFurthermore, the incentive to 'stay and play' must be considered, and whether the possibility of longer scene time would be mitigated by more efficient overall system utilization is unknown. The implications for a change in the training of EMS providers, to include a foundation of pathophysiology sufficient to troubleshoot and understand the implications of positive and negative tests, must be a factor in the decision to introduce POC testing.",
        "How practical is this POC test?": "The system must consider an estimate of the upfront and ongoing costs, and weigh these against other system priorities. Consider whether the test will work in an ambulance. On a system level, assess the potential effect on performance or process measures, and the capacity of the system to handle required changes to infrastructure, for example training, follow-up, CQI infrastructure. Multiple factors go into the decision as to whether introducing a given POC is right for your EMS system.",
        "Specific POC tests for consideration in the EMS setting": "Medical devices in the United States are regulated by Food and Drug Administration (FDA). POC tests, as with other laboratory testing devices, fall under the FDA Clinical Laboratory Improvement Amendments (CLIA). CLIA sets standards for quality assurance and categorizes testing based on how complex it is for the analyst to run the test (e.g. training, knowledge, interpretation). The categorization (waived, moderate, or high complexity) has implications for who can use the tests, and the quality oversight infrastructure required. EMS systems in other settings need to investigate local regulations as they apply to medical devices. In all settings, the general discussion in this chapter with regard to important questions and infrastructure still applies.",
        "Detection of coagulopathy": "Is it valid? In terms of accuracy as compared to laboratory testing, and ease of use at the point of care, the best POC test appears to be INR/PT, better than aPTT, hemoglobin, or fibrinogen. One important exception is coagulopathy from platelet inhibition; POC remains limited, as does the ability to reverse anticoagulation.\n\nIs it logical/feasible for EMS? Point-of-care testing for INR/PT performs with comparable sensitivity to the standard tests, returning a result in a matter of seconds. The machines are expensive, and per-use cost is in the range of $9 USD. This POC test is CLIA-moderate complexity.\n\nWill it matter clinically? In trauma There are two types of coagulopathy to consider in trauma: that from anticoagulant/antiplatelet medications and that induced by trauma itself. EMS should already be addressing the root causes of mortality in trauma-induced coagulopathy, through prevention of hypothermia and targeted /low-pressure resuscitation (goal systolic blood pressure 85 mmHg). In-hospital strategies such as blood transfusion, cryoprecipitate, fresh frozen plasma, and recombinant factor VIIA are not easily translated to the field, with the need for refrigeration being a major limitation. Treatment of hypoperfusion may be the most important factor. In terms of medication-induced coagulopathy, head-injured patients are at particular risk from oral anticoagulation. A potential action would be notification of the trauma center to call for fresh frozen plasma or initiate a massive transfusion protocol. Supratherapeutic INR could factor into field trauma triage. Vitamin K may have a role in the specific case of oral anticoagulation with warfarin, and could potentially be administered in the field.\n\nIn stroke German researchers have used INR POC testing in the field in an on-scene stroke diagnosis and treatment protocol, with a reduction in time to needle. However, these studies also had portable computed tomography (CT), and the EMS team included a paramedic, a physician, and access to a neuroradiologist. That being said, it suggests that the use of POC INR testing is feasible. If it affected regional stroke triage and/or the activation of a stroke protocol at the receiving facility, it would have clinical importance in our EMS systems.",
        "Troponin": "Is it valid and reliable? The manufacturer\u2019s instructions state the device should be on a flat, stable surface during measurement. Fortunately, Venturini et al. found no significant difference between measurement of the same sample in the ED or the moving ambulance.\n\nIs it practical? Manipulating the tiny cartridge could be challenging, but several studies suggest it can be done. As the results take 10\u201315 minutes, it is suggested that the test be initiated on scene but to transport while awaiting results. Issues of cost are not negligible. One of the assays, the iSTAT, is in the range of US$11,000, and US$15 per use. The iSTAT cartridges only have a shelf-life of 2 weeks without refrigeration. This POC test is CLIA-moderate complexity.\n\nWill it make a difference clinically? In chest pain A paramedic-based EMS system in Denmark has demonstrated increased diagnostic clarity for chest pain patients, with nine of 78 patients triaged directly for primary percutaneous coronary intervention (PCI) based primarily on the positive POC troponin T in the setting of an equivocal ECG or bundle branch block of uncertain origin. This study also suggests good prehospital feasibility of troponin T POC testing with a 97% success rate in 958 attempts. The sensitivity was only 31%; this likely is related to the fact that 65% of patients had symptoms for less than 2 hours, making it very early in the troponin rise. A low sensitivity, or greater utility as a rule-in for ambiguous patients, is supported by other work.\n\nTroponin along with creatine kinase-MB, myoglobin, negative ECG, and low-risk assessment was used to rule out acute myocardial infarction with at least 6 hours of chest pain. In this Israeli EMS system there are both a physician and a paramedic on scene. Evidence for use as a rule-out in the prehospital setting is lacking; there is perhaps a greater role in a community paramedicine setting where contact times can be longer and follow-up options may exist. As a rule-in, studies have shown increased detection and improved access to definitive care, particularly for those with non-diagnostic ECGs.\n\nIn stroke Prehospital POC troponin T and N-terminal pro brain natriuretic peptide (NT-proBNP) have been suggested as predictors for stroke mortality in a Slovenian physician-based EMS system. The authors of this study argue that this predicts patients who need more intensive monitoring. However, it is unclear whether this would affect our current EMS standard stroke care.",
        "Lactate": "Is it reliable? A POC lactate test is available and valid/reliable in both adults and children. High prehospital lactate was significantly associated with the need for critical care during admission, and a high lactate (>2.0 mmol/L) occurred in the presence of normal vital signs in 13% of children. POC lactate as a triage tool has been supported in other studies, posited as more accurate than traditional field triage measures like SBP <90 mmHg. The test strips for the LP2 also calibrate. The LP devices claim to be the only CLIA-waived lactate POC.\n\nWill it make a difference clinically? In trauma Addition to the triage algorithm would help identify patients in need of more aggressive intervention, particularly those with \u201coccult hypoperfusion\u201d which might otherwise result in failure to resuscitate adequately and triage to a trauma center. Conversely, could a normal prehospital lactate (1.0 mmol/L or less) be used to avoid overtriage? Shah et al. showed that no patient with normal vital signs, a normal Glasgow Coma Scale score, and a lactate less than 1 mmol/L needed critical care.\n\nIn sepsis Prehospital POC lactate testing as part of a sepsis alert protocol was found to reduce mortality. In this study lactate and systemic inflammatory response criteria formed a prehospital protocol to detect and aggressively manage sepsis; this produced a \u201csepsis alert\u201d with dedicated staff in the emergency department prepared for the patient\u2019s arrival, and an aggressive prehospital and in-hospital management of the patient.",
        "Brain natriuretic peptide (BNP)": "Studies are heterogeneous in care provided and in definition of \u201cprehospital.\u201d No conclusion can be drawn.",
        "Carbon monoxide (CO)": "Most common in the EMS/fireground environment, two options for POC CO detection exist: an end-exhalation breath analysis and a pulse cooximeter. Both have been tested in this environment and found to be feasible to deploy. Notable limitations to validity include baseline CO in smokers, and the inability to detect peak or cumulative exposure. Actions that would result in meaningful clinical and system effects could include recognition of clinically significant acute exposure, rule-in or rule-out need for transport and oxygen, and consideration of hyperbarics.",
        "Capnography": "Is it valid and reliable? With good correlation to blood gas and multiple uses in the EMS environment, capnography is viewed by many as \u201cstandard of care.\u201d\n\nIs it practical/feasible? Qualitative capnography detectors can be placed on the endotracheal tube to detect expired carbon dioxide as evidence of proper tube placement. Quantitative capnography is an integrated feature in many monitor-defibrillator packages. Sensors can be in-line with the endotracheal tube-ventilation tubing when positive pressure ventilation is being used, and intranasal sensors are also available to monitor for hypoventilation in patients who are breathing spontaneously but sedated.\n\nWill it make a difference clinically? Uses of capnography include titration of ventilation, particularly in brain-injured or lung disease patients. Safety indications include recognition of misplaced or dislodged endotracheal tubes. Novel applications include recognition of return of spontaneous circulation.",
        "Near-infrared cranial scanner": "This scanner uses near-infrared transcranial spectroscopy, in adults and children, to enable detection of intracranial hemorrhage. One advantage is that it does not require the technical expertise needed for ultrasound, although a disadvantage is the limitation to one disease.\n\nIs it valid and reliable? Is it feasible? Sensitivities are quoted as 100% in a pediatric intensive care unit and 88.9% in an EMS setting. Specificities are in the range of 80%. It has been demonstrated to be feasible for use in the prehospital setting.\n\nWill it make a difference? None of the studies has suggested it can replace CT for diagnosis, but it may have some utility in triage to or away from trauma centers, or assignment of triage acuity scales.",
        "Integration": "A number of \u201ctests\u201d done routinely in EMS such as temperature, blood glucose, and oxygen saturation would qualify as POC. Considerations of training, quality improvement, cost, validity, practicality, and clinical significance should apply to them all. There are also a number of devices which are not strictly speaking POC but figure into implementation: audio communication (beyond VHF/UHF radio, cell phone), real-time vital signs/electrocardiogram, picture transmission, video streaming, interface of POC tests with tablets and cell phones, integrated monitor-defibrillator, real-time telemedicine link, including potential to interact. A network of optimized information technology capabilities could greatly enhance EMS capacity to get the right care to the right patient at the right time. The capabilities of the information technology world have moved light years, and EMS can learn a lot from enterprises like banking, couriers, and taxis. The potential for POC to improve quality and efficiency of EMS care is real. Careful consideration will be important to ensure valid, reliable POC tests are implemented with positive effects on outcomes."
    },
    {
        "Introduction": "At 17:00, two paramedics respond to the home of a 65-year-old man for a \u2018sick\u2019 call type. No other dispatch information is available for the crew pre-arrival. On scene, the patient states he feels \u201cunwell\u201d but is unable to better characterize his symptoms other than mild nausea. He has a PMH of chronic back pain and no other medical problems, with infrequent primary care visits. He denies any specific complaints other than his typical back pain. His wife reports that he was acting normal earlier today and she doesn\u2019t know what\u2019s wrong with him. She\u2019s a bit surprised he asked her to call 911, saying \u201cHe wasn\u2019t really complaining all that much.\u201d He takes naproxen for his back pain, which generally alleviates the pain. He denies any allergies or prior surgical history.",
        "Emergency Medical Dispatch (EMD)": "A medical call-receiving operator (CRO) trained in EMD has limited time to accurately identify the chief complaint and obtain vital medical information from the 911 caller. They are trained to collect information in a structured manner to perform priority dispatch. Due to callers\u2019 heightened anxiety or altered mental status, unreliable or misleading information is often transmitted to the responding EMS crews.",
        "Undertriaged and Overtriaged Dispatch": "Undertriaged dispatch: Inappropriate or unprepared resources rendering substandard level of care (eg, BLS providers responding to a \u201csick\u201d call type that turns out to be a patient in severe respiratory distress. Overtriaged dispatch: Excessive resources responding with lights and sirens, which puts the public and responders at risk and at great cost to the 911 system, to a stable patient (eg, first responders, BLS ambulance, ALS ambulance, EMS supervisor responding to a \u201cCardiac Arrest\u201d call that turns out to be a person sleeping).",
        "Clinical Decisions": "EMS providers must accumulate a great deal of information in a short time period. They then incorporate this information with their clinical skills and exam into their clinical decision-making. Delays in treatment and transport can impact patients\u2019 morbidity and mortality. Providers must make quick decisions based on limited information while providing thorough and efficient care. This has been termed heuristics. There are 4 main strategies that providers use in clinical decision-making (Table 1).",
        "History and Physical": "Field personnel must acquire a detailed and unbiased history using effective communication strategies. Regardless of the dispatch information, providers should approach each patient in the same manner. A balance of open-ended (Can you describe your pain?) and close-ended (Is your pain sharp or dull?) questions will produce a sufficient, succinct history. Traditional teaching professes that a diagnosis can usually be made by a thorough history alone.",
        "Diagnostic Assessment": "If the history and physical exam have not collectively identified a chief complaint, providers should use appropriate pre-hospital diagnostic tests to facilitate a working diagnosis, such as a point of care blood glucose level or 12-lead ECG. Some EMS systems offer prehospital point of care lactate testing to assist the providers in their differential diagnosis (eg, early diagnosis of sepsis). When crews have identified an undifferentiated patient, they should minimize the time to transport while continuing to obtain information and reassessing vital signs as warranted.",
        "Transition of Care": "Knowing the importance of a good transition of care to the triage nurse, especially with an undifferentiated patient, the crew clearly explains they do not have a presumptive diagnosis. Importantly, they note, he just had one episode of emesis prior to arrival and an acute worsening of his chronic back pain. The senior paramedic states, \u201dI\u2019m not sure what\u2019s going on with him, and that makes me even more concerned about him.\u201d The triage nurse listens to their assessment and obtains a new set of vital signs: 105/70, 110, 20, 97%. The EMS providers astutely notice the drop in blood pressure since their previous measurement, which prompts the nurse to triage the patient into the critical care area of the ED. After evaluation by the ED staff, and with the benefit of a bedside ultrasound, a ruptured abdominal aortic aneurysm is quickly diagnosed. As the crew walks out of the ER, they realize the quality care they provided led to a quick diagnosis of a critical condition and any delay in assessment, treatment, or transport would have resulted in missing this critical life-threatening event."
    },
    {
        "Key Terms": "Agonal breaths: Isolated or infrequent gasping in the absence of normal breathing in an unconscious person; can occur after the heart has stopped beating. Agonal breaths are not normal breathing and are considered a sign of cardiac arrest., Airway: The pathway for air from the mouth and nose through the pharynx, larynx and trachea and into the lungs., AVPU: Mnemonic describing the four levels of patient response: Alert, Verbal, Painful and Unresponsive., Brachial artery: The main artery of the upper arm; runs from the shoulder down to the bend of the elbow., Breathing rate: Term used to describe the number of breaths per minute., Capillary refill: A technique for estimating how the body is reacting to injury or illness by checking the ability of the capillaries to refill with blood., Carotid artery: The major artery located on either side of the neck that supplies blood to the brain., CPR breathing barrier: Device that allows for ventilations without direct mouth-to-mouth contact between the responder and the patient; includes resuscitation masks, face shields and bag-valve-mask (BVM) resuscitators., Cyanotic: Showing bluish discoloration of the skin, nailbeds and mucous membranes due to insufficient levels of oxygen in the blood., Glasgow Coma Scale (GCS): A measure of level of consciousness (LOC) based on eye opening, verbal response and motor response., Head-tilt/chin-lift maneuver: A common method for opening the airway unless the patient is suspected of having an injury to the head, neck or spine., Hypoxic: Having below-normal concentrations of 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., Level of consciousness (LOC): A person\u2019s state of awareness, ranging from being fully alert to unconscious; also referred to as mental status., Minute volume: The amount of air breathed in a minute; calculated by multiplying the volume of air inhaled at each breath (in mL) by the number of breaths per minute., Perfusion: The circulation of blood through the body or through a particular body part for the purpose of exchanging oxygen and nutrients with carbon dioxide and other wastes., Primary (initial) assessment: A check for conditions that are an immediate threat to a patient\u2019s life., Pulse: The beat felt from each rhythmic contraction of the heart., Respiratory arrest: A condition in which there is an absence of normal breathing., Respiratory distress: A condition in which a person is having difficulty breathing or requires extra effort to breathe., Signs: Term used to describe any observable evidence of injury or illness, such as bleeding or unusual skin color., Signs of life: A term sometimes used to describe normal breathing and a pulse in an unresponsive patient., Stoma: A surgical opening in the body; a stoma may be created in the neck following surgery on the trachea to allow the patient to breathe., Symptoms: What the patient reports experiencing, such as pain, nausea, headache or shortness of breath., Vital signs: Important information about the patient\u2019s condition obtained by checking respiratory rate, pulse and blood pressure.",
        "INTRODUCTION": "In previous chapters, you learned how to prepare for an emergency, the precautions to take when approaching the scene and how to recognize a dangerous situation. You also learned about your roles and responsibilities. As an emergency medical responder (EMR), you can make a difference in an emergency\u2014you may even save a life. But to do this, you must learn how to provide care for an injured or ill person, and set priorities for that care. When an emergency occurs, one of the most essential aspects of your job is the primary (initial) assessment. The primary assessment is the process used to quickly identify those conditions that represent an immediate threat to the patient\u2019s life, so that you may properly treat them as they are found. An effective primary assessment includes creating a general impression of the patient, checking for responsiveness and checking airway, breathing and circulatory status. After reading this chapter, and completing the class activities, you should be able to: \u2022 Perform a primary assessment. \u2022 Demonstrate how to assess LOC. \u2022 Demonstrate how to open the airway using the head-tilt/chin-lift maneuver and the jaw-thrust (without head extension) maneuver. \u2022 Demonstrate how to use a resuscitation mask.",
        "THE IMPORTANCE OF THE SCENE SIZE-UP": "Once you recognize that an emergency has occurred and decide to act, always remember the importance of sizing up the scene first. A primary assessment should never occur until after the scene size-up. The four main components to consider during a scene size-up include: 1. Scene safety. 2. The mechanism of injury (MOI) or nature of illness. 3. The number of patients involved. 4. The resources needed. Ensuring Scene Safety Always begin by making sure the scene is safe for you, other responders, the patient(s) and any bystanders, as discussed in Chapter 6. Take the necessary precautions when working in a dangerous environment. If you do not have the necessary training and equipment, do not approach the patient\u2014summon the appropriate personnel. Keep assessing the situation, and, if conditions change, you then may be able to approach the patient. Remember, nothing is gained by risking your safety. An emergency that begins with one injured or ill person could end up with two if you are hurt.",
        "Determining Mechanism of Injury or Nature of Illness": "When attempting to determine the MOI or nature of illness, you must look around the scene for clues to what caused the emergency and the extent of the damage. Consider the force that may have been involved in creating an injury. These considerations will help you to think about the possible types and extent of the patient\u2019s injuries. Take in the whole picture. How a motor vehicle is damaged or the presence of nearby objects, such as shattered glass, a fallen ladder or a spilled medicine container, may suggest what happened. If the patient is unconscious, determining the MOI or nature of illness may be the only way you can identify what occurred.",
        "Recognizing Patients": "When you size up the scene, look carefully for more than one patient. You may not see everyone 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 bleeding or screaming loudly, you may overlook another patient who is unconscious. It is also easy in an emergency situation to overlook small children or infants if they are not crying.",
        "CRITICAL FACTS 2": "Primary assessment is essential to the job of an EMR to ensure proper care. 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.",
        "Summoning More Advanced Medical Personnel": "At times, you may be unsure if more advanced medical personnel are needed. For example, the patient may ask you not to call an ambulance or transport vehicle to avoid embarrassment about creating a scene. Your training as an EMR will help you make the decision. As a general rule, summon more advanced medical personnel for any of the following conditions:\n\uf0a7 Unconsciousness, an altered level of consciousness (LOC) or a brief loss of consciousness\n\uf0a7 Breathing problems (difficulty breathing or no breathing)\n\uf0a7 Chest pain, discomfort or pressure lasting more than a few minutes, that goes away and comes back or that radiates to the shoulder, arm, neck, jaw, stomach or back\n\uf0a7 Persistent abdominal pain or pressure\n\uf0a7 No pulse\n\uf0a7 Severe, life-threatening bleeding (bleeding that spurts or gushes steadily from a wound)\n\uf0a7 Vomiting blood or passing blood\n\uf0a7 Severe (critical) burns\n\uf0a7 Suspected poisoning\n\uf0a7 Seizures\n\uf0a7 Stroke (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)\n\uf0a7 Suspected or obvious injuries to the head, neck or spine\n\uf0a7 Painful, swollen, deformed areas (suspected broken bone) or an open fracture\nIt is impossible to provide a complete or definitive list\u2014there are always exceptions. Trust your instincts and follow local protocols. It is better to have more advanced medical personnel respond to a nonemergency than arrive at an emergency too late to help.",
        "The Role of Bystanders": "Do not underestimate the role of bystanders in an emergency situation. Scene safety is always first and foremost, so look for bystanders who are in potential danger and instruct them to move to safety. Ask anyone present how many people may be involved in the emergency; bystanders may provide essential information to help you identify patients. Bystanders may also be able to tell you what happened or help in other ways. A bystander who knows the patients may know whether they have any medical conditions or allergies. Bystanders can also meet and direct an ambulance to your location.",
        "CRITICAL FACTS": "Many conditions warrant summoning advanced medical personnel. These include severe, life-threatening bleeding, breathing problems, prolonged chest pain, seizures, and suspected head, neck or spinal injuries\u2014to name a few.",
        "GENERAL IMPRESSION OF THE PATIENT": "Once you have conducted a scene size-up and assessed that the scene is safe for you and your colleagues, your first step in the primary assessment is to determine what has occurred and what is happening with the patient\u2014a general impression. This general impression will determine your immediate course of action.\nQuestions to ask yourself include:\n\uf0a7 Does the patient look sick or injured?\n\uf0a7 Is there a noticeable MOI?\n\uf0a7 Is the patient awake or alert?\n\uf0a7 Does the patient appear to be breathing?\n\uf0a7 Is the patient bleeding?\n\uf0a7 What is the patient\u2019s approximate age?\nYour general impression may alert you to a serious problem that requires additional resources or to a minor problem you can care for easily. You will discover these problems by looking for any signs and symptoms the patient may have. Signs are evidence of injury or illness that you can observe, such as bleeding or unusual skin appearance. Symptoms are what the patient reports experiencing, such as pain, nausea, headache or shortness of breath. If you see severe, life-threatening bleeding as you are forming your general impression, immediately control the bleeding with any available resources if it is safe to do so, or delegate the responsibility to another responder so you can begin your primary assessment. You may even ask the patient, if they are conscious and alert, to apply pressure to their wound while you prepare to provide care. For step-by-step instructions on performing a primary assessment, see Skill Sheet 7-1. As you perform the primary assessment, check for immediate life-threatening conditions. This means assessing whether the patient:\n\uf0a7\tIs conscious.\n\uf0a7\tHas an open and clear airway.\n\uf0a7\tIs breathing.\n\uf0a7\tHas a pulse.\nAs you assess the patient, determine if spinal precautions are necessary based on your general impression and the suspected MOI. If the scene suggests an MOI in which the patient may have a head, neck or spinal injury, you must ensure that the patient\u2019s head and neck do not move by using manual stabilization and the jaw-thrust (without head extension) maneuver.",
        "GENERAL IMPRESSION OF THE PATIENT - Age Delineation": "As part of gaining a general impression, attempt to determine the patient\u2019s 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.\nFor use of automated external defibrillators (AEDs)\u2014based on Food and Drug Administration (FDA) approval of these devices\u2014a 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.",
        "CRITICAL FACTS 3": "Always check for life-threatening conditions: unconsciousness; severe, life-threatening bleeding; a blocked airway; abnormal or absent breathing; and no pulse.",
        "RESPONSIVENESS": "Establishing Responsiveness\nWhen approaching a patient, check for responsiveness and assess their level of consciousness (LOC) . This can range from being fully alert to being unconscious and unresponsive to any stimuli such as voice or pain.First, speak to the patient. This may be to warn the patient to remain still if there is a situation that could cause damage to the head, neck or spine. For example, in a motor-vehicle collision or a fall off a ladder, the patient would need to remain still. Identify yourself as a responder and state that you are there to help. Obtain consent from the patient before beginning the primary assessment and providing care.\nWhen approaching a patient, you should try to approach from the front so that the patient can see you without needing to turn their head. This is especially important in the case of a suspected head, neck or spinal injury.\nAsk questions such as:\n\uf0a7\tWhat happened?\n\uf0a7\tWhat is your name?\n\uf0a7\tWhere are you?\n\uf0a7\tWhat day of the week is it? The answers to these questions will give you an idea of the patient\u2019s LOC and orientation. Keep in mind that certain pre-existing conditions and diseases may be responsible for a patient\u2019s orientation. If possible, speak with family members to establish if this is usual behavior for the patient or if it represents a change.",
        "RESPONSIVENESS - Pediatric Considerations": "Be aware that children and infants may be fully aware of you but unable to answer your questions. This response can be for a variety of reasons. Children may not be able to speak or understand your questions, they may not speak or understand English, they may be too frightened of the situation or of you as a stranger, or they may be crying too hard and be unable to stop. If possible, try to assess a young child or an infant in a parent\u2019s or caregiver\u2019s arms or lap. Approach slowly and gently, and give the child or infant some time to get used to you, if possible. Use the child\u2019s name, if you know it.",
        "RESPONSIVENESS - Considerations for Older Adults": "In older patients, certain conditions and diseases may be responsible for changes in LOC. For example, a patient with dementia may be confused by your questions. The patient also may not speak or understand English. When you think this might be the case, speak with family members if possible to establish if this is usual behavior for the patient or if it represents a change. Also, do not assume that difficulty responding to questions about time and current events necessarily means the patient is disoriented. It is not unusual for people who live alone to lose track of time, and some may not follow current events. In this case, alter your questions so that they address information related to the patient\u2019s immediate environment and the circumstances surrounding why you were called in order to truly gauge the patient\u2019s orientation.",
        "Patient Response\u2014AVPU": "In describing a patient\u2019s 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. Alert: Patients who are alert are conscious and aware of their surroundings, able to acknowledge your presence and able to respond to your questions. Verbal: Sometimes the patient is only able to react to sounds, such as your voice. The patient\u2019s eyes may be closed but they open when hearing your voice or when the patient is told to open them. The patient may appear to be lapsing into unconsciousness. A patient who has to be stimulated by sound to respond is described as responding to verbal stimuli. Painful: A patient who does not respond to verbal stimuli or commands, but does respond when someone inflicts pain, is described as responding to painful stimuli. Pinching the earlobe or the skin above the collarbone are examples of painful stimuli used to try to get a response. Be cautious however about pinching the earlobe in patients who may have neck trauma, as they may try to move their head away from an irritating stimulus. Instead, forcefully pinch or squeeze the fleshy section of skin between the patient\u2019s thumb and forefinger. Unresponsive: Patients who do not respond to any stimuli are described as being unconscious or unresponsive to stimuli.",
        "CRITICAL FACTS 4": "To assess LOC, ask simple questions such as, \u201cWhat is your name?\u201d LOC can range from being fully alert to unconsciousness. Always approach a patient from the front to avoid head turning. In describing a patient\u2019s 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.",
        "CRITICAL FACTS 5": "Without an open airway, the patient cannot breathe. A patient who can speak or cry is conscious, has an open airway, is breathing and has a pulse. However, the patient may still be at risk of a compromised airway. Once you have assessed the patient\u2019s LOC, the next thing you must do is to check the patient\u2019s airway, breathing and circulation (pulse and skin characteristics).",
        "AIRWAY STATUS": "The pathway for air passage between the mouth and nose to the lungs is called the airway. Without an open airway, the patient cannot breathe. A patient who can speak or cry is conscious, has an open airway, is breathing and has a pulse. However, the patient may still be at risk of a compromised airway. Assess the airway with the unconscious patient face-up. First, verify if the airway is patent (open and clear). If the patient is breathing (chest is rising and falling with air moving in and out) or the patient is speaking to you and aware of the surroundings, then you need to ensure that the airway remains open and clear. Continue to assess the patient\u2019s respiratory status throughout the period that you provide care. The airway can become blocked by fluids, solid objects, the tongue or swollen tissue caused by trauma or severe allergic reaction. Determine whether there is a need for any interventions to establish or maintain patency. For example, does the patient require suctioning to remove fluids or a finger sweep to remove solid 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\u2019s mouth and cheeks, making it easier to seal the resuscitation mask if you need to provide ventilations.",
        "Opening the Mouth": "If you need to open the mouth to clear the airway of fluids or debris and the patient is unresponsive, use the cross-finger technique to open the patient\u2019s mouth with a gloved hand: \uf0a7 Kneel beside the patient near their head. \uf0a7 Ensure that the patient is unresponsive. \uf0a7 Cross the thumb and forefinger of one hand. \uf0a7 Put your thumb on the patient\u2019s lower teeth and your forefinger on the patient\u2019s upper teeth. \uf0a7 Use a scissors motion to open the mouth.",
        "Assessing Airway and Breathing in the Responsive Patient": "If the patient speaks, you know that the airway is functional, but the patient may still be at risk. If a patient\u2019s breathing is noisy, the sounds can indicate the type of problem. For example, stridor (high-pitched whistling sound) can indicate that the airway is narrowing through swelling, a foreign body or trauma. Continually reassess and monitor the patient\u2019s breathing because breathing status, rate and quality can change suddenly.",
        "Assessing Airway and Breathing in the Unresponsive Patient": "It is more difficult to tell if an unconscious patient has an open airway. To open the airway for a patient who has not suffered an injury to the head, neck or spine, open and maintain the airway using 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\u2019s or an infant\u2019s head back as far as an adult\u2019s. Tilting the head back too far can close off a child\u2019s airway. Tilt a child\u2019s head so the airway is slightly past the neutral position and tilt an infant\u2019s head so the airway is in a neutral position.",
        "Opening the Airway\u2014Head-Tilt/Chin-Lift Maneuver": "To open the airway with the head-tilt/chin-lift maneuver: 1. Kneel beside the patient\u2019s head and neck. 2. Place one hand on the patient\u2019s forehead. 3. Place the fingertips of two or three fingers of your other hand under the bony part of the patient\u2019s lower jaw near the chin. If the patient is a child or an infant, use only one or two fingers. 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. If the patient is a child, tilt the head so the airway is only slightly past neutral. For an infant, tilt the head so the airway is in a neutral position. 5. Keep pressure on the patient\u2019s forehead to help maintain the airway in an open position.",
        "Opening the Airway\u2014Jaw-Thrust (Without Head Extension) Maneuver": "To open the airway for someone who has a suspected head, neck or spinal injury, use the jaw-thrust (without head extension) maneuver to keep the head and neck in a neutral position. This maneuver moves the tongue away from the back of the throat, allowing air to enter the lungs without moving the head and neck. After 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.",
        "CRITICAL FACTS 6": "For an unconscious and unresponsive patient, look, listen and feel for breathing and check for a pulse for at least 5 seconds, but no more than 10 seconds.",
