2001 EMT-Paramedic: NSC Refresher Curriculum2001 EMT-Paramedic: NSC Refresher Curriculum Instructor Course Guide Table of Contents Introduction History and Development Philosophy Course Overview NREMT Practice Analysis Task Items Objectives and Declarative Material Time Requirements Course Planning Considerations Needs Assessment Course Design Methods of Delivery Instructor Attributes Instructional Approach Distributed Learning Evaluating the Participants Cognitive Evaluation Psychomotor Evaluation Remediation Program Evaluation Acknowledgments Module I: Airway / Ventilation Module II: Cardiovascular Module III: Medical Module IV: Trauma Module V: Pediatrics Module VI: Other Recommended Content Areas Appendixes Appendix A - 1999 NREMT Practice Analysis Extract Appendix B – Practice Scenario and Scenario Template Appendix C- Practical Evaluation Skill Sheets INTRODUCTION HISTORY AND DEVELOPMENT PHILOSOPHY As part of the revision project for the EMT-Intermediate and EMT-Paramedic: National Standard Curricula (NSC), the contractor was directed to develop the EMT-Paramedic and EMT-Intermediate Continuing Education, National Guidelines. The guidelines document, developed as a substitute for traditional refresher courses, gives the reader an overview of competency assurance mechanisms to promote the delivery of medically appropriate patient care. The guidelines document defined refresher programs as follows: Refresher programs are a review of the original program in a condensed number of hours. While ideal for the purpose of remediation, they are not intended to expand the cognitive or psychomotor ability above the entry level. Therefore, refresher courses should not be considered a means of continued expansion of cognitive information and introduction of new psychomotor skills. They are not intended to deliver relevant contemporary information to practitioners who are currently active in the field. Although the guidelines document is widely used by the EMS community, the definition for refresher programs caused the EMS community to ask that refresher courses be developed. A contract to develop the refresher courses went to the National Association of EMS Educators (NAEMSE) and they convened a task force of EMS stakeholders inclusive of regulators, physicians, association representatives, providers, and educators. Some challenges undertaken by the task force were: The development of a refresher program based on scientific data. A program that could be delivered in different formats. A program flexible enough to meet the specific needs of different systems while maintaining the intent of a refresher program. The need to incorporate relevant contemporary material. The task force used EMS provider practice data, an EMS literature review, expert opinion, and a final EMS community review to develop the refresher programs. Previous versions of EMS refresher programs have been based on a perceived need and not on scientific evidence. With this in mind, the Refresher Development Task Force relied heavily on the findings of the 1999 NREMT Practice Analysis and the following documents: The EMS Agenda for the Future The EMS Education Agenda for the Future, A Systems Approach The National EMS Education and Practice Blueprint EMT-Paramedic and EMT-Intermediate Continuing Education, National Guidelines 1999 EMT-Intermediate National Standard Curriculum Each of the above documents was created as individual projects, but they are designed to work as a systems approach to EMS and integrate with one another. Contact the NHTSA EMS Division to obtain copies of these resources. In 1994, the National Registry of Emergency Medical Technicians (NREMT) performed the first nationally conducted practice analysis of EMS. The information obtained in the first analysis was used in the development of the 1998 EMT-Paramedic and 1999 EMT-Intermediate: NSC. In 1999, the NREMT conducted its second practice analysis. The 1999 NREMT Practice Analysis is a scientific, randomized national sampling of practicing EMT-Paramedic and EMT-Intermediates. The EMT’s participating in the practice analysis provided data on 123 various patient assessments focusing on patient care and operational tasks that make up the day-to-day functions of the providers. Each provider indicated the frequency they performed each task and the potential for harm they experienced accomplishing each task. A Practice Analysis Committee reviewed the data, validated the responses, and published the data in a peer reviewed medical journal. The NREMT Practice Analysis Committee used this data to develop a plan that grouped the identified tasks into the following six content areas: Airway and Breathing Cardiology Medical Trauma Pediatrics/Obstetrics Operations The specific tasks from the practice analysis are listed in appendix A. The NREMT supplied the data from their practice analysis to the EMT-Paramedic refresher development task force. This information was used to help determine specific content for the refresher course. The refresher task force used the NREMT data to identify tasks that are infrequent and may cause potential harm to the patient if delayed, performed improperly, or omitted when providing care. The panel decided to "refresh" these tasks since patient outcome is jeopardized if the task is not correctly performed. An example of this would be "Provide care to an infant or child with cardiac arrest." The practice analysis categorizes this task as number 113 of 123 for frequency, but lists it as the number one task for potential for harm. The panel agreed and decided to include this task as a mandatory part of the refresher program. Likewise, a task such as "Provide care to a patient with a painful, swollen, deformed extremity" is listed as task number 98 in frequency and number 100 as potential for harm. This task is not included as a mandatory part of the refresher program. Other tasks that are performed frequently and lack potential for harm are not included as a mandatory part of this refresher program. Again, the refresher course only targets infrequently performed tasks with a high potential for harm. Upon further review of the practice analysis, the task force identified a few frequently performed tasks that have a very high potential for harm. The task force decided to also include all tasks with a high potential for harm, regardless of their frequency of performance. Another tool used in the development of this refresher program was an EMS literature review. The literature review found issues not identified by the data from the NREMT Practice Analysis. The task force also sought expert opinion and feedback from the EMS community to identify additional course content. COURSE OVERVIEW Traditional refresher programs refresh material already known by the students. The intent of these programs is to maintain a student’s competence in knowledge and skill performance. This refresher program embraces the same concept, but it also encourages the inclusion of new and expanded information. New and expanded information may be added to the course but not at the expense of content that is core material for the program. This course is not designed to be continuing education for the participants. If a system wishes to incorporate additional information or a new intervention that requires a substantial amount of time to teach, the information must be offered in addition to the content of the refresher program. Moreover, this course is not a transition or bridge course for current EMT-Paramedics to become certified at the revised 1998 EMT-Paramedic level. The participant make-up in a refresher program may challenge the instructional staff. Participants who attend a refresher program may do so for a variety of reasons. Some students may not have practiced for a period of time and are attending to gain back their level of competence prior to practicing again. Others may attend to remediate or gain refresher or continuing education hours. Knowledge of the participant make-up will help the instructors meet the participant’s needs. A thorough knowledge of the re-credentialing requirements and approval process is a must for any organization sponsoring a refresher program. NREMT PRACTICE ANALYSIS TASK ITEMS The NREMT Practice Analysis task items are listed at the beginning of each module. These tasks are included based upon their performance frequency and potential for harm. OBJECTIVES and DECLARATIVE MATERIAL The objectives and declarative material are extracted from the 1998 EMT-Paramedic: NSC and they support the identified practice analysis tasks. The objectives and declarative material are renumbered for formatting purposes; however, the original objective number from the NSC is found at the end of each objective. The declarative material provides guidance for programs to use to establish their own individual lesson plans. The objectives in modules 1-5 are mandatory objectives and must be included in every refresher program. The objectives for the operational section should be considered recommended content for the refresher course. Any other objectives and declarative information has not been included and should be developed by the sponsoring agency. TIME REQUIREMENTS The length of this refresher program will vary according to a number of factors. Some of these factors are as follows: The student’s basic academic skills competence The student’s EMS knowledge and skills The faculty to student ratio The student’s motivation The student’s prior emergency/health care experience The student’s prior academic achievements The clinical and academic resources available The quantity of patient contacts The recommended time to instruct the mandatory objectives for the refresher program is 40 to 80 hours. Training institutes will need to adjust these times based on their individual needs. The agencies responsible for program oversight are cautioned against using these hours as a measure of program quality. Competence of the participants, not adherence to arbitrary time frames, is the true measurement of program quality. COURSE PLANNING CONSIDERATIONS NEEDS ASSESSMENT The first step for the needs assessment is the performance of a comprehensive analysis of the factors that influence the local pre-hospital emergency care delivery system. Some factors included in this analysis are: Recertification requirements (local, state, national, professional). System structure. Call characteristics (i.e., volume, type). Community demographics. Community hazard assessment. The second step of the needs assessment is an analysis of the education needs of the course participants. This assessment may include the following: Pre-testing Surveys Observations Expert Judgments Data Analysis The information collected during the assessment process may be used as a guide to select specific material for the classroom. The assessment results can determine the course format, course schedule, and course methods. The selected material may be subjected to national, State, and local standards. COURSE DESIGN The following steps will assist with the design and implementation of the course design. Determine regulatory requirements for course conduct: The refresher course will be approved or accredited by the appropriate local or state agency. A part of this approval process will be the length of the course, the course content, and the faculty requirements or restrictions. Develop schedule: The course is designed to allow programs to present the material in a variety of formats. The program may be delivered in class sessions that might include 8 hour consecutive days or may be taught in a shorter sessions extended over a period of months. Determine class size: The course emphasizes the evaluation of participant skills. Class size should be manageable and allow students an opportunity to ask questions and receive answers or assistance from the instructor. Since the instructor must observe and evaluate student performance, it is essential that the group’s size not be too large when evaluating practical skills. Consider segmenting the class into smaller