        "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\u2019s mouth and nose so you can hear and feel air as it escapes. At the same time, look for the chest to rise and fall. Look, listen and feel for breathing for at least 5 seconds, but no more than 10 seconds. You will simultaneously check for breathing and a pulse. Pulse checks will be discussed later in this chapter. Check the patient\u2019s neck to see if they 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 breathe entirely through the stoma instead of through the nose and mouth. Use a round, pediatric mask if you need to provide ventilations. Isolated or infrequent gasping in the absence of normal breathing in an unconscious person may be agonal breaths, which can occur after the heart has stopped beating. Agonal breaths are not breathing and are considered a sign of cardiac arrest. Do not confuse this with normal breathing. If there are only agonal breaths, care for the patient as if they are not breathing at all. If the patient is breathing, assess the rate and depth of the breathing. A healthy adult breathes regularly, quietly and effortlessly. The normal breathing rate for an adult is between 12 and 20 breaths per minute. However, some people breathe slightly slower or faster (Table 7-2). You can usually observe the chest rising and falling. To determine the breathing rate, listen for the sounds as the patient inhales and exhales. Count the number of times the patient breathes (inhaling and exhaling is one breath) for either 15 seconds and multiply that number by 4, or 30 seconds and multiply that number by 2. If the patient is awake and alert, do not to let the patient know or disclose when you are observing breathing, as the patient may become self-conscious. This can cause a change in breathing pattern and not provide an accurate assessment. Simultaneously checking breathing and the pulse is a good way to not alert the conscious patient that you are observing their breathing. If the patient is breathing, continue to maintain an open airway.     Breathing rate may be abnormal for the patient\u2019s age, meaning either too slow or too fast. Respirations may be too slow: less than 8 per minute for adults, less than 10 per minute for children and less than 20 per minute for infants; or they may be too fast: greater than 20 per minute for adults, greater than 30 per minute for children and greater than 60 per minute for infants. Depth of breathing may also be abnormal, with shallow movement of the chest as it rises and falls. Abnormal breathing may be noisy. There may be a gurgling noise without secretions in the mouth or wheezing. Other abnormal breath sounds include whistling sounds, crowing sounds or snoring. The amount of effort a conscious patient puts into breathing can be observed by watching to see if the patient is using the accessory muscles\u2014the muscles in the neck, between the ribs and/or the abdomen\u2014to breathe. Nasal flaring is another indication of difficulty breathing, as is the tripod position, where the patient sits and leans forward, bracing both arms on knees or an adjacent surface for support to aid breathing.\nAdminister supplemental oxygen or provide ventilations as appropriate, based on local protocols, if the patient is having trouble breathing. This would be necessary if the patient is:\n\uf0a7 Unresponsive. Monitor the patient\u2019s airway to ensure that respirations are continuing and are effective.\n\uf0a7 Hypoxic . Pale, cool, clammy, moist skin is an early sign of inadequate oxygenation.\n\uf0a7 Cyanotic . The patient is not receiving adequate oxygen. This is a clear but late sign of inadequate oxygenation. The mouth, lips and nailbeds would appear blue in color.\uf0a7 Breathing very shallow respirations. The patient is likely not receiving an adequate supply of oxygen.\n\uf0a7 Breathing increasingly slow. Oxygen intake will be dropping and the patient is likely not receiving an adequate supply of oxygen.\n\uf0a7 Tolerant of assisted ventilation. For those who are not tolerant of assisted ventilation, you can use a \u201cblow-by\u201d technique. Refer to Chapter 12 for more information.\nIt is important to remember that the respiratory status of a patient can change suddenly.\nIf the patient is not breathing normally and has no pulse and the cause is the result of a drowning, give 2 ventilations prior to beginning CPR. Provide ventilations using a resuscitation mask or BVM. These CPR breathing barriers can help protect against disease transmission when performing CPR or giving ventilations to a patient",
        "BREATHING STATUS - Pediatric Considerations": "Children and infants breathe more quickly than adults. Children can breathe up to 30 breaths per minute, while infants can have a respiratory rate up to 50 breaths per minute. While counting the breaths, assess whether breathing is shallow, deep or normal, and whether the child or infant appears to be having difficulty breathing. Normal (effective) breathing appears effortless. Keep in mind that infants have periodic breathing, so changes in the pattern of breathing are normal. Also, agonal breaths do not occur frequently in children. As with adults, if a child or an infant is breathing spontaneously, you must still reassess regularly to ensure that the breathing status does not change.",
        "CRITICAL FACTS 8": "It is important to remember that the respiratory status of a patient can change suddenly.",
        "Artificial-Ventilation Rates": "AGE NUMBER OF VENTILATIONS PER MINUTE* Adult (12 years old and older) About 12 (1 ventilation about every 5\u20136 seconds) Child (1 year to about 12 years old) About 20 (1 ventilation about every 3 seconds) Infant (under 1 year of age) About 20 (1 ventilation about every 3 seconds) Newborn 30 to 60 (1 ventilation about every 1\u20132 seconds) *Each ventilation should be approximately 1 second in duration.",
        "Bag-Valve-Mask Resuscitators": "Bag-valve-mask (BVM) resuscitators are difficult to use by a single responder. Two emergency medical responders (EMRs) should provide ventilations with a BVM: one to establish and maintain the airway and seal of 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\u2014and have frequent opportunities to perform\u2014one-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 mask while the other delivers ventilations.",
        "Resuscitation Mask": "To use a resuscitation mask, select the proper size of mask for the patient (adult, child or infant), kneel to the side of or above the patient\u2019s head and then: \uf0a7 Assemble the mask and valve, attaching the one-way valve to the mask, if necessary. \uf0a7 Open the airway past a neutral position for an adult and slightly past neutral for a child. For an infant, tilt the head so that the airway is in a neutral position. \uf0a7 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. \uf0a7 Seal the mask. \uf0a7 Blow into the mask. Give 2 ventilations. Each ventilation should last about 1 second and make the chest begin to rise. Pause briefly between ventilations to let the exhaled air escape. For step-by-step instructions on using a resuscitation mask, see Skill Sheets 7-3 and 7-4. See Table 7-4 and Chapter 10 for more information about the use of breathing devices and artificial ventilations. If breathing is too slow for the age of the patient, 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 to ensure the respiratory rate does not drop again. If the patient is not breathing, the patient will likely need assistance. Assist breathing by either giving ventilations or administering supplemental oxygen, if available, based on local protocols. Someone with asthma or emphysema who is in respiratory distress may try to do pursed-lip breathing. Have the patient assume a position of comfort. After the patient inhales, have them slowly exhale through the lips, pursed as though blowing out candles. This creates back pressure, which can help open airways slightly until more advanced medical personnel arrive. If the patient is not breathing normally (respiratory arrest) but has a pulse, provide ventilations with a resuscitation mask and administer supplemental oxygen, if available, based on local protocols. If additional EMRs and equipment are available, use a BVM. Once you have begun giving ventilations, continue until the patient begins to breathe spontaneously and adequately or until more advanced medical personnel take over.",
        "CIRCULATORY STATUS": "While assessing the patient\u2019s 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.",
        "CIRCULATORY STATUS - Pediatric Considerations": "A normal pulse in a child varies according to age, from 80 to 130 for children ages 1\u20133, to 60 to 105 in adolescents ages 11\u201314. 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 according to age.",
        "CIRCULATORY STATUS - 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.When the heart is healthy, it beats with a steady rhythm. This beat creates a regular pulse. A normal pulse for an adult ranges from 60 to 100 beats per minute. A well-conditioned athlete may have a pulse of 50 beats per minute or lower. A pulse of greater than 100 beats per minute is too high. 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: \uf0a7 Irregular pulse. \uf0a7 Weak and hard-to-find pulse. \uf0a7 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. 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 \u201cnormal\u201d 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 irregular heartbeat as part of the patient history. Checking a pulse involves placing two fingers on top of a major artery located close to the skin\u2019s surface and over a bony structure. Pulse sites that are easy to locate are the carotid arteries in the neck, the radial arteries in the wrists and the brachial arteries in the upper arms. There are also other pulse sites you may use. To check the pulse rate, count the number of beats in either 15 seconds and multiply that number by 4 or in 30 seconds and multiply that number by 2. The number you get is the number of heartbeats per minute. An injured or ill patient\u2019s pulse may be hard to find. If you have trouble finding a pulse, keep checking for one periodically. If a patient is breathing normally, the heart is also beating. There may be a loss in circulation to the injured area, however, causing a loss of pulse. If you cannot find the pulse in one place of a responsive patient, try another location, such as in the other wrist. If the patient is conscious and breathing, check the pulse to determine the rate and quality of the pulse. For conscious adults and children, you usually check the radial pulse on the thumb side of the patient\u2019s wrist. For infants, you should check the brachial artery located on the inside of the upper arm, midway between the shoulder and elbow. If the patient is unconscious, remember to simultaneously find out whether the patient has an open and clear airway, is breathing and has a pulse. If the patient is not breathing normally, you should only be concerned whether the pulse is present or absent and not with the rate and quality. Check the pulse for an adult or a child at either of the carotid arteries located in the neck. Check the brachial pulse of an infant in the middle of the upper arm. Check for breathing and a pulse for at least 5 seconds, but no more than 10 seconds. To find the carotid pulse, place two fingers on the front of the neck, then slide your fingers toward you and down into the groove at the side of the neck. Feel for at least 5 seconds, but no more than 10 seconds. Sometimes the pulse may be difficult to find, since it may be slow or weak. However, if you do not find a definite pulse within 10 seconds, do not waste any more time attempting to find one. Assume there is no pulse and begin resuscitation immediately. In some cases, the person may be unresponsive but breathing normally. Generally that person should be placed in a side-lying recovery position, if there is no suspected head, neck, spinal, hip or pelvic injury. However, there are a few situations when you should move a person into a recovery position even if there is a suspected head, neck, spinal, hip or pelvic injury. Examples of these situations include if you are alone and have to leave the person (e.g., to call for additional resources), or you cannot maintain an open and clear airway because of fluids or vomit. Placing a person in a recovery position will help keep the airway open and clear. If the patient does not have a pulse, you need to keep blood containing oxygen circulating. This involves performing chest compressions to circulate the oxygen to the brain and providing ventilations to get oxygen into the patient\u2019s lungs. This procedure is called CPR and is described in Chapter 13.",
        "Perfusion": "The next step is to establish whether the patient is maintaining adequate blood flow. Perfusion describes the circulation of blood through the body or through a particular body part. The appearance of the skin and its temperature can be helpful in providing information about the patient\u2019s circulation. Checking the skin characteristics requires you to look at and feel the skin. There are four aspects of skin conditions to note, including: \uf0a7 Color. Is it pale and ashen, or flushed and pink? \uf0a7 Temperature. Is it hot or cold? \uf0a7 Moisture. Is it moist or dry? \uf0a7 Capillary refill. Is it normal or slow?",
        "Skin Color": "In some people, the skin looks red when the body is forced to work harder. The heart pumps faster to get more blood to the tissues, and this increased blood flow causes reddened skin or a flushed appearance. Reddening or flushing may not appear in darker skin tones. In contrast, the skin may look",
        "Skin Temperature": "Skin temperature is also a sign of blood circulation. Increased blood flow makes the skin feel warm. Cool skin may indicate low body temperature or shock.",
        "Skin Moisture": "You can also gain information from the degree of moisture on the skin. Normal skin is dry or slightly moist. Wet or sweaty skin may indicate physical exertion, stress, severe pain or shock.",
        "Capillary Refill": "One technique for estimating how the body is reacting to injury or illness is to check the ability of the capillaries to refill with blood. This technique, known as capillary refill, is more reliable in children and infants up to the age of 6 than it is in adults. Capillary refill is an estimate of the amount of blood 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 color under the fingernails. When a serious injury or illness occurs, the body attempts to conserve blood in the vital organs. As a result, capillaries in the fingertips are among the first blood vessels to constrict, thereby limiting their blood supply. Environmental temperature can play a role in the effectiveness of capillary refill. If the patient is exposed to cold temperatures, the capillary refill will normally be slow. Refill slows because blood is directed away from the peripheral areas of the body, like the limbs, in an effort to maintain core body temperature.",
        "Capillary Refill - Pediatric Considerations": "In children, check capillary refill in fingernails or toenails. In infants, check capillary refill in 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. If the area does not return to pink within 2 seconds (the time it takes to say \u201ccapillary refill\u201d), 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 normally will be slow as the body is attempting to maintain core body temperature.",
        "IDENTIFYING LIFE THREATS": "Consciousness, breathing and circulation, including pulse and skin characteristics, are called vital signs . They are sometimes referred to as \u201csigns of life.\u201d Check the vital signs often as you monitor a patient while you wait for more advanced medical personnel to take over. Assess the patient to determine if it is a life-threatening condition. If the patient is unstable, care for the life-threatening condition as soon as it is discovered. For stable patients (vital signs within normal range), assess the patient\u2019s condition and provide care as necessary. Patients who are unstable should be reassessed at least every 5 minutes, or more often if indicated by the patient\u2019s condition. Reassess stable patients every 15 minutes, or as deemed appropriate by the patient\u2019s condition.",
        "IDENTIFYING LIFE THREATS - Newborn Considerations": "The APGAR scoring system is the universally accepted method of assessing a newborn at 1 minute after birth, at 5 minutes after birth and again at 10 minutes after birth. APGAR stands for Appearance, Pulse, Grimace, Activity and Respiration. The term APGAR also stands for the person who developed it, Virginia Apgar, MD. For more information on assessing a newborn, refer to Chapter 24.",
        "SHOCK": "If the patient shows signs of shock, you will need to provide care for shock during the primary assessment. In order to determine whether shock should be treated immediately, watch for:\n\uf0a7\tDecreased responsiveness.\n\uf0a7\tUnresponsiveness to verbal commands.\n\uf0a7\tA heart rate that is too fast or too slow.\n\uf0a7\tSkin signs of shock.\n\uf0a7\tA weak or no radial pulse (brachial pulse for infants).Other signs that indicate a person may be going into shock include restlessness or irritability; altered LOC; nausea or vomiting; pale, ashen, cool, moist skin; rapid breathing and pulse; and excessive thirst. In particular, restlessness and irritability are often the first signs of shock. If the patient is in shock, control any external bleeding as soon as possible to minimize blood loss and administer supplemental oxygen, if available, based on local protocols. Lay the patient flat (supine). Keep the patient from getting chilled or overheated.",
        "PUTTING IT ALL TOGETHER": "The primary assessment helps to identify any life-threatening conditions so they can be cared for rapidly. Problems that are not an immediate threat can become serious if you do not recognize them and provide care. By following the proper steps when conducting the primary assessment, you will give the patient with a serious injury or illness the best chance for survival. Before you proceed with a primary assessment, be certain to size up the scene to make sure there are no dangers to you, the patient and bystanders, and to consider the MOI, nature of illness, the number of patients involved and additional resources you may need. The essential aspects to the primary assessment are making a general impression of the patient and checking responsiveness, airway, breathing and circulation. Determine if there are any immediate threats to life, such as the presence of severe, life-threatening bleeding, or an absence of breathing or pulse. Although this plan of action can help you decide what care to provide in any emergency, providing care is not an exact science. Because each emergency and each patient is unique, an emergency may not occur exactly as it did in a classroom setting. Even within a single emergency, the care needed may change from one moment to the next.",
        "CRITICAL FACTS 9": "Check vital signs, such as pulse and respiratory rate, often while you wait for more advanced medical personnel to take over.",
        "Primary Assessment": "NOTE: Always follow standard precautions when providing care. Size up the scene for safety, form a general impression and then:\nSTEP 1: Check for responsiveness:\n  \u25aa Shout, \u201cAre you OK?\u201d and then tap the shoulder and shout again.\n  \u25aa For an infant, tap the underside of the foot.\nSTEP 2: If no response:\n  \u25aa Summon more advanced medical personnel.\n  \u25aa If the patient is face-down, roll them onto their back while supporting the head, neck and back.\nSTEP 3: Open the airway and check for breathing and pulse for 5\u201310 seconds.\n  \u25aa Use head-tilt/chin-lift or jaw-thrust depending on position and suspected injury.\n  \u25aa Feel for carotid pulse in adults/children and brachial pulse in infants.\n  \u25aa NOTE: For drowning victims, give 2 ventilations before Step 4.\nSTEP 4: Provide care based on conditions found.\n  \u25aa If unresponsive but breathing normally with no suspected injury, place in recovery position.\n  \u25aa Avoid movement for suspected head/spine/pelvis injuries unless necessary to manage airway or call for help.",
        "Skill Sheets and GCS": "Skill Sheet 7-2: Jaw-Thrust (Without Head Extension)\n  \u25aa Kneel above patient\u2019s head.\n  \u25aa Place thumbs near mouth, fingers under jawbone.\n  \u25aa Use two or three fingers for child/infant.\n  \u25aa Lift jaw without moving head.\n  \u25aa Pull back lower lip if lips close.\n\nSkill Sheet 7-3: Using a Resuscitation Mask\n  \u25aa Assemble mask and one-way valve.\n  \u25aa Open airway: head-tilt/chin-lift (adjusted for age).\n  \u25aa Position mask from bridge of nose to below mouth.\n  \u25aa Seal the mask:\n    - Side of head: one-hand \u201cC-E\u201d grip.\n    - Above head: two-hand \u201cC-E\u201d grip.\n  \u25aa Give 2 ventilations, 1 second each, chest rise.\n\nSkill Sheet 7-4: Using a Mask with Suspected Head/Neck Injury\n  \u25aa Assemble mask, kneel above head.\n  \u25aa Place and seal mask without moving head.\n  \u25aa Open airway with jaw thrust (no head tilt).\n  \u25aa Give 2 ventilations.\n\nGlasgow Coma Scale (GCS):\n  \u25aa Assesses LOC based on Eye (E), Verbal (V), and Motor (M).\n  \u25aa Score range: 3 (coma) to 15 (fully alert).\n  \u25aa GCS \u2264 8 = severe brain injury\n  \u25aa Pediatric GCS (PGCS) adjusts verbal responses for children <5.\n\nTable 7-7: Pediatric Glasgow Coma Scale\nEye Opening:\n  - Opens spontaneously: 4 pts\n  - Verbal command: 3 pts\n  - Pain: 2 pts\n  - No response: 1 pt\nVerbal Response:\n  - Oriented/babbles: 5 pts\n  - Confused/irritable: 4 pts\n  - Inappropriate words/cries: 3 pts\n  - Incomprehensible/moans: 2 pts\n  - No response: 1 pt\nMotor Response:\n  - Obeys/moves purposefully: 6 pts\n  - Localizes pain/withdraws to touch: 5\u20134 pts\n  - Posturing: 3\u20132 pts\n  - No response: 1 pt"
    },
    {
        "Key Terms": "Auscultation: Listening to sounds within the body, typically through a stethoscope., Blood pressure (BP): The force exerted by blood against the blood vessel walls as it travels throughout the body., Chief complaint: A brief description, usually in the patient\u2019s own words, of why emergency medical services (EMS) personnel were called to the scene., DCAP-BTLS: A mnemonic to help remember the signs to look for during a physical exam, which is often done during the secondary assessment; the initials stand for deformities, contusions, abrasions, punctures/penetrations, burns, tenderness, lacerations and swelling. Detailed physical exam: An in-depth head-to-toe physical exam; takes more time than the rapid assessment, and is only done when time and the patient\u2019s condition allow., Diastolic blood pressure: The force exerted against the arteries when the heart is between contractions, or at rest., DOTS: A mnemonic to help remember what to look for during the physical exam; the initials stand for deformities, open injuries, tenderness and swelling., Focused trauma assessment: A physical exam on a trauma patient, focused only on an isolated area with a known injury such as a hand with an obvious laceration., Ongoing assessment: The process of repeating the primary assessment and physical exam while continually monitoring the patient; performed while awaiting the arrival of more highly trained personnel or while transporting the patient., OPQRST: Mnemonic to help remember the questions used to gain information about pain; the initials stand for onset, provoke, quality, region/radiate, severity and time., Palpation: Examination performed by feeling part of the body, especially feeling for a pulse., Physical exam: Exam performed after the primary assessment; used to gather additional information and identify signs and symptoms of injury and illness., Pulse oximetry: A test to measure the percentage of oxygen saturation in the blood using a pulse oximeter., Rapid medical assessment: A term describing a rapid head-to-toe exam of a medical patient., Rapid trauma assessment: A term describing a rapid head-to-toe exam of a trauma patient., Respiratory rate: The number of breaths per minute; normal rates vary by age and other factors., SAMPLE history: A way to gather important information about the patient, using the mnemonic SAMPLE; the initials stand for signs and symptoms, allergies, medications, pertinent medical history, last oral intake and events leading up to the incident., Secondary assessment: A head-to-toe physical exam as well as the focused history; completed following the primary assessment and management of any life-threatening conditions., Sphygmomanometer: A device for measuring BP; also called a BP cuff., Stethoscope: A device for listening, especially to the lungs, heart and abdomen; may be used together with a BP cuff to measure BP., Systolic blood pressure: The force exerted against the arteries when the heart is contracting., Vial of Life: A community service program that provides emergency medical services (EMS) personnel and other responders with vital health and medical information (including any advance directives) when a person who suffers a medical emergency at home is unable to speak; consists of a label affixed to the outside of the refrigerator to alert responders and a labeled vial or container that has pertinent medical information, a list of medications, health conditions and other pertinent medical information regarding the occupant(s).KEY TERMS",
        "INTRODUCTION": "In Chapter 7, you learned how to conduct a primary assessment, which helps you to determine if the patient has any life-threatening conditions through checking level of consciousness (LOC), airway, breathing and circulatory status. However, as you will learn in this chapter, you can obtain more information about the patient through history taking and the secondary assessment, which includes interviewing the patient and bystanders, monitoring vital signs and conducting a physical exam. As with the primary assessment in the case of serious injury or illness, performing and documenting a thorough history and secondary assessment can increase the patient\u2019s chance of survival.",
        "OBTAINING THE FOCUSED/ MEDICAL HISTORY": "A crucial aspect of your job is to find out as much as possible about the emergency situation, so that you can communicate this information to more advanced medical personnel. In addition to your close observation of the scene and patient, interviews with those involved are generally your best sources of information. Remember never to enter a scene unless you are sure you can do so safely. 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. Keep in mind that, for a critical trauma patient or an unconscious medical patient, the history will likely be performed after the physical exam. For a medical patient who is responsive, the history will likely be performed first. Under ideal circumstances, patients will be able to tell you themselves all you need to know about what happened and any related medical issues. Help relieve the patient\u2019s anxiety by explaining who you are and that you are there to help. Also ask the patient\u2019s name and use it. Always obtain consent before touching or providing care to a patient. Necessary information cannot always be obtained from the patient. The patient may 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. Sources of information may also be all around you. Be sure to check the patient for a medical identification tag or bracelet, or other medical information sources, such as wallet cards or mobile phone apps. Other hints include the presence of medication containers, medical equipment or a service animal. If you are in the patient\u2019s home, you should also look for a Vial of Life label on the outside of the refrigerator door\u2014it signifies that a vial or container, such as a sealable plastic bag, contains vital medical information and has been placed on the top shelf of the refrigerator door. Some people keep their medications in the refrigerator, so it also is a good idea to look for these items.",
        "Considerations for Older Adults": "Keep in mind that older people usually prefer to be addressed more formally, as in \u201cMr. Smith\u201d or \u201cMrs. Smith.\u201d Position yourself at eye level with the patient and speak slowly. Older patients may sometimes appear confused. This can be caused by conditions such as dementia or Alzheimer\u2019s disease. It can also be the result of an acute medical condition and may not be typical behavior for that person. Make sure the patient can see and hear you, as an older patient may have vision or hearing problems. Allow time for the older patient to respond. Always treat the patient with dignity and respect.",
        "Pediatric Considerations": "If a child or an infant does not respond to your questions, it does not always mean the child or infant is unable to respond. Children and infants may be frightened of you or the situation, may not understand the question or may not be able to speak. Position yourself at or below eye level with the child to avoid being intimidating. Do not separate the child from a parent or legal guardian, unless absolutely necessary",
        "CRITICAL FACTS 2": "A crucial aspect of your job is to find out as much as possible about the emergency 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.",
        "Mechanism of Injury or Nature of Illness": "The next piece of information to determine is the MOI for a trauma patient or the nature of illness for a medical patient.",
        "COMPONENTS OF A PATIENT HISTORY": "Obtaining a full patient history involves several components. Key among them is the chief complaint, which will allow you to make the important distinction of whether you are dealing with a trauma or medical emergency. Other components to consider are the mechanism of injury (MOI) or nature of illness, the presence and assessment of pain, as well as an evaluation of any relevant medical information.",
        "Chief Complaint": "The most important component of a patient history is the chief complaint. This is the reason why emergency medical services (EMS) personnel were called to the scene. The best way to determine the chief complaint is to ask the patient, \u201cWhy did you call for EMS personnel?\u201d Record the chief complaint in the patient\u2019s own words. Keep in mind that the most obvious problem is not always the most serious problem. For instance, if a patient\u2019s arm is mangled in a car crash, it may appear to be the chief complaint, until you find out the patient is having chest pain and crashed the car after blacking out. When interviewing the patient about the chief complaint, remember to ask the \u201cwho, what, when, where and how\u201d of the incident.\nUnderstanding the chief complaint generally makes it clear whether you are dealing with a trauma patient\u2014someone who is injured\u2014or a medical patient\u2014someone who is ill\u2014or a combination. This primary division will guide how you manage the patient.",
        "CRITICAL FACTS": "Necessary information cannot always be obtained from the patient. The patient may 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.",
        "Nature of Illness": "In the case of a medical patient, ask the patient, family, friends or any bystanders why EMS personnel were called. If no one is available to interview, observe the scene. Look for clues such as a very hot or very cold environment or the presence of drugs or poisons. The steps involved in conducting a secondary assessment on a medical patient depend on whether the patient is responsive or unresponsive. If the medical patient is responsive, obtain the history first and then perform your exam. In this situation, the history is your first priority because it may be the most valuable information you obtain and also because it is prudent to speak immediately with a responsive patient, since this status might change.",
        "Mechanism of Injury": "In the case of an injury, it is important to find out how the injury occurred and determine what the forces were that caused the injury. This may help predict the specific type of injuries the patient may have. It will also help you determine whether there is any risk of a spinal injury. If the MOI suggests there is, tell the patient not to move and provide manual stabilization by restricting motion and supporting the head and neck in the position in which you found it. Once you have dealt with the risk of spinal injury, follow the steps for trauma patients. These steps depend on whether there is a significant MOI or not. Examples of a significant MOI include: \uf0a7 Being ejected from a vehicle or thrown from a motorcycle. \uf0a7 A fall from greater than 15 feet or three times the patient\u2019s height. \uf0a7 A vehicle rollover. \uf0a7 A vehicle collision. \uf0a7 A pedestrian struck by a vehicle. \uf0a7 An injury that causes a change in mental status, respiratory distress or signs of shock. \uf0a7 A penetrating injury to the head, neck, chest or abdomen. \uf0a7 A blast injury or significant burn.",
        "SAMPLE HISTORY": "Using the mnemonic SAMPLE, determine the following six items for the patient history: \uf0a7 Signs and symptoms \uf0a7 Allergies \uf0a7 Medications \uf0a7 Pertinent medical history \uf0a7 Last oral intake \uf0a7 Events leading up to the incident. Sometimes the patient will be unable to give you the information. This is often the case with child or with an adult who momentarily lost consciousness and may not be able to recall what happened or is disoriented. Ask family members, friends or bystanders what happened. They may be able to give you helpful information, such as telling you if a patient has a medical condition you should be aware of. They may also be able to help calm the patient, if necessary. Obtain consent before approaching or touching the patient. Patients may be frightened; offer reassurance. Be calm and patient and, if possible, ensure you are in a comfortable and private location where you will not be interrupted. Use open-ended questions, and encourage the patient to talk using verbal and nonverbal cues. Show you are listening by repeating and paraphrasing the patient\u2019s replies. Maintain eye contact and speak slowly, deliberately and in simple terms. For step-by-step instructions on obtaining a SAMPLE history, see Skill Sheet 8-1. In addition to the SAMPLE history, ask the patient to explain what happened. Ask questions such as: \uf0a7 What happened? \uf0a7 Are you having any pain? \uf0a7 How would you describe the pain? You can expect to hear descriptions such as burning, throbbing, aching or sharp pain. \uf0a7 Is the pain spreading or radiating? \uf0a7 On a scale of 1 to 10, with 1 being lowest and 10 being highest, how bad is the pain? \uf0a7 When did the pain start? (See OPQRST.)",
        "CRITICAL FACTS 3": "Assessing the MOI may help predict the specific type of injuries the patient may have. Significant MOIs include being ejected or thrown from a vehicle; falling from greater than 15 feet or three times the patient\u2019s 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.",
        "Signs and Symptoms": "Signs include any medical or trauma assessment findings you can see, feel, hear or smell. For example, this would include measuring blood pressure (BP), seeing an open wound or feeling skin temperature. Symptoms refer to what the patient reports, for example, \u201cI\u2019m having trouble breathing,\u201d \u201cI have a headache\u201d or \u201cMy chest hurts.\u201d For further symptoms, ask the patient to describe the current problem. Ask questions such as: \uf0a7 Where do you have pain? \uf0a7 Are you feeling nauseated? \uf0a7 Do you have a headache? \uf0a7 Are you having any difficulty breathing?",
        "Allergies": "Ask the patient whether they are allergic to any medications, food or environmental elements, such as dust, pollen or bees.",
        "Medications": "Ask the patient questions to determine whether they are currently using any medications, both prescription and over-the-counter (OTC). Ask additional questions such as: \uf0a7 Do you take any vitamins or herbal remedies? \uf0a7 Have you taken someone else\u2019s medications? \uf0a7 Did you take any recreational drugs? \uf0a7 Are you using any medication patches?",
        "Pertinent Medical History": "Determine whether the patient is under a healthcare provider\u2019s care for any condition, if the patient has had a similar problem in the past, or if the patient has been recently hospitalized or had recent surgeries. If the patient is female, ask if she is or could be pregnant.",
        "Last Oral Intake": "Determine when the patient last had something to eat or drink and what it was. Also, ask if the patient has recently taken any medication, and if so, what.",
        "Events Leading Up to the Incident": "Determine what the patient was doing before and at the time of the incident. The events leading up to the incident could help identify the MOI or nature of illness.",
        "THE SECONDARY ASSESSMENT": "The purpose of the secondary assessment is to locate and further assess the signs and symptoms of an injury or illness. The secondary assessment consists of a head-to-toe physical exam. It may only consist of a rapid assessment (rapid trauma assessment or rapid medical assessment) or it may also include a detailed physical exam at a later stage. If you find life-threatening injuries or medical conditions during the primary assessment, such as unconsciousness; severe, life-threatening bleeding; no breathing or no pulse, do not waste time with the detailed physical exam. Instead, focus your attention on providing care for the life-threatening conditions. Complete a secondary assessment following the primary assessment, once all life-threatening conditions are addressed and have been stabilized, if time and resources permit. For patients with a significant MOI or other critical finding such as altered mental status, take the following steps during the secondary assessment: 1. Continue to maintain spinal motion restriction and an open airway. 2. 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 airway trauma). 3. Reassess the patient\u2019s mental status, as this may change at any time. 4. Perform a rapid trauma assessment, which is a rapid head-to-toe physical exam. \uf0a7 A rapid trauma assessment involves checking the head, neck, chest, abdomen, pelvic region, legs, arms and then the back for signs of trauma. 5. Assess baseline vital signs. 6. Obtain a SAMPLE history. If the patient is responsive, ask some history questions simultaneously with the physical exam. 7. Prepare the patient for transport (simultaneously as assessment is being conducted). 8. Provide emergency care. 9. Obtain trauma score (e.g., Glasgow Coma Scale [GCS]), if trained. Your major concern during the rapid trauma assessment is any potentially life-threatening injuries that you must manage immediately. For the trauma patient who does not have a significant MOI such as those outlined above, follow these steps: 1. Perform a focused trauma assessment (e.g., for a laceration to the leg). 2. Obtain a SAMPLE history and baseline vital signs. 3. Perform components of a detailed physical exam, as needed. 4. Provide emergency care. For a responsive trauma patient, follow these steps for the secondary assessment (Skill Sheet 8-2): 1. Obtain the SAMPLE history. 2. Assess the patient\u2019s complaints (OPQRST\u2014onset, provoke, quality, region/radiate, severity and time). 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). 4. Assess baseline vital signs. 5. Perform components of the detailed physical exam, as needed. 6. Provide emergency care. 7. 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 a medical or trauma patient is unresponsive, consider the patient as critical, requiring that you begin with a rapid patient assessment, to gain as much information as possible on the nature of illness: For an unresponsive patient who is breathing normally, take the following steps for the secondary assessment (Skill Sheet 8-3): 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). 2. Perform a rapid medical or trauma assessment (head to toe). \uf0a7 A rapid patient assessment involves checking the head, neck, chest, abdomen, pelvic region, legs, arms and then the back for signs of medical problems. 3. Assess baseline vital signs. 4. Position a patient who is unresponsive, but breathing normally, with no suspected head, neck, spinal, hip or pelvic injury, in a side-lying recovery position and ensure protection of their airway. 5. Obtain a SAMPLE history from the family or any bystanders, if available. 6. Provide emergency care.",
        "Physical Exam - Pediatric Considerations": "You may find it helpful to use distracting measures, such as a teddy bear or doll, to gain the trust of a child. Keeping the child with the parent or legal guardian can also help ease the child\u2019s fear. If the child becomes extremely agitated or upset, conduct a toe-to-head assessment of the child, unless there is a suspected life-threatening injury or illness.",
        "Physical Exam - Considerations for Older Adults": "When assessing older patients, consider that they may have glasses and/or hearing aids and will be better able to participate in the assessment process if they are wearing them. Expect the assessment to take a little longer with older adult patients than with a younger adult. Keep in mind that it might take older adult patients a little longer to respond. For other considerations for older adults, refer to Chapter 26.",
        "CRITICAL FACTS 4": "Complete a secondary assessment following the primary assessment, once all life-threatening conditions are addressed and have been stabilized, if time and resources permit.",
        "Physical Exam": "Many patients view a physical exam with apprehension and anxiety\u2014they feel vulnerable and exposed. Maintain professionalism throughout the physical exam and display compassion toward the patient. Explain what areas you are going to assess. If you have questions about an area and the patient is responsive, ask questions prior to examining the area. Maintain the patient\u2019s privacy during the physical exam, such as by conducting the exam in an area that cannot be seen by bystanders. When you need to remove the patient\u2019s clothing, cut it away rather than manipulating the patient to remove it. Cover each area after you have examined it. Try to keep the patient calm, and keep the patient from moving the head, neck and spine and any body part that hurts to move. Your exam may focus on a specific area, based on the patient\u2019s chief complaint, or be specific to a particular injury or illness. As you discover certain signs and symptoms, there may be specific relevant questions you should ask. Your exam may focus on a specific area, based on the patient\u2019s chief complaint, or be specific to a particular injury or illness. As you discover certain signs and symptoms, there may be specific relevant questions you should ask. For the rapid assessment, be sure to examine the patient systematically from head to toe, placing special emphasis on areas suggested by the chief complaint, but remembering to examine the whole body. The patient may focus on a bothersome complaint or a painful one, and fail to identify a more serious problem. The physical exam for trauma and medical patients is similar, in that the purpose is to gather additional information. However, the type of information you are assessing for may be different in the two different types of patients. With the trauma patient, 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 examining a limb in the trauma patient, you may be most interested in tenderness, pain, swelling and deformities, as well as pulse and motor/sensory function, as an indication of injury. For the medical patient, you may be looking for signs of inadequate circulation, discoloration or swelling, as well as motor/sensory function, as a sign of the status of the brain or heart. When you perform the physical exam, gather additional information on the patient\u2019s condition. As you examine the patient, compare each body part on one side of the body to the other. You can gain information by inspecting visually as well as palpating (feeling) areas of the body.",
        "DOTS": "The mnemonic DOTS may be helpful during the physical exam for patients who have been injured. It stands for Deformities: Deformities may include depressions or indentations, parts that have shifted away from their usual position, parts that are more rigid or less rigid than normal (e.g., abdomen) or obvious signs of broken bones. Open injuries: Open injuries may include anywhere there is bleeding, including the scalp. These may be serious, such as open injuries to the chest, or less serious, as in cuts and scrapes. Open injuries also include penetrating wounds, such as knife or gunshot wounds.Tenderness: Tenderness may be experienced even when there are no obvious signs of injury. When there is tenderness of the abdomen, it is important to determine in which quadrant the patient feels pain. Begin in the quadrant where the patient feels the least pain so this does not influence the remaining assessment of the abdomen. Swelling: Swelling may indicate an accumulation of blood, air or other fluid in the tissues below the skin. In an extremity, it may indicate that the bone is broken.",
        "OPQRST": "As part of the physical exam, if the patient is responsive, ask questions to gain information about pain. One method of questioning can be remembered using the mnemonic OPQRST, which stands for onset, provoke, quality, region/radiate, severity and time. It can be used for both patients who have been injured and those who have a medical condition. Onset: What were you doing when the pain started? Was the onset abrupt or gradual? Provoke or palliation: What makes it worse? What makes it better? Quality: Is the pain blunt, sharp, burning, crushing or tearing? Region/ Radiate: Where is the pain and does it radiate (spread)? Do you have pain or discomfort somewhere else? Severity: On a scale of 1 to 10, how intense is the pain? Time: When did it start? How long has it been present? How has it changed since it started? For trauma patients, the mnemonic DCAP-BTLS will remind you of the most common signs you may find.",
        "CRITICAL FACTS 5": "As part of the physical exam of a responsive patient, ask questions using the OPQRST mnemonic.",
        "DCAP-BTLS": "During the detailed physical exam, the mnemonic DCAP-BTLS may help you remember the signs you are looking for as you conduct your head-to-toe assessment. The letters stand for: \u2022 Deformities. \u2022 Contusions. \u2022 Abrasions. \u2022 Punctures/ Penetrations. \u2022 Burns. \u2022 Tenderness. \u2022 Lacerations. \u2022 Swelling. Keep these types of injuries in mind as you check each major area. Remember to use each of your senses. Many of these types of injuries can be seen upon examination. By palpating (feeling) for injuries, you can determine if there are any deformities or swelling and if the patient is experiencing any pain or tenderness. Even if the patient cannot tell you, you can observe any grimacing on the patient\u2019s face. In addition to seeing and feeling for signs of injury, listen for abnormal breathing sounds, for example gurgling or stridor in the upper airway. Auscultate (listen) to the lungs with a stethoscope for breath sounds. You can also listen for the sound of broken bones rubbing against each other, which is called crepitus. Use your sense of smell. This is one way you can detect any unusual or unexpected odors such as the presence of alcohol or a fruity-smelling breath, as well as the possible presence of urine or feces. As with any physical exam, try to keep the patient calm and comfortable. Rather than focusing on your findings, explain what you are doing to minimize any distress about the injuries. Do not move the patient unnecessarily if you suspect a neck or spinal injury. If there is a serious MOI, it is crucial to completely expose the patient to look for additional injuries. Protect the patient\u2019s privacy by covering all patients, male or female of any age, with a sheet and only expose the area you are examining. When you need to remove clothing, cut it away rather than manipulating the patient to remove it. Cover each area after you have examined it.",
        "DETAILED PHYSICAL EXAM ": "Once the focused history and physical exam have been completed and any life-threatening conditions have been managed, a detailed physical exam may be conducted. This exam is not carried out on every patient. It requires much more time than a rapid assessment to conduct, as it is more detailed, and so can only be performed when time and the patient\u2019s condition allow. Often, it is conducted in the ambulance or other transport vehicle, en route to the hospital. The detailed physical exam is a systematic head-to-toe exam that helps you gather additional information about injuries or conditions that may need care. These injuries or conditions are not immediately life threatening but could become so if not cared for. For example, you might find minor bleeding or possible broken bones as you conduct your exam of the patient. As you conduct the physical exam, tell the patient what you are going to do. The physical exam process involves looking (inspection), listening (auscultation) and feeling (palpation). You may even smell something you can gather as information, such as the smell of bleach on the breath, which may indicate poisoning. After telling the patient exactly what you are going to do and asking the patient to hold still, inspect and palpate each part of the body, starting with the head, before you move on to the next area. Ask the patient to tell you if any areas hurt. Avoid touching any painful areas or having the patient move any area that causes discomfort. Watch facial expressions and listen for a tone of voice that may reveal pain. Look for a medical identification tag or bracelet or a medical identification app on the patient\u2019s mobile phone. This information may help you determine what is wrong, whom to call for help and what care to provide. As you do the head-to-toe exam, think about how the body normally looks and feels. Be alert for any sign of injuries\u2014anything that looks or feels 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 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. 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. 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 breathe entirely through the stoma instead of through the nose and mouth. 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)? 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 from a height, minimize movement to the patient\u2019s 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. 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 evidence of an effort to breathe? Are there any open wounds? Is the chest symmetrical?",
        "Abdomen": "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, avoiding any areas where the patient had indicated pain.",
        "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, with your fingertips. Check for any reaction to pain. 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. If the patient can move all body parts without pain or discomfort and there are no other apparent signs or symptoms of injury, have the patient attempt to rest for a few minutes in a sitting position. If more advanced help is not needed, continue to check the signs and symptoms and monitor the patient\u2019s condition. Take note of the information you find during the physical exam. Sometimes you may need to have a partner fill out the form with the information you gather. This will help you when it is time to give a verbal report to the next level of care as you transfer the patient. Immediately treat any life-threatening problems found in the detailed physical exam by delegating care to another responder if one is available. It is important to complete the entire exam so that nothing is missed.",
        "OBTAINING BASELINE VITAL SIGNS": "The initial set of vital signs provides a starting point for establishing a baseline to determine the status of your patient. The vital signs can tell you how the body is responding to injury or illness. Look for changes in vital signs as you provide care and note anything unusual (see Skill Sheet 8-5). Vital signs are taken after managing life-threatening problems found during the primary assessment. They are normally taken after the rapid assessment is complete; however, if several responders are on scene, they may be taken simultaneously. Note that absolute values are not as important as trends. There are three major vital sign measures to be taken: \uf0a7 Respiratory rate \uf0a7 Pulse \uf0a7 BP You may also measure skin characteristics (color, temperature and moisture) and pupils at this stage.",
        "Respiratory Rate": "A healthy person breathes regularly, quietly and effortlessly. The normal respiratory rate for an adult is between 12 and 20 breaths per minute. However, some people breathe slightly slower or faster. Excitement, fear and exercise cause breathing to increase and become deeper. Certain injuries or illnesses can also cause both the rate and quality of breathing to change. As you assess the patient, watch and listen for any changes in breathing. Abnormal breathing may indicate a potential problem. The signs and symptoms of abnormal breathing include: \uf0a7 Gasping for air. \uf0a7 Noisy breathing, including whistling sounds, wheezing, crowing, gurgling or snoring. \uf0a7 Excessively fast or slow breathing. \uf0a7 Painful breathing. Pediatric Considerations Respiratory rates in children and infants vary by age. The following are the normal respiratory rates by age category: \uf0a7 Newborns: 30 to 50 breaths per minute \uf0a7 Infants (0 to 5 months): 25 to 40 breaths per minute \uf0a7 Infants (6 to 12 months): 20 to 30 breaths per minute \uf0a7 Toddlers (1 to 3 years): 20 to 30 breaths per minute \uf0a7 Preschoolers (3 to 5 years): 20 to 30 breaths per minute \uf0a7 School age (6 to 10 years): 15 to 30 breaths per minute \uf0a7 Adolescents (11 to 14 years): 12 to 20 breaths per minute In the primary assessment, the goal is to determine whether a patient is breathing at all, whereas in the secondary assessment, you are concerned with the rate, rhythm and quality of breathing. Look, listen and feel again for breathing (Fig. 8-12) . Look for the rise and fall of the patient\u2019s chest or abdomen. Listen for sounds as the patient inhales and exhales. Count the number of times a patient breathes (inhales and exhales) in 30 seconds and multiply that number by 2, or in 15 seconds and multiply that number by 4. This is the number of breaths per minute. As you check for the rate and quality of breathing, try to do it without the patient\u2019s 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.\nRefer to Chapter 7 for more information on breathing rate and quality.\nLung sounds, or breath sounds, are the noises produced by the lungs during breathing. Some are normal and others are abnormal. The most common abnormal breath sounds are crackles, rhonchi, stridor and wheezing. Crackles, also called rales, are small popping, rattling or bubbly sounds that are produced when closed spaces pop open. They can be described as fine or coarse. Rhonchi are low-pitched snoring sounds caused by the narrowing of the airway and the presence of secretions in the airway. Stridor is a harsh, high-pitched sound due to constriction in the upper airways. Wheezing is a high-pitched whistling sound created by air flowing through narrow airways; it can be heard on exhalation and inhalation.\nAbsent or decreased normal sounds on one or both sides of the chest can also be an indication of problems with breathing, for example, because of air or fluid around the lungs or reduced air flow to part of the lungs",
        "CRITICAL FACTS 6": "When obtaining baseline vital signs, the respiratory rate, pulse and BP are essential. Skin characteristics and pupils can be assessed as well.",
        "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 arteries near the surface of the skin. In the primary assessment, the goal is to determine whether a pulse is present. To determine this, you check the carotid arteries. In the secondary assessment, you are trying to determine pulse rate, rhythm and quality. This is most often done by checking the radial pulse located on the thumb side of the patient\u2019s wrist.\nWhen the heart is healthy, it beats with a steady rhythm. This beat creates a regular pulse. A normal pulse for an adult is between 60 and 100 beats per minute. A well-conditioned athlete may have a pulse of 50 beats per minute or lower. Refer to Chapter 7, Table 7-5 for average pulse rates by age. If the heartbeat changes, so does the pulse. An abnormal pulse may be a sign of a potential problem. These signs include:\n\uf0a7 An irregular pulse.\n\uf0a7 A weak and hard-to-find pulse.\n\uf0a7 An excessively fast or slow pulse. When severely injured or unhealthy, the heart may beat unevenly, producing an irregular pulse. The rate at which the heart beats can also change. The pulse speeds up when a patient is excited, anxious, in pain, losing blood or under stress. It slows down when a patient is relaxed. Some heart conditions can also speed up or slow down the pulse rate. Sometimes changes may be subtle and difficult to detect. The most important change to note is a pulse that changes from being present to no pulse at all. Checking a pulse is a simple procedure. Place two fingers on top of a major artery where it is located close to the skin\u2019s surface and over a bony structure. Pulse points that are easy to locate include the carotid arteries in the neck, the radial artery in the wrist, the femoral arteries in the groin and, for infants, the brachial artery in the inside of the upper arm. To check the pulse rate, count the number of beats in 30 seconds and multiply that number by 2, or the number of beats in 15 seconds and multiply that number by 4. The result is the number of heartbeats per minute. If you find the pulse is irregular, you may need to check it for more than 30 seconds. An injured or ill patient\u2019s pulse may be hard to find. Remember, if a patient is breathing normally, the heart is also beating. However, 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 location, such as in the other wrist.",
        "Pulse - Pediatric Considerations": "When measuring the pulse in an infant, use the brachial artery rather than the radial artery, as in adults. Pulse measurement in children and infants varies by age:\n\uf0a7 Newborns: 120 to 160 beats per minute (bpm)\n\uf0a7 Infants (0 to 5 months): 90 to 140 bpm\n\uf0a7 Infants (6 to 12 months): 80 to 140 bpm\n\uf0a7 Toddlers (1 to 3 years): 80 to 130 bpm\n\uf0a7 Preschoolers (3 to 5 years): 80 to 120 bpm\n\uf0a7 School age (6 to 10 years): 70 to 110 bpm\n\uf0a7 Adolescents (11 to 14 years): 60 to 105 bpm",
        "Blood Pressure": "Another vital sign used to assess a patient\u2019s 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. Because a patient\u2019s BP can vary greatly, it is only one of several factors that give you an overall picture of a patient\u2019s condition. Stress, excitement, injury and illness can affect BP. When a person is injured or ill, a single BP measurement is often of little value. A more accurate picture of a patient\u2019s condition immediately after an injury or the onset of an illness is whether BP changes over time while you provide care. For example, a patient\u2019s initial BP reading 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 \u201cwhite coat hypertension.\u201d 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 resulting in a severe loss of blood may cause BP 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 illness are present.",
        "CRITICAL FACTS 7": "To measure BP, you need two pieces of equipment: a sphygmomanometer (BP cuff) and a stethoscope.",
        "Equipment for Measuring Blood Pressure": "To measure BP, you need two pieces of equipment: a sphygmomanometer (BP cuff) and a stethoscope.\nA sphygmomanometer is made up of two main parts: an inflatable cuff that is wrapped around the patient\u2019s arm (or leg) and a manometer. The cuff is made of fabric and comes in several sizes. It has a rubber bladder inside, which is connected at the end to a hose with a rubber ball, called a bulb. A valve in the bulb opens and closes to control the flow of air into the bladder. The valve is controlled by a screw. If you turn the screw to the left, it opens the valve and lets the air escape from the bladder. If you turn the screw to the right, it closes the valve so that when you pump air into the bladder with the bulb, the valve keeps the air inside the bladder, making the cuff tight.\nWhen you pump air into the cuff, the bladder pressure increases until it is strong enough to stop the blood flow through the brachial artery.At this point, you do not hear anything through the stethoscope. As you turn the valve to slowly release pressure on the brachial artery, the cuff pressure eventually matches and then drops below the systolic blood pressure. When the cuff pressure reaches this point, you begin to hear the pulse sounds. As the cuff pressure drops to equal the diastolic blood pressure in the artery, the sounds change or fade away.\nThe second part to the sphygmomanometer is the manometer, a gauge that measures systolic and diastolic pressure. The numbers on the gauge show the pressure in millimeters; the higher the number, the greater the pressure. There are three types of manometers: mercury, aneroid and electronic.\nThe aneroid manometer shows the pressure readings on a round dial with an arrow that points to the numbers. Although there is no mercury column, the numbers on the dial are equal to millimeters of mercury (mmHg). The arrow moves from zero to the higher numbers as you inflate the cuff. \nThe electronic manometer eliminates the need for using a stethoscope and listening for the pulse sounds, because it takes the BP readings for you and displays them on a digital screen like the one on an electronic thermometer.\n The stethoscope is used together with the sphygmomanometer to allow you to hear the BP sounds. It consists of two pieces of tubing that are connected at one end to a flat disk called a diaphragm. The earpieces, which are connected to the other end of the tubing, fit into your ears and allow you to hear sounds. Some stethoscopes have a bell-shaped end in addition to the diaphragm. Before taking a person\u2019s BP, check the tubing and diaphragm for cracks and holes that could make it difficult to hear and could cause you to make an error in the BP reading. To prevent the spread of infection, use alcohol 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. 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 against the arteries when the heart is between contractions, with an average adult reading of 80 mmHg.\nAn accurate reading can be acquired through auscultation (listening) or by palpation (feeling).\nTo measure BP by auscultation, use the BP cuff together with the stethoscope as follows:\n\uf0a7 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.\n\uf0a7 Select an appropriately sized cuff for the patient. The cuff should cover approximately two-thirds of the patient\u2019s upper arm. Place the cuff so that the bladder is centered over the brachial artery and the bottom edge of the cuff is about 1 inch above the crease of the elbow. Place the stethoscope earpieces in your ears, with the earpieces facing forward. Center the diaphragm of the stethoscope firmly over the brachial artery, about 1 inch above the crease of the elbow. Close the thumb valve by rotating the knob clockwise and then squeeze the rubber bulb to inflate the cuff. This compresses the brachial artery, momentarily stopping the blood flow. Stop inflating when you can no longer hear the pulse. Next, slowly release the air in the cuff at approximately 2 to 4 mmHg per second by turning the valve counterclockwise and listen with the stethoscope. Watch the pressure gauge and note the number, recorded in even numbers, when you first hear the pulse again. This is the systolic pressure, or the pressure of the blood when the heart beats. Continue to release the air from the bulb and watch the manometer. Once you hear the last sound, record the reading on the gauge. This is the diastolic pressure, or the pressure between heartbeats. Palpation can prove particularly helpful and recommended in noisy environments where auscultation may prove difficult or potentially inaccurate. Measuring BP by palpation requires you to feel the radial artery as you inflate the BP cuff. 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\u2019s upper arm. Place the cuff so that the bladder is centered over the brachial artery and the bottom edge of the cuff is about an inch above the crease of the elbow.Locate the patient\u2019s radial pulse: Then close the thumb valve by rotating the knob clockwise and then squeeze the rubber bulb to inflate the cuff. This compresses the brachial artery which in turn compresses the radial artery, momentarily stopping the blood flow. Stop inflating when you can no longer feel the radial pulse. Record the reading on the manometer. Continue to inflate the cuff: For another 20 mmHg beyond this point. Release the pressure slowly by turning the regulating valve counterclockwise, and allow it to deflate at about 2 to 4 mmHg per second. Continue to feel for the radial pulse as the cuff deflates. The point at which the pulse returns is the approximate systolic blood pressure. This BP reading should be shown with an even number followed by the letter P to indicate palpation, for example, 130/P. It is important to note whether the patient was lying or sitting when the reading was taken. When the proper equipment is not available: You can approximate the systolic blood pressure in certain pulse locations. For example, the radial artery, located at the wrist, indicates a systolic pressure of about 80 mmHg. The femoral artery indicates a systolic pressure of about 70 mmHg. The carotid artery in the neck indicates a systolic pressure of about 60 mmHg. Two options for approximating the systolic blood pressure include asking the patient what their normal BP is or inflating the cuff to 160 mmHg. For precautions to be aware of when taking blood pressure, see Table 8-2.",
        "Measuring Blood Pressure - Pediatric Considerations": "It is difficult to obtain an accurate BP reading on a child. First, the cuff must fit correctly, and it is difficult to have the correct size for a wide range of children. However, determining BP in children is not as important as it is with adults. In general, children under 3 years of age do not have their BP taken. What is more important in assessing children is adequate airway management. Children\u2019s BP may not drop until there has been a significant loss of blood. Therefore, provide care for shock if the MOI calls for it, regardless of BP. BP may be estimated in children. The formula for the average BP for a child is 90 + (2 \u00d7 the age of the child in years). This formula can be used for children up to the age of 12. BP numbers in children and infants vary by age (see Table 8-3 ). \uf0a7 Infants (1 to 12 months): systolic 70 mmHg (lower limit of normal); diastolic 2/3 of systolic pressure. Ranges for newborns vary depending on birth weight and whether the newborn is full term or premature. \uf0a7 Children (1 to 12 years): yLower limit of normal: systolic 70 mmHg + (2 \u00d7 age in years); diastolic 2/3 of systolic pressure yUpper limit of normal: systolic 90 mmHg + (2 \u00d7 age in years); diastolic 2/3 of systolic pressure \uf0a7 Adolescents: systolic 90 mmHg (lower limit of normal); diastolic 2/3 of systolic pressure For other pediatric considerations, see Chapter 25.",
        "Table 8-3: Normal Blood Pressure Ranges in Children and Infants": "AGE SYSTOLIC DIASTOLIC\nChildren (1 to 12 years old) 90 + (2 \u00d7 age in years) mmHg 2/3 of systolic pressure\nInfants (1 to 12 months) 70 + (2 \u00d7 age in years) mmHg 2/3 of systolic pressure\nNewborns (ages 1 to 28 days) > 60 mmHg (varies depending on birth weight and gestation) > 14 mmHg (varies depending on birth weight and gestation)",
        "Table 8-2: Precautions for Taking a Patient\u2019s Blood Pressure": "PRECAUTION REASON\nPlace the cuff on the patient\u2019s bare arm or lightly clothed arm. Heavy clothing may give an incorrect reading. When the diaphragm is placed on heavy clothing, it creates noises that make it difficult to hear pulse sounds.\nSelect the correct cuff size: adult-size for most adults, extra-large for some adults and child-size for small people. Using the correct size results in an accurate reading.\nWrap the cuff smoothly and snugly. A smooth wrap gives an accurate reading.\nPosition the cuff correctly, with the center of the bladder over the brachial artery. Correct positioning gives an accurate reading.\nDo not place the cuff on a cast. The cuff cannot compress the cast, which results in no reading.\nDo 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.\nDo not place the cuff on the weak arm of a patient who has had a stroke or on a patient\u2019s paralyzed arm. For a woman who has had a mastectomy, do not place the cuff on the arm that is on the same side as the mastectomy. Circulation in these conditions is impaired, resulting in an inaccurate reading. Also, an inflated cuff decreases circulation in the arm and may cause some damage.\nDo not place the cuff on an arm that has an AV fistula that is used for hemodialysis. Placing and inflating the blood pressure cuff over this 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.",
        "Reassess Vital Signs": "Repeat vital signs as necessary each time you reassess the patient. Repeat BP, pulse and respiration (see Table 8-4 ).",
        "Reassess Chief Complaint": "Constantly reassess the patient\u2019s chief complaint or major injury. Determine if the pain or discomfort is remaining the same, getting worse or getting better. Ask the patient whether there are any new or previously undisclosed complaints.",
        "Reassess Primary Assessment": "Reassess each aspect of the primary assessment and compare to the patient\u2019s baseline status. For LOC, is the patient maintaining the same level of responsiveness or becoming more or less alert? Recheck the airway to ensure it is open and clear. Reassess the adequacy of breathing by monitoring breathing rate, depth and effort. Auscultate breath sounds to determine if there has been a change. Reassess the adequacy of circulation by checking both carotid and radial pulses. Recheck skin characteristics (color, temperature and moisture).",
        "CRITICAL FACTS 8": "Ongoing assessment should be done after the secondary assessment. Its purpose is to identify and care for any changes in the patient\u2019s condition and to monitor the effectiveness of care provided.",
        "ONGOING ASSESSMENT": "Once you have completed the secondary assessment and provided care for any injuries and illnesses, provide ongoing assessment and care while you wait for more advanced medical care to arrive. The purpose of the ongoing assessment is to identify and treat any changes in the patient\u2019s condition in a timely manner and to monitor the effectiveness of interventions or care provided. Record additional findings and turn this information over to the next level of care. The patient\u2019s 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 because there were no serious problems at first. Reassess the patient at regular intervals. Patients who are unstable should be reassessed at least every 5 minutes or more often if indicated by the patient\u2019s condition. Reassess stable patients every 15 minutes, or as deemed appropriate by the patient\u2019s condition. The physical exam and history do not need to be repeated unless there is a specific reason to do so. If any life-threatening conditions develop, stop whatever you are doing and provide appropriate care immediately. Reassessment includes the: \uf0a7 Primary assessment. \uf0a7 Vital signs. \uf0a7 Chief complaint. \uf0a7 Interventions, or care provided.",
        "Reassess Interventions": "Reassess the effectiveness of each intervention performed. Consider the need for new interventions or modifications to care already being provided.",
        "THE NEED FOR MORE ADVANCED MEDICAL PERSONNEL": "While waiting for more advanced medical care (Table 8-5 ), help the injured or ill patient stay calm and as comfortable as possible. These conditions are by no means a complete list. It is impossible to describe every possible condition since there are always exceptions. Trust your instincts. If you think there is an emergency, there probably is. It is better to call for more advanced medical care than to wait.",
        "PUTTING IT ALL TOGETHER": "Once you have sized up the scene and performed a primary assessment, you are ready to move on to the secondary assessment. This requires you to perform a physical exam to find and care for any other problems that are not an immediate threat to life but might become serious if you do not recognize them and provide care. This head-to-toe physical exam involves looking at and feeling the body for abnormalities. Use the mnemonic DOTS as you perform the physical exam. For many patients, this will be a rapid medical or trauma assessment. Obtain pertinent history from the patient. This is especially important if the patient is suffering from an illness that has already been diagnosed and is being cared for by a healthcare provider. Whether you obtain the history before, after or during the physical exam depends on the MOI or nature of illness and whether the patient is responsive or unresponsive. Use the mnemonic SAMPLE to gather all of the necessary information. For some patients, if there is time and the patient\u2019s condition warrants it, you will go back and complete a detailed physical exam. Once the assessment is complete, perform ongoing assessments until more advanced personnel take over. Reassess at least every 5 minutes for unstable patients and every 15 minutes for stable ones, or as dictated by the patient\u2019s condition. Although this plan of action can help you decide what care to provide in any emergency, providing care is not an exact science. Because each emergency and each patient are unique, an emergency may not occur exactly as it did in a classroom setting. The care needed may change from one moment to the next. For example, the primary assessment may indicate the patient is conscious, has no severe, life-threatening bleeding, is breathing and has a pulse. However, during your physical exam, you may notice that the patient begins to experience difficulty breathing. At this point, there is a need to summon more advanced medical personnel, if this has not already been done, and provide appropriate care. Provide necessary information about the patient\u2019s condition once more advanced medical personnel arrive. Many variables exist when dealing with emergencies. You do not need to \u201cdiagnose\u201d what is wrong with the patient to provide appropriate care. Treat the conditions you find, always caring for life-threatening conditions first. Perform the primary and secondary assessments as a guideline to help you assess the patient\u2019s condition. As you read the remaining chapters, remember the steps of the assessments. They form the basis for providing care in any emergency",
        "Unconscious or decreased level of consciousness": "Patient does not respond to tapping, loud voices or other attempts to awaken.",
        "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\u2019s 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 pressure in the chest": "There is chest pain, discomfort or pressure lasting more than a few minutes; that goes away and comes back; or that radiates to the shoulder, arm, neck, jaw, stomach or back.",
        "Persistent pain or pressure in the abdomen": "Patient has persistent pain or pressure in the abdomen that is not relieved by resting or changing positions.",
        "Vomiting blood or passing blood": "You can see blood in vomit, urine or feces.",
        "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 assistance": "Patient has seizures, severe headaches, slurred speech or changes in the level of 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 (spinal) injuries": "Consider how the injury happened: for example, a fall, severe blow or collision 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.",
        "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\u2019s 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.",
        "How to Perform a Secondary Assessment for a Responsive Trauma Patient": "NOTE: Always follow standard precautions when providing care.\nSTEP 1\nObtain a SAMPLE history (see Skill Sheet 8-1).\n\u25bc\nSTEP 2\nAssess the patient\u2019s complaints (use the mnemonic OPQRST\u2014onset, provoke, quality, region/radiate, severity and time).\n\u25bc\nSTEP 3\nPerform 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).\n\u25bc\nSTEP 4\nAssess baseline vital signs.\n\u25bc\nSTEP 5\nPerform components of the detailed physical exam, as needed.\n\u25bc\nSTEP 6\nProvide emergency care.\n\u25bc\nNOTE: 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).\nIf 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.",
        "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.",
        "Physical Exam NOTE: Always follow standard precautions when providing care.": "\nSTEP 1\nPerform physical exam beginning with the head and neck.\n\u25bc\nSTEP 2\nCheck the shoulders and chest.\n\u25bc\nSTEP 3\nCheck the abdomen.\nSTEP 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\u2019s back.",