groups, such as 6:1 (students to instructor) when doing the practical skills session. METHODS of DELIVERY INSTRUCTOR ATTRIBUTES Instructing a refresher program for practicing EMT-Paramedics is a challenge. We often hear that refresher programs lack challenge, cover material already well known, and are not deemed as useful for the participants. Faculty members must possess expertise in both the content area they instruct and in multiple delivery styles. Instructors must be proficient in performing the skills that they are instructing. Knowing your student’s abilities and the local EMS system’s expectations is essential for a successful program. Instructional staff must be appropriately credentialed according to local or state requirements. The course medical director must be available throughout the program and be aware of the course design and evaluation instruments being used. The course medical director may be utilized for medical expertise. INSTRUCTIONAL APPROACH Given the repetitive nature of refresher education, it is easy for participants to become bored and lack enthusiasm about the program. The overuse of lecturing is ineffective as the sole method of learning. To improve the quality of the educational experience for instructors and participants, creative and innovative instructional activities are strongly recommended. Consider using some of the following: Case Presentation Case presentation and discussion helps participants apply and understand the content by relating to their field experiences. The instructional staff can generate cases by using actual calls. Instructors should develop case studies to highlight key points of their presentations and the area of content being delivered. The most successful case presentations are those placing the participant(s) in a decision-making role allowing them to see the consequences of their decisions. Case presentations can be used in any format, such as, large classes, small groups, and individual instruction. Several examples and templates for case construction are in Appendix B. Simulations Simulations are case presentations incorporating role-playing situations. The role players may be other participants, programmed (standardized) patients, or manikins. Simulations work best when they are realistic and present situations the participant(s) may encounter, highlighting key points of the content area. Instructors and participants may critique simulations if the classroom environment is adequate. Technology We live in a time when technology is expanding in development and practical use. Though it is hard to say what will be the state of the art delivery system for education resources in the future, participation by the student will likely enhance the learning process. DISTRIBUTED LEARNING Distributed learning includes several alternative methods and media usage. Self-study programs, videotapes, audiotapes, and computer-based instruction are just a few examples of distributed learning. These alternative methods of instruction provide an opportunity to review and learn new cognitive knowledge, but they may not replace the need to practice or demonstrate a psychomotor skill. The use of a distributed learning process may best be applied in the remediation of cognitive knowledge identified in a needs assessment. Course directors and the credentialing agency should evaluate distributed learning products to assure that they meet the course goals and objectives. EVALUATING THE PARTICIPANTS In order for the refresher program sponsor to issue a certificate of program completion an evaluation process must be employed. The evaluation process should measure both cognitive knowledge and psychomotor skills. Individuals who are unsuccessful may be counseled and a course of action for remediation developed. COGNITIVE EVALUATION Authoring a valid written evaluation is both a science and an art. While some instructors possess skills in writing test questions, some others may not. A variety of commercially available test question banks may be useful to the instructional staff during the refresher program. Regardless of the tool used, the purpose of the cognitive measurement tool must be known before a test can be validated. The instructional staff must use basic test construction principles to develop written evaluation instruments. Written evaluation questions should be balanced to the program content. Items should be based upon what is taught and emphasized throughout the program and should have a difficulty measurement. A test written so each participant can obtain a score of 90% without taking the course lacks measurement ability and validation. Test items must be reviewed by faculty members, including the course medical director, to ensure content validation. Correct answers need to be the best choice or the only correct answer. Incorrect answers and distracters should be plausible to the item and have some attraction to the less than competent participant. Finally, a pass/fail score should be established based upon item analysis and judgment by faculty members responsible for issuing course completion certificates. PSYCHOMOTOR EVALUATION The following have been identified as essential items in the 2001 EMT-Paramedic Refresher Program: Trauma assessment Medical assessment Ventilation Adult Pediatric Cardiac arrest management Adult Pediatric Medication administration Intravenous Intraosseous Oral scenarios Basic skills Seated spinal immobilization Femoral/longbone immobilization Wounds, bleeding, and shock management Lifting, moving, and carrying patients Validation of psychomotor performance must be accomplished prior to issuing a certificate of course completion. Three opportunities are available to the instructional staff to validate a participant’s performance. Pretest The use of a psychomotor pretest is the best measurement of an individual’s performance. The pretest identifies skills that need to be emphasized during the course. Likewise, if all candidates possess competency in a skill prior to taking the program, it may not be necessary to cover that skill. Skill Labs When the sponsoring agency does not administer a pretest, the staff can use the skill labs to measure the competency of each participant. The skill labs ensure validation is sprinkled throughout the refresher program. End of Program At the end of the refresher program an evaluation process can be utilized if a pretest and skill labs were not used. If an end of program evaluation process is used, some skills may need to be re-evaluated if participants are unsuccessful. Participants must have documentation of demonstrating competence for each skill identified during the program regardless of what process is used. The refresher curriculum is the minimum acceptable content to be covered by education programs. With certifying agency approval, the student may meet some program objectives by satisfactorily completing a nationally recognized trauma life support program, cardiac care program, or pediatric care program. Although some certifying agencies allow providers to attend continuing education programs, it is recommended that providers participate in regularly scheduled group education sessions as well. REMEDIATION Participants who do not complete the program’s objectives or pass the evaluation process should have their performance reviewed by one of the instructional staff members. The participant’s strengths and weaknesses should be identified and a plan developed that helps the participant successfully complete the requirements. This plan may include additional classroom time, clinical time, field time, or repeating the entire program. PROGRAM EVALUATION Refresher programs are often provided by the same instructional staff in a variety of settings to different groups of participants. The program staff should evaluate each program for its effectiveness when completed. The evaluation can include the participant’s point of view by administering post program evaluation surveys. Some questions to ask when evaluating program effectiveness include: Did the program conform to the course design? Were the resources adequate? Were the skills labs effective? Did the test provide valuable information? Were the instructors effective in delivering the material? Can other instructional methods be incorporated in future courses? What were the participant comments? Was the course cost effective? At the end of each program, the faculty and course medical director must meet to determine if the course met its desired needs. The faculty needs to review content design, measurements, course completion criteria, and participant comments. Adjustments to future programs may be indicated once the evaluation process is complete. Acknowledgments The development of this document would not have been possible without the involvement and help of the following task force members and organizations. Gratitude and thanks are also extended to all the individuals who made comments during the development of this document. Refresher Curriculum Development Task Force Members Linda M. Abrahamson Education Coordinator Silver Cross Hospital Joliet, Illinois NAEMTJoann Freel Executive Director National Association of EMS Educators Carnegie, Pennsylvania NAEMSE Task Force Administrator Mike Armacost Director Colorado Department of Health Prehospital Care Program Denver, Colorado NASEMSDArt Hsieh Section Chief – EMS Inservice Training San Francisco Fire Department San Francisco, California NAEMSE David Bryson EMS Specialist NHTSA Washington, DC NHTSAJon Krohmer, MD Kent County EMS Grand Rapids, Michigan NAEMSP William E. Brown Jr. Executive Director National Registry of EMTs Columbus, Ohio NREMTDavid LaCombe Deputy Chief Sanibel Fire Rescue District Sanibel, Florida Expert Writer Debra Cason EMS Program Director UT Southwestern Medical Center Dallas, Texas NAEMSE Project DirectorDennis Mitchell EMS Instructor University of Arkansas for Medical Sciences Little Rock, Arkansas NAEMT Russell Crowley EMS Education Director Alabama Department of Health EMS Division Montgomery, Alabama NCSEMSTCSteve Mercer Education Coordinator Iowa Department of Public Health Bureau of EMS Des Moines, Iowa NAEMSE Project Coordinator Robert K. Waddell II Director – EMS Systems MCHB/EMSC National Resource Center Washington, DC MCHB/EMSC Module I: Airway / Ventilation NREMT PRACTICE ANALYSIS TASK ITEM Provide ventilatory support for a patient. COGNITIVE OBJECTIVES At the completion of this unit, the paramedic will be able to: 1.1Describe the indications, contraindications, advantages, disadvantages, complications, and technique for ventilating a patient by: (C-1) / 2-1.43 Mouth-to-mouth Mouth-to-nose Mouth-to-mask One person bag-valve-mask Two person bag-valve-mask Three person bag-valve-mask Flow-restricted, oxygen-powered ventilation device 1.2Compare the ventilation techniques used for an adult patient to those used for pediatric patients. (C-3) / 2-1.45 1.3Describe indications, contraindications, advantages, disadvantages, complications, and technique for ventilating a patient with an automatic transport ventilator (ATV). (C-1) / 2-1.46 1.4Define how to ventilate with a patient with a stoma, including mouth-to-stoma and bag-valve-mask-to-stoma ventilation. (C-1) / 2-1.54 1.5Describe the special considerations in airway management and ventilation for patients with facial injuries. (C-1) / 2-1.55 1.6Describe the special considerations in airway management and ventilation for the pediatric patient. (C-1) / 2-1.56 PSYCHOMOTOR OBJECTIVES At the completion of this unit, the paramedic will be able to: 1.7Demonstrate ventilating a patient by the following techniques: (P-2) / 2-1.95 Mouth-to-mask ventilation One person bag-valve-mask Two person bag-valve-mask Three person bag-valve-mask Flow-restricted, oxygen-powered ventilation device Automatic transport ventilator Mouth-to-stoma Bag-valve-mask-to-stoma ventilation 1.8Ventilate a pediatric patient using the one and two person techniques. (P-2) / 2-1.96 1.9Perform bag-valve-mask ventilation with an in-line small-volume nebulizer. (P-2) / 2-1.97 1.10Perform