        "How to Obtain Baseline Vital Signs": "STEP 1 Check respirations for rate, rhythm and quality of breathing.\n \u25a0Look, listen and feel for breathing.\n  zLook for the rise and fall of the patient\u2019s chest or abdomen.\n  zListen for sounds as the patient inhales and exhales.\n \u25a0Count the number of times a patient breathes in 30 seconds.\n  zMultiply that number by 2 (or in 15 seconds by 4). This is the number of breaths per minute.\n \u25a0Record your findings.\nNOTE: As you check for the rate and quality of breathing, try to do it without the patient\u2019s 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.\n \u25a0Place two fingers on top of a major artery near the skin\u2019s surface and over a bony structure.\n  zPulse 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.\n  zTo check the pulse rate, count the number of beats in 30 seconds and multiply that number by 2 (or in 15 seconds by 4).\n \u25a0Record your findings.\nNOTE: An injured or ill patient\u2019s 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. STEP 3 Check skin characteristics and pupils. 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. \u25a0To check skin characteristics look or feel for: zColor. Is it pale and ashen, or flushed and pink? zTemperature. Is it hot or cold? zMoisture. Is it moist or dry? zCapillary refill. Is it normal or slow? \u25a0Record your findings.",
        "Taking and Recording a Patient\u2019s Blood Pressure (by Auscultation)": "NOTE: Always follow standard precautions when providing care.\nSTEP 1\nApproximate systolic blood pressure.\n\u25a0Either ask the patient what their BP is or use 160 mmHg as an alternative.\nNOTE: 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.\n\u25bc\nSTEP 2\nSelect an appropriately sized cuff for the patient.\n\u25bc\nSTEP 3\nPosition the cuff.\n\u25bc\nSTEP 4\nLocate brachial pulse.\n\u25bc(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\u2019s 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.STEP 8\nContinue deflating cuff until the pulse is no longer heard.\n\u25bc\nSTEP 9\nQuickly deflate cuff by opening the valve.\n\u25bc\nSTEP 10\nRecord findings.\n \u25a0Watch the pressure gauge and note the number, recorded in even numbers, when you first hear the pulse again (systolic pressure).\n \u25a0Continue 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).",
        "Taking and Recording a Patient\u2019s Blood Pressure (by Palpation)": "NOTE: Always follow standard precautions when providing care. STEP 1 Select an appropriately sized cuff for the patient\u2019s arm and position the cuff. \u25bc STEP 2 Locate the radial pulse. \u25bc STEP 3 Inflate the cuff beyond where pulse disappears. STEP 4\nDeflate the cuff slowly until pulse returns; the point where the pulse returns is the approximate systolic blood pressure.\n\u25bc\nSTEP 5\nQuickly deflate the cuff by opening the valve.\n\u25bc\nSTEP 6\nRecord the approximate systolic blood pressure with a \u201cP\u201d for palpation method (e.g., 130/P).",
        "Pulse oximetry": "Pulse oximetry is used to measure the percentage of oxygen saturation in the blood. The reading is taken by a pulse oximeter 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. 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\u2019s 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. Pulse oximetry should be applied whenever a patient\u2019s oxygenation is a concern and for the following situations: \uf0a7 All patients with neurologic, respiratory or cardiovascular complaints \uf0a7 All patients with abnormal vital signs \uf0a7 All patients who receive respiratory depressants (morphine, diazepam, midazolam) \uf0a7 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. 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 \u2264 85 percent Administer supplemental oxygen using a non-rebreather mask or bag-valve-mask resuscitator with positive pressure, based on local protocols.",
        "Pulse oximetry - Procedure": "When using a pulse oximeter, refer to the manufacturer\u2019s 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\u2019s finger. The manufacturer also may recommend alternative measuring sites, such as the finger and then the earlobe on the next measurement.",
        "Pulse oximetry - 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\u2019s 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.",
        "Pulse oximetry - Limitations": "Some factors may reduce the reliability of the pulse oximetry reading, including: \uf0a7 Hypoperfusion, poor perfusion (shock). \uf0a7 Cardiac arrest (absent perfusion to fingers). \uf0a7 Excessive motion of the patient during the reading. \uf0a7 Fingernail polish. \uf0a7 Carbon monoxide poisoning (carbon monoxide saturates hemoglobin). \uf0a7 Hypothermia or other cold-related illness. \uf0a7 Sickle cell disease or anemia. \uf0a7 Cigarette smokers (due to carbon monoxide). \uf0a7 Edema (swelling). \uf0a7 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.)"
    },
    {
        "Introduction": "As an emergency medical responder (EMR), you will often be the first trained emergency medical services (EMS) provider at the incident scene. Your initial actions will affect not only you but also the patient and other responders. Your assessment of the scene and the patient will affect the level of care requested for the patient. It is important that you are able to perform a systematic patient assessment to determine whether your patient has a medical condition or has sustained injuries from trauma. The patient assessment sequence consists of the following five steps:\n\nStep 1. Perform a scene size-up.\nStep 2. Perform a primary assessment.\nStep 3. Obtain the patient\u2019s medical history.\nStep 4. Perform a secondary assessment.\nStep 5. Perform a reassessment.\nBy performing these five steps, you can systematically gather the information you need. After you have learned these steps, you will discover that you can modify the order in which you perform them to gather needed information about a patient who is experiencing a medical problem as opposed to a patient who has sustained trauma (a wound or injury).\n\nThe skills and knowledge presented in this chapter follow an assessment-based care model. With assessment-based care, the treatment rendered is based on the patient\u2019s symptoms. Assessment-based care requires you to conduct a careful and thorough evaluation of the patient so that you can provide appropriate care. If a given condition has already been diagnosed by a physician and is known to the patient, you will sometimes know the patient\u2019s diagnosis. Other times, you will have to respond to the signs and symptoms you find during the assessment process.",
        "Patient Assessment Sequence": "The patient assessment sequence is designed to provide you with a framework so you can safely approach an emergency scene, determine the need for additional resources, examine the patient to determine whether injuries or illnesses are present, obtain the patient\u2019s medical history, and report the results of your assessment to other EMS personnel. Recall that a complete patient assessment consists of the following five steps: Step 1, Scene size-up; Step 2, Primary assessment; Step 3, History taking; Step 4, Secondary assessment; and Step 5, Reassessment.",
        "scene size-up": "The scene size-up is best defined as a general overview of the incident and its surroundings. On the basis of this information, you can determine the safety of the scene, the type of incident, any mechanism of injury, and the need for additional resources.",
        "Review Dispatch Information": "Your scene size-up actually begins before you arrive at the scene of the emergency. When you are alerted for an emergency call, you can anticipate possible conditions by reviewing and understanding the information received from the dispatcher. Your dispatcher should have obtained the following information: the location of the incident, the main problem or type of incident the number of people involved, and any safety issues at the scene. As you receive the dispatcher\u2019s information, you should begin to assess it In addition to the information obtained from the dispatcher, other factors can affect your actions. Consider, for example, factors such as the time of day, the day of the week, and weather conditions. A call from a school during school hours may require a different response than a call during the weekend. Finally, think about the resources that may be needed and mentally prepare for other situations you may find when you arrive on the scene.\n\nIf you come across a medical emergency, notify the emergency medical dispatch center by using your two-way radio. If you do not have a two-way radio, use a cellular phone or send someone to call for help. Relay the following information: the location of the incident, the main problem or type of incident, the number of people involved, and any safety issues at the scene.",
        "Ensure Scene Safety": "When you arrive at the scene, remember to park your vehicle so it helps to secure the scene and to minimize traffic blockage. As you approach the scene, scan the area to determine the extent of the incident, the possible number of people injured, and the presence of possible hazards. It is important to scan the scene to ensure that you are not putting yourself in danger.\n\nHazards can be visible or invisible. Visible hazards include downed electrical wires, traffic, spilled gasoline, unstable buildings, a crime scene, weather, and crowds. Unstable surfaces such as slopes, ice, and water also pose potential hazards. Invisible hazards include electricity, biologic hazards, hazardous materials, and poisonous fumes. Downed electrical wires or broken poles may indicate an electrical hazard. Never assume a downed electrical wire is safe. Confined spaces such as farm silos, industrial tanks, and below-ground pits often contain poisonous gases or lack enough oxygen to support life. Hazardous materials placards on vehicles may indicate the presence of a chemical hazard.\n\nAs you take note of the hazards, consider your ability to manage them and decide whether to call for assistance. This assistance may include the fire department, additional EMS units, law enforcement officers, heavy-rescue equipment, hazardous materials teams, electric or gas company personnel, or other specialized resources. If a hazardous condition exists, make every effort to ensure that bystanders, rescuers, and patients are not exposed to it unnecessarily. If possible, see to it that any hazardous conditions are corrected or minimized as soon as possible. Noting such conditions early keeps them from becoming part of the problem later. Sometimes the first action needed at an incident scene is to prevent it from becoming worse. For example, it may be necessary to control traffic to prevent further crashes before it is safe to begin caring for injured patients.\n\nSome emergency scenes will not be safe for you to enter. These scenes will require personnel with special training and equipment. If a scene is unsafe, keep people away until specially trained teams arrive. It is also important to identify potential exit routes from the scene in the event a hazard becomes life threatening to you or your patients and to wear appropriate personal protective equipment (PPE)",
        "Safety": "Never enter an enclosed space unless you have received proper training and are equipped with self-contained breathing apparatus (SCBA).",
        "Determine the Mechanism of Injury or Nature of Illness": "As you approach the scene, look for clues that may indicate how the incident happened. This is called the mechanism of injury (MOI). If you can determine the MOI or the nature of the illness (NOI), you can sometimes predict the patient\u2019s injuries. For example, a ladder lying on the ground next to a spilled bucket of paint most likely indicates that the patient fell from the ladder and may have sustained bone fractures or a spinal injury. If the incident is a vehicle crash, knowing what type of crash occurred makes it possible to anticipate the types of injuries that may be present. For example, a rollover crash results in different injuries than a vehicle that has collided with a tree. It is also possible to anticipate injuries by examining the extent of damage to a vehicle. If the windshield is broken, look for head and spine injuries; if the steering wheel is bent, check for a chest injury.\n\nAsk the patient (if conscious), family members, or bystanders for additional information about the MOI or the NOI. This may provide you with important trauma or medical information that you can use to assist the patient. You can use the same type of overview that gives you information at the scene of an incident to help provide you with information about a patient\u2019s condition. Do not, however, rule out any injury without conducting a secondary assessment of the entire body of the patient. The mechanism of the accident may provide clues, but it cannot be used to determine what injuries are present in a particular patient. Using the previous example, the house painter may have fallen from the ladder because he had a heart attack.",
        "Take Standard Precautions": "Before arriving at the scene, prepare yourself by anticipating the types of standard precautions for infectious diseases that may be required. You should always have gloves readily available and use them. Consider whether the use of additional protection, such as eye protection, gowns, or masks, may be necessary. Try to anticipate your needs for equipment to ensure that you and your patients are well protected from exposure to infectious diseases. Regardless of the standard precautions you take, wash your hands thoroughly after contact with a patient or contaminated materials.",
        "Determine the Number of Patients": "Check to see if there is more than one patient. Then determine the total number of patients who need emergency care. Call for additional assistance if you think you might need help. It may be necessary to sort patients into groups according to the severity of their injuries to determine which patients should be treated and transported first. ",
        "Consider Additional Resources": "Many kinds of resources may be needed at the scene of an emergency. These resources include additional EMS units for treatment and transport; law enforcement personnel for traffic control or crowd control; fire department units for spilled fuel, fire, or extrication; utility company personnel for damaged utility lines; and wrecker operators for vehicle removal. As you prepare to make your initial report to the dispatcher, you may find it easier to report on the need for additional resources at the same time you report on the number of patients. Remember that your dispatcher cannot see the emergency scene. The only information the dispatcher has is the information you see and then communicate to the dispatcher.",
        "Words of Wisdom": "If you determine that additional resources are required, call for further assistance before beginning to treat the patient(s). It will take time for more help to arrive, so the sooner you request aid, the better. In addition, you are less likely to call for help if you are already involved in patient care, which can be detrimental to the patient\u2019s chance for recovery.",
        "Primary Assessment": "The second part of the patient assessment sequence is the primary assessment. This is sometimes called the primary patient assessment or the initial patient assessment. The purpose of the primary assessment is to identify life threats to the patient. Life threats are defined as problems with the patient\u2019s airway, breathing, and circulation (the ABCs). It is important to quickly identify any life-threatening conditions so you can take immediate actions to correct these conditions. Notice that the primary assessment consists of evaluating the same functions that you evaluate when you are beginning to perform cardiopulmonary resuscitation (CPR). The first step of the primary assessment is to form a general impression of the patient. You can do this as you approach the patient. The second step of the primary assessment is to determine the patient\u2019s level of responsiveness. The third step of the primary assessment consists of three parts: checking and correcting life-threatening problems connected to the airway, breathing, and circulation. These three parts taken together comprise a rapid exam to identify life threats. The fourth and final step of the primary assessment is to update responding EMS units about the patient\u2019s condition.",
        "Form a General Impression": "As you approach the patient, form a general impression. Note the sex and the approximate age of the patient. Your scene size-up and general impression may help determine whether the patient has experienced trauma or illness you cannot determine whether the patient is experiencing an illness or has sustained an injury, treat the patient as a trauma patient.) The patient\u2019s position or the sounds he or she is making may also help indicate to you the nature of the emergency. As you address the patient, you may gain some insight into the patient\u2019s level of consciousness. A quick look at the patient\u2019s face will often give you an idea of the level of pain he or she is experiencing. Although your first impression is valuable, keep an open mind and do not let it block out later information that may lead you in another direction (tunnel vision).",
        "Assess the Level of Responsiveness": "The first part of determining the patient\u2019s level of responsiveness is to introduce yourself. Many patients will be conscious and able to interact with you. As you approach the patient, tell the patient your name and function. For example, say: \u201cI\u2019m Jesse Phillips from the sheriff\u2019s department, and I\u2019m here to help you.\u201d This simple introduction helps establish: Your reason for being at the scene, The fact that you will be helping the patient, The level of consciousness of the patient. As you approach the patient, introduce yourself. If a patient appears unconscious, gently touch or shake the patient\u2019s shoulder to get a response. The introduction is your first contact with the patient. You should be able to put the patient at ease by conveying that you are a trained person ready to help.\n\nNext, ask the patient\u2019s name and then use it when talking with the patient, family, or friends. The patient\u2019s response helps you determine the patient\u2019s level of responsiveness (consciousness). Avoid telling the patient that everything will be all right.\n\nEven If a patient appears to be unresponsive (unconscious), speak to the patient in a tone of voice that is loud enough for the patient to hear. If the patient does not respond to the sound of your voice, gently touch the patient or shake the patient\u2019s shoulder to see if you can generate a response from the patient.\n\nThe patient\u2019s level of consciousness can range from fully conscious to unconscious. Describe the patient\u2019s level of consciousness using the four-level AVPU scale\n\nAlert. An alert patient is able to answer the following questions accurately and appropriately: What is your name? Where are you? What is today\u2019s date? A patient who can answer these questions is said to be \u201calert and oriented.\u201d\nVerbal. A patient is said to be \u201cresponsive to verbal stimuli\u201d even if the patient reacts only to loud sounds.\nPain. A patient who is responsive to pain will not respond to a verbal stimulus but will move or cry out in response to pain. Response to pain is tested by pinching the patient\u2019s earlobe or pinching the patient\u2019s skin over the collarbone. If the patient withdraws from the painful stimulus, he or she is said to be \u201cresponsive to painful stimuli.\u201d\nUnresponsive. An unresponsive patient will not respond to either a verbal or a painful stimulus. This patient\u2019s condition is described as \u201cunresponsive.\u201d\n\nIf the patient has sustained any type of major trauma, provide manual stabilization of the patient\u2019s neck as soon as possible. This step will prevent",
        "Safety_1": "Remember, performing a patient assessment may bring you in contact with the patient\u2019s blood and other body fluids, waste products, and mucous membranes. You need to wear approved gloves and PPE and take other standard precautions to prevent any exposure to infected body fluids. Follow the latest standards from the Centers for Disease Control and Prevention and Occupational Safety and Health Administration.",
        "Special Populations": "Infants and children may not have the verbal skills to answer the questions used to assess responsiveness in adults. Therefore, you should assess how the children and infants interact with their environment and with their parents or caregivers.",
        "Perform a Rapid Exam to Identify Life Threats": "The rapid exam to identify life threats consists of three steps. The first step is to check the airway and correct any serious airway problems, such as a blocked airway. The second step is to check for breathing and correct any serious breathing problems, such as a lack of breathing or open chest injuries that interfere with adequate breathing. The third step of the rapid exam to identify life threats is to check the status of circulation and correct any life-threatening circulation problems. These problems include a lack of circulation because of cardiac arrest and control of serious external bleeding. In most cases, identifying and correcting life-threatening issues begins with the airway, followed by breathing and circulation (ABC). However, when a patient is in cardiac arrest, you must first check for circulation followed by airway and breathing (CAB). This sequence minimizes the time to the beginning of chest compressions. With practice, you will learn to check the patient\u2019s circulation and breathing at the same time.",
        "Assess the Airway": "The third part of the primary assessment starts with checking the patient\u2019s airway. If the patient is alert and able to answer questions without difficulty, then the airway is open. If the patient is unresponsive to verbal stimuli, then assume the airway may be closed. If the patient is unconscious, open the airway by using the head tilt\u2013chin lift maneuver for patients with medical problems and use the jaw-thrust maneuver (without tilting the patient\u2019s head) for patients who have sustained trauma. After the airway is open, inspect it for foreign bodies or secretions. Clear the airway as needed, using finger sweeps or suction. You may need to insert an airway adjunct to keep the airway open.",
        "Assess Breathing": "If the patient is conscious, assess the rate and quality of the patient\u2019s breathing. Does the chest rise and fall with each breath or does the patient appear to be short of breath? If the patient is unconscious, check for breathing by placing the side of your face next to the patient\u2019s nose and mouth. You should be able to hear the sounds of breathing, see the chest rise and fall, and even feel the movement of air on your cheek. If the patient is having difficulty breathing or if you hear unusual breath sounds, check for an object in the patient\u2019s mouth, such as food, vomitus, dentures, gum, chewing tobacco, or broken teeth, and remove it.\n\nIf you cannot detect any movement of the chest and no sounds of air are coming from the nose and mouth, breathing is absent. Take immediate steps to check the patient\u2019s carotid pulse to assess whether there is any circulation. This step is described in the next section. If a carotid pulse is present but the patient is not breathing or only gasping, perform rescue breathing. If you suspect trauma, protect the cervical spine by keeping the patient\u2019s head in a neutral position and using the jaw-thrust maneuver to open the airway. Maintain manual cervical stabilization until the head and neck are fully immobilized. (These procedures are covered in Chapter 7, Airway Management.)",
        "Assess Circulation": "Next, check the patient\u2019s circulation (heartbeat). If the patient is unconscious, check the carotid pulse. Place your index and middle fingers together and touch the larynx (Adam\u2019s apple) in the patient\u2019s neck. Then slide your two fingers off the larynx toward the patient\u2019s ear until you feel a slight notch. Practice this maneuver until you are able to find a carotid pulse within 5 seconds of touching the patient\u2019s larynx. If you cannot feel the carotid pulse with your fingers in 5 to 10 seconds, begin CPR, which is covered in Chapter 8, Professional Rescuer CPR.\n\nIf the patient is conscious, assess the radial pulse rather than the carotid pulse. Place your index and middle fingers on the patient\u2019s wrist at the thumb side. Practice taking the radial pulse often to develop this skill. Take the radial pulse if the patient is conscious.\n\nNext, quickly check the patient for any severe external bleeding. If you discover severe bleeding, you must take immediate action to control it by applying direct pressure over the wound or by applying a tourniquet. These procedures are covered in Chapter 14, Bleeding, Shock, and Soft-Tissue Injuries.\n\nQuickly assess the patient\u2019s skin color and temperature. This assessment will help you determine whether the patient is experiencing internal bleeding and shock. It is important to check the color of the patient\u2019s skin when you arrive at the scene so that you can monitor the patient\u2019s skin for color changes as time goes on.\n\nSkin color is described as:\nPale. White or light in color, indicating decreased circulation to that part of the body or to all of the body. This could be caused by blood loss, poor blood flow, or low body temperature.\nFlushed. Red in color, indicating excess circulation to that part of the body \nBlue. Also called cyanosis, indicating lack of oxygen and possible airway problems \nYellow. Also called jaundice, indicating liver problems \nNormal. \n\nPatients with deeply pigmented skin may show color changes in the fingernail beds, in the whites of the eyes, on the palm of the hand, or inside the mouth.",
        "Safety_3": "Remember to wear gloves to avoid contact with body fluids that may contain blood.",
        "Special Populations_2": "To assess circulation in an infant, check the brachial pulse, located on the inside of the upper arm. You can feel the brachial pulse by placing your index and middle fingers on the inside of the infant\u2019s arm halfway between the shoulder and the elbow. Check for 5 to 10 seconds.",
        "Update Responding EMS Units": "In some EMS systems, you will be expected to update responding EMS units about the condition of your patient. This report should include the age and sex of the patient; the chief complaint; the level of responsiveness; and the status of airway, breathing, and circulation. This update helps other responders know what to expect when they arrive at the scene. Because many conditions present an immediate threat to life, you should try to perform all four steps of the primary assessment quickly as you make contact with the patient.",
        "History Taking": "Investigate the Chief Complaint\nAs you perform the primary assessment, you will often form an impression of\nthe patient\u2019s chief complaint. It is important to acknowledge the patient\u2019s\nprimary or chief complaint and provide reassurance. A conscious\npatient will often report an injury that is causing him or her great pain or direct\nyou to an injury that has obvious bleeding. However, keep in mind that this\ninjury may not be the most serious injury the patient has sustained. Do not\nallow a conscious patient\u2019s comments to distract you from completing the\npatient assessment sequence. Acknowledge the patient\u2019s chief complaint by\nsaying something like, \u201cYes, I can see that your arm appears to be broken, but\nlet me finish checking you completely in case there are any other injuries. I will\nthen treat your injured arm.\u201d In an unconscious patient, the primary \u201ccomplaint\u201d\nis unconsciousness.\n\nThe purpose of obtaining a medical history is to gather a systematic account of\nthe patient\u2019s past medical conditions, illnesses, and injuries to determine the\nevents leading up to the present medical situation and to determine the signs\nand symptoms of the current condition. It is important to question\nthe patient in a clear and systematic manner to gain as much information as\npossible. Do not underestimate the importance of a good medical history.\nPhysicians are taught that they can diagnose a patient\u2019s condition about 80%\nof the time after\ncompleting a thorough medical history. You are not expected\nto have the knowledge and training of a physician, but you should be able to Obtain a thorough medical history from a patient. Performing a medical history is an important part of the patient assessment sequence for injured patients and for ill patients, and it will help tie together your findings from the primary assessment.\n\nLearn the relevant facts about the patient\u2019s past medical history. Ask the patient about any serious injuries, illnesses, or surgeries. Ask the patient what medications he or she is currently taking, including prescription, over-the-counter (OTC), and herbal medications. Find out if the patient is allergic to any medications, foods, or seasonal allergens such as ragweed.",
        "Obtain SAMPLE History": "To obtain a patient medical history in a consistent and thorough manner, remember the acronym SAMPLE. By using this easy-to-remember acronym, you can gain the information you need about past medical history as well as the events leading to the current episode of illness or injury.\n\nIt is important to use a systematic approach when obtaining a patient\u2019s medical history. The SAMPLE history provides a framework to ask needed questions of the patient. Remember to ask the patient one question at a time. Give the patient time to answer before you ask the next question. Listen carefully and maintain eye contact to let the patient know you are listening to the response. Designate one EMS provider to ask questions to avoid confusing the patient. Use the mnemonic SAMPLE to obtain the following information\n\nS\nSigns and symptoms. These should be the reasons that caused the patient to call 9-1-1. Ask the patient what signs and symptoms occurred at the beginning of the event. Ask the patient what signs and symptoms he or she is experiencing now. Ask the patient if he or she is feeling any pain. If the patient is experiencing pain, ask him or her to describe the pain.\nA\nAllergies. Ask whether the patient is allergic to any medications or foods or has seasonal allergies. Ask the patient to describe his or her reactions to any allergies. If the patient states that he or she has no allergies, communicate this to other EMS personnel.\nM\nMedications. Ask the patient if he or she is taking any medications prescribed by a physician. If the patient is taking prescription medications, ask the patient the purpose of these medications. Ask the patient if he or she is taking OTC supplements or herbal remedies.\nP\nPertinent past medical history. Ask if the patient is currently under the care of a physician. Ask the patient if he or she has any existing medical conditions, such as diabetes or a heart condition. Ask the patient if he or she has had a serious illness or a serious injury. Ask the patient if he or she has been hospitalized recently. Try to keep this part of the history relevant to the current condition. A cardiac bypass operation is probably very relevant to a patient experiencing chest pains because it indicates cardiovascular disease. An operation to remove an inflamed appendix 10 years ago, however, is most likely not relevant to an illness today.\nL\nLast oral intake. Ask when the patient last had something to eat or drink. If the patient is experiencing abdominal pain, ask the patient what he or she had to eat and drink in the last few hours and how much he or she consumed.\nE\nEvents leading up to this illness or injury. Ask the patient to describe what he or she was doing when the symptoms of this event started or when the injury occurred. Ask the patient if he or she noticed anything unusual in the hours before this event started or if the patient was doing anything unusual just prior to the start of the illness or when the injury happened.\n\nIf the patient is unconscious or senile, a family member, friend, or coworker may be able to answer your questions. Look for important information on a medical identification necklace, bracelet, or card. The information you gain will help determine what steps you need to take to treat the patient. Next, communicate this information to other EMS personnel to help them in their assessment and treatment of the patient",
        "Words of Wisdom_4": "Pay particular attention to patients who tell you their pain feels just like the kidney stone episode they had last year or their pain feels just like the heart attack they had 2 years ago. Patients who have experienced a certain kind of pain before are often correct in identifying that pain if it recurs.",
        "Secondary Assessment": "After you have completed the primary assessment and stabilized any life-threatening conditions, perform a secondary assessment (the physical examination) of the patient from head to toe to assess non\u2013life-threatening conditions. Vital signs are taken as part of the secondary assessment. They may be obtained before the physical examination is completed or after the examination is done. They can also be obtained by a second person while other parts of the patient assessment are being completed. Information on signs and symptoms and vital signs is being presented here in this section because you need to understand how to measure some of these vital signs to provide a complete secondary assessment. The physical examination you conduct during the secondary assessment helps you to locate and begin initial management of the signs and symptoms of illness or injury. After you complete the secondary assessment, review any positive signs and symptoms of injury or illness. This review will help you get a better picture of the patient\u2019s overall condition.",
        "Signs and Symptoms": "In a careful and systematic patient assessment, you need to understand the difference between a sign and a symptom. Simply put, a sign is something about the patient you can see or feel for yourself. A symptom is something the patient tells you about his or her condition, such as, \u201cMy back hurts\u201d or \u201cI think I am going to vomit.\u201d You need to be able to assess selected signs and report them systematically when you transfer care. You also need to be able to understand and report the symptoms that the patient reports.",
        "Systematically Assess the Patient": "As you perform the secondary assessment, look and feel for the following signs of injury: deformities, open injuries, tenderness, and swelling. Use the mnemonic DOTS to remember these signs. Alternately, some EMS providers find it helpful to use the mnemonic DCAP-BTLS when performing a full body examination to help them remember the patient\u2019s injuries. This acronym is presented in Table 9-3. It is another option you can use for remembering the signs of injury.",
        "Signs of Injury": "the acronym **DOTS** stands for **Deformities**, **Open injuries**, **Tenderness**, and **Swelling**. These four key indicators help identify potential injuries when assessing a patient.",
        "**DCAP-BTLS** acronym": "**D**eformities, **C**ontusions (bruises), **A**brasions, **P**unctures or Penetrations, **B**urns, **T**enderness, **L**acerations, and **S**welling. These are the key elements to look for during a physical assessment for injuries.",
        "Secondary Assessment of the Entire Body": "Conduct a thorough, hands-on, secondary assessment of the entire body in a logical, head-to-toe, systematic manner. It is important to conduct the examination the same way each time to be sure you inspect all areas of the body for injuries. Use a clear, concise format to communicate your findings to other medical personnel. The secondary assessment of the entire body can be done whether the patient is conscious or unconscious. Watch the reactions of a conscious patient during your examination. If you detect signs of discomfort, you may want to ask what the patient is feeling as you proceed with your examination. Remember that your secondary assessment of the entire body is the main focus of this part of the patient assessment. It is permissible to question the patient during your assessment, but do not let the questions distract you from completing a thorough assessment.\n\nIf the patient is unconscious, it is vitally important that you assess the airway, breathing, and circulation during the primary assessment. After you have addressed any problems with the patient\u2019s breathing and pulse, begin a secondary assessment of the entire body of the unconscious patient. Assessing an unconscious patient is difficult because the patient cannot cooperate or tell you where something hurts\u2014although your assessment often will elicit grimaces or moans from an unconscious patient. Assume all unconscious, injured patients have spinal injuries. Manually stabilize the head and spine to minimize movement during the patient examination. It is essential to immobilize all injured, unconscious patients on a backboard before transporting them. Be cautious when treating a patient who is unconscious because of illness.\n\nFollow the steps in Skill Drill 9-1 to perform a secondary assessment of the entire body. \n1. Assess the head. Use both hands to thoroughly examine all areas of the scalp. Do not move the patient\u2019s head! This precaution is especially important if the patient is unconscious or has sustained a spinal injury. Injuries to the head tend to bleed excessively. Be sure to find the actual wound; do not be fooled by areas of matted, bloody hair. If necessary, remove the patient\u2019s eyeglasses and put them in a safe place. Many patients who need eyeglasses become upset if their eyeglasses are taken away. Use your judgment in each case. Be considerate of the patient. If the patient is wearing a wig, it may be necessary to remove the hairpiece to complete the head examination. Be sure to check the entire head for bumps, areas of tenderness, and bleeding Step 1.\n2. Assess the eyes. Cover one of the patient\u2019s eyes for 5 seconds. Then quickly open the eyelid and watch the pupil, the dark part at the center of the eye Step 2. The normal reaction of the pupil is to constrict (get smaller) within about 1 second. If you are examining a patient\u2019s eyes at night or in the dark, use a flashlight and aim the light at the closed eye. A pupil that fails to react to light or pupils that are unequal in size may be important diagnostic signs; report this information to personnel at the next level of medical care.\n3. Assess the nose. Assess the nose for tenderness or deformity, which may indicate a broken nose. Check to see if there is any blood or fluid coming from the nose.\n4. Assess the mouth. Your first assessment of the mouth should have taken place when you checked to see whether the patient was breathing. Now recheck the mouth for foreign objects such as food, vomitus, dentures, gum, chewing tobacco, and loose teeth. Be sure to carefully clear away any material that obstructs the patient\u2019s airway. In addition, be ready to manage any vomiting. It is important to prevent aspiration (inhalation) of vomitus into the lungs. Use your sense of smell to determine whether any unusual odors are present.\n5. Assess the neck. Assess the neck carefully using both hands, one on each side of the patient\u2019s neck. Be sure to touch the vertebrae (the bony part of the back of the neck) to see whether gentle pressure produces pain. Check the neck veins. Swollen (distended) neck veins may indicate heart conditions or major trauma to the chest. Examine the neck for a stoma (opening), which indicates that the patient is a \u201cneck breather.\u201d A neck breather is a person who has undergone a surgical procedure in which the airway above the stoma has been removed. The stoma may be the patient\u2019s only means of breathing, and the patient may not be able to speak normally. The stoma is often concealed behind an article of clothing or a bib.\n6. Assess the face. While you are performing the hands-on assessment of the head and neck, be sure to note the color of the facial skin, its temperature, and whether it is moist or dry. After you have completed the head examination, be sure to note any bumps, bruises, cuts, or other abnormalities.\n7. Assess the chest. If the patient is conscious, ask him or her to take a deep breath and tell you whether he or she feels any pain on inhalation or exhalation. Note whether the patient breathes with difficulty. Look and listen for signs of difficult breathing such as coughing, wheezing, or foaming at the mouth. It is important to look at both sides of the chest completely, noting any injuries, bleeding, or sections of the chest that move abnormally, unequally, or painfully. Unequal motion of one side or section of the chest may be a sign of a serious condition, called a flail chest, which can result from multiple rib fractures (breaks). Be sure to run your hands over all parts of the chest. Like the head and neck examinations, try to move the patient as little as possible while you assess the chest. Apply firm but gentle pressure to the collarbone (clavicle) to check for fractures. Check the chest for fractured ribs by placing your hands on the chest and pushing down gently but firmly. Then put your hands on each side of the chest and push inward, squeezing the chest.\n8. Assess the abdomen. Continue your assessment downward to the abdomen (stomach and groin). Look for any signs of external bleeding, penetrating injuries, or protruding parts, such as intestines. Ask the patient to relax the stomach muscles and observe whether the stomach remains rigid. Rigidity is often a sign of abdominal injury. Swelling is also a sign of abdominal injury. Note whether the clothing has been soiled with urine or feces. This finding may be an important diagnostic sign for certain illnesses or injuries, such as stroke. Make sure you check the genital area for external injuries. Although both the patient and you may be socially uncomfortable during this examination, it must be done if there is any suspicion of injury.\n9. Assess the pelvis. Next, check for fractures of the pelvis. First check for signs of obvious bruising, bleeding, or swelling. If no pain is reported by the patient, then gently press on the pelvic bones. If the patient reports pain or tenderness or if you note any movement, a severe injury may be present in this region.\n10. Assess the back. The patient\u2019s back should be checked one side of the back at a time. Use one hand to gently lift the patient\u2019s shoulder and then, using your other hand, slide it down the patient\u2019s back as you inspect the surface. In cases where a patient has been injured, move the patient as a unit, taking care to support the head and spine to keep them in proper alignment. Continue to stabilize the head and neck to prevent movement while you examine the patient. As you check each side of the back, be sure that your hands go all the way to the midline of the patient\u2019s body so you can feel the spinal column. Check half the back from one side, then switch sides and check the other side in the same manner. This ensures that no part of the back is missed during the examination. If the patient is lying on his or her side or stomach, it will be much easier to examine the patient\u2019s back. If the patient must be rolled onto a backboard, you can examine the patient\u2019s back while the patient is on his or her side. Do not wait for a backboard if this will delay your examination of the patient.\n11. Assess the extremities. Do a systematic assessment of each extremity to determine whether there are any injuries. This examination consists of the following five steps:\nA. Observe the extremity to determine whether there is any visible injury. Look for bleeding and deformity.\nB. Examine for tenderness in each extremity by encircling it with both hands and gently, but firmly, squeezing each part of the limb\nStep 12. Watch the patient\u2019s face and listen to see if the patient shows any signs of pain.\nC. Ask the patient to move the extremity. Check for normal movement. Determine whether there is any pain when the patient moves the extremity.\nD. Check for sensation by touching the bare skin of each extremity. See if the patient can feel your touch.\nE. Assess the circulatory status of each extremity by checking for the presence of a pulse in that extremity and by checking for capillary refill (discussed later in this chapter).\n\nEach upper extremity consists of the arm, the forearm, the wrist, and the hand. The arm extends from the shoulder to the elbow; the forearm extends from the elbow to the wrist. Examine one upper extremity at a time as follows:\nA. Observe the extremity. Start by looking at its position. Is it in a normal or an abnormal position? Does it look broken (deformed) to you?\nB. Examine for tenderness. Encircle the upper extremity with your hands. Work from the shoulder downward to the hand. Firmly squeeze the limb to locate any possible fractures.\nC. Check for movement. Take the patient\u2019s hand in yours and ask the patient to squeeze your hand. Squeezing is usually painful for the patient if he or she has a fracture or other injury. If a conscious patient cannot squeeze your hand, assume the extremity is seriously injured or paralyzed.\nD. Check for sensation. Ask the patient if he or she feels any tingling or numbness in the extremity. Sensations such as tingling or numbness may be a sign of a spinal injury. Check for sensation by touching the palm of the patient\u2019s hand. See if the patient can feel your touch.\nE. Assess the circulatory status. Check the patient\u2019s radial pulse. Absence of a radial pulse indicates blood vessel damage. Check the fingers for capillary refill. Check the color, temperature, and moisture of the hand.\n\nEach lower extremity consists of the thigh, the leg, the ankle, and the foot. The thigh extends from the hip to the knee. The leg extends from the knee to the ankle. Examine one lower extremity at a time, as follows: \nA. Observe the extremity. Look at the position and shape of the lower extremity. Is it deformed? Is the foot rotated inward or outward? \nB. Examine for tenderness. Encircle the lower extremity with your hands, as you did with the upper extremities. Move from the groin to the foot. Be sure to make contact with all surfaces of the limb. Use firm but gentle pressure to identify tender (injured) areas.\nC. Check for movement. Ask the patient to move the limb only if you have found no signs of injury in the first two steps. If there is a significant injury, movement most likely will be painful. If a conscious patient cannot move the foot or toes, the limb is seriously injured or paralyzed.\nD. Check for sensation. Ask the patient whether he or she can feel your touch as you examine the extremity. Tingling or numbness in a limb is a sign of spinal injury.\nE. Assess circulatory status. Check the posterior tibial pulse, located just behind the ankle bone on the medial (inner) side of the ankle. Absence of this pulse indicates blood vessel damage, which is sometimes caused by fractures. Check the toes for capillary refill. Check the skin color, temperature, and moisture of the extremity.",
        "Words of Wisdom_5": "As your hands move down the patient\u2019s scalp and onto the neck, check for the presence of an emergency medical identification neck chain. Look for medical identification (MedicAlert) emblems as an indication of the patient\u2019s medical history. The internationally recognized symbol is found on necklaces, arm bracelets, ankle bracelets, watches, rings, and wallet cards and is carried by people who have a medical condition that warrants special attention if they become ill or injured. This is a patient directive that allows EMS personnel to access the patient\u2019s stored medical information by calling the MedicAlert Foundation. Each MedicAlert member has a unique, secure patient identifier engraved at the bottom of his or her emblem. By wearing this emblem, the patient has consented to the release of information to attending medical personnel. The stored patient history can include conditions, allergies, medications and dosages, and implanted devices. If you find such a warning on a patient, it is your responsibility to give this information to the next person in the EMS system.",
        "Treatment": "Be careful not to move the neck or head!\nContinue talking to the patient throughout the entire patient assessment. Tell the patient what you are doing and why.",
        "Skill Drill 9-1: Performing a Secondary Assessment": "Step 1\nObserve and palpate the head.\nStep 2 Assess the eyes.\nStep 3 Check the nose for blood and drainage.\nStep 4 Assess the mouth.\nStep 5 Check for unusual breath odors.\nStep 6 Assess the neck. \nStep 7 Inspect the chest and observe breathing motion.\nStep 8 Gently palpate the chest. \nStep 9 Assess the abdomen. \nStep 10Gently press on the pelvic bones.\nStep 11 Log roll the patient and assess the back.\nStep 12 Inspect the extremities.",
        "Treatment_6": "Do not ask the patient to move an extremity if you find any deformity or tenderness during your examination.",
        "Exam of a Specific Area of the Body": "An exam of a specific area of the body is generally performed on patients who have sustained nonsignificant MOIs or on responsive medical patients. This type of examination is based on the chief complaint. For example, in a person reporting a headache, you should carefully and systematically assess the head and/or neurologic system. A person with a laceration to the arm may need to have only that arm evaluated. The goal of the exam of a specific area of the body is to focus your attention on the immediate problem.",
        "Words of Wisdom_7": "While you are examining patients, it is important to preserve patient privacy and to maintain body temperature. Patients who are in public places need to be covered with a sheet or blanket to maintain their privacy. It is often necessary to cover patients to preserve their body temperature. Ill or injured patients will often be cold even when it does not feel cold to you.",
        "Assess Vital Signs": "The patient\u2019s vital signs consist of respiration, pulse, blood pressure, and skin condition.",
        "Respiration": "The respiratory rate is a vital sign that indicates how fast the patient is breathing. It is measured as breaths per minute. In a normal adult, the resting respiratory rate is between 12 and 20 breaths per minute. One cycle of inhaling (breathing in) and exhaling (breathing out) is counted as one breath (respiration). Count the patient\u2019s breaths for 1 minute to determine the respiratory rate. Respirations may be rapid and shallow (characteristic of shock) or slow (characteristic of a stroke or drug overdose). Respirations may also be described as deep, wheezing, gasping, panting, snoring, noisy, or labored. If the patient is not breathing, respiration is described as absent, a condition that would have been addressed during the primary assessment. When you are checking the rate or noting the quality of respirations, make sure that your face or hand is close enough to the patient\u2019s face to feel the exhaled air on your skin. Also watch for the rise and fall of the chest. When counting respirations in a conscious patient, try not to let the patient know that you are counting. If the patient knows you are counting respirations, you may not get an accurate count.",
        "Pulse": "The second vital sign is the pulse, which indicates the speed and force of the heartbeat. A pulse can be felt anywhere on the body where an artery passes over a hard structure such as a bone. Although there are many such places on the body, the four most common pulse points are the radial (wrist), the carotid (neck), the brachial (arm), and the posterior tibial (ankle). The most commonly taken pulse is the radial pulse, located at the wrist where the radial artery passes over one of the forearm bones, the radius. The carotid pulse is taken over a carotid artery, located on either side of the patient\u2019s neck, just under the jawbone. The brachial pulse is taken on the inside of the arm, halfway between the shoulder and the elbow. The posterior tibial pulse is located on the inner aspect of the ankle, just behind the ankle bone.\n\nIn general, take the radial pulse of a conscious patient and the carotid pulse of an unconscious patient. When examining an infant, use the brachial pulse. The posterior tibial pulse is used to assess the circulatory status of a leg. When checking a patient\u2019s pulse, determine three things: rate, rhythm, and quality. To determine the pulse rate (heartbeats per minute), find the patient\u2019s pulse with your fingers, count the beats for 30 seconds, and multiply by two. In a normal adult, the resting pulse rate is about 60 to 100 beats per minute, although in a physically fit person (such as a jogger) the resting rate may be lower (about 40 to 60 beats per minute). In children, the pulse rate is normally faster (about 70 to 150 beats per minute). A very slow pulse (fewer than 40 beats per minute) can be the result of a serious illness, whereas a very fast pulse (more than 120 beats per minute) can indicate that the patient is in shock. Remember, however, that a person who is in excellent physical condition may have a pulse rate of less than 50 beats per minute, and a person who is simply anxious or worried could have a fast pulse rate (more than 110 beats per minute). You should also be able to determine the rhythm and describe the quality of the pulse. Note whether the pulse is regular or irregular. A strong pulse is often referred to as a bounding pulse. This is similar to the heart rate that follows physical exertion such as running or lifting heavy objects. The beats are very strong and well defined. A weak pulse is often called a thready pulse. The pulse is present, but the beats are not easily detected. A thready pulse is a more dangerous sign than a bounding pulse. A bounding pulse can be dangerous if the patient has high blood pressure and is at risk for a stroke.",
        "Capillary Refill": "Capillary refill is the ability of the circulatory system to return blood to the capillary vessels after the blood has been squeezed out. The capillary refill test is done on the patient\u2019s fingernails or toenails. To perform this test, squeeze the patient\u2019s nail bed firmly between your thumb and forefinger. The patient\u2019s nail bed will look pale. Release the pressure. Count 2 seconds by saying \u201ccapillary refill.\u201d The patient\u2019s nail bed should become pink. This indicates a normal capillary refill time.\n\nIf the patient has lost a significant amount of blood and is in shock, or if the blood vessels supplying that limb have been damaged, the capillary refill will be delayed or entirely absent. Capillary refill will be delayed in a cold environment and should not be used as the sole means for assessing the circulatory status of an extremity. Check with your medical director to determine whether you should use the capillary refill test.",
        "Blood Pressure": "Blood pressure is another way to measure the condition of a patient\u2019s circulatory system. High blood pressure may indicate that the patient is susceptible to a stroke. Low blood pressure generally indicates one of the various types of shock.\n\nThe blood pressure measurement consists of a reading of two numbers (for example, 120 over 80, or 120/80). These numbers represent the pressures found in the arteries as the heart contracts and relaxes. The numbers are determined by the pressure exerted in millimeters of mercury (mm Hg), as shown on the dial. The higher number (120 mm Hg in the example of 120 over 80) is called the systolic pressure. The systolic pressure is the force exerted on the walls of the arteries as the heart contracts. The lower number (80 mm Hg in the example of 120 over 80) is known as the diastolic pressure. The diastolic pressure represents the arterial pressure during the relaxation phase of the heart.",
        "Normal Blood Pressure": "Blood pressure ranges may vary greatly. Excitement or stress may raise a person\u2019s blood pressure. Hypertension (high blood pressure) exists when the blood pressure remains greater than 140/90 mm Hg after repeated examinations over several weeks. Hypertension is a serious medical condition that requires treatment by a physician. Hypotension (low blood pressure) exists when the systolic pressure (the higher number) falls to 90 mm Hg or below. A patient with this condition is usually in serious trouble. Immediately start treatment of shock if the patient is also experiencing other signs of shock (for example, cold, clammy, pale skin or dizziness) or if repeat measurements of blood pressure are decreasing.",
        "Checking Blood Pressure by Palpation": "To take a patient\u2019s blood pressure by palpation (by feeling it), apply the blood pressure cuff to the uninjured (or less injured) arm. Wrap the cuff around the upper arm. The bottom of the cuff should be 1 to 2 inches (3 cm to 5 cm) above the crease of the elbow. The arrow should point to the brachial artery. Blood pressure cuffs come in different sizes for adults, children, and infants. Be sure to use the appropriate size for your patient, such as a narrow cuff for a child and an extra-large cuff for an adult with obesity. Cuffs that are too small may give falsely high readings, and cuffs that are too large may give falsely low readings. Place the indicator dial in a position where you can easily see the movement of the indicator needle. Turn the control knob on the blood pressure inflator bulb clockwise to close the valve. Do not tighten it too much. With the fingers of your other hand, locate the radial pulse at the patient\u2019s wrist. Slowly pump up the blood pressure cuff until you can no longer feel the radial pulse. Continue to pump up the cuff for another 30 mm beyond the disappearing point of the radial pulse. Slowly release the pressure in the cuff (at 2 to 4 mm per second), by turning the valve counterclockwise. Continue to feel for the radial pulse and when you first feel the pulse return, carefully note the position of the indicator needle on the dial. This number is the systolic pressure.\n\nThe palpation method of taking blood pressure does not give you a diastolic pressure. You will have only one number, the systolic pressure, instead of the two numbers. Report the results as \u201cthe blood pressure by palpation is 90.\u201d",
        "Checking Blood Pressure by Auscultation.": "To take blood pressure by auscultation (by hearing it), you need both a blood pressure cuff and a stethoscope. Apply the blood pressure cuff in the same manner and position as in the palpation method. After you apply the cuff, locate the brachial artery pulse on the medial side of the arm at the crease of the elbow.\n\nPut the earpieces of the stethoscope in your ears with the earpieces pointing forward. Place the diaphragm of the stethoscope over the site of the brachial pulse. Using your index and middle fingers, hold the diaphragm snugly against the patient\u2019s arm. Do not use your thumb! If you use your thumb, you may hear your own heartbeat in the stethoscope.\n\nListen as you inflate the blood pressure cuff. When you can no longer hear the sound of the brachial pulse, note the pressure on the dial. Continue to inflate the cuff for another 30 mm over the pressure at which the brachial pulse disappeared. Then slowly and smoothly release air from the cuff by opening the control valve at a rate of 2 to 4 mm per second. Carefully watch the indicator needle, listen for the pulse to return, and note the pressure reading when you first hear the pulse return. This is the systolic pressure. As the cuff pressure continues to fall (at 2 to 4 mm per second), listen for the moment when the pulse disappears. Note the number when you can no longer hear the pulse; this is the diastolic pressure.\n\nBlood pressure taken by auscultation is reported as systolic pressure over diastolic pressure (the larger number over the smaller number) and is always given in even numbers (for example, 120/84, 90/40, or 186/98).\n\nIt takes practice to become skilled in taking blood pressures. Take every opportunity to practice on as many healthy, uninjured people as possible. Practice on children and older people as well as on your friends and coworkers. This will help prepare you to measure the blood pressure of a seriously ill or injured patient. Many different types of automatic blood pressure devices are available today. Some EMS departments use these devices to measure blood pressure. If your department uses an automatic blood pressure machine, you need to become proficient in its operation.",
        "Table 9-5 Typical Vital Sign Values Based on Age": "Table 9-5 shows **typical vital sign values based on age**. **Infants (newborn to age 1 year)** generally have a pulse rate of 90\u2013180 beats/min, a respiratory rate of 25\u201360 breaths/min, and a systolic blood pressure ranging from 50\u201395 mm\u202fHg. **Children (ages 1 to 12 years)** typically show a pulse rate of 70\u2013150 beats/min, a respiratory rate of 15\u201330 breaths/min, and a systolic blood pressure of 80\u2013110 mm\u202fHg. **Adults** generally present with a pulse rate of 60\u2013100 beats/min, a respiratory rate of 12\u201320 breaths/min, and a systolic blood pressure between 90\u2013140 mm\u202fHg. These values are derived from the American Heart Association\u2019s 2015 Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.",
        "Skin Condition": "Check the patient\u2019s skin for color, temperature, and moisture. Normal body temperature is about 98.6\u00b0F (37\u00b0C). Precise body temperature is taken with a thermometer, but you can estimate a patient\u2019s body temperature by placing the back of your hand on the patient\u2019s forehead. The patient\u2019s skin temperature is judged, in relation to your skin temperature, as hot or cold. Some illnesses can cause the skin to become excessively moist or excessively dry. Therefore, together with its relative temperature, the patient\u2019s skin might be described as hot and dry, hot and moist, cold and dry, or cold and moist. Normal skin conditions are described as warm, pink, and dry. After determining the patient\u2019s vital signs, you should also be able to identify and measure these other important signs: pupil size and reactivity and level of consciousness.",
        "Pupil Size and Reactivity": "It is important to examine each eye to detect signs of head injury, stroke, or drug overdose. Look to see whether the pupils (the circular openings in the middle of the eyes) are of equal size and whether they both react (constrict) when you shine a light into them. The following findings are abnormal: Pupils of unequal size. Unequal pupils can indicate a stroke or injury to the brain. A small percentage of people normally have unequal pupils, but in an unconscious patient, unequal pupils are often a sign of serious illness or injury. \nUnequal pupils may indicate a stroke or injury to the brain. \nPupils that remain constricted are often present in a person who is taking narcotics. They are also a sign of certain central nervous system diseases.\nPupils that remain dilated (enlarged) Dilated pupils indicate a relaxed or unconscious state. Pupils will dilate within 30 to 60 seconds of cardiac arrest. Head injuries and the use of certain drugs, such as barbiturates or sleeping pills, can also cause dilated pupils.",
        "Level of Responsiveness": "You will usually assess the patient\u2019s level of responsiveness (consciousness) as part of your primary assessment. However, it is important to observe and note any changes that occur between the time of your arrival and the time you turn over the patient\u2019s care to personnel at the next level of the EMS system. Report any changes from one level of consciousness to another, using the AVPU scale.",
        "Signs Review": "Signs are indicators of illness or injury that you can observe in a patient. They help you determine what is wrong with the patient and the severity of the patient\u2019s condition. Vital signs include the patient\u2019s respirations (respiratory status), pulse, capillary refill, blood pressure (circulatory status), skin condition, and temperature. Other signs include pupil size and reactivity and level of consciousness. To assess a patient\u2019s respiratory status, determine the patient\u2019s breathing rate and determine whether breaths are rapid or slow, shallow or deep, noisy or quiet. In assessing a patient\u2019s circulatory status, determine the rate, rhythm and quality of the patient\u2019s pulse. You can also determine whether the patient\u2019s capillary refill is normal, slow, or absent. Determine the patient\u2019s blood pressure. Although you may not be able to determine the patient\u2019s exact temperature, you will be able to state whether the patient is hot or cold. Skin condition is measured by color and moisture and can be described as pale, flushed, blue, yellow, normal, dry, or moist. To assess the patient\u2019s pupils, check to see whether the pupils are equal or unequal in size and whether they remain constricted or dilated. Use the AVPU scale to assess the patient\u2019s level of consciousness: awake and alert, responsive to verbal stimuli, responsive to pain, or unresponsive.",
        "Reassessment": "The first four steps of the patient assessment sequence help you determine the patient\u2019s initial condition. If other EMS personnel arrive to take over the care of the patient at any point, all you need to do is provide them with a report of your findings in the form of a handoff report. However, if you need to continue to care for the patient, it is necessary to regularly repeat some parts of the patient assessment. This is the process of reassessment. Repeat the Primary Assessment. \nThe first step is to repeat the primary assessment. Recheck the patient\u2019s level of responsiveness and recheck the patient\u2019s airway, breathing, and circulation. Continue to maintain an open airway and to monitor breathing and the pulse for rate and quality.\nReassess Vital Signs: The second step is to reassess the patient\u2019s vital signs. Observe the patient\u2019s skin color and temperature. Reassess the patient\u2019s blood pressure.\nReassess the Chief Complaint: The third step is to reassess the chief complaint to see if there is any change.\nRecheck the Effectiveness of the Treatment: Check to see if the interventions you took were effective. When there is a change, determine whether you need to alter your care of the patient.\nIdentify and Treat Changes in the Patient\u2019s Condition: The next step is to identify and treat changes you have noticed in the patient\u2019s condition.\nReassess Patient: Patients who appear stable can become unstable quickly. Therefore, it is essential that you reassess all patients carefully for changes in status. Reassess all stable patients every 15 minutes. If the patient is unstable, repeat the reassessment every 5 minutes.\nProvide a Handoff Report: It is important that you describe your findings concisely and accurately to the EMS personnel who take over the care of your patients in a handoff report.\n\nThe easiest way to report your patient assessment results is to use the same systematic approach you followed during the patient assessment:\n1. Provide the age and sex of the patient.\n2. Describe the history of the incident.\n3. Describe the patient\u2019s primary or chief complaint.\n4. Describe the patient\u2019s level of responsiveness.\n5. Describe how you found the patient.\n6. Report the status of the vital signs: airway, breathing, and circulation (including severe bleeding).\n7. Describe the results of the secondary patient assessment.\n8. Report any pertinent medical conditions using the SAMPLE format.\n9. Report the interventions you provided and how the patient responded to them.\nWorking in a systematic manner will help ensure that you do not overlook any significant symptoms, signs, or injuries and will help to make the handoff report complete and accurate. For example, a handoff report on a 23-year-old man injured in a motor vehicle crash might include the following information:\n1. The patient is a 23-year-old man.\n2. He was involved in a two-vehicle, head-on collision.\n3.He is reporting stomach pain and has a 2-inch (5-cm) cut on his forehead.\n4. He is conscious and alert.\n5. His pulse rate is 78 beats per minute and strong. His blood pressure is 128/82 mm Hg. His respirations are 16 breaths per minute and are regular and deep.\n6. Examination revealed a 2-inch (5-cm) cut on his forehead, marks on his stomach, and moderate pain midway between his right knee and ankle.\n7.He has no known medical conditions.\n8. The patient is on his back, covered with a blanket to preserve his body heat. We have bandaged his laceration and immobilized his leg with an inflatable splint.\n\nThe purpose of the patient assessment sequence is to: Assist in finding the patient\u2019s injuries so you can treat them.\nObtain information about the patient\u2019s condition, which you provide to the EMS personnel at the next level of medical care.\nWith practice, you can complete the entire patient assessment sequence in about 2 minutes. This is not a complete medical examination, but it allows you to perform a systematic patient assessment to determine what injuries or illnesses the patient may have. Remember that there are times when you may need to perform some of the steps of the patient assessment sequence in a slightly different order. Each step is numbered only to help you keep track of where you are in the patient assessment sequence.\n\nExamine every patient involved in an incident before you begin major treatment of any single patient. The exceptions to this rule are patients with airway, breathing, and circulatory problems (severe bleeding or shock). These emergencies must be treated as you encounter them during patient assessment. Except for these life-threatening conditions, do not begin treatment until you have examined all patients to determine the extent and severity of injuries and to make sure that you treat injuries in the order of severity.",
        "Voices Experience": "We were called to respond to a report of a 50-year-old man who had attempted suicide. On arrival, we found the patient naked in a bathtub full of water, unconscious (responsive to pain only) but breathing. The patient had lacerated both wrists and was bleeding. The bath water was discolored by blood and feces. My team dressed and bandaged the wounds. We then lifted him out of the tub, put him on an ambulance blanket, which we used to quickly dry him, then transferred him to the gurney and covered him with another blanket. While this was happening, I took his pulse, respirations, listened to breath sounds, and checked his pupils. Each of these vital signs was unremarkable.\n\n\u201cWhat is a guy who has lost enough blood to be unconscious doing with a pulse of 68 and respirations of 14? What else did he do to himself?\u201d I thought out loud. A rapid trauma exam revealed nothing more than the lacerations already noted.\n\nWe started an intravenous line, drew blood samples, and checked his blood glucose; it was 67 mg/dL; again, unremarkable. There was no smell of alcohol on his breath; his pupils were normal size, equal, and only slightly sluggish in response to light. His blood pressure was 110/68 mm Hg.\n\nPeople who were at the scene said that he had had financial and legal troubles and had been despondent for several days. None of them knew of any medications that he might be taking and no bottles were found at the scene.\n\nThe next set of vital signs showed his heart rate had slowed to 58 beats per minute and his respirations had decreased to 9 breaths per minute! We were missing something. While reviewing everything we knew about the patient and the scene, I remembered thinking that when we pulled him out of the bathtub, the water was cold. A quick gloved hand placed under the blanket on the patient\u2019s belly confirmed what I should have already known. What we needed to be treating was hypothermia.\n\nWith 40 minutes left in our transport, we began aggressive reheating\u2014hot packs, more blankets, turning up the heat in the ambulance, and so on. Within minutes, the patient\u2019s level of consciousness improved to the point where he would momentarily open his eyes when his name was called. By the time we arrived at the hospital he was able to ask where he was and complain about our treatment.\n\nAfter 40 minutes of rewarming en route, his core temperature taken in the emergency room was a little over 85\u00b0F (29.6\u00b0C).\n\nFocusing on the suicide attempt caused us to miss the incidental and accidental severe hypothermia that ultimately was the patient\u2019s only life-threatening problem.",
        "A Word About Medical and Trauma Patients": "Patients generally can be divided into two main categories: those who have a sudden illness and those who sustain trauma. Examples of sudden illnesses include heart attacks, strokes, asthma, and gallbladder conditions. Trauma is the term used for an injury to a patient. The injury may be major or minor. Some incidents that cause trauma include falls, motor vehicle crashes, and sports-related injuries. The patient assessment sequence you have learned can be used to examine patients who have experienced illnesses, trauma, or both. \nWhen you examine medical patients, follow the patient assessment sequence as you learned it: 1. Complete a scene size-up. 2. Perform a primary assessment. 3. Obtain the patient\u2019s medical history (SAMPLE). 4. Perform a secondary assessment. 5. Perform reassessment. This sequence gives the information about the medical patient in a logical order. It allows you to assess the most critical factors first. Although you may have to vary the order of the steps somewhat for certain patients, you should generally try to follow this order.\nWhen caring for a trauma patient, modify the preceding sequence slightly. Perform the scene size-up and the primary assessment just like you do for a medical patient. However, when examining a trauma patient, perform the secondary assessment before taking the patient\u2019s medical history. By performing the secondary assessment of the entire body before the medical history, you gain information about the patient\u2019s injuries. In trauma situations, this is often more important than obtaining the medical history.\nAlthough it is often helpful to consider whether the patient\u2019s problem is caused by trauma or sudden illness, avoid jumping to conclusions. Some patients need to be treated for both trauma and sudden illness. (For example, a person who has a heart attack while driving a vehicle needs to be treated for the heart attack and for any trauma sustained in the motor vehicle crash.) The most important factor to remember is to follow a system of patient assessment that will gather all the information needed.",
        "Prep Kit-Ready for Review": "Below is a concise overview of the five-step patient assessment process and key considerations for medical versus trauma patients: \n\n1. **Scene Size-Up**  - Assess the overall situation for safety.  - Determine the nature of the incident (mechanism of injury or illness).  - Identify the number of patients and decide if additional resources are needed. \n\n2. **Primary Assessment**  - Form a general impression of the patient and check responsiveness.  - Identify and correct any life-threatening issues involving Airway, Breathing, and Circulation (the \u201cABC\u201d priorities).  - Provide an update to responding EMS units.\n\n3. **Obtain the Patient\u2019s Medical History**  - Use the SAMPLE format (Signs/Symptoms, Allergies, Medications, Past medical history, Last oral intake, Events leading up) to gather important health information.\n\n4. **Secondary Assessment**  - Conduct a thorough head-to-toe examination to locate non\u2013life-threatening injuries or illnesses.  - Check vital signs once life threats have been addressed.\n\n5. **Reassessment**  - Continuously monitor the patient\u2019s condition.  - For a stable patient, recheck vital signs every 15 minutes; for an unstable patient, every 5 minutes.  - If there is any change in condition, repeat the primary assessment to catch new or worsening problems.\n\n**Handoff to EMS**  - Provide a concise, accurate report of the patient\u2019s status and care given.\n\n**Medical vs. Trauma Patients**  - **Medical Patients**: Typically follow the 1\u20135 sequence (scene size-up, primary assessment, medical history, secondary assessment, reassessment).  - **Trauma Patients**: Often perform the secondary assessment before gathering the medical history, due to the nature of their injuries."