assessment to confirm correct placement of the endotracheal tube (P-2) / 2-1.103 1.11Intubate the trachea by the following methods: Orotracheal intubation Nasotracheal intubation Multi-lumen airways 1.12Perform transtracheal catheter ventilation (needle cricothyrotomy). (P-2) / 2-1.107 DECLARATIVE Ventilation Mouth-to-mouth Most basic form of ventilation Indications Apnea from any mechanism when other ventilation devices are not available Contraindications Awake patients Communicable disease risk limitations Advantages No special equipment required Delivers excellent tidal volume Delivers adequate oxygen Disadvantages Psychological barriers from Sanitary issues Communicable disease issues Direct blood/ body fluid contact Unknown communicable disease risks at time of event Complications Hyperinflation of patient's lungs Gastric distention Blood/ body fluid contact manifestation Hyperventilation of rescuer Mouth-to-nose Ventilating through nose rather than mouth Indications Apnea from any mechanism Contraindications Awake patients Advantages No special equipment required Disadvantages Direct blood/ body fluid contact Psychological limitations of rescuer Complications Hyperinflation of patient's lungs Gastric distention Blood/ body fluid manifestation Hyperventilation of rescuer Mouth-to-mask Adjunct to mouth-to-mouth ventilation Indications Apnea from any mechanism Contraindications Awake patients Advantages Physical barrier between rescuer and patient blood/ body fluids One-way valve to prevent blood/ body fluid splash to rescuer May be easier to obtain face seal Disadvantages Useful only if readily available Complications Hyperinflation of patient's lungs Hyperventilation of rescuer Gastric distention Method for use Position head by appropriate method Position and seal mask over mouth and nose Ventilate as appropriate One person bag-valve-mask Fixed volume self inflating bag can deliver adequate tidal volumes and O2 enrichment Indications Apnea from any mechanism Unsatisfactory respiratory effort Contraindications Awake, intolerant patients Advantages Excellent blood/ body fluid barrier Good tidal volumes Oxygen enrichment Rescuer can ventilate for extended periods without fatigue Disadvantages Difficult skill to master Mask seal may be difficult to obtain and maintain Tidal volume delivered is dependent on mask seal integrity Complications Inadequate tidal volume delivery Poor technique Poor mask seal Gastric distention Method for use Position appropriately Choose proper mask size - seats from bridge of nose to chin Position, spread/ mold/ seal mask Hold mask in place Squeeze bag completely over 1.5 to 2 seconds for adults Avoid overinflation Reinflate completely over several seconds Special considerations Medical Observe for Gastric distention Changes in compliance of bag with ventilation Improvement or deterioration of ventilation status ( i.e., color change, responsiveness, air leak around mask) Trauma Very difficult to perform with cervical spine immobilization in place Two-person bag-valve-mask ventilation method Most efficient method Indications Bag-valve-mask ventilation on any patient Especially useful for cervical spine immobilized patients Difficulty obtaining or maintaining adequate mask seal Contraindications Awake, intolerant patients Advantages Superior mask seal Superior volume delivery Disadvantages Requires extra personnel Complications Hyperinflation of patient's lungs Gastric distention Method for use First rescuer maintains mask seal by appropriate method Second rescuer squeezes bag Special considerations Observe chest movement Avoid overinflation Monitor lung compliance with ventilations Three-person bag-valve-mask ventilation Indications Bag-valve-mask ventilation on any patient Especially useful for cervical spine immobilized patients Difficulty obtaining or maintaining adequate mask seal Contraindications Awake, intolerant patients Advantages Superior mask seal Superior volume density Disadvantages Requires extra personnel "Crowded" around airway Complications Hyperinflation of patient’s lungs Gastric distention Method for use First rescuer maintains mask seal by appropriate method Second rescuer holds mask in place Third rescuer squeezes bag and monitors compliance Special considerations Avoid overinflation Monitor lung compliance with ventilations Flow-restricted, oxygen-powered ventilation devices The valve opening pressure at the cardiac sphincter is approx 30 cm H2O These devices operate at or below 30 cm H2O to prevent gastric distention Indications Delivery of high volume/ high concentration of O2 (1 L/ sec) Awake compliant patients Unconscious patient with caution Contraindications Non-compliant patients Poor tidal volume Small children Advantages Self administered Delivers high volume/ high concentration O2 O2 delivered in response to inspiratory effort (no O2 wasting) O2 volume delivery is regulated by inspiratory effort minimizing overinflation risk O2 volume delivery is also restricted to less than 30 cm H2O Disadvantages Cannot monitor lung compliance Requires O2 source Complications Gastric distention Barotrauma Method Mask is held manually in place Negative pressure upon inspiration triggers O2 delivery or medic triggers release button Patient is monitored for adequate tidal volume and oxygenation Automatic transport ventilators Volume/ rate controlled Indications Extended ventilation of intubated patients In situations in which a BVM is used Can be used during CPR Contraindications Awake patients Obstructed airway Increased airway resistance Pneumothorax (after needle decompression) Asthma Pulmonary edema Advantages Frees personnel to perform other tasks Lightweight Portable Durable Mechanically simple Adjustable tidal volume Adjustable rate Adapts to portable O2 tank Disadvantages Cannot detect tube displacement Does not detect increasing airway resistance Difficult to secure Dependent on O2 tank pressure Cricoid pressure - Sellick’s maneuver Pressure on cricoid Ring Occludes esophagus Facilitates intubation by moving the larynx posteriorly Helps to prevent passive emesis Can help minimize gastric distention during bag-valve-mask ventilation Indications Unconscious patients receiving BVM ventilations Patient cannot protect own airway Contraindications Use with caution in cervical spine injury Advantages Noninvasive Minimizes risk of aspiration as long as pressure is maintained Disadvantages May have extreme emesis if pressure is removed Second rescuer required for bag-valve-mask ventilation May further compromise injured cervical spine Complications Laryngeal trauma with excessive force Esophageal rupture from unrelieved high gastric pressures Excessive pressure may obstruct the trachea in small children Method Locate the anterior aspect of the cricoid ring Apply firm, posterior pressure Maintain pressure until the airway is secured with an endotracheal tube Artificial ventilation of the pediatric patient Flat nasal bridge makes achieving mask seal more difficult Compressing mask against face to improve mask seal results in obstruction Mask seal best achieved with jaw displacement (two person bag-valve-mask) Bag-valve-mask ventilation Bag size Full-term neonates and infants - minimum of 450 ml tidal volume (pediatric BVM) Children up to eight years of age - pediatric BVM preferred but adult-sized BVM (1500 ml) may be used Children over eight years of age require adult-sized BVM for adequate ventilation Proper mask fit Length based resuscitation tape Bridge of nose to cleft of chin Proper mask position and seal (EC-clamp) Place mask over mouth and nose; avoid compressing the eyes Using one hand, place thumb on mask at apex and index finger on mask at chin (C-grip) With gentle pressure, push down on mask to establish adequate seal Maintain airway by lifting bony prominence of chin with remaining fingers forming an "E"; avoid placing pressure on the soft area under chin May use one or two rescuer technique Ventilate according to current standards Obtain chest rise with each breath Begin ventilation and say "squeeze"; provide just enough volume to initiate chest rise; DO NOT OVERVENTILATE Allow adequate time for exhalation Begin releasing the bag and say "release, release" Continue ventilations using "squeeze, release, release" method Assess BVM ventilation Look for adequate chest rise Listen for lung sounds at third intercostal space, midaxillary line Assess for improvement in color and/ or heart rate Apply cricoid pressure to minimize gastric inflation and passive regurgitation Locate cricoid ring by palpating the trachea for a prominent horizontal band inferior to the thyroid cartilage and cricothyroid membrane Apply gentle downward pressure using one fingertip in infants and the thumb and index finger in children Avoid excessive pressure as it may produce tracheal compression and obstruction in infants Ventilation of stoma patients Mouth-to-stoma Locate stoma site and expose Pocket mask to stoma preferred Seal around stoma site, check for adequate ventilation Seal mouth and nose if air leak evident Bag-valve-mask to stoma Locate stoma site and expose Seal around stoma site, check for adequate ventilation Seal mouth and nose if air leak evident Translaryngeal cannula ventilation High volume/ high-pressure ventilation of lungs through cannulation of trachea below the glottis Oxygen delivery differs from other methods Delivers a large volume of O2 through a small port Delivers a very high pressure to the lungs compared to other methods (50 psi versus less than 1 psi through a regulator) Indications Apnea Delayed or inability to ventilate the patient by other means Contraindications Total airway obstruction (both inspiratory and expiratory) Equipment not immediately available Advantages Rapidly performed Provides adequate ventilation when performed properly Does not manipulate the cervical spine Does not interfere with subsequent attempts to intubate Disadvantages Requires jet ventilator Expends high volumes of oxygen more rapidly May not protect against aspiration Equipment Large bore IV catheter (14-16 gauge) 10 cc syringe 3 ccs of water or saline (optional) Oxygen source (50 psi) Jet ventilator Method Prepare equipment Identify cricothyroid membrane Insert needle with syringe midline through cricothyroid membrane at a slight angle towards sternum Withdraw on syringe plunger until air is freely withdrawn (bubbles if fluid is in syringe) Advance additional 1 cm Hold needle steady, advance catheter to hub Attach jet ventilator Ventilate once per five seconds Exhalation is passive through the glottis Complications Bleeding From improper catheter placement Subcutaneous emphysema From excessive air leak around catheter site or undetected laryngeal trauma Airway obstruction Result of excessive bleeding or subcutaneous air which compresses trachea Barotrauma Resulting from overinflation Hypoventilation Airway Techniques Endotracheal intubation techniques Medical patient Orotracheal intubation by direct laryngoscopy Trauma patient Orotracheal intubation by direct laryngoscopy Nasotracheal intubation techniques Indications Confirming placement Direct re-visualization Tube condensation Auscultation Palpation of balloon cuff at sternal notch Pulse oximetry Expired CO2 Bag-valve ventilation compliance Field extubation Endotracheal tube securing device Multi-lumen airways Pharyngo-tracheal lumen airway Indications Advantages Disadvantages Method Complications Special considerations Combitube Indications Advantages Disadvantages Method Complications Special considerations Module II: Cardiovascular NREMT PRACTICE ANALYSIS TASK ITEMS Provide care to a patient experiencing cardiovascular compromise. Attempt to resuscitate a patient in cardiac arrest. Provide post-resuscitation care to a cardiac arrest patient. COGNITIVE OBJECTIVES At the completion of this unit, the paramedic will be able to: 2.1Identify the major therapeutic objectives in the treatment of patients with any arrhythmia. (C-1) / 5-2.51 2.2Identify the major mechanical, pharmacological and electrical therapeutic interventions. (C-3) / 5-2.52 