    },
    {
        "Average Vital Signs": "This section provides average vital signs for various age groups, including weight, resting heart rate, resting respiratory rate, and systolic blood pressure. For neonates under 28 days, weight is less than 3 kg, with a resting heart rate between 100 and 160 bpm, a resting respiratory rate of 40 to 60 breaths per minute, and systolic blood pressure difficult to measure. As age increases, weight ranges from 2 to 32 kg, with corresponding changes in heart rates, respiratory rates, and blood pressures. For example, at 13 years and older, weight exceeds 32 kg, resting heart rate is between 60 and 100 bpm, resting respiratory rate is 12 to 20 breaths per minute, and systolic blood pressure is 120 mmHg or higher. The chart also includes specific ranges for systolic blood pressure based on age, such as 65 to 100 mmHg for 3-month-olds and 90 to 120 mmHg for 11- to 12-year-olds.",
        "Hypotension (Low Blood Pressure)": "This section defines low blood pressure, or hypotension, based on age range. For infants aged 1 month to 1 year, systolic blood pressure considered clinically low/hypotensive is below 70 mmHg. For children aged 1 to 10 years, it is below 70 plus twice the age in years in mmHg. For individuals aged 11 years and above, it is below 90 mmHg. Anaphylaxis generally causes systolic blood pressure to drop by 30% or more."
    },
    {
        "FAST VAN Stroke Mnemonic": "The FAST VAN mnemonic helps identify stroke symptoms by assessing five key areas: Face, Arm, Speech, Time, and Vision. For the Face, check for right-sided droop or left-sided droop. For the Arm, assess for right-sided weakness or left-sided weakness. For Speech, look for slurred speech. For Time, determine if signs/symptoms started less than 6 hours ago. If any of these criteria are met, urgent transport to the hospital is required. Additionally, if there are naming difficulties or neglecting one side of the body (typically the left side), notify the receiving hospital of possible large vessel occlusion.",
        "IV Drip Set Calculations": "This section explains how to calculate IV drip rates using different sizes of drip sets. Standard (Regular) drip sets have 15 drops per milliliter, Macro (Adult) sets have 10 drops per milliliter, and Micro (Mini) sets have 60 drops per milliliter. The formula to calculate the drip rate is: (volume in milliliters to be infused x drops per milliliter) / infusion time in minutes.",
        "Common IV Solutions": "This section lists common IV solutions and their uses. Ringer's Lactate is used for blood loss, D5W and D10W for hypoglycaemia, Normal Saline for dehydration, and 2/3 \u2013 1/3 for dehydration.",
        "Common IV Complications": "This section outlines various complications associated with intravenous therapy. These include interstitial issues, circulatory overload, thrombosis and thrombophlebitis, catheter embolism, infection at the catheter site, allergic reaction, and air embolism."
    },
    {
        "Scene Assessment": "The Scene Assessment section outlines critical questions to consider when evaluating an incident. It includes inquiries about hazards and personal protective equipment (PPE), the environment's safety, the mechanism of the event, the number of patients involved, and whether additional resources are needed. This section helps responders prioritize safety and prepare for the situation effectively.",
        "Primary Assessment": "The Primary Assessment focuses on quickly assessing the patient's condition. It begins with a general impression of what is happening and whether spinal motion restriction measures are necessary. The assessment then evaluates the patient's level of responsiveness (LOR), airway, breathing, and circulation. A Rapid Body Survey (RBS) is conducted to check for skin conditions, major bleeding, and obvious injuries. Critical interventions are outlined based on the patient's needs, such as managing life-threatening problems and treating for shock.",
        "Decision Point": "The Decision Point section addresses the patient's main concern and urgent considerations. It involves determining the initial transport decision, categorizing urgency using Urgent/Rapid Transport Category (RTC) or Delayed (Non-Urgent) Transport, and deciding whether to continue or discontinue Spinal Motion Restriction (SMR). Pre-Hospital Report instructions include updating the receiving medical center, calling Medical Oversight as needed, and checking ABCs after any movement.",
        "Secondary Assessment": "The Secondary Assessment involves a detailed interview to gather signs and symptoms, allergies, medications, past medical history, last oral intake, and events leading up to the incident. It also covers onset, provocation/palliation, quality, region/radiation, severity, and timing of symptoms. Vital signs are checked every 5 minutes if urgent or 15 minutes if non-urgent, covering responsiveness, blood pressure, respiration, pulse, SpO2, pupils, and capillary blood glucose (CapBgl). A Head-to-Toe Examination includes assessing skin, palpating for injuries, and checking distal extremities for bilateral radial and pedal pulses and motor/sensory deficits.",
        "Ongoing Assessment": "The Ongoing Assessment section emphasizes continuous treatment and reassessment. Rescuers should provide appropriate medications and interventions, continuously monitor and re-evaluate the patient, decisions, and circumstances. Documentation includes ensuring a complete and accurate patient care report, notifying the receiving medical center of significant updates, and providing a concise and accurate verbal report upon handover."
    },
    {
        "Head to Toe Assessment Mnemonics": "This section provides a mnemonic for assessing a patient's level of consciousness and injuries during a head-to-toe assessment. It lists potential causes of altered consciousness such as Alcohol, Epilepsy, Insulin (Diabetic), Overdose, Uremia, Trauma, Infection, Psychiatric, Poison, and Stroke. During the assessment, specific signs like Burns, Open Wounds, Lacerations, Deformity, Contusions, Abrasions, Penetrations, Swelling, Crepitus, Rigidity, Instability, Punctures, Tenderness, and Subcutaneous Emphysema are noted.",
        "Relevant S-A-M-P-L-E and Mechanism of Injury Information": "This section outlines the relevant information to gather when assessing a patient based on the mechanism of injury. For Motor Vehicle Accidents (MVA), details include the location of the patient, which vehicle they were in, the number of vehicles involved, impact speed, exterior damage, interior damage, type of restraints, initial position of the patient, condition of the patient, loss of consciousness, and condition of other patients. For Falls, information includes where the fall occurred, height, landing surface, position at impact, what hit first, and cause of fall. For Pedestrian Struck incidents, details involve what hit them, size and weight of the object, velocity of the vehicle, vehicle part that hit the patient, damage to the vehicle, distance the patient was thrown, loss of consciousness, and condition of the patient and vehicle occupants. For Shootings, information includes the type of firearm, range and angle, loss of consciousness, type of bullet, entrance and exit wounds, and initial position and condition of the patient. For Stabbings, details cover the type and size of the weapon, loss of consciousness, type of wound, number of wounds, other injuries, and initial position and condition."
    },
    {
        "Common Units of Measurement": "This section lists common units of measurement used in healthcare, including Millimeters of Mercury (mmHg) for blood pressure, Millimoles per Litre (mmol/L) for blood glucose levels, Milligrams (mg) for medications like ASA and Nitro, Litres per minute (lpm) for oxygen flow rates, Drips per millilitre (gtts/ml) for dripset size, and Drips per minute (gtts/minute) for the number of droplets through the dripset in one minute.",
        "Assisted Ventilations": "This section outlines assisted ventilation rates for adults and children/infants based on specific respiratory issues. For adults, the ventilation rate is 1 breath every 5-6 seconds when respirations are absent but a pulse is present, greater than 30 breaths per minute, less than 10 breaths per minute, or signs of hypoxia or respiratory distress. For children/infants, the rate is 1 breath every 3-5 seconds under similar conditions. Ventilations are timed between or with the patient's own breaths, and OPA/NPA can be used after the first two successful ventilations.",
        "Weight Estimation for Pediatric Patients": "This section provides an age-based weight estimation formula for pediatric patients up to 10 years old: 2 times the age in years plus 8 equals the estimated weight in kilograms. It notes that parent or caregiver estimations are generally more accurate than age-based calculations.",
        "A-T-M-I-S-T A-M-B-O": "This section details the verbal handover process using the mnemonic ATMIST and AMBO. ATMIST includes Age, Time, Mechanism, Injuries, Signs, and Treatment, which are the details to mention during the verbal handover. AMBO covers Allergies, Medication, Background, and Other Information, also to be included in the verbal handover."
    },
    {
        "EMALB NEXUS SMR Decision Matrix for Injuries with Spinal Mechanism": "This cheat sheet outlines a decision matrix for determining whether a Simple Medical Restraint (SMR) is required for patients with injuries involving a spinal mechanism. The process begins by assessing multiple trauma, asking if the patient has two or more significant traumatic injuries. If yes, a Full SMR is applied, which includes a collar, lifting device and straps, head secured if transport is uneven or bumpy, and the head of the cot raised 30\u00b0. If no, the next step involves evaluating the NEXUS criteria: midline tenderness, altered LOC, new focal neurological deficits, intoxication, and major distracting injury. If any of these criteria are present, a Simple SMR is applied, which includes a collar, supine on a mattress/cot without a clamshell/spineboard, head not taped, and the head of the cot raised 30\u00b0. If none of the NEXUS criteria are met, the patient does not require an SMR. Additionally, the cheat sheet highlights thoracolumbar injuries, advising against sitting the patient upright or raising the head of the stretcher even if an SMR is not required due to specific dangerous mechanisms of injury such as a fall from a height above 3 meters, axial load to the head/base of the spine, MVA at 100 km/hr or faster, rollover MVA, pre-existing spinal pathology, new back deformity or bruising, and bony midline tenderness."
    },
    {
        "Assessment": "Applies scene information and patient assessment findings (scene size-up, primary and secondary assessment, patient history, and reassessment) to guide emergency management.",
        "Scene safety": "Scene management\nImpact of the environment on patient care\nAddressing hazards\nViolence",
        "Scene management (cont\u2019d)": "Need for additional or specialized resources\nStandard precautions\nMultiple-patient situations",
        "Primary Assessment": "Primary assessment for all patient situations\nLevel of consciousness\nABCs\nIdentifying life threats\nAssessment of vital functions\nInitial general impression",
        "Primary Assessment (cont\u2019d)": "Begin interventions needed to preserve life\nIntegration of treatment/procedures needed to preserve life Primary Assessment Begins when you greet your patient\nThe goal is to identify and initiate treatment of immediate or potential life threats.\nPhysically examine the patient and assess:\nLOC\nABCs",
        "History Taking": "Determining the chief complaint\nMechanism of injury/nature of illness\nAssociated signs and symptoms\nInvestigation of the chief complaint\nPast medical history\nPertinent negatives\n\nUse the OPQRST mnemonic to assess symptoms.\nOnset\nProvocation or palliation\nQuality\nRegion/radiation\nSeverity\nTiming\nIdentify pertinent negatives.",
        "Secondary Assessment": "Performing a rapid full-body scan\nFocused assessment of pain\nAssessment of vital signs\nTechniques of physical examination\nRespiratory system\nPresence of breath sounds",
        "Secondary Assessment (cont\u2019d)": "Techniques of physical examination (cont\u2019d)\nCardiovascular system\nNeurologic system\nMusculoskeletal system\nAll anatomic regions Systematically assess the patient\u2014secondary assessment\nGoal is to identify hidden injuries or identify causes missed during 60- to 90-second exam during primary assessment.",
        "Monitoring Devices": "Obtaining and using information from patient monitoring devices including (but not limited to):\nPulse oximetry\nNoninvasive blood pressure",
        "Reassessment": "How and when to reassess patients\nHow and when to perform a reassessment for all patient situations\n\nPerform at regular intervals during the assessment process.\nRepeat the primary assessment.\nReassess vital signs.\nCompare with the baseline vital signs obtained during the primary assessment.\nLook for trends. Reassess the chief complaint.\nAsk and answer the following questions:\nIs the current treatment improving the patient\u2019s condition?\nHas an already identified problem gotten better?\nHas an already identified problem gotten worse?\nWhat is the nature of any newly identified problems? Recheck interventions.\nCheck all interventions.\nMost important are the patient\u2019s ABCs.\nEnsure management of bleeding.\nEnsure adequacy of other interventions, and consider the need for new interventions. Identify and treat changes in the patient\u2019s condition.\nDocument any changes, whether positive or negative.\nReassess the patient.\nUnstable patients: approximately every 5 minutes\nStable patients: approximately every 15 minutes",
        "Introduction": "Patient assessment is very important.\nEMTs must master the patient assessment process.\nPatient assessment is used, to some degree, in every patient encounter. Five main parts:\nScene size-up\nPrimary assessment\nHistory taking\nSecondary assessment\nReassessment Rarely does one sign or symptom show you the patient\u2019s status or underlying problem.\nSymptom: subjective condition the patient feels and tells you about\nSign: objective condition you can observe about the patient",
        "Scene Size-up Your evaluation of the conditions in which you will be operating": "Maintain situational awareness.\nScene size-up combines: \nAn understanding of the situation and conditions prior to responding \nDispatcher\u2019s basic information\nObservation of the scene",
        "Ensure Scene Safety": "Issues can range from minor difficulties to major dangers.\nDo not enter until the scene is safe for you and your team.\nTypically, the way you enter an area is the way you will leave.\nWear a high-visibility safety vest on roadways. Consider difficult terrain.\nConsider traffic safety issues.\nConsider environmental conditions. FIGURE 10-1 At times, you may need to move patients out of areas with difficult terrain. Courtesy of the National Ski Patrol. If appropriate, help protect bystanders from becoming patients.\nHazards range from extreme weather conditions to the threat of physical violence.\nAn emergency scene is a dynamically changing environment.",
        "Determine Mechanism of Injury/Nature of Illness": "Calls for assistance can be categorized as medical conditions, traumatic injuries, or both.\nMechanism of injury (MOI)\nType or amount of force\nHow long it was applied\nWhere it was applied to the body Blunt trauma\nThe force occurs over a broad area.\nSkin is usually not broken.\nTissues and organs below the area of impact may be damaged. Penetrating trauma\nThe force of the injury occurs at a small point of contact between the skin and the object.\nOpen wound with high potential for infection For medical patients, determine the nature of illness (NOI).\nSimilarities between MOI and NOI\nTalk with the patient, family, or bystanders.\nUse your senses to check for clues. Be aware of scenes with more than one patient with similar signs or symptoms.\nExample: carbon monoxide poisoning\nCould indicate an unsafe scene for the EMT as well",
        "Importance of MOI and NOI Considering the MOI or NOI early can be of value in preparing to care for the patient.": "You may be tempted to categorize the patient immediately as either trauma or medical.",
        "Take Standard Precautions": "Wear personal protective equipment (PPE).\nShould be adapted to the prehospital task at hand FIGURE 10-4 Proper protective equipment is vital when\nyou are called to a scene in which you may be exposed to\ninfection or blood or other body fluids. \u00a9 Jones & Bartlett Learning. Courtesy of MIEMSS Standard precautions have been recommended for use in dealing with:\nObjects\nBlood\nBody fluids\nOther potential exposure risks of communicable disease When you step out of the EMS vehicle, standard precautions must have been already taken or initiated.\nAt a minimum, gloves must be in place.\nConsider glasses and a mask.",
        "Determine Number of Patients": "During scene size-up, accurately identify the total number of patients.\nCritical in determining the need for additional resources\nWhen there are multiple patients, use the incident command system, identify the number of patients, and then begin triage. Triage is the process of sorting patients based on the severity of each patient\u2019s condition. FIGURE 10-5 With multiple patients, use the incident\ncommand system, call for additional resources, and then\nbegin triage. A multiple casualty incident involving two\ntrains that collided in 2005. \u00a9 David McNew/Getty Images News/Getty Images.",
        "Some situations may require:": "More ambulances\nSpecialized resources FIGURE 10-6 Scenes involving toxic substances may require specially trained rescuers with extra protective equipment. Courtesy of Tempe Fire Department.",
        "Specialized resources include:": "Advanced life support (ALS)\nAir medical support\nFire departments, who may handle high-angle rescue, hazardous materials, or water rescue\nLaw enforcement",
        "To determine if you require additional resources, ask yourself:": "Does the scene pose a threat to me, my patient, or others?\nHow many patients are there?\nDo we have the resources to respond to their conditions?",
        "Form a General Impression": "Formed to determine the priority of care\nFirst part of primary assessment\nMake a note of the person\u2019s:\nAge, sex, and race\nLevel of distress\nOverall appearance Note the patient\u2019s position.\nAvoid standing over the patient.\nAddress the patient by name.\nIntroduce yourself.\nAsk about the chief complaint.\nAddress life-threats immediately. Determine if the patient\u2019s condition is:\nStable\nStable but potentially unstable\nUnstable",
        "Scan for Signs of Uncontrolled Bleeding": "Scan for Signs of Uncontrolled Bleeding Uncontrolled external bleeding takes priority over other assessments.",
        "Assess Level of Consciousness": "The level of consciousness (LOC) can tell you a great deal about the patient\u2019s neurologic and physiologic status. Assessment of an unconscious patient focuses on airway, breathing, and circulation.\nSustained unconsciousness should warn you of a critical respiratory, circulatory, or central nervous system problem. Conscious with an altered LOC may be due to inadequate perfusion.\nCould also be caused by medications, drugs, alcohol, or poisoning To assess for responsiveness, use the mnemonic AVPU:\nAwake and alert\nResponsive to Verbal stimuli\nResponsive to Pain \nUnresponsive Test responsiveness to painful stimuli. FIGURE 10-9 Methods of gauging a patient\u2019s responsiveness to painful stimuli. A. Gently but firmly pinch the patient\u2019s ear lobe. B. Press on the bone above the eye. C. Gently but firmly pinch the muscles of the neck. \u00a9 Jones & Bartlett Leaning. Orientation tests mental status.\nEvaluates a patient\u2019s ability to remember:\nPerson\nPlace\nTime\nEvent Evaluates long-term memory, intermediate-term memory, and short-term memory\nAltered mental status \nAny deviation from alert and oriented to person, place, time, and event\nAny deviation from the patient\u2019s normal baseline",
        "Identify and Treat Life-Threats": "Conditions that cause sudden death:\nAirway obstruction\nRespiratory failure\nRespiratory arrest\nShock\nSevere bleeding\nPrimary cardiac arrest In most cases, begin with airway, followed by breathing and circulation (ABC). \nIn some cases, it may be appropriate to address life threats to circulation first (CAB).",
        "Moving through the primary assessment, stay alert for signs of airway obstruction.": "Ensure the airway remains open (patent) and adequate. Responsive patients\nPatients who are talking or crying have an open airway.\nWatch and listen to how patients speak.\nIf you identify an airway problem, stop the assessment and work to clear the patient\u2019s airway. Unresponsive patients\nImmediately assess the airway.\nUse the jaw-thrust technique when necessary.\nUse the head tilt\u2013chin lift technique when necessary.\nRelaxation of the tongue muscles is a cause of airway obstruction. Signs of obstruction in an unconscious patient:\nObvious trauma, blood, or obstruction\nNoisy breathing (snoring, bubbling, gurgling, crowing, abnormal sounds)\nExtremely shallow or absent breathing",
        "Assess Breathing": "Make sure the patient\u2019s airway is open. \nMake sure the patient\u2019s breathing is present and adequate.\nAsk yourself:\nIs the patient breathing?\nIs the patient breathing adequately?\nIs the patient hypoxic? Respiratory failure\nOccurs when the blood is inadequately oxygenated, or ventilation is inadequate to meeting the oxygen demands of the body\nThe ultimate result of respiratory failure if it is not corrected",
        "Consider providing positive pressure ventilations with an airway adjunct when:": "Respirations exceed 28 breaths/min\nRespirations are fewer than 8 breaths/min\nThe goal for oxygenation for most patients is an oxygen saturation of approximately 94% to 99%.",
        "Observe how much effort is required for the patient to breathe:": "Retractions\nUse of accessory muscles\nNasal flaring\nTwo- to three-word dyspnea\nTripod position\nSniffing position\nLabored breathing",
        "Respiratory distress": "Increased work of breathing\nIncreased effort and rate",
        "Assess": "Mental status\nPulse\nSkin condition",
        "Assess pulse": "The pulse is the pressure wave that occurs as each heartbeat causes a surge in the blood circulating through the arteries.\nPalpate (feel) the pulse.\nIf you cannot palpate a pulse in an unresponsive patient, begin CPR.",
        "Skin condition": "Evaluate the patient\u2019s skin color, temperature, moisture, and capillary refill.\nA normally functioning circulatory system perfuses the skin with oxygenated blood.",
        "Skin color": "Determined by the blood circulating through vessels and the amount and type of pigment present in the skin\nPoor circulation will cause the skin to appear pale, white, ashen, or gray.",
        "Skin color (cont\u2019d)": "When blood is not properly saturated with oxygen, it appears blue.\nChanges in skin color may result from chronic illness. FIGURE 10-13 Cyanosis occurs when the patient has low levels of oxygen in the blood. \u00a9 St. Bartholomew\u2019s Hospital, London/Photo Researchers, Inc.",
        "Skin temperature": "Normal skin will be warm to the touch.\nAbnormal skin temperatures are hot, cool, cold, and clammy.",
        "Skin moisture": "Dry skin is normal.\nSkin that is wet, moist, or excessively dry and hot suggests a problem.",
        "Capillary refill": "Evaluated to assess the ability of the circulatory system to restore blood to the capillary system\nPress on the patient\u2019s fingernail.\nRemove the pressure.\nThe nail bed should restore to its normal pink color.",
        "Capillary refill (cont\u2019d)": "Should be restored to normal within 2 seconds FIGURE 10-14 A. To test capillary refill, gently compress\nthe fingertip until it blanches. B. Release the fingertip, and\ncount until it returns to its normal pink color. A., B: \u00a9 Jones & Bartlett Learning. Courtesy of MIEMSS.",
        "Assess and control external bleeding in trauma patients.": "Should occur before addressing airway or breathing concerns.\nBleeding from a large vein is characterized by a steady flow of blood.\nBleeding from an artery is characterized by a spurting flow of blood.",
        "Controlling external bleeding can be simple.": "Apply direct pressure.\nApply a tourniquet if: \nDirect pressure is not quickly successful.\nObvious arterial hemorrhage of an extremity",
        "Perform a Rapid Exam Identify injuries that must be managed or protected before the patient is transported.": "Take 60 to 90 seconds to perform.\nNot a systematic or focused physical examination",
        "Determine Priority of Patient Care and Transport": "Primary assessment assists in determining transport priority.\nHigh-priority patients include those with any of the following conditions:\nUnresponsive\nDifficulty breathing\nUncontrolled bleeding High-priority patients (cont\u2019d):\nAltered level of consciousness\nSevere chest pain\nPale skin or other signs of poor perfusion\nComplicated childbirth\nSevere pain in any area of the body The Golden Hour (Golden Period) is the time from injury to definitive care.\nTreatment of shock and traumatic injuries must occur.\nImmediate transport is one of the keys to survival of patients who need immediate care that the EMT cannot provide. FIGURE 10-16 The Golden Hour, also called the Golden Period, is the time during which treatment of shock or traumatic injuries is most critical and the potential for survival is best. \u00a9 Jones & Bartlett Learning. Transport decisions should be made at this point, based on:\nPatient\u2019s condition\nAvailability of advanced care\nDistance of transport\nLocal protocols",
        "Provides detail about the chief complaint and the patient\u2019s signs and symptoms": "Includes demographic information:\nDate of the incident\nPatient\u2019s age, gender, race, past medical history, and current health status",
        "Investigate the chief complaint.": "Make introductions, make the patient feel comfortable, and obtain permission to treat.\nAsk a few simple and direct questions.\nRefer to the patient as Mr., Ms., or Mrs., using the patient\u2019s last name.\nAsk open-ended questions.",
        "If the patient is unresponsive, patient information and clues about the incident may be obtained from:": "Family members present\nA person who may have witnessed the situation\nBystanders\nMedical alert jewelry\nOther patient medical history documentation",