2.3Based on field impressions, identify the need for rapid intervention for the patient in cardiovascular compromise. (C-3) / 5-2.53 2.4Identify the clinical indications for transcutaneous and permanent artificial cardiac pacing. (C-1) / 5-2.55 2.5Describe the components and the functions of a transcutaneous pacing system. (C-1) / 5-2.56 2.6Explain what each setting and indicator on a transcutaneous pacing system represents and how the settings may be adjusted. (C-2) / 5-2.57 2.7Describe the techniques of applying a transcutaneous pacing system. (C-1) / 5-2.58 2.8Specify the measures that may be taken to prevent or minimize complications in the patient suspected of myocardial infarction. (C-3) / 5-2.83 2.9Describe the most commonly used cardiac drugs in terms of therapeutic effect and dosages, routes of administration, side effects and toxic effects. (C-3) / 5.2.84 2.10List the interventions prescribed for the patient in acute congestive heart failure. (C-2) / 5-2.94 2.11Describe the most commonly used pharmacological agents in the management of congestive heart failure in terms of therapeutic effect, dosages, routes of administration, side effects and toxic effects. (C-1) / 5-2.95 2.12Identify the paramedic responsibilities associated with management of a patient with cardiac tamponade. (C-2) / 5-2.101 2.13From the priority of clinical problems identified, state the management responsibilities for the patient with a hypertensive emergency. (C-2) / 5-2.109 2.14Identify the drugs of choice for hypertensive emergencies, rationale for use, clinical precautions and disadvantages of selected antihypertensive agents. (C-3) / 5-2.110 2.15Describe the most commonly used pharmacological agents in the management of cardiogenic shock in terms of therapeutic effects, dosages, routes of administration, side effects and toxic effects. (C-2) / 5-2.118 2.16Identify the paramedic responsibilities associated with management of a patient in cardiogenic shock. (C-2) / 5-2.120 2.17Identify the critical actions necessary in caring for the patient with cardiac arrest. (C-3) / 5-2.125 2.18Describe the most commonly used pharmacological agents in the management of cardiac arrest in terms of therapeutic effects. (C-3) / 5-2.129 2.19Develop, execute, and evaluate a treatment plan based on field impression for the patient in need of a pacemaker. (C-3) / 5-2.158 2.20Develop, execute, and evaluate a treatment plan based on the field impression for the heart failure patient. (C-3) / 5-2.168 2.21Develop, execute and evaluate a treatment plan based on the field impression for the patient with cardiac tamponade. (C-3) / 5-2.171 2.22Develop, execute and evaluate a treatment plan based on the field impression for the patient with a hypertensive emergency. (C-3) / 5-2.171 2.23Develop, execute, and evaluate a treatment plan based on the field impression for the patient with cardiogenic shock. (C-3) / 5-2.177 2.24Integrate pathophysiological principles to the assessment and field management of a patient with chest pain. (C-3) / 5-2.183 PSYCHOMOTOR OBJECTIVES At the completion of this unit, the paramedic will be able to: 2.25Set up and apply a transcutaneous pacing system. (P-3) / 5-2.202 2.26Given the model of a patient with signs and symptoms of heart failure, position the patient to afford comfort and relief. (P-2 ) / 5-2.203 2.7Demonstrate satisfactory performance of psychomotor skills of basic and advanced life support techniques according to the current American Heart Association Standards and Guidelines, including: (P-3) / 5-2.205 Cardiopulmonary resuscitation Defibrillation Synchronized cardioversion Transcutaneous pacing DECLARATIVE Management of the patient with arrhythmias Assessment Pharmacological Gases (such as oxygen) Sympathetic (such as epinephrine) Anticholinergic (such as atropine) Antiarrhythmic (such as lidocaine) Beta blocker Selective (such as metoprolol) Non-selective (such as propranolol) Vasopressor (such as dopamine) Calcium channel blocker (such as verapamil) Purine nucleoside (such as adenosine) Platelet aggregate inhibitor (such as aspirin) Alkalinizing agents (such as sodium bicarbonate) Cardiac glycoside (such as digitalis) Narcotic/ analgesic (such as morphine) Diuretic (such as furosemide) Nitrate (such as nitroglycerin) Antihypertensive (such as sodium nitroprusside) Electrical Purpose Methods Synchronized cardioversion Defibrillation Cardiac pacing Implanted pacemaker functions Characteristics Pacemaker artifact ECG tracing of capture Failure to sense ECG findings Clinical significance Failure to capture ECG findings Clinical significance Failure to pace ECG findings Clinical significance Pacer-induced tachycardia ECG findings Clinical significance Treatment Transcutaneous pacing Criteria for use Bradycardia Patient is hypotensive/ hypoperfusing No change with pharmacologic intervention Second degree AV block Patient is hypotensive/ hypoperfusing No change with pharmacologic intervention Complete AV block Patient is hypotensive/ hypoperfusing No change with pharmacologic intervention Asystole Overdrive Deter occurrence of recurrent tachycardia Set-up Placement of electrodes Rate and milliampere (mA) settings Pacer artifact Capture Failure to sense Causes Implications Interventions Failure to capture Causes Implications Interventions Failure to pace Causes Implications Interventions Hazards Complications Interventions Transport Indications for rapid transport Indications for no transport required Indications for referral Support and communications strategies Explanation for patient, family, significant others Communications and transfer of data to the physician Myocardial infarction Epidemiology Morbidity / Mortality Initial Assessment Findings Focused History Detailed Physical Exam Management Position of comfort Pharmacological Gases Nitrates Platelet aggregate inhibitor Analgesia Increase or decrease heart rate Possible antiarrhythmic Possible antihypertensives Electrical Constant ECG monitoring Defibrillation/ synchronized cardioversion Transcutaneous pacing Transport Criteria for rapid transport No relief with medications Hypotension/ hypoperfusion Significant changes in ECG ECG criteria for rapid transport and reperfusion Time of onset of pain ECG rhythm abnormalities Indications for "no transport" Refusal No other indications for no-transport Support and communications strategies Explanation for patient, family, significant others Communications and transfer of data to the physician Heart failure Epidemiology Morbidity / Mortality Initial Assessment Focused History Detailed Physical Exam Complications Management Position of comfort Pharmacological Gases Afterload reduction Analgesia Diuresis Other Transport Refusal No other indications for no-transport Support and communications strategies Explanation for patient, family, significant others Communications and transfer of data to the physician Cardiac tamponade Pathophysiology Morbidity / Mortality Initial Assessment Focused History Detailed Physical Examination Management Airway management and ventilation Circulation Pharmacological Non-pharmacological Rapid transport for pericardiocentesis Support and communications strategies Explanation for patient, family, significant others Communications and transfer of data to the physician Hypertensive Emergencies Epidemiology and precipitating causes Mortality / Morbidity Hypertensive encephalopathy Stroke Initial Assessment Airway/breathing Circulation Focused History Chief complaint Medication history Home oxygen use Detailed Physical Examination Airway Breathing Circulation Diagnostic signs/symptoms Management Non-pharmacologic Position of comfort Airway and ventilation Pharmacological Gases Other Rapid transport Refusal No other indications for no transport Support and communications strategies Explanation for patient, family, significant others Communications and transfer of data to the physician Cardiogenic Shock Pathophysiology Initial Assessment Focused History Detailed Physical Examination Management Position of comfort May prefer sitting upright with legs in dependent position Pharmacological Gases Vasopressor Analgesia Diuretics Glycoside Sympathetic agonist Alkalinizing agent Other Transport Refusal No other indications for no transport Support and communications strategies Explanation for patient, family, significant others Communications and transfer of data to the physician Cardiac arrest Pathophysiology Initial assessment Focused history Management Related terminology Resuscitation - to provide efforts to return spontaneous pulse and breathing to the patient in full cardiac arrest Survival - patient is resuscitated and survives to hospital discharge Return of spontaneous circulation (ROSC) - patient is resuscitated to the point of having pulse without CPR; may or may not have return of spontaneous respirations; patient may or may not go on to survive Indications for NOT initiating resuscitative techniques Signs of obvious death For example - rigor; fixed lividity; decapitation Local protocol For example - out-of-hospital advance directives Advanced airway management and ventilation Circulation CPR in conjunction with defibrillation IV therapy Defibrillation Pharmacological Gases (oxygen) Sympathetic Anticholinergic Antiarrhythmic Vasopressor Alkalinizing agents Parasympatholytic Rapid transport Support and communications strategies Explanation for patient, family, significant others Communications and transfer of data to the physician Module III: Medical NREMT PRACTICE ANALYSIS TASK ITEMS Assess a patient experiencing an allergic reaction Provide care to the patient experiencing an allergic reaction Assess a near drowning patient Provide care to a near drowning patient Assess a patient with a possible overdose COGNITIVE OBJECTIVES At the completion of this unit, the paramedic will be able to: 3.1Describe physical manifestations in anaphylaxis. (C-1) / 5-5.13 3.2Differentiate manifestations of an allergic reaction from anaphylaxis. (C-3) / 5-5.14 3.3Recognize the signs and symptoms related to anaphylaxis. (C-1) / 5-5.15 3.4Differentiate among the various treatment and pharmacological interventions used in the management of anaphylaxis. (C-3) / 5-5.16 3.5Correlate abnormal findings in assessment with the clinical significance in the patient with anaphylaxis. (C-3) / 5-5.18 3.6Develop a treatment plan based on field impression in the patient with allergic reaction and anaphylaxis. (C-3) / 5-5.19 3.7List signs and symptoms of near-drowning. (C-1) 5-10.54 3.8Describe the lack of significance of fresh versus saltwater immersion, as it relates to near-drowning. (C-3) / 5-10.55 3.9Discuss the incidence of "wet" versus "dry" drownings and the differences in their management. (C-3) 5-10.56 3.10Discuss the complications and protective role of hypothermia in the context of near-drowning. (C-1) / 5-10.57 3.11Correlate the abnormal findings in assessment with the clinical significance in the patient with near-drowning. (C-3) / 5-10.58 3.12Differentiate among the various treatments and interventions in the management of near-drowning. (C-3) 5-10.59 3.13Integrate pathophysiological principles and assessment findings to formulate a field impression and implement a treatment plan for the near-drowning patient. (C-3) / 5-10.60 3.14Differentiate toxic substance emergencies based on assessment findings. (C-3) / 5-8.60 3.15Correlate abnormal findings in the assessment with the clinical significance in the patient exposed to a toxic substance. (C-3) / 5-8.61 3.16Correlate the abnormal findings in assessment with the clinical significance in patients with the most common poisonings by overdose. (C-3) / 5-8.44 3.17Correlate the abnormal findings in assessment with the clinical significance in patients using the most commonly abused drugs. (C-3) / 5-8.53 3.18List the clinical uses, street names, pharmacology, assessment finding and management for patient who have taken the following drugs or been exposed to the following substances: (C-1) / 5-8.56 Cocaine Marijuana and cannabis compounds Amphetamines and amphetamine-like drugs Barbiturates Sedative-hypnotics Cyanide Narcotics/ opiates Cardiac medications Caustics Common household substances Drugs abused for sexual purposes/ sexual gratification Carbon monoxide Alcohols Hydrocarbons Psychiatric medications Newer anti-depressants and serotonin syndromes Lithium MAO inhibitors Non-prescription pain medications Nonsteroidal antiinflammatory agents Salicylates Acetaminophen Metals Plants and mushrooms DECLARATIVE Anaphylaxis Epidemiology Pathophysiology Assessment findings Not all signs and symptoms are present in every case History Previous exposure Previous experience to exposure Onset of symptoms Dyspnea Level of consciousness Unable to speak Restless Decreased level of consciousness Unresponsive Upper airway Hoarseness Stridor Pharyngeal edema/ spasm Lower airway Tachypnea Hypoventilation Labored - accessory muscle use Abnormal retractions Prolonged expirations Wheezes Diminished lung sounds Skin Redness Rashes Edema Moisture Itching Urticaria Pallor Cyanotic Vital signs Tachycardia Hypotension Gastrointestinal Abnormal cramping Nausea/ vomiting Diarrhea Assessment tools Cardiac monitor Pulse oximetry low End tidal CO2 high Management of anaphylaxis Remove offending agent (i.e. remove stinger) Airway and ventilation Positioning Oxygen Assist ventilation Advanced airway Circulation Venous access Fluid resuscitation Pharmacological Oxygen Epinephrine - main stay of treatment Bronchodilator Decrease vascular permeability Antihistamine Antiinflammatory/ immunosuppressant Vasopressor Psychological support Transport considerations Management of allergic reaction Without dyspnea Antihistamine With dyspnea Oxygen Subcutaneous epinephrine Antihistamine Near-Drowning Definition Submersion episode with at least transient recovery Pathophysiology Wet versus dry drownings Fluid in posterior oropharynx stimulates laryngospasm Aspiration occurs after muscular relaxation Suffocation occurs with or without aspiration Aspiration presents as airway obstruction Fresh versus saltwater considerations Despite mechanistic differences, there is no difference in metabolic result No difference in out-of-hospital treatment Hypothermic considerations in near-drownings Common concomitant syndrome May be organ protective in cold-water near-drownings Always treat hypoxia first Treat all near-drowning patients for hypothermia Treatment Establish airway Conflicting recommendations regarding prophylactic abdominal thrusts Questionable scientific data to support prophylactic abdominal thrusts Ventilation Oxygen Trauma considerations Immersion episode of unknown etiology warrants trauma management Post-resuscitation complications Adult respiratory distress syndrome (ARDS) or renal failure often occur post-resuscitation Symptoms may not appear for 24 hours or more, post-resuscitation All near-drowning patients should be transported for evaluation General toxicology, assessment and management Types of toxicological emergencies Unintentional poisoning Dosage errors Idiosyncratic reactions Childhood poisoning Environmental exposure Occupational exposures Neglect and Abuse Drug/ alcohol abuse Intentional poisoning/ overdose Chemical warfare Assault/ homicide Suicide attempts Use of poison control centers Routes of absorption Ingestion Inhalation Injection Absorption Poisoning by ingestion Examples Assessment findings General management considerations Poisoning by inhalation Examples Assessment findings General management considerations Poisoning by injection Examples Assessment findings General management considerations Poisoning by absorption Examples Assessment findings General management considerations Alcoholism Epidemiology Psychological issues Psycho-social issues Pathophysiology of long term alcohol abuse End organ damage Malnutrition Withdrawal syndrome Assessment findings Toxic syndromes Cholinergics Common causative agents Pesticides (organophosphates / carbamates) Nerve agents (sarin / Soman) Assessment findings Headache Dizziness Weakness Nausea SLUDGE (salivation, lacrimation, urination, defecation, GI upset, emesis) Bradycardia, wheezing, bronchoconstriction, myosis, coma, convulsions Diaphoresis, seizures Management Anticholinergic Common causative agents Assessment findings Management Hallucinogens Common causative agents lysergic acid diethylamide (LSD) phenyclicidine (PCP) Peyote mushrooms Assessment findings Chest pain Management Narcotics/ opiates Common causative agents - heroin morphine codeine meperidine propoxyphene Assessment findings Euphoria Hypotension Respiratory depression/ arrest Nausea Pinpoint pupils Seizures Coma Management Sympathomimetics Common causative agents Assessment findings Management Specific toxicology, assessment and management Cocaine Clinical uses Common causative agents Common street names Assessment findings Management Marijuana and cannabis compounds Clinical uses Common causative agents Common street names Assessment findings Management Amphetamines and amphetamine-like drugs Clinical uses Common causative agents Common street names Assessment findings Management Barbiturates Clinical uses Common causative agents Common street names Assessment findings Management Sedative-hypnotics Clinical uses Common causative agents Common street names Assessment findings Management Cyanide Clinical uses Common causative agents Common street names Assessment findings Management Narcotics/ opiates Clinical uses Common causative agents Common street names Assessment findings Management Cardiac medications Clinical uses Common causative agents Common street names Assessment findings Management Caustics Clinical uses Common causative agents Common street names Assessment findings Management Common household poisonings Clinical uses Common causative agents Common street names Assessment findings Management Drugs abused for sexual purposes/ sexual gratification Clinical uses Common causative agents Common street names Assessment findings Management Carbon monoxide Clinical uses Common causative agents Common street names Assessment findings Management Alcohols Clinical uses Common causative agents Common street names Assessment findings Management Hydrocarbons Clinical uses Common causative agents Common street names Assessment findings Management Tricyclic antidepressants Clinical uses Common causative agents Common street names Assessment findings Management Newer anti-depressants and serotonin syndromes Clinical uses Common causative agents Common street names Assessment findings Management Lithium Clinical uses Common causative agents Common street names Assessment findings Management Non-prescription pain medications Clinical uses Common causative agents Common street names Assessment findings Management Nonsteroidal anti-inflammatory agents Salicylates Clinical uses Common causative agents Common street names Assessment findings Management Acetaminophen Clinical uses Common causative agents Common street names Assessment findings Management Metals Clinical uses Common causative agents Common street names Assessment findings Management Plants and mushrooms Clinical uses Common causative agents Common street names Assessment findings Management Module IV: Trauma NREMT PRACTICE ANALYSIS TASK ITEMS Perform a rapid trauma assessment Provide care to a patient with shock (hypoperfusion) Assess a patient with a head injury Assess a patient with a suspected spinal injury Provide care to a patient with a suspected spinal injury Provide care to a patient with a chest injury Provide care to a patient with a open abdominal injury Cognitive Objectives At the completion of this unit, the paramedic will be able to: 4.1State the reasons for performing a rapid trauma assessment. (C-1) / 3-3.35 4.2Recite examples and explain why patients should receive a rapid trauma assessment. (C-1) / 3-3.36 4.3Apply the techniques of physical examination to the trauma patient. (C-1) / 3-3.37 4.4Describe the areas included in the rapid trauma assessment and discuss what should be evaluated. (C-1) / 3-3.38 4.5Differentiate cases when the rapid assessment may be altered in order to provide patient care. (C-3) / 3-3.39 4.6Discuss the treatment plan and management of hemorrhage and shock. (C-1) / 4-2.8 4.7Develop, execute and evaluate a treatment plan based on the field impression for the hemorrhage or shock patient. (C-3) / 4-2.44 4.8Relate assessment findings associated with head/ brain injuries to the pathophysiologic process. (C-3) / 4-5.43 4.9Classify head injuries (mild, moderate, severe) according to assessment findings. (C-2) / 4-5.44 4.10Relate assessment findings associated with concussion, moderate and severe diffuse axonal injury to pathophysiology. (C-3) / 4-5.49 4.11Relate assessment findings associated with skull fracture to pathophysiology. (C-3) / 4-5.52 4.12Relate assessment findings associated with cerebral contusion to pathophysiology. (C-3) / 4-5.55 4.13Relate assessment findings associated with intracranial hemorrhage to pathophysiology, including: (C-3) / 4-5.58 Epidural Subdural Intracerebral Subarachnoid 4.14Integrate the pathophysiological principles to the assessment of a patient with head/ brain injury. (C-3) / 4-5.63 4.15Differentiate between the types of head/ brain injuries based on the assessment and history. (C-3) / 4-5.64 4.16Formulate a field impression for a patient with a head/ brain injury based on the assessment findings. (C-3) / 4-5.65 4.17Describe the assessment findings associated with spinal injuries. (C-1) / 4-6.6 4.18Identify the need for rapid intervention and transport of the patient with spinal injuries. (C-1) / 4-6.8 4.19Integrate the pathophysiological principles to the assessment of a patient with a spinal injury. (C-3) / 4-6.9 4.20Differentiate between spinal injuries based on the assessment and history. (C-3) / 4-6.10 4.21Formulate a field impression based on the assessment findings (spinal injuries). (C-3) / 4-6.11 4.22Develop a patient management plan based on the field impression (spinal injuries). (C-3) / 4-6.12 4.23Describe the assessment findings associated with traumatic spinal injuries. (C-1) / 4-6.14 4.24Describe the management of traumatic spinal injuries. (C-1) / 4-6.15 4.25Integrate pathophysiological principles to the assessment of a patient with a traumatic spinal injury. (C-3) / 4-6.16 4.26Differentiate between traumatic and non-traumatic spinal injuries based on the assessment and history. (C-3) / 4-6.17 4.27Formulate a field impression for traumatic spinal injury based on the assessment findings. (C-3) / 4-6.18 4.28Develop a patient management plan for traumatic spinal injury based on the field impression. (C-3) / 4-6.19 4.29Describe the assessment findings associated with non-traumatic spinal injuries. (C-1) / 4-6.21 4.30Describe the management of non-traumatic spinal injuries. (C-1) / 4-6.22 4.31Integrate pathophysiological principles to the assessment of a patient with non-traumatic spinal injury. (C-3) / 4-6.23 4.32Differentiate between traumatic and non-traumatic spinal injuries based on the assessment and history. (C-3) / 4-6.24 4.33Formulate a field impression for non-traumatic spinal injury based on the assessment findings. (C-3) 4-6.25 4.34Develop a patient management plan for non-traumatic spinal injury based on the field impression. (C-3) / 4-6.26 4.35Discuss the management of thoracic injuries. (C-1) / 4-7.7 4.36Identify the need for rapid intervention and transport of the patient with chest wall injuries. (C-1) / 4-7.11 4.37Discuss the management of chest wall injuries. (C-1) / 4-7.12 4.38Discuss the management of lung injuries. (C-1) / 4-7.15 4.39Identify the need for rapid intervention and transport of the patient with lung injuries. (C-1) / 4-7.16 4.40Discuss the management of myocardial injuries. (C-1) / 4-7.19 4.41Identify the need for rapid intervention and transport of the patient with myocardial injuries. (C-1) / 4-7.20 4.42Discuss the management of vascular injuries. (C-1) / 4-7.23 4.43Identify the need for rapid intervention and transport of the patient with vascular injuries. (C-1) / 4-7.24 4.44Discuss the management of diaphragmatic injuries. (C-1) / 4-7.27 4.45Identify the