        "Obtain a SAMPLE History Use the mnemonic SAMPLE to obtain the following information:": "Signs and symptoms\nAllergies\nMedications\nPertinent past medical history\nLast oral intake\nEvents leading up to the injury/illness",
        "Critical Thinking in Assessment Gathering": "Seeking facts\nEvaluating\nConsidering what the information means\nSynthesizing\nPutting the information together to plan scene management and patient care",
        "Alcohol and drugs": "Signs may be confusing, hidden, or disguised.\nPatient may deny having any problems.\nHistory gathered may be unreliable.\nDo not judge the patient. \nBe professional in your approach.",
        "Taking History on Sensitive Topics": "Physical abuse or violence\nReport all physical abuse or domestic violence to the appropriate authorities.\nFollow local protocols.\nDo not accuse; instead, immediately involve law enforcement. Sexual history\nConsider all female patients of childbearing age who report lower abdominal pain to be pregnant.\nAsk about the patient\u2019s last menstrual period.\nInquire about urinary symptoms with male patients.\nWhen appropriate, ask all patients about the potential for sexually transmitted diseases.",
        "Special Challenges in Obtaining Patient History": "Silence\nPatience is extremely important.\nUse a closed-ended question that requires a simple yes or no answer.\nConsider whether the silence is a clue to the patient\u2019s chief complaint. Overly talkative\nReasons why a patient may be overly talkative:\nExcessive caffeine consumption\nNervousness\nIngestion of cocaine, crack, or methamphetamines\nUnderlying psychological issue Multiple symptoms\nPrioritize the patient\u2019s complaints as you would in triage.\nStart with the most serious and end with the least serious. Anxiety\nSome anxious patients show signs of psychological shock:\nPallor\nDiaphoresis\nShortness of breath\nNumbness in the hands and feet\nDizziness or light-headedness\nLoss of consciousness Anger and hostility\nFriends, family, or bystanders may direct their anger and rage toward you.\nRemain calm, reassuring, and gentle.\nIf the scene is not safe or secured, get it secured. Intoxication\nDo not put an intoxicated patient in a position where he or she feels threatened.\nPotential for violence and a physical confrontation is high.\nAlcohol dulls a patient\u2019s senses. Crying\nA patient who cries may be sad, in pain, or emotionally overwhelmed.\nRemain calm.\nBe patient, reassuring, and confident.\nMaintain a soft voice. Depression\nAmong the leading causes of disability worldwide\nSymptoms include sadness, hopelessness, restlessness, irritability, sleeping and eating disorders, and a decreased energy level.\nBe a good listener. Confusing behavior or history\nConditions such as hypoxia, stroke, diabetes, trauma, medications, and other drugs could alter a patient\u2019s explanation of events.\nOlder patients could have dementia, delirium, or Alzheimer disease. Limited cognitive abilities\nKeep your questions simple, and limit the use of medical terms.\nBe alert for partial answers, and keep asking questions. \nRely on the presence of family, caregivers, and friends to supply answers. Hearing problems\nAsk questions slowly and clearly.\nUse a stethoscope to function as a hearing aid.\nLearn simple sign language to help with communication.\nUse a pencil and paper. Visual impairments\nIdentify yourself verbally when you enter the scene.\nReturn any items that have been moved to their previous positions.\nExplain to the patient what is happening in each step of the assessment of vital signs.",
        "Cultural challenges": "Do not use medical language. \nPatients may prefer to speak with health care providers of the same gender.\nGain the assistance of the patient\u2019s friends or family members.\nEnlist the help of health care providers of the same culture or background, if possible.",
        "Language barriers": "Find an interpreter, if possible.\nIf not, determine if the patient understands who you are.\nKeep questions straightforward and brief.\nUse hand gestures.\nBe aware of the language diversity in your community.",
        "May be performed on-scene, in the back of the ambulance en route to the hospital, or not at all": "Purpose is to perform a systematic physical examination of the patient.\nMay be a systematic head-to-toe secondary assessment or an assessment that focuses on a certain area or system of the body",
        "How and what to assess:": "Inspection\u2014Look at the patient for abnormalities.\nPalpation\u2014Touch or feel the patient for abnormalities.\nAuscultation\u2014Listen to the sounds a body makes by using a stethoscope.",
        "Use the mnemonic DCAP-BTLS.": "Compare findings on one side of the body with the other side when possible.",
        "Focused Assessment Performed on patients who have sustained nonsignificant MOIs or on responsive medical patients": "Typically based on the chief complaint\nGoal is to focus your attention on the body part or systems affected by the priority problems.",
        "Expose the patient\u2019s chest.": "Look for signs of airway obstruction.\nInspect for symmetry.\nListen to breath sounds.\nMeasure the respiratory rate.\nLook for retractions and increased work of breathing.",
        "Respiratory System": "Respiratory rate\nA normal rate in adults ranges from 12 to 20 breaths/min.\nChildren breathe at even faster rates.\nCount the number of breaths in a 30-second period and multiply by two. Respiratory rhythm\nRegular \nThe time from one peak chest rise to the next is fairly consistent.\nIrregular \nThe respirations vary or the rate changes frequently. Quality of breathing\nNormal breathing is silent.\nBreathing accompanied by other sounds may indicate a significant respiratory problem. Depth of breathing\nAmount of air the patient exchanges depends on the rate and tidal volume.\nBreath sounds\nYou can almost always hear breath sounds better from the patient\u2019s back. FIGURE 10-23 Locations for auscultating breath sounds: both sides of the chest in multiple lung fields, as shown. A. Stethoscope position for auscultating the front of the chest. B. Stethoscope position for auscultating the back. \u00a9 Jones & Bartlett Learning. What are you listening for?\nNormal breath sounds\nSnoring breath sounds\nWheezing breath sounds\nCrackles\nRhonchi\nStridor",
        "Cardiovascular System": "Look for trauma to the chest and listen for breath sounds. \nConsider the pulse, respiratory rate, and blood pressure.\nPay attention to rate, quality, and rhythm. Consider your findings when assessing the skin.\nCheck and compare distal pulses.\nConsider auscultation for abnormal heart sounds. Pulse rate\nNormal resting pulse for an adult is between 60 and 100 beats/min.\nThe younger the patient, the faster the pulse. Pulse quality\nDescribe a stronger than normal pulse as \u201cbounding.\u201d\nA pulse that is weak and difficult to feel is described as \u201cweak\u201d or \u201cthready.\u201d Pulse rhythm\nRegular \nThe interval between each contraction should be the same.\nThe pulse should occur at a constant, regular rhythm. \nIrregular\nIf the heart periodically has an early or late beat.\nIf a pulse beat is missed. Blood pressure\nPressure of circulating blood against the walls of the arteries\nA drop in blood pressure may indicate:\nA loss of blood or fluid components \nA loss of vascular tone and sufficient arterial constriction\nA cardiac pumping problem Blood pressure (cont\u2019d)\nDecreased blood pressure is a late sign of shock.\nAbnormally high blood pressure may result in a rupture or other critical damage in the arterial system. A blood pressure cuff with gauge contains the following components:\nA wide outer cuff\nAn inflatable wide bladder\nA ball-pump with a one-way valve\nA pressure gauge Auscultation is the most common means of measuring blood pressure. \nPalpation method does not depend on the ability to hear sounds. Follow standard precautions. Check for a dialysis\nfistula, central line, previous mastectomy, and\ninjury to the arm. If any are present, use the\nbrachial artery on the other arm. Apply the cuff\nsnugly. The lower border of the cuff should be\nabout 1 inch (2.5 cm) above the antecubital space. Normal blood pressure\nHypotension: Blood pressure is\n   lower than normal.\nHypertension: Blood pressure is\n   higher than normal.",
        "Neurologic System": "Neurologic assessment\nShould be performed with any patient who has:\nChanges in mental status\nA possible head injury\nStupor\nDizziness/drowsiness\nSyncope Neurologic assessment (cont\u2019d)\nEvaluate the level of consciousness and orientation.\nUse the AVPU scale if appropriate.\nThe Glasgow Coma Scale (GCS) score can be helpful in providing additional information.",
        "The pupil is the black center portion of the eye.": "Normally round and of approximately equal size\nIn the absence of any light, the pupils will become fully relaxed and dilated. FIGURE 10-26 A. Constricted pupils. B. Dilated pupils. C. Unequal pupils. A., B., C: \u00a9 American Academy of Orthopaedic Surgeons. A small number of the population exhibit unequal pupils (anisocoria).\nCauses of depressed brain function:\nInjury of the brain or brainstem\nTrauma or stroke\nBrain tumor\nInadequate oxygenation or perfusion\nDrugs or toxins PEARRL is a useful assessment guide:\nPupils\nEqual\nAnd\nRound\nRegular in size\nReact to Light",
        "Neurovascular Status Check for bilateral muscle strength and weakness.": "Complete a thorough sensory assessment.\nTest for pain, sensations, and position. \nCompare distal and proximal sensory and motor responses and one side with the other.",
        "Head, neck, and cervical spine": "Palpate the scalp and skull.\nCheck the patient\u2019s eyes.\nCheck the color of the sclera.\nAssess the patient\u2019s cheekbones.\nCheck the patient\u2019s ears and nose for fluid.",
        "Head, neck, and cervical spine (cont\u2019d)": "Check the upper (maxillae) and lower (mandible) jaw.\nOpen the patient\u2019s mouth and look for any broken or missing teeth.\nNote any unusual odors in the mouth.",
        "Chest": "Inspect, visualize, and palpate.\nWatch for both sides of the chest to rise and fall together with normal breathing. \nObserve for abnormal breathing signs.",
        "Abdomen": "Palpate for tenderness, rigidity, and patient guarding.\nFour quadrants:\nLeft upper quadrant (LUQ)\nLeft lower quadrant (LLQ)\nRight upper quadrant (RUQ)\nRight lower quadrant (RLQ)",
        "Pelvis": "Inspect for symmetry and any obvious signs of injury, bleeding, and deformity.\nExtremities\nInspect for symmetry, cuts, bruises, swelling, obvious injuries, and bleeding.\nPalpate for deformities.\nCheck for pulses and motor and sensory functions.",
        "Posterior body": "Inspect the back for DCAP-BTLS, symmetry, and open wounds.\nPalpate the spine from the neck to the pelvis for tenderness and deformity.",
        "Use appropriate monitoring devices.": "Should never replace your comprehensive assessment of the patient\nPulse oximetry\nUsed to evaluate oxygenation\u2019s effectiveness FIGURE 10-36 The pulse oximeter is a device that measures the saturation of oxygen in the blood as a percentage. \u00a9 juanrvelasco/iStock.",
        "Pulse oximetry (cont\u2019d)": "Measures the oxygen saturation of hemoglobin in the capillary beds\nPatients with difficulty breathing should receive oxygen regardless of their pulse oximetry value.",
        "Capnography": "Can quickly provide information on a patient\u2019s ventilation, circulation, and metabolism\nBlood glucometry\nMeasures the level of glucose in the bloodstream",
        "Noninvasive blood pressure measurement": "Noninvasive blood pressure measurement FIGURE 10-24 A sphygmomanometer. \u00a9 WizData, Inc./Shutterstock."
    },
    {
        "National EMS Education Standard Competencies": "Preparatory\nApplies fundamental knowledge of the emergency medical services (EMS) system; safety/well-being of the emergency medical technician (EMT), medical/legal, and ethical issues to the provision of emergency care. Life Span Development\nApplies fundamental knowledge of life span development to patient assessment and management.",
        "Introduction Humans develop throughout their lives.": "EMTs must be aware of the physical changes a person undergoes at various stages of life.\nMay affect the approach to patient care",
        "Neonates and Infants": "Neonates\nBirth to 1 month\nInfants\n1 month to 1 year\nDevelop at a startling rate FIGURE 7-1 An infant is 1 month to 1 year of age. \u00a9 Johanna Goodyear/ShutterStock. Weight\nNeonate weighs 6 to 8 lb (3 to 3.5 kg) at birth.\nThe head accounts for 25% of body weight.\nGrowth of about 1 oz per day\nWeight triples by the end of the first year Cardiovascular system\nAt birth, neonate makes transition from fetal to independent circulation.\nPulmonary system\nInfants younger than 6 months are prone to nasal congestion.\nInfants have larger tongues and shorter, narrower airways, so airway obstruction is more common than in older children or adults. Nervous system\nEvolution continues after birth.\nMoro reflex: neonate opens arms wide, spreads fingers, and seems to grab at things.\nPalmar grasp: occurs when an object is placed into the neonate\u2019s palm\nRooting reflex: neonate instinctively turns head when something touches its cheek.\nSucking reflex: occurs when a neonate\u2019s lips are stroked Fontanelles\nSpaces between the bones that eventually fuse to form the skull\nPosterior fontanelle fuses by 3 months.\nAnterior fontanelle fuses between age 9 and 18 months. FIGURE 7-2 Fontanelles. \u00a9 Jones & Bartlett Learning. Nervous system (cont\u2019d)\n2 months of age: tracking objects with their eyes and recognize familiar faces\n6 months of age: sitting upright and babbling\n12 months of age: walking with minimal assistance Immune system\nMaintains some of the mother\u2019s immunities\nInfants can also receive antibodies via breastfeeding. Psychosocial changes\nBegin at birth and evolve as the infant interacts with the environment Psychosocial changes (cont\u2019d)\nCrying is the main method of communicating distress.\nInfants develop relationships with their parents or caregivers at different rates. Psychosocial changes (cont\u2019d)\nBonding is based on a secure attachment.\nAnxious-avoidant attachment is found in infants who are repeatedly rejected.\nSeparation anxiety is common in older infants.\nTrust and mistrust involves an infant\u2019s needs being met.",
        "Toddlers and Preschoolers": "The cardiovascular system of a toddler (1 to 3 years) or preschooler (4 to 6 years) is not dramatically different from an adult. FIGURE 7-4 A toddler is 1 to 3 years of age. \u00a9 EML/Shutterstock. Preschoolers (3 to 6 years)\nPulse: 80 to 140 beats/min\nRespiratory rate: 20 to 25 breaths/min\nSystolic blood pressure: 80 to 100 mm Hg FIGURE 7-5 A preschooler is 3 to 6 years of age. \u00a9 Maxim Bolotnikov/Shutterstock. Preschoolers (cont\u2019d)\nDo not have well-developed lung musculature\nWeight gain should level off.\nPassive immunity is lost.\nNeuromuscular growth also makes considerable progress at this age.\nAverage age for completion of toilet training is 28 months. Psychosocial changes\nLearn to speak and express themselves\nMaster basic language \nInteract and play games with other children\nBegin to understand cause and effect\nLearn to recognize gender differences by observing role models",
        "School-Age Children": "6 to 12 years\nPhysical traits and functions continue to mature at a rapid rate FIGURE 7-7 A school-age child is 6 to 12 years of age. \u00a9 Trout55/Shutterstock. Growth of 4 lb and 2.5 inches each year\nPermanent teeth come in.\nBrain activity increases in both hemispheres. Psychosocial changes\nPreconventional reasoning: children act to avoid punishment and get what they want.\nConventional reasoning: children look for approval from peers and society.\nPostconventional reasoning: children make decisions guided by their conscience.\nSelf-concept and self-esteem develop.",
        "12 to 18 years": "Vital signs level off.\nPulse: 60 to 100 beats/min\nRespirations: 12 to 20 breaths/min\nSystolic blood pressure: 90 to 110 mm Hg FIGURE 7-8 An adolescent is 12 to 18 years of age. \u00a9 Jamie Wilson/Shutterstock. 2- to 3-year growth spurt\nGirls finish by 16 years; boys by 18 years.\nReproductive system matures.\nSecondary sexual development takes place.\nVoices start to change.\nMenstruation begins.\nAcne can occur. Psychosocial changes\nAdolescents and their families often deal with conflict.\nPrivacy becomes an issue.\nSelf-consciousness increases.\nAdolescents may struggle to create their own identity. Psychosocial changes (cont\u2019d)\nAntisocial behavior and peer pressure peak at age 14 to 16 years.\nSmoking, illicit drug use, unprotected sex\nEating disorders\nCode of ethics develops.\nHigh risk of suicide and depression",
        "Early Adults": "19 to 40 years\nVital signs do not vary greatly.\nPulse: 60 to 100 beats/min\nRespiratory rate: 12 to 20 breaths/min\nSystolic blood pressure: 90 to 120 mm Hg FIGURE 7-10 An early adult is 19 to 40 years of age. \u00a9 Rubberball Productions. From age 19 to 25 years, the body should be functioning at its optimal level.\nLifelong habits are solidified.\nPsychosocial changes\nLife centers on work, family, and stress.\nSettling down, marriage, and family\nOne of the more stable periods of life",
        "Middle Adults": "41 to 60 years\nVital signs remain the same.\nPulse: 60 to 100 beats/min\nRespiratory rate: 12 to 20 breaths/min\nSystolic blood pressure: 90 to 140 mm Hg FIGURE 7-11 A middle adult is 41 to 60 years of age. \u00a9 Photodisc. Vulnerable to vision and hearing loss\nCancer incidence increases.\nMenopause occurs in late 40s or early 50s.\nDiabetes, hypertension, and weight problems are common.\nExercise and healthy diet can diminish the effects of aging. Psychosocial changes\nFocus on achieving life goals\nReadjust lifestyle as children leave home\nGenerally have the physical, emotional, and spiritual reserves to handle life\u2019s issues\nFinances become a concern.\nMay be caring for both children leaving for college and aging parents",
        "61 years and older": "Life expectancy is constantly changing.\nNow approximately 78 years FIGURE 7-12 An older adult is 61 years of age or older. \u00a9 Photodisc. Cardiovascular system\nDeclines with age largely due to atherosclerosis\nHeart rate and cardiac output decrease.\nVascular system becomes stiff.\nAbility to produce replacement blood cells declines, as does blood volume. Respiratory system\nSize of airway increases.\nSurface area of alveoli decreases.\nNatural elasticity of the lungs decreases.\nBreathing becomes more labor intensive. Respiratory system (cont\u2019d)\nVital capacity decreases.\nChest becomes more rigid and fragile.\nCough and gag reflex diminish.\nGreater risk for aspiration and airway obstruction\nMore susceptible to lung infections Endocrine system\nInsulin production drops off.\nMetabolism decreases.\nThe reproductive system changes to some extent. Digestive system\nTaste sensations decrease.\nSaliva secretion decreases.\nAbility of the intestines to contract and move food diminishes.\nGallstones become increasingly common.\nAnal sphincter changes can produce fecal incontinence. Renal system\nFiltration function declines.\nKidney mass decreases by 20%.\nDiminished blood flow to the kidneys\nDecreased ability to clear wastes from the body and ability to conserve fluids when needed Nervous system\nMotor and sensory neural networks become slower.\nNeurons are lost but there is no loss of knowledge or skill.\nSleep patterns change. Nervous system (cont\u2019d)\nAge-related shrinkage creates a void between the brain and the outermost layer of the meninges. FIGURE 7-14 Age-related atrophy or shrinkage of the brain\ncreates space between the brain and dura mater (subdural\nspace). When the bridging veins are stretched and torn,\nblood may accumulate in this area. \u00a9 Jones & Bartlett Learning. Nervous system (cont\u2019d)\nPeripheral nerve sensation is diminished.\nIncreased reaction times cause longer delays between stimulation and motion.\nSlowdown in reflexes and decreased kinesthetic sense may contribute to falls and trauma. Sensory changes\nMost older adults can see and hear well.\nMay need glasses or hearing aids\nVisual distortions are common.\nHearing loss is four times more common than vision loss. Psychosocial changes\nUntil about 5 years before death, most people retain high brain function.\nStatistics indicate that 95% of the elderly live at home.\nFinancial limits may restrict access to health care or medications. Psychosocial changes (cont\u2019d)\nMore than 50% of all single women in the United States who are 60 years of age or older are living at or below the poverty line.\nElderly need to face their own mortality.\nIsolation and depression can be challenges."
    },
    {
        "c": "celsius",
        "cc": "cubic centimeter",
        "ci": "curie",
        "cm": "centimeter",
        "db": "decibel",
        "dl": "deciliter",
        "fl": "fluid",
        "f": "fahrenheit",
        "fl oz": "fluid ounce",
        "g": "gram",
        "hz": "hertz",
        "kg": "kilogram",
        "km": "kilometer",
        "l": "liter",
        "l/min": "liters per minute",
        "lb": "pound",
        "m": "thousand, meter, molar",
        "mcg": "microgram",
        "meq": "milliequivalent",
        "mg": "milligram",
        "ml": "milliliter",
        "mmhg": "millimeters of mercury",
        "mol wt (mw)": "molecular weight",
        "oz": "ounce",
        "ppm": "parts per million",
        "pt": "pint",
        "rad": "radiation-absorbed dose",
        "rev/min, rpm": "revolutions per minute",
        "u": "unit",
        "mu, u": "micron",
        "v": "volt",
        "vol %": "volume percent",
        "v/v": "volume per volume",
        "w": "watt",
        "w/v": "weight per volume"
    },
    {
        "acp": "acid phosphatase",
        "afp": "alpha fetoprotein",
        "a/g": "albumin-globulin ratio",
        "alt": "alanine aminotransferase",
        "ana": "antinuclear antibodies",
        "aptt": "activated partial thromboplastin time",
        "aso": "antistreptolysin-o",
        "ast": "aspartate aminotransferase",
        "bt": "bleeding time",
        "bun": "blood urea nitrogen",
        "ca": "calcium",
        "cat": "computed axial tomography",
        "cbc": "complete blood count",
        "cea": "carcinoembryonic antigen",
        "chol": "cholesterol",
        "cl": "chloride",
        "cpk": "creatine phosphokinase",
        "creat": "creatinine",
        "crp": "c-reactive protein",
        "cxr": "chest x ray",
        "dexa": "dual energy x ray absorptiometry",
        "diff": "differential (blood count)",
        "dr": "diagnostic radiography",
        "dsa": "digital subtraction angiography",
        "ekg, ecg": "electrocardiogram",
        "echo": "echocardiography",
        "eeg": "electroencephalogram",
        "esr": "erythrocyte sedimentation rate",
        "fbs": "fasting blood sugar",
        "gtt": "glucose tolerance test",
        "hct": "hematocrit",
        "hdi": "high-definition imaging",
        "hdl": "high density lipoprotein",
        "hgb": "hemoglobin",
        "k": "potassium",
        "ldh": "lactate dehydrogenase",
        "ldl": "low density lipoprotein",
        "lytes": "electrolytes",
        "mch": "mean corpuscular hemoglobin",
        "mchc": "mean corpuscular hemoglobin concentration",
        "mcv": "mean corpuscular volume",
        "mri": "magnetic resonance imaging",
        "muga": "multiple-gated acquisition scanning",
        "na": "sodium",
        "pcv": "packed-cell volume",
        "pet": "positron emission tomography",
        "pft": "pulmonary function test",
        "ph": "hydrogen ion concentration",
        "plt": "platelets",
        "pt, pro. time": "prothrombin time",
        "ptt": "partial thromboplastin time",
        "riu": "radioactive iodine uptake",
        "rast": "radioallergosorbent test",
        "rbc": "red blood cell, red blood count",
        "rdw": "red (cell) distribution width",
        "ria": "radioimmunoassay",
        "sma": "sequential multiple analysis",
        "spect": "single photon emission computed tomography",
        "sp gr": "specific gravity",
        "trig": "triglycerides",
        "tt": "thrombin time",
        "ua": "urinalysis",
        "us": "ultrasound",
        "vldl": "very low density lipoprotein",
        "wbc": "white blood cell, white blood count",
        "xr": "x-ray"
    },
    {
        "erythr/o (color)": "red",
        "cyan (color)": "blue",
        "xanth (color)": "yellow",
        "polio (color)": "gray",
        "melano (color)": "black",
        "chlor/o (color)": "green",
        "cirrh/o (color)": "yellow, tawny",
        "alb, albin/o, leuk/o (color)": "white",
        "acar/o": "mites",
        "arachn/o": "spiders",
        "bacteri/o": "bacteria",
        "coccus": "berry shaped bacterium",
        "fung/i": "fungus or mushroom",
        "helminth/o": "worm",
        "hirud/i": "leech",
        "ixod/i": "ticks",
        "myc/o": "fungus/mushroom",
        "parasit/o": "parasite",
        "pedicul/o": "louse",
        "scolec/o": "worm",
        "verm/i": "worm",
        "vir/o": "virus",
        "acous/o (sense)": "hearing",
        "acoust/o (sense)": "hearing",
        "audi/o (sense)": "hearing",
        "audit/o (sense)": "hearing",
        "cusis (sense)": "hearing",
        "olfact (sense)": "smell",
        "osmia (sense)": "smell",
        "osm/o (sense)": "smell",
        "osphresia (sense)": "smell",
        "osphresi/o (sense)": "smell",
        "haph/e (sense)": "touch",
        "pselaphes/o (sense)": "touch",
        "tact/o (sense)": "touch",
        "thigm (sense)": "touch",
        "geusia (sense)": "taste",
        "gustat/o (sense)": "taste",
        "gust/o (sense)": "taste",
        "opia (sense)": "vision",
        "opsia (sense)": "vision",
        "opt/o (senses)": "vision"
    },
    {
        "normal breath sounds made by air moving in and out of the alveoli?": "vesicular breath sounds",
        "normal breath sounds made by air moving through the bronchi?": "bronchial breath sounds",
        "stridor is an indication of?": "airway obstruction",
        "rales": "a crackling, rattling breath sound that signals fluid in the air spaces of the lungs.",
        "wheezing": "high-pitched, musical, whistling sound heard most commonly on exhalation. caused by a constriction of bronchioles.",
        "high-pitched sound that is indicates an upper airway blockage?": "stridor",
        "tachypnea": "rapid breathing",
        "crackles": "caused by fluid in the small airways. they are popping sounds that are heard when air is forced through the small airways that are being narrowed by the accumulation of fluid, mucus, or pus.",
        "apnea": "absence of breathing",
        "conditions that could cause tachypnea?": "fever, exercise, anxiety, shock."