need for rapid intervention and transport of the patient with diaphragmatic injuries. (C-1) / 4-7.28 4.46Discuss the management of esophageal injuries. (C-1) / 4-7.31 4.47Identify the need for rapid intervention and transport of the patient with esophageal injuries. (C-1) / 4-7.32 4.48Discuss the management of tracheo-bronchial injuries. (C-1) / 4-7.35 4.49Identify the need for rapid intervention and transport of the patient with tracheo-bronchial injuries. (C-1) / 4-7.36 4.50Discuss the management of traumatic asphyxia. (C-1) / 4-7.39 4.51Identify the need for rapid intervention and transport of the patient with traumatic asphyxia. (C-1) / 4-7.40 4.52Develop a patient management plan based on the field impression (thoracic injuries). (C-3) / 4-7.44 4.53Describe the management of abdominal injuries. (C-1) / 4-8.8 4.54Develop a patient management plan for patients with abdominal trauma based on the field impression. (C-3) / 4-8.12 4.55Formulate a field impression based upon the assessment findings for a patient with abdominal injuries. (C-3) / 4-8.36 4.56Develop a patient management plan for a patient with abdominal injuries, based upon field impression. (C-3) / 4-8.37 Psychomotor Objectives At the completion of this unit, the paramedic will be able to: 4.57Using the techniques of physical examination, demonstrate the assessment of a trauma patient. (P-2) / 3-3.77 4.58Demonstrate the rapid trauma assessment used to assess a patient based on mechanism of injury. (P-2) / 3-3.78 4.59Demonstrate the management of a patient with signs and symptoms of hemorrhagic shock. (P-2) / 4-2.46 4.60Demonstrate the management of a patient with signs and symptoms of compensated hemorrhagic shock. (P-2) / 4-2.48 4.61Demonstrate the management of a patient with signs and symptoms of decompensated hemorrhagic shock. (P-2) / 4-2.50 4.62Demonstrate a clinical assessment to determine the proper management modality for a patient with a suspected traumatic spinal injury. (P-1) / 4-6.29 4.63Demonstrate a clinical assessment to determine the proper management modality for a patient with a suspected non-traumatic spinal injury. (P-1) / 4-6.30 4.64Demonstrate immobilization of the urgent and non-urgent patient with assessment findings of spinal injury from the following presentations: (P-1) / 4-6.31 Supine Prone Semi-prone Sitting Standing 4.65Demonstrate preferred methods for stabilization of a helmet from a potentially spine injured patient. 4-6.33 4.66Demonstrate the following techniques of management for thoracic injuries: (P-1) / 4-7.50 Needle decompression Fracture stabilization Elective intubation ECG monitoring Oxygenation and ventilation 4.67Demonstrate a clinical assessment to determine the proper treatment plan for a patient with suspected abdominal trauma. (P-1) / 4-8.41 Declarative Focused history and physical exam - trauma patients Re-consider mechanism of injury Helps to identify priority patients Helps to guide the assessment Significant mechanism of injury Ejection from vehicle Death in same passenger compartment Falls > 20 feet Roll-over of vehicle High-speed vehicle collision Vehicle-pedestrian collision Motorcycle crash Unresponsive or altered mental status Penetrations of the head, chest, or abdomen Hidden injuries Seat belts If buckled, may have produced injuries If patient had seat belt on, it does not mean they do not have injuries Airbags May not be effective without seat belt Patient can hit wheel after deflation Lift the deployed airbag and look at the steering wheel for deformation Additional infant and child considerations Falls >10 feet Bicycle collision Vehicle in medium speed collision Perform rapid trauma physical examination on patients with significant mechanism of injury to determine life-threatening injuries In the responsive patient, symptoms should be sought before and during the trauma assessment Continue spinal stabilization Reconsider transport decision Assess mental status As you inspect and palpate, look and feel for injuries or signs of injury Examination Assess the head, inspect and palpate for injuries or signs of injury Assess the neck, inspect and palpate for injuries or signs of injury Apply cervical spinal immobilization collar (CSIC) (may use information from the head injury unit at this time) Assess the chest Assess the abdomen, inspect and palpate for injuries or signs of injury Assess the pelvis, inspect and palpate for injuries or signs of injury Assess all four extremities, inspect and palpate for injuries or signs of injury Roll patient with spinal precautions and assess posterior body, inspect and palpate, examining for injuries or signs of injury Look for medical identification devices Assess baseline vital signs Assess patient history Chief complaint History of present illness Past medical history Current health status Shock Epidemiology Pathophysiology Stages of Shock Assessment Management/ treatment plan Airway and ventilatory support Ventilate and suction as necessary Administer high concentration oxygen Reduce increased intrathoracic pressure in tension pneumothorax Circulatory support Hemorrhage control Intravenous volume expanders Types Isotonic solutions Hypertonic solutions Synthetic solutions Blood and blood products Experimental solutions Blood substitutes Rate of administration External hemorrhage that can be controlled External hemorrhage that can not be controlled Internal hemorrhage Pneumatic anti-shock garment Effects Increased arterial blood pressure above garment Increased systemic vascular resistance Immobilization of pelvis and possibly lower extremities Increased intra-abdominal pressure Mechanism Increases systemic vascular resistance through direct compression of tissues and blood vessels Negligible autotransfusion effect Indications Hypoperfusion with unstable pelvis Conditions of decreased SVR not corrected by other means As approved locally, other conditions characterized by hypoperfusion with hypotension Research studies Contraindications Advanced pregnancy (no inflation of abdominal compartment) Object impaled in abdomen or evisceration (no inflation of abdominal compartment) Ruptured diaphragm Cardiogenic shock Pulmonary edema Needle chest decompression of tension pneumothorax to improve impaired cardiac output Recognize the need for expeditious transport of suspected cardiac tamponade for pericardiocentesis Pharmacological interventions Hypovolemic shock Volume expanders Cardiogenic shock Volume expanders Positive cardiac inotropes Vasoconstrictor Rate altering medications Distributive shock Volume expanders Positive cardiac inotropes Vasoconstriction PASG Obstructive shock Volume expanders Spinal shock Volume expanders Psychological support/communication strategies Transport considerations Indications for rapid transport Indications for transport to a trauma center Considerations for air medical transportation Head trauma Review of anatomy and physiology Mechanisms of injury General categories of injury Causes of brain injury Head injury – broad and inclusive Brain injury Pathophysiology of head/brain injury Increased intracranial pressure Mechanism Assessment Pressure exerted downward Cerebral cortices and/ or reticular activating system effected Altered level of consciousness - amnesia of event, confusion, disorientation, lethargy or combativeness, focal deficit or weakness Hypothalamus - vomiting Brain stem Blood pressure elevates to maintain MAP and thus CPP Vagal nerve pressure - bradycardia Respiratory centers - irregular respirations or tachypnea Oculomotor nerve paralysis - unequal/ unreactive pupils Posturing - flexion/ extension Seizures - depending on location of injury Levels of increasing ICP Cerebral cortex and upper brain stem involved BP rising and pulse rate begins slowing Pupils still reactive Cheyne-Stokes respirations Initially try to localize and remove painful stimuli All effects reversible at this stage Middle brain stem involved Wide pulse pressure and bradycardia Pupils nonreactive or sluggish Central neurogenic hyperventilation (CNH) Extension Few patients function normally from this level Lower portion of brain stem involved/ medulla Pupil blown - same side as injury Respirations ataxic (erratic, no rhythm) or absent Flaccid Labile pulse rate, irregular often great pulse swings in rate QRS, S-T and T wave changes Decreased BP, often labile BP Not considered survivable Glasgow coma scale - method to assess level of consciousness Three independent measurements Eye opening Verbal response Motor response Numerical score - 3 to 15 Head injury classified according to score Mild - 13 to 15 Moderate - 8 to 12 Severe - < 8 Vital signs Pupil size and reaction Presence of focal deficit History of unconsciousness or amnesia of event Management Specific Injuries - diffuse axonal injury and focal injuries Diffuse axonal injury - shearing, stretching or tearing of nerve fibers with subsequent axonal damage Concussion (mild DAI) - physiologic neurologic dysfunction without substantial anatomic disruption which results in transient episode of neuronal dysfunction with rapid return to normal neurologic activity Epidemiology Assessment - confusion, disorientation, amnesia of the event Management Moderate DAI - shearing, stretching or tearing results in minute petechial bruising of brain tissue, brain stem and reticular activating system may be involved leading to unconsciousness Epidemiology Assessment - may result in immediate unconsciousness or persistent confusion, disorientation and amnesia of the event extending to amnesia of moment-to-moment events; may have focal deficit; residual cognitive (inability to concentrate), psychologic (frequent periods of anxiety, uncharacteristic mood swings) and sensorimotor deficits (sense of smell altered) may persist Management Severe DAI - formerly called brain stem injury, involves severe mechanical disruption of many axons in both cerebral hemispheres and extending to the brainstem Epidemiology Assessment - unconsciousness for prolonged period, posturing common, other signs of increased ICP occur depending on various degrees of damage Management Focal injury Skull fracture - the significance is in the amount of force involved Epidemiology Types Linear (80% of all skull fractures) Depressed Basilar Open skull fractures Assessment - linear fractures may be missed, depressed and open skull fractures usually found on palpation of head, use balls of fingers to palpate Airway patency and breathing adequacy a priority Vomiting and inadequate respirations are common Assess for signs and symptoms of increased intracranial pressure Management Cerebral contusion - a focal brain injury in which brain tissue is bruised and damaged in a local area; may occur at both the area of direct impact (coup) and/or on the opposite side (contrecoup) of impact Epidemiology Assessment Airway patency and breathing adequacy a priority Alteration in level of consciousness May complain of progressive headache and/ or photophobia May be unable to lay down memory - repetitive phrases common Assess for signs and symptoms of increased intracranial pressure Management Intracranial hemorrhage Types Epidural Subdural Intracerebral Subarachnoid Epidemiology Assessment May be impossible to tell which type of hematoma is present More important to recognize the presence of brain injury Signs/ symptoms of increasing intracranial pressure Signs/ symptoms of neurological deficit Early signs and symptoms of alterations in level of consciousness Signs of brain irritation - change in personality, irritability, lethargy, confusion, repeating words or phrases, changes in consciousness, paralysis of one side of the body, seizures GCS Management Spinal trauma Introduction Incidences Morbidity and mortality Traditional spinal assessments/ criteria Based upon mechanism of injury (MOI) Past emphasis for spinal immobilization considerations Unconscious accident victims Conscious accident victims checked for SCI prior to movement Any patient with a "motion" injury Lack of clear clinical guidelines or specific criteria to evaluate for SCI Signs which may indicate SCI Pain Tenderness Painful movement Deformity Cuts/ bruises (over spinal area) Paralysis Paresthesias Paresis (weakness) Shock Priapism Not always practical to immobilize every "motion" injury Most suspected injuries were moved to a normal anatomical position Lying flat on a spine board No exclusion criteria used for moving patients to an anatomical position Need to have clear criteria to assess for the presence of SCI General spinal anatomy and physiology review General assessment of spinal injuries Determine mechanism of injury/ nature or injury Positive MOI Always requires full spinal immobilization High speed motor vehicle crash(es) Falls greater than three times patient’s height Violent situations occurring near the spine Sports injuries Other high impact situations Some medical directors may allow field personnel to not immobilize patients with MOI but without signs and/ or symptoms of a SCI Based on assessment Negative MOI Forces or impact involved does not suggest a potential spinal injury Does not require spinal immobilization Examples Uncertain MOI Unclear or uncertainty regarding the impact or forces Clinical criteria used for a basis of whether to employ spinal immobilization Examples Clinical criteria versus mechanism of injury Initial management Based solely upon MOI Positive MOI Spine immobilization Negative MOI Without signs or symptoms Uncertain MOI Need for further clinical assessment and evaluation In some non-traumatic spinal conditions immobilization may be necessary/indicated Altered LOC or unconsciousness requires spine stabilization Assessment of uncertain MOIs Specific clinical criteria Necessary to assess when electing not to immobilize a trauma patient Begins with patient reliability Continually reassessed during specific exam If specific criteria cannot be clearly satisfied; complete spine immobilization undertaken Positive MOI always equals spine immobilization This specific assessment may still be used to determine level of injury Specific criteria Prevent motion of the spine by assistant maintaining stabilization throughout the exam Reliable patients/ exam In order for assessments of pain, tenderness, motor, and sensory function to be accurate the patient must be reliable Patient must be Calm Cooperative Sober Alert and oriented Unreliable patient defined Acute stress reaction Brain injury Intoxication Abnormal mental status Distracting injuries Communication problems Unreliable indicators present Full spinal immobilization indicated Assess for spinal pain Patient is asked about Any related spinal pain Signs Symptoms May be poorly localized Might not feel directly over the spinous process Pain with active movement of head and neck Patient is asked to slowly move their head and neck If any pain occurs Assess for spine tenderness Palpate over each of the spinous processes of the vertebra Begin at the neck and work towards the pelvis May be beneficial to palpate back up from the pelvis to the neck Upper extremity neurological function assessment Motor function Finger abduction/ adduction Finger/ hand extension Sensory function Pain sensation Lower extremity neurological function assessment Motor function Foot plantar flexion Foot/ great toe dorsiflexion Sensory function Pain sensation General motor function assessment Tests nerve roots at both cervical and lumbar/ sacral spine levels Check two sets of nerve roots at each level as well as left and right sides Able to determine most clinical patterns of SCI Motor exams can to be completed even if local injury exists If exam cannot be completed due to local injury entire exam is unreliable Sensory function assessment Test (exam) sensory At cervical and lumbar/ sacral spine levels Sensory exam will detect clinical patterns of SCI Any signs or symptoms of abnormal sensation Spinal immobilization indicated General management of spinal injuries Principles of spinal immobilization Primary goal is to prevent further injury Treat spine as a long bone with a joint at either end (head and pelvis) 15% of secondary spinal injuries are preventable with proper immobilization Always use "complete" spine immobilization Impossible to isolate and splint specific injury site Spine stabilization begins in the initial assessment Continues until the spine is completely immobilized on a long backboard Head and neck should be placed in a neutral, in-line position unless contraindicated Neutral positioning allows for the most space for the cord Reducing cord hypoxia Reducing excess pressure Most stable position for the spinal column Reduces instability Spinal stabilization/ immobilization Systematic approach Cervical immobilization Manual Rigid collar Interim immobilization device When indicated (vest type mobilization device, short backboard) Movement of a stable patient from a seated position to a long backboard Long backboard Full body vacuum splints Padding (body shims) Use to maintain anatomical position Limits movement of patient Fill all voids Pillows Towels Blankets Straps Sufficient to immobilize to the long backboard Cervical immobilization device Commercial Tape Blanket roll Pillows Helmeted patients Special assessment needs for patients wearing helmets Indications for leaving the helmet in place Indications for helmet removal Types of helmets General guidelines for helmet removal Thoracic trauma General Introduction Epidemiology Mechanism of injury Anatomy and physiology review of the thorax Pathophysiology Assessment findings Management Airway and ventilation Oxygen therapy Endotracheal intubation Needle cricothyrotomy Surgical cricothyrotomy Positive pressure ventilation Occlude open wounds Stabilize chest wall Circulation Manage cardiac dysrhythmias Intravenous access Pharmacologic Analgesics Antiarrhythmics Non-pharmacologic Needle thoracostomy Tube thoracostomy - in hospital management Pericardiocentesis - in hospital management Transport considerations Appropriate mode Appropriate facility Chest wall injuries Rib fractures Epidemiology Anatomy and physiology review Pathophysiology Assessment findings Management Airway and ventilation Oxygen therapy Positive pressure ventilation Encourage coughing and deep breathing Pharmacological Analgesics Non-pharmacological Splint - but avoid circumferential splinting Transport consideration Appropriate mode Appropriate facility Psychological support/ communication strategies Flail segment Epidemiology Pathophysiology Assessment findings Management Airway and ventilation Positive pressure ventilation may be needed Oxygen (high concentration) Evaluate the need for endotracheal intubation Stabilize flail segment (may be controversial locally) Positive end expiratory pressure (PEEP) Circulation Restrict fluids Pharmacologic Analgesics Non-pharmacologic Positioning Endotracheal intubation and positive pressure ventilation for internal splinting effect Transport considerations Appropriate mode Appropriate facility Psychological support/ communication strategies Sternal fracture Epidemiology Pathophysiology Assessment findings Management Airway and ventilation Circulation Restrict fluids if pulmonary contusion is suspected Pharmacologic Analgesics Non-pharmacologic Allow chest wall self-splinting Transport considerations Appropriate mode Appropriate facility Psychological support/ communication strategies Injury to the lung Simple pneumothorax Epidemiology Pathophysiology Assessment findings Management Airway and ventilation Positive pressure ventilation if necessary Monitor for development of tension pneumothorax Non-pharmacologic Needle thoracostomy Transport consideration Appropriate mode Appropriate facility Psychological support/ communication strategies Open pneumothorax Epidemiology Pathophysiology Assessment findings Management Airway and ventilation Positive pressure ventilation if necessary Monitor for development of tension pneumothorax Non-pharmacologic Occlude open wound Tube thoracostomy - in hospital management Transport consideration Appropriate mode Appropriate facility Psychological support/ communication strategies Tension pneumothorax Epidemiology Pathophysiology Assessment findings Management Airway and ventilation Positive pressure ventilation if necessary Circulation Relieve tension pneumothorax to improve cardiac output Non-pharmacologic Occlude open wound Needle thoracentesis Tube thoracostomy - in hospital management Transport consideration Appropriate mode Appropriate facility Psychological support/ communication strategies Hemothorax Epidemiology Pathophysiology Assessment findings Management Airway and ventilation Positive pressure ventilation if necessary Circulation Re-expand the affected lung to reduce bleeding Non-pharmacological Needle chest decompression Tube thoracostomy - in hospital management Transport considerations Appropriate mode Appropriate facility Psychological support/ communication strategies Hemopneumothorax Epidemiology Pathophysiology Assessment findings Management Management is the same as a hemothorax Pulmonary contusion Epidemiology Pathophysiology Assessment findings Management Airway and ventilation Positive pressure ventilation if necessary Circulation Restrict intravenous fluids (use caution restricting fluids in hypovolemic patients) Transport considerations Appropriate mode Appropriate facility Psychological support/ communication strategies Myocardial injuries Pericardial tamponade Epidemiology Anatomy and physiology Pathophysiology Assessment findings Management Airway and ventilation Circulation Fluid challenge Non-pharmacological Pericardiocentesis - in hospital management Transport considerations Appropriate mode Appropriate facility Psychological support/ communication strategies Myocardial contusion (blunt myocardial injury) Epidemiology Anatomy and physiology Pathophysiology Assessment findings Management Airway and ventilation Oxygen therapy Circulation Intravenous fluid volume Pharmacological Antiarrhythmics Vasopressors Transport considerations Appropriate mode Appropriate facility Psychological support/ communication strategies Myocardial rupture Epidemiology Anatomy and physiology Pathophysiology Assessment findings Management is supportive Vascular injuries Aortic dissection/ rupture Epidemiology Anatomy and physiology Pathophysiology Assessment findings Management Airway and ventilation Circulation Do not over hydrate Transport considerations Appropriate mode Appropriate facility Psychological support/ communication strategies Penetrating wounds of the great vessels Epidemiology Anatomy and physiology Pathophysiology Assessment findings Management Manage hypovolemia PASG not recommended Relief of tamponade if present Expeditious transport Other thorax injuries Diaphragmatic injury Epidemiology Pathophysiology Assessment Management Airway and ventilation Positive pressure ventilation if necessary Caution IPPB may worsen the injury Non-pharmacologic Do not place patient in Trendelenburg position Transport consideration Appropriate mode Appropriate facility Psychological support/ communication strategies Esophageal injury Epidemiology Pathophysiology Assessment Management Airway and ventilation Transport consideration Appropriate mode Appropriate facility Psychological support/ communication strategies Tracheo-bronchial injuries Epidemiology Pathophysiology Assessment Management Airway and ventilation Circulation Transport consideration Appropriate mode Appropriate facility Traumatic asphyxia Epidemiology Pathophysiology Assessment Management Airway and ventilation Circulation Expect hypotension once compression is released Pharmacological Sodium bicarbonate should be guided by ABGs in hospital Transport considerations Appropriate mode Appropriate facility Abdominal trauma General introduction Epidemiology Anatomy review Mechanism of injury review General system pathophysiology, assessment, and management Pathophysiology of abdominal injuries Assessment Management/ treatment plan Surgical intervention only effective therapy No definitive therapy possible out-of-hospital Rapid evaluation Initiation of shock resuscitation Rapid packaging and transport to nearest appropriate