    },
    {
        "abn": "abnormal",
        "amb": "ambulatory",
        "a&o x 4": "alert and oriented to person, place, time and event",
        "a/o": "alert and oriented",
        "a&p": "auscultation and palpation/percussion",
        "asx": "asymptomatic",
        "ause": "auscultation",
        "a&w": "alive and well",
        "bp": "blood pressure",
        "ca": "chronological age",
        "c&a": "conscious and alert",
        "cc": "chief complaint",
        "dob": "date of birth",
        "du": "diagnosis undetermined",
        "dx": "diagnosis",
        "ex": "examination",
        "f": "female",
        "fh": "family history",
        "fod": "free of disease",
        "fu": "follow up",
        "fuo": "fever of unknown origin",
        "h/o": "history of",
        "h&p": "history and physical",
        "ht": "height",
        "hx": "history",
        "ibw": "ideal body weight",
        "ippa": "inspection, palpation, percussion, auscultation",
        "iq": "intelligence quotient",
        "l&w": "living and well",
        "m": "male",
        "ma": "mental age",
        "mhx": "medical history",
        "nap": "no appreciable disease",
        "n/c": "no complaints",
        "nd": "not diagnosed",
        "ndf": "no disease found",
        "ned": "no evidence of disease",
        "nka": "no known allergies",
        "nkda": "no known drug allergies",
        "norm": "normal",
        "nvs": "neurological vital signs",
        "nyd": "not yet diagnosed",
        "p": "pulse",
        "p&a": "percussion and auscultation",
        "pe": "physical examination",
        "ph": "poor health",
        "px": "past history",
        "pi": "present illness",
        "pphx": "previous psychiatric history",
        "prog": "prognosis",
        "pt": "patient",
        "r": "respiration",
        "ro": "rule out",
        "ros": "review of symptoms",
        "rvc": "responds to verbal commands",
        "soap": "subjective, objective, assessment, plan",
        "soi": "severity of illness",
        "sonp": "soft organs not palpable",
        "s/s": "signs and symptoms",
        "sx": "symptoms, signs",
        "t": "temperature",
        "tpr": "temperature, pulse and respiration",
        "tx": "treatment",
        "uchd": "usual childhood diseases",
        "uo": "under observation",
        "vs": "vital signs",
        "wdwn": "well developed, well nourished",
        "wnl": "within normal limits",
        "wt": "weight",
        "x&d": "examination and diagnosis",
        "yr": "year",
        "y/o": "years old",
        "yob": "year of birth"
    },
    {
        "what is a measurement of the carbon dioxide that is transported by the circulatory system and exhaled during respiration?": "capnography or end tidal co2",
        "what diagnostic tool changes more rapidly with the patient's condition, pulse oximetry or capnography?": "capnography",
        "what measurement is used to communicate the value of etco2?": "mmhg or millimeters of mercury",
        "what is a normal measurement of etco2?": "35-45 mmhg",
        "how does a qualitative capnography device indicate the presence of co2?": "change colors",
        "what two types of devices are used to measure quantitative capnography?": "sidestream and mainstream",
        "what type of quantitative capnography device pulls a sample of air to a measuring device?": "sidestream",
        "what type of quantitative capnography device measures co2 at the site of the patient's exhaled air?": "mainstream",
        "name two types of quantitative capnography devices?": "etco2 nasal cannula and in-line device",
        "what factors can impact the effectiveness of a qualitative capnography device?": "age and how it is stored",
        "true or false.  an in-line quantiative capnography device can be used on a bag valve mask device?": "true",
        "name three types of respiratory patients that should receive capnography monitoring.": "respiratory distress, copd exacerbation, asthma, pulmonary embolism, chest trauma with suspected lung involvement",
        "name two types of metabolic complaints that would benefit from capnography monitoring.": "diabetic ketoacidosis, sepsis, hyperosmolar hyperglycemic non-ketoacidosis",
        "name two types of circulatory complaints that would benefit from capnography monitoring.": "hypovolemic shock, congestive heart failure, trauma with significant blood loss, trauma to the circulatory system",
        "true or false.  during a cardiac arrest, capnography can indicate the quality of chest compressions?": "true",
        "how does capnography change when return of spontaneous circulation occurs during cardiac arrest?": "there will be a rapid rise in capnography values",
        "why is capnography a valueable tool for patients with an advanced airway?": "it provides continuous monitoring of the airway's placement and efficacy",
        "fill in the blanks.  capnography with a reading consistently below ___ mmhg after __ minutes of cpr can predict death with 100% sensitivity and specificity.": "10 mmhg, 20 minutes",
        "in addition to providing an etco2 value, what additional informaiton can a quantitative capnography device provide?": "capnography waveform",
        "what three physiological factors can impact a patient's capnography?": "metabolism, circulation and ventilation"
    },
    {
        "cheyne-stokes respirations": "deep, rapid breaths that slow down to a period of apnea, and then repeat again.",
        "kussmaul respirations": "deep, labored, continuous breaths.",
        "cause of biot respirations": "may indicate severe brain injury or brain stem herniation.",
        "apnea": "absence of breathing",
        "what is bradypnea?": "slow and shallow respirations",
        "eupnea": "normal breathing. in adults, it's a breathing rate of 12-20 breaths per minute with symmetrical chest rise and fall.",
        "biot respirations": "abnormal breathing pattern. deep breaths (gasps) followed by periods of apnea.",
        "what conditions can cause cheyne-stokes respirations?": "stroke, heart failure, brain tumor, traumatic brain injuries",
        "agonal breathing": "gasping breaths, usually due to cardiac arrest.",
        "paradoxical breathing": "respiratory distress noted by the chest wall moving in the opposite direction when taking a breath (moves inward).",
        "you respond to the scene of a 55 year old male who is unconscious. he is breathing deep and rapid and has a blood sugar of 512. what type of respiratory pattern is this patient exhibiting and what is causing it?": "this patient's deep, rapid respirations are indicative of kussmaul respirations, which is caused by diabetic ketoacidosis, or dka.",
        "seesaw breathing": "movement of the diaphragm causes the chest and abdomen to move in opposite direction. seen in infants and children in respiratory distress."
    },
    {
        "ab (prefix)": "away from",
        "ante (prefix)": "before, in front",
        "bi (prefix)": "two, double",
        "circum (prefix)": "around",
        "co (prefix)": "together",
        "demi (prefix)": "half",
        "en (prefix)": "into, in, within",
        "ex (prefix)": "out, away from, outside",
        "extra (prefix)": "outside, beyond",
        "fore (prefix)": "before, in front of",
        "hypo (prefix)": "under, below, beneath, less than normal",
        "inter (prefix)": "between",
        "in (prefix)": "inside, within, not",
        "intra (prefix)": "within",
        "justa (prefix)": "near, beside",
        "medio (prefix)": "middle",
        "ob (prefix)": "against, in front of",
        "para (prefix)": "near, beside, beyond",
        "post (prefix)": "after, behind",
        "pre (prefix)": "before, in front",
        "quadri (prefix)": "four",
        "re (prefix)": "back, again",
        "retro (prefix)": "backward, behind",
        "semi (prefix)": "half",
        "sub (prefix)": "under, below",
        "super (prefix)": "above, excess",
        "supra (prefix)": "above, over",
        "trans (prefix)": "across, through",
        "ultra (prefix)": "beyond, excess",
        "uni (prefix)": "one",
        "de (prefix)": "down, from",
        "ecto (prefix)": "outside",
        "dia (prefix)": "through",
        "endo (prefix)": "within, inner",
        "latero (prefix)": "the side",
        "ventro (prefix)": "front part of body",
        "anterior": "the front of the body (anatomic position) (synonym = ventral)",
        "ventral": "the front of the body (anatomic position) (synonym = anterior)",
        "posterior": "the back of the body (anatomic position) (synonym = dorsal)",
        "dorsal": "the back of the body (anatomic position) (synonym = posterior)",
        "superior": "upper or higher relative to another body part (synonym = cranial)",
        "cranial": "upper or higher, relative to another body part (synonym = superior)",
        "inferior": "lower or below, relative to another body part (synonym = caudal)",
        "caudal": "lower or below, relative to another body part (synonym = inferior)",
        "lateral": "at the side or toward the side of the body",
        "medial": "towards the middle of the body, opposite of lateral",
        "superficial": "refers to a position which is closest to the body\u2019s surface",
        "deep": "a position which is distant or away from the body\u2019s surface"
    },
    {
        "introduction": "a stroke is an interruption of blood flow to the brain. there are two main types of strokes: hemorrhagic strokes and ischemic strokes. strokes are the third leading cause of death in the united states and are the leading cause of disability in the united states.",
        "ischemic stroke": "ischemic strokes are caused by blot clots that inhibit blood flow to the brain. due to lack of oxygen and nutrients, brain cells die the longer blood flow is occluded. ischemic strokes can be further divided into thrombotic strokes and embolic strokes. thrombotic strokes occur when a blood clot forms inside the brain whereas embolic strokes occur when a blood clot forms elsewhere in the body and lodges itself in the brain. ischemic strokes make up around 87% of all strokes.",
        "hemorrhagic stroke": "hemorrhagic strokes occur when there is a rupture of a blood vessel in the brain or a blood vessel that supplies the brain with blood. this stops the brain from being delivered oxygen or nutrients and causes death of brain tissue. this bleeding can also cause increased icp (inter-cranial pressure) leading to brain swelling and further anoxic brain injury. hemorrhagic strokes make up about 13% of all strokes.",
        "stroke screening tools": "strokes fall under the large umbrella of altered mental status. the key symptoms of a stroke are: sudden onset of confusion, altered mental status, lack of coordination, vision or balance issues, weakness in the arm, leg, or face, specifically in one side. sometimes right before the change in mentation or strength, the patient will report a splitting headache. there are specific algorithms used to help determine the likelihood of a stroke and one of them is the cincinnati prehospital stroke scale (cpss). the cpss evaluates facial droop, arm drift, and speech on a normal or abnormal scale. this scale has been built upon by many local protocols, with an example being the portland prehospital stroke screen. the portland prehospital screen accounts for altered mental status being a signature symptom of a stroke by ruling out other common causes of altered mental status prior to prehospital providers calling a stroke alert and mobilizing the stroke team at the receiving hospital. after ruling out causes of altered mental status and acute onset of the condition, the screening process moves to an evaluation similar to the cpss.",
        "prehospital treatment": "as usual, start with a scene size-up and provider safety first. do a primary assessment to make sure the patient is alive and for assessment of abss. stroke patients are generally altered so start an evaluation of altered mental status right away, with no delay as every minute counts when it comes to preserving brain tissue. if you have a high index of suspicion for a stroke, do a quick cpss right away and look for deficits. get capillary blood glucose, blood pressure, oxygen saturation, and cardiac rhythm to investigate other possible causes of altered mental status. work through the stroke screening tools while also considering trauma, infection/sepsis, and drug ingestion or poisoning as well. if the patient is determined to have a stroke, definitive care is at the hospital. emts and paramedics do not have the tools to fix the stroke in the field so rapid transport to the hospital is necessary. making sure to choose the best destination is important, specifically based on your local protocols. different hospitals will have different capabilities including some that are able to handle cstat negative strokes but not cstat positive strokes. it is important to understand the capabilities of the facilities within the area you work and serve. if als capabilities are available, establishing a large bore (generally 18ga or larger) iv, allows the hospital to use the iv for ct and speed up the patient treatment course.",
        "scenario": "a construction manager called 911 for a 55-year-old male on his staff with a sudden onset of slurred speech and weakness. scene size up and primary survey: scene is safe and patient is altered, but abcs appear to be intact perform a quick and complete altered mental status assessment. oxygen: 96% cbg: 130 cardiac: sinus rhythm at a rate of 85 stroke scale: the patient has a left-sided facial droop and is slurring speech you ask the manager if the patient has been sick recently (possible infection) and he says no. no signs of trauma on physical assessment and no signs of drug use as well. stroke scale now determined to be positive initiate rapid transport: gather all necessary information for the patient and initiate rapid transport. cstat test shows patient unable to hold arms up and unable to follow commands cstat positive transport to nearest stroke center as local protocols allow monitor vital signs en route and establish iv access (18ga or larger if possible) reassess symptoms throughout transport",
        "final thoughts": "ems do not have the ability to provide definitive care for stroke patients. the most important thing ems providers can do is quick and complete assessments of altered mental status patients to catch strokes as quickly as possible. then scene time should be minimized such that almost all interventions are done en-route to the hospital. this decreases time the patient has lack of oxygen to the brain and increases the patient\u2019s chances at having a positive outcome."
    },
    {
        "introduction": "anatomy and physiology overview of the cranial nerves. the human brain has 12 cranial nerves. there are three general types of cranial nerves, afferent nerves, efferent nerves, and mixed nerves. afferent nerves receive sensory input from the body and move it to the central nervous system (cns) and brain. efferent nerves pass impulses from the brain and cns to the motor system and control movement, specifically of the face.",
        "cranial nerves": "i: olfactory nerve. (sensory) receives sensory input from the molecules in the nose and sends neural messaging back to the olfactory bulb. ii: optic nerve. (sensory) receives sensory input from eyes via nerves that meet at the optic chasm. input is sent back to the opposite side of the brain from the eye the sensory input comes from. iii: oculomotor nerve. (motor) controls motor function of eyes. also controls pupillary response as they respond to light. iv: trochlear nerve (motor) controls the oblique muscles. these muscles control outward, inward, and downward eye movements. v: trigeminal nerve (both) the largest cranial nerve. the trigeminal nerve is divided into 3 separate divisions, the maxillary (which sends sensory information from the middle of the head), the ophthalmic division (which sends sensory information from the scalp, forehead, and upper eyelids), and the mandibular division (which sends both sensory and motor information from the jaw, chin, lower lip, and tongue). vi: abducens nerve (motor) controls outwards eye motor movements. vii: facial nerve (both) transmits sensory input from the taste buds as well as controlling muscle function for tear production and saliva production. viii: vestibulocochlear nerve (sensory) consists of two divisions, the vestibular division, and the cochlear division. the vestibular division collects sensory input on balance and orientation. the cochlear branch receives sensory input from the inner ear regarding sound and pitch. ix: glossopharyngeal nerve (both) a sensory and motor nerve that carries nerve impulses for swallowing and the gag reflex. x: vagus nerve (both) the longest cranial nerve, divided into the left and right vagus nerves. a large focus of the parasympathetic response within the body involving the heart, lungs, and digestive system. xi: spinal accessory nerve (motor) a motor nerve that is associated with movement of the head, neck, and shoulders. xii: hypoglossal nerve (motor) a motor nerve that controls the movement of the tongue.",
        "prehospital assessment and treatment": "in patients with suspected cranial nerve damage or head injury, a prehospital crania nerve assessment can be very useful for helping make a clinical impression of the injury and track changes in the patient's neurologic deficits. the cranial nerve assessment is less useful for massive head trauma or an obvious stroke with a large vessel occlusion. in those patients, it is not a hard assessment to determine that there is an injury to the brain. the cranial nerve assessment is really useful for in-between situations. a minor fall, a roll-out of bed, a patient that seems ok but just a little off. the cranial nerve assessment allows you to gather more information to help have a better guess at the severity of the injury to the patient. the pneumonic peee ffutss can be used for a complete cranial nerve assessment.",
        "cranial nerve assessment": "pupils: use penlight to confirm pupillary response. eyes: test eye motion to all fields of direction. eyelids: have the patient close their eyes and try to keep them closed. using your fingers lightly, try to push the eyelids up so the eyes are open. they should not be able to open their eyes. ears: compare hearing in each ear and ask about ringing or other noises. facial sensation and mastication: hold the sides of the patient's mandibles and ask them to pretend like they are chewing. observe for equal strength. have the patient close their eyes and touch different parts of the face to test sensation. facial movement: have the patient smile and observe for symmetry. uvula: ask the patient to open their mouth and say 'ahhhhhh.' observe uvula to not have any traumatic damage and to be midline. tongue: ask the patient to stick out their tongue. the tongue should stick out normal. swallow: ask the patient to swallow and observe for any abnormalities. shrug: resting your hands on the patient's shoulders, have them shrug. their strength should be equal.",
        "scenario": "you are dispatched to some sort of accident on the road. when you arrive, it looks like an electric scooter had hit a pothole at around 20 mph and the rider is sitting on the curb. there is a helmet sitting next to the rider with a solid dent in it. when making patient contact, the patient is a/o x4, gcs 15, but very slow to answer questions. the patient states they don't need to go to the hospital. you are not comfortable letting the patent sign a refusal also you ask if they will let you conduct a cranial nerve exam. the cranial exam conducted shows deficits within their shrug, eye movement, and eyelid strength. you decide to call online medical control to convince the patient to go to the hospital and they are successful. you conduct serial cranial nerve assessments throughout the transport and pick up on progressing neurological symptoms. this allows you to anticipate the need for advanced airway interventions before the patient crashes, even though the patient still has the same gcs score.",
        "final thoughts": "the brain is the most important part of the body and also one that is so protected it can be hard to assess. due to this, conducting cranial nerve assessments can be an extremely valuable resource to assess brain injury, but also track changes in condition of patients with a brain injury. consistent assessments of the cranial nerves throughout time of patient care can help paramedics and emts anticipate changes in the patient condition before they occur."
    },
    {
        "introduction": "there are 4 main electrolytes in the body: sodium (na+), potassium (k+), chloride (cl-), and calcium (ca2+). magnesium (mg+) is another ion present in trace amounts. these electrolytes are used in many processes, but especially in contraction of muscles (including the heart). an imbalance of electrolytes could be an immediate life threat if it causes an arrhythmia in the heart.",
        "lessons and concepts": "the primary job of electrolytes in the body is in cellular action potentials. recall that in skeletal muscles at rest, na+ ions are outside the cell and k+ ions are mostly inside the cell. when the cell contracts, na+ floods the cell first, then k+ exits the cell to end the contraction. pumps in the cell walls return the cell to its resting state. in cardiac tissue, ca2+ plays an increased role. in pacemaker cells, ca2+ is responsible for the majority of depolarization. in contractile cells, ca2+ enters the cell after depolarization is complete (initiated by na+) to keep the cell depolarized longer. this prevents the contraction from proceeding the wrong way back up the heart. k+ still plays a role in returning both types of cells to their baseline, or resting potential.",
        "recognition": "most of the time, the body does a decent job of managing the balance of electrolytes through the kidneys. a history of renal disease or failure is almost always present for patients with an electrolyte imbalance. an imbalance can also arise from the loss of electrolytes, for example after prolonged exertion without adequate replacement. finally, toxicological mechanisms (such as an overdose) could lead to a true or relative electrolyte imbalance. for example, a calcium channel blocker overdose might lead to similar symptoms as hypocalcemia.",
        "potassium (k+)": "hyperkalemia is sometimes called the great imitator, because it can mimic other arrhythmias like v-tach on the monitor. any time you see kidney problems in a patient's medical history, this is a red flag for potential electrolyte imbalances, but especially potassium. at a dialysis center, patients at least slightly hyperkalemic, are dialyzed, and leave somewhat hypokalemic. missed dialysis treatments or incomplete treatments are a good indicator that someone could be hyperkalemic. peaked t waves are the hallmark sign on an ekg strip, but this is a late changing sign. other signs to look for include: sine wave morphology, a rhythm that looks like v-tach, but is slower than 130 bpm, may present with a sensation of cramping, especially in the feet and hands.",
        "hypokalemia": "typically associated with hypomagnesemia. ecg changes include larger p waves, longer pri, and development of u waves. look for atrial arrhythmias, possibly leading to ventricular arrhythmias (including torsades des pointes) in later stages.",
        "sodium (na+)": "hyponatremia typically presents as cramping, especially in the feet and hands. early signs are nausea/vomiting, lethargy, and confusion. late signs include seizures, coma, and eventually death. usually brought on by extensive exercise or exertion. for example, an ultramarathon runner or someone performing manual labor outdoors in the summer heat might be at increased risk for hyponatremia. hypernatremia chronically has long term health effects, but few in the short term. in severe cases, can still lead to seizures/coma. neonates/infants are more susceptible.",
        "calcium (ca2+)": "blood calcium levels are regulated by the parathyroid glands, so if a patient has a problem with this gland, it could lead to a calcium imbalance, but otherwise calcium is generally well managed by the body. as blood calcium levels get low, calcium is released from bones. when there is an excess of calcium in the blood, it is stored in bone tissue. hypocalcemia chronically low calcium can contribute to more brittle bones (since calcium is removed from bones to balance blood calcium levels). a calcium channel blocker overdose may present as relative hypocalcemia of the heart, since the calcium isn\u2019t able to have its necessary effect.",
        "magnesium (mg+)": "hypomagnesemia thought to be associated with torsades des pointes, which is why magnesium sulfate (mgso4) is given to correct torsades. could lead to weakness, seizures, or cardiac arrest (in the case of torsades).",
        "treatment and management": "most of these conditions will need to be confirmed by a blood test and corrected at the hospital, but a few might be discernible in the field. hyperkalemia: continuous albuterol neb (if allowed per protocol), request als if not already en route, establish iv access and obtain a 12-lead ecg if not done already. calcium channel blocker overdose: scene safety considerations for overdoses, wait for police to clear scene, back out and request police if scene is unsecured or scene becomes unsafe.",
        "scenario": "you are dispatched as a first response (non-transport) unit for chest pain. the patient is a 62-year-old male who says he just doesn't feel right today. the scene is a single family residence in a mobile home park. you notice a wheelchair accessible van parked in the carport.",
        "key takeaways": "potassium problems are common for dialysis patients, especially when a treatment is missed or there are other complications with their dialysis treatment. having the iv established already allowed the paramedic to administer drugs which addressed the underlying problem. once a patient loses their pulse, treatment falls into the acls algorithms with few deviations start compressions, and get the defibrillator pads attached right away.",
        "tips and tricks": "ask your opqrst questions on every patient, even if they are unresponsive and you have to ask a bystander. when testing, these questions are worth a total of 8 points\u2014more than any other category on the medical patient assessment skill station. electrolyte imbalances are fairly rare to begin with, and almost always have some preceding event or underlying condition. when you see dialysis patients, think potassium problems. when you see overexertion, think sodium problems. when your patient says they have a parathyroid problem, it could mean they have a calcium problem too."
    },
    {
        "introduction": "anatomy and physiology review one of the byproducts of cellular metabolism is carbon dioxide. carbon dioxide travels through the blood stream and remains in the circulatory system until it reaches the lungs. once carbon dioxide reaches the lungs, it is expelled into the air through respiration.",
        "what is capnography?": "capnography is a measurement of the carbon dioxide that is transported by the circulatory system and exhaled during respiration. capnography can be impacted by metabolism, a ventilation perfusion mismatch, or a failure of the circulatory system. a change to one of these factors will change the patients capnography reading. capnographys ease of use and diagnostic capabilities make it a valuable tool for the ems provider. unlike pulse oximetry, capnography changes rapidly with the patients condition and can provide immediate feedback after interventions are taken. capnography can also indicate a patients impending decompensation much more quickly than changes in blood pressure, pulse rate or pulse oximetry.",
        "what are the indications for capnography?": "patients with respiratory complaints. respiratory distress copd exacerbation asthma pulmonary embolism chest trauma with suspected lung involvement patients with metabolic related complaints. diabetic ketoacidosis hyperosmolar hyperglycemic non-ketoacidosis sepsis exacerbation of disease processes that can alter a patients metabolism. patients with circulatory complaints. congestive heart failure hypovolemic shock trauma with significant blood loss trauma to the circulatory system capnography should be used in any patient with an advanced airway. capnography can be used as a tool to confirm advanced airway placement. continuous monitoring of capnography can provide constant feedback on tube placement and prevent failure to recognize airway dislodgement. capnography should be used during cpr to determine chest compression effectiveness and determine when to cease resuscitation efforts. capnography can provide immediate feedback on chest compression quality. a decline in capnography could indicate a decrease in the quality the chest compressions provided. capnography with a reading consistently below 10 mmhg after 20 minutes of cpr can predict death with 100% sensitivity and specificity",
        "what is the procedure for measuring capnography?": "capnography is measured using a device that actively samples exhaled air and provides a measurement of the carbon dioxide. this measurement is referred to as etco2, also known as end tidal carbon dioxide. capnography is measured in mmhg or millimeters of mercury. a normal measurement of etco2 is 35-45 mmhg. capnography can be measured by qualitative and quantitative devices. a qualitative device indicates to the provider if carbon dioxide is present by changing colors in a measuring device. the device is placed directly on an advanced airway. depending on age and how it is stored, it can be unreliable for use in the prehospital environment or only work effectively for a short duration of time.",
        "types of capnography devices": "there are two types of devices that measure quantitative capnography, sidestream and mainstream. a quantitative device provides a specific measurement of expired etco2 and provides a capnography waveform with diagnostic value. sidestream: a sidestream capnography monitor pulls a sample of air from the patients breath when they exhale. this sample of air travels to a measuring device and provides a measurement of etco2. sidestream capnography monitors are more commonly used by prehospital agencies. capnography nasal cannulas, commonly referred to as etco2 nasal cannulas, can be used on conscious and alert patients to measure their respiratory rate and etco2. they are placed on the patient similarly to how you would place a standard nasal cannula. they can also be used under bvm, cpap or bipap masks as they typically do not interfere with the seal of the mask against the patient. they can also be used under non-rebreather masks. capnography in-line monitors can be placed on an advanced airway to monitor the effectiveness of ventilations, continuously confirm airway placement and alert providers to patient decline. in-line devices are placed between the advanced airway and the bag valve mask or ventilator. mainstream: a mainstream capnography monitor actively measures expired co2 from where the patient is exhaling with a reusable device.",
        "what complications can occur when using capnography?": "the capnography monitor (nasal cannula or in-line) may become dislodged during patient care. this can provide inaccurate readings and even cause false apnea alarms to occur. the capnography monitor tubing, specifically for sidestream devices, can become plugged with bodily fluids. this prevents the sample of air to travel to the measuring device.",
        "conclusion": "capnography provides an additional vital sign, that when used in conjunction with a physical exam and patient history, can provide valuable information regarding the cause and severity of a patients condition."
    },
    {
        "introduction": "ecg is an important tool in the assessment of a patient's cardiovascular status. permits early identification of certain types of heart attack. provides insight into dozens of other emergencies. not universally available in all ems systems but its use has grown substantially in the past decade.",
        "lessons and concepts": "ecg and ekg refer to the same terminology. electrocardiogram (english) and elektrokardiogram (german).",
        "equipment": "many ems organizations carry cardiac monitors with 12-lead ecg capability. 3-lead ecg involves equipment with 3 limb electrodes. provides leads i, ii, and iii. adding a 4th electrode permits 3 additional augmented leads. provides leads avl, avf, and avf. 6-lead ecg may be referred to as a quick 6. 6 additional precordial leads produce a full 12-lead ecg.",
        "cardiac monitoring vs 12-lead ecg": "cardiac monitoring allows a paramedic to continuously monitor the patient's heart rate and rhythm. this permits early identification of arrhythmias and electrical abnormalities which may require immediate treatment. this may also identify abnormalities that explain a patient's symptoms. generally looks at a single lead (commonly lead ii) at a time. 12-lead ecg involves assessment of electrical information in 12 different leads (angles) of the heart.",
        "identify certain types of myocardial infarction (heart attack)": "dozens of medical emergencies will affect a 12-lead ecg.",
        "electrical movement: upward and downward deflections": "an upward deflection on an ecg lead indicates that a wave of positive charge (depolarizing myocytes) is traveling toward that lead. or a wave of negative charge (repolarizing myocytes) moving away. conversely, a downward deflection reflects a wave of positive charge (depolarizing myocytes) moving away from a lead.",
        "a 12-lead ecg": "a 12-lead ecg simply looks at the heart from 12 different angles and gives us a view of the electrical movement through the heart. this view of electrical movement allows us to infer a great deal of information about the patient's cardiac health.",
        "heart electrical anatomy": "the sa node is often called the pacemaker node. it is located in the right atrium and controls the heart rate in a sinus rhythm. the sa node has a theoretical maximum discharge rate of (220-age). the av node creates a delay between atrial and ventricular depolarization. this affects the pr interval and allows the atria to contract before the ventricles.",
        "the bundle of his": "the bundle of his is the only electrical route to the ventricles in a normal heart. this is because the atria and ventricles are electrically isolated (insulated) from each other except through the bundle of his.",
        "waves and intervals and segments": "define waves and intervals and segment. a wave is an upward or downward deflection that represents an electrical event in the heart. an interval is the time between two events (eg pr interval, qt interval, etc). a segment is the length between two specific points (eg st segment).",
        "the p wave": "the p wave reflects depolarization of cardiac myocytes through the atria.",
        "the pr interval": "the pr interval reflects the delay of depolarization though the av node.",
        "the qrs complex": "the qrs complex reflects ventricular depolarization. in a normal ecg it should be narrow.",
        "a q wave": "a q wave is an initial negative deflection, if the first deflection is negative. usually reflects depolarization of the septum.",
        "the r wave": "the r wave is the initial upward deflection of the qrs complex.",
        "the s wave": "the s wave is the downward deflection after the r wave.",
        "the st segment": "the st segment is scrutinized when assessing for signs of ischemia. st segment elevation may reflect transmural (full thickness) ischemia. st segment depression may reflect sub-endocardial (deep) ischemia.",
        "the t wave": "the t wave reflects ventricular repolarization.",
        "axis": "axis referees to the overall direction of electrical movement through the heart.",
        "leads and surfaces": "inferior wall: leads ii, iii, and avf. anterior wall: leads v1 and v2 turned the septal leads. leads v3 and v4 termed the anterior leads.",
        "artifact": "artifact refers to electrical interference that makes ecg interpretation very difficult. electrical interference can come from a variety of sources (power chairs, electric blankets, etc).",
        "rate": "there are several methods to calculate heart rate from an ecg or rhythm strip. remember that ecg shows electrical movement only. always confirm that a physical pulse matches the monitor.",
        "stemi": "stemi refers to a specific type of heart attack accompanied by st segment elevation. also called occlusion myocardial infarction.",
        "stemi mimics": "acute pericarditis. left bundle branch block (lbbb). left ventricular hypertrophy. benign early repolarization.",
        "scenario": "you and your paramedic partner respond to the home of a 74-year-old male complaining of chest pain.",
        "tips and tricks": "always obtain a 12-lead ecg where there in concern for a patient's cardiovascular status. a good rule of thumb is to obtain an ecg anytime the patient's complain is above the waist (altered mental status, respiratory distress/shortness of breath, nausea/abdominal pain)."
    }
]