facility Facility must have immediate surgical capability Rapid transport Defeated if hospital cannot provide immediate surgical intervention Crystalloid fluid replacement En route to hospital Airway support Breathing support Circulatory support Control obvious hemorrhage Tamponade bleeding Manage hypotension Patient packaging Transport Indications for rapid transport Indications for transport to trauma center Indications for transport to acute care facility Indications for no transport required Specific injuries Solid organ injuries Overview Epidemiology Prevention strategies Anatomy and physiology review Pathophysiology Assessment Management/ treatment plan Airway support Breathing support Circulatory support Patient packaging Transport Psychological support/ communications strategies Liver injuries Morbidity and mortality Result of blood loss Injuries result of Blunt trauma Penetrating trauma Splenic injuries Most frequently injured organ Blunt trauma Commonly associated with other intra abdominal injuries May present with left shoulder pain Kidney injuries Often presents with hematuria Back pain Pancreas Most common with penetrating injuries May also occur as a result of pancreas being compressed against vertebral column by Steering wheels Handle bars Other structures stronger then the pancreas Products of pancreas have an irritation effect on peritoneum Auto-digestion of tissue Diaphragm Injury often insidious Herniation of abdominal contents into chest may occur Hollow organ injuries Overview Epidemiology Prevention strategies Anatomy and physiology review Pathophysiology Assessment Management/ treatment plan Airway support Breathing support Circulatory support Patient packaging Transport Psychological support/ communications strategies Small and large intestines Most often injured as a result of penetrating injuries Can occur with deceleration injuries Stomach Most often injured as a result of Blunt trauma Full stomach prior to incident increases risk of injury Duodenum Most often injured as a result of Blunt trauma Recognition often delayed Bladder Most often injured as a result of Blunt trauma Full bladder prior to incident may increase risk of injury Associated with pelvic injury Abdominal vascular injuries Overview Epidemiology Prevention strategies Anatomy and physiology review Pathophysiology Assessment Management/ treatment plan Airway support Breathing support Circulatory support Patient packaging Transport Psychological support/ communications strategies Other related abdominal injuries Eviscerations Epidemiology Prevention strategies Anatomy and physiology review Pathophysiology Assessment Management/ treatment plan Airway support Breathing support Circulatory support Patient packaging Transport Psychological support Module V: Pediatrics NREMT PRACTICE ANALYSIS TASK ITEMS Assess an infant or child w/ cardiac arrest Provide care to an infant or child w/ cardiac arrest Assess an infant or child w/ respiratory distress Provide care to an infant or child in respiratory distress Assess an infant or child with shock (hypoperfusion) Provide care to an infant or child with shock (hypoperfusion) Assess an infant or child with trauma Provide care to an infant or child with trauma Cognitive Objectives At the completion of this unit, the paramedic will be able to: 5.1Describe techniques for successful assessment of infants and children. (C-1) / 6-2.8 5.2Describe techniques for successful treatment of infants and children. (C-1) / 6-2.9 5.3Discuss the appropriate equipment utilized to obtain pediatric vital signs. (C-1) / 6-2.14 5.4Determine appropriate airway adjuncts for infants and children. (C-1) 6-2.15 5.5Discuss complications of improper utilization of airway adjuncts with infants and children. (C-1) 6 2.16 5.6Discuss appropriate ventilation devices for infants and children. (C-1) 6-2.17 5.7Discuss complications of improper utilization of ventilation devices with infants & children. (C-1) 6-2.18 5.8Discuss appropriate endotracheal intubation equipment for infants and children. (C-1) / 6-2.19 5.9Identify complications of improper endotracheal intubation procedure in infants and children. (C-1) / 6-2.20 5.10List the indications and methods for gastric decompression for infants and children. (C-1) / 6-2.21 5.11Differentiate between upper airway obstruction and lower airway disease. (C-3) / 6-2.25 5.12Describe the general approach to the treatment of children with respiratory distress, failure, or arrest from upper airway obstruction or lower airway disease. (C-3) / 6-2.26 5.13Discuss the common causes of hypoperfusion in infants and children. (C-1) / 6-2.27 5.14Evaluate the severity of hypoperfusion in infants and children. (C-3) / 6-2.28 5.15Identify the major classifications of pediatric cardiac rhythms. (C-1) 6-2.29 5.16Discuss the primary etiologies of cardiopulmonary arrest in infants and children. (C-1) / 6-2.30 5.17Discuss age appropriate vascular access sites for infants and children. (C-1) 6-2.31 5.18Discuss the appropriate equipment for vascular access in infants and children. (C-1) 6-2.32 5.19Identify complications of vascular access for infants and children. (C-1) 6-2.33 5.20Describe the primary etiologies of altered level of consciousness in infants and children. (C-1) 6-2.34 5.21Identify common lethal mechanisms of injury in infants and children. (C-1 ) / 6-2.35 5.22Discuss anatomical features of children that predispose or protect them from certain injuries. (C-1) / 6-2.36 5.23Describe aspects of infant and children airway management that are affected by potential cervical spine injury. (C-1) / 6-2.37 5.24Identify infant and child trauma patients who require spinal immobilization. (C-1) / 6-2.38 5.25Discuss fluid management and shock treatment for infant and child trauma patient. (C-1) / 6-2.39 5.26Discuss the parent/ caregiver responses to the death of an infant or child. (C-1) / 6-2.44 5.27Discuss basic cardiac life support (CPR) guidelines for infants and children. (C-1) / 6-2.47 5.28Identify appropriate parameters for performing infant and child CPR. (C-1) / 6-2.48 5.29Integrate advanced life support skills with basic cardiac life support for infants and children. (C-3) / 6-2.49 5.30Discuss the indications, dosage, route of administration and special considerations for medication administration in infants and children. (C-1) / 6-2.50 5.31Discuss appropriate transport guidelines for infants and children. (C-1) / 6-2.51 5.32Discuss appropriate receiving facilities for low and high risk infants and children. (C-1) / 6-2.52 5.33Describe the epidemiology, including the incidence, morbidity/ mortality, risk factors and prevention strategies for respiratory distress/ failure in infants and children. (C-1) / 6-2.53 5.34Discuss the pathophysiology of respiratory distress/ failure in infants and children. (C-1) / 6-2.53 5.35Discuss the assessment findings associated with respiratory distress/ failure in infants and children. (C-1) / 6-2.55 5.36Discuss the management/ treatment plan for respiratory distress/ failure in infants and children. (C-1) / 6-2.56 5.37Describe the epidemiology, including the incidence, morbidity/ mortality, risk factors and prevention strategies for hypoperfusion in infants and children. (C-1) / 6-2.57 5.38Discuss the pathophysiology of hypoperfusion in infants and children. (C-1) 6-2.58 5.39Discuss the assessment findings associated with hypoperfusion in infants and children. (C-1) / 6-2.59 5.40Discuss the management/ treatment plan for hypoperfusion in infants and children. (C-1) / 6-2.60 5.41Discuss the assessment findings associated with cardiac dysrhythmias in infants and children. (C-1) / 6-2.63 5.42Discuss the management/ treatment plan for cardiac dysrhythmias in infants and children. (C-1) / 6-2.64 5.43Describe the epidemiology, including the incidence, morbidity/ mortality, risk factors and prevention strategies for trauma in infants and children. (C-1) / 6-2.69 5.44Discuss the pathophysiology of trauma in infants and children. (C-1) / 6-2.70 5.45Discuss the assessment findings associated with trauma in infants and children. (C-1) / 6-2.71 5.46Discuss the management/ treatment plan for trauma in infants and children. (C-1) / 6-2.72 PSYCHOMOTOR OBJECTIVES At the completion of this unit, the paramedic will be able to: 5.47Demonstrate the appropriate approach for treating infants and children. (P-2) / 6-2.91 5.48Demonstrate appropriate intervention techniques with families of acutely ill or injured infants and children. (P-2) / 6-2.92 5.49Demonstrate an appropriate assessment for different developmental age groups. (P-2) / 6-2.93 5.50Demonstrate an appropriate technique for measuring pediatric vital signs. (P-2) / 6-2.93 5.51Demonstrate the use of a length-based resuscitation device for determining equipment sizes, drug doses and other pertinent information for a pediatric patient. (P-2) / 6-2.95 5.52Demonstrate the appropriate approach for treating infants and children with respiratory distress, failure, and arrest. (P-2) / 6-2.96 5.53Demonstrate proper technique for administering blow-by oxygen to infants and children. (P-2) / 6-2.97 5.54Demonstrate the proper utilization of a pediatric non-rebreather oxygen mask. (P-2) / 6-2.98 5.55Demonstrate proper technique for suctioning of infants and children. (P-2) / 6-2.99 5.56Demonstrate appropriate use of airway adjuncts with infants and children. (P-2) / 6-2.100 5.57Demonstrate appropriate use of ventilation devices for infants and children. (P-2) 6-2.101 5.58Demonstrate endotracheal intubation procedures in infants and children. (P-2) / 6-2.102 5.59Demonstrate appropriate treatment/ management of intubation complications for infants and children. (P-2) / 6-2.103 5.60Demonstrate appropriate needle cricothyroidotomy in infants and children. (P-2) / 6-2.104 5.61Demonstrate proper placement of a gastric tube in infants and children. (P-2) / 6-2.105 5.62Demonstrate an appropriate technique for insertion of peripheral intravenous catheters for infants and children. (P-2) / 6-2.106 5.63Demonstrate an appropriate technique for administration of intramuscular, inhalation, subcutaneous, rectal, endotracheal and oral medication for infants and children. (P-2) / 6-2.106 5.64Demonstrate an appropriate technique for insertion of an intraosseous line for infants and children. (P-2) / 6-2.108 5.65Demonstrate appropriate interventions for infants and children with a partially obstructed airway. (P-2) / 6-2.109 5.66Demonstrate age appropriate basic airway clearing maneuvers for infants and children with a completely obstructed airway. (P-2) / 6-2.110 5.67Demonstrate proper technique for direct laryngoscopy and foreign body retrieval in infants and children with a completely obstructed airway. (P-2) / 6-2.111 5.68Demonstrate appropriate airway and breathing control maneuvers for infant and child trauma patients. (P-2) / 5.69Demonstrate appropriate treatment of infants and children requiring advanced airway and breathing control. (P-2) / 6-2.113 5.70Demonstrate appropriate immobilization techniques for infant and child trauma patients. (P-2) / 6-2.114 5.71Demonstrate treatment of infants and children with head injuries. (P-2) / 6-2.115 5.72Demonstrate appropriate treatment of infants and children with chest injuries. (P-2) / 6-2.116 5.73Demonstrate appropriate treatment of infants and children with abdominal injuries. (P-2) / 6-2.117 5.74Demonstrate appropriate treatment of infants and children with extremity injuries. (P-2) / 6-2.118 5.75Demonstrate appropriate treatment of infants and children with burns. (P-2) / 6.2.119 5.76Demonstrate appropriate parent/ caregiver interviewing techniques for infant and child death situations.(P-2) / 6-2.120 5.77Demonstrate proper infant CPR. (P-2) / 6-2.121 5.78Demonstrate proper child CPR. (P-2) / 6-2.122 5.79Demonstrate proper techniques for performing infant and child defibrillation and synchronized cardioversion.(P-2) / 6-2.123 DECLARATIVE Assessment General considerations Many components of the initial patient evaluation can be done by observing the patient. Utilize the parent/ guardian to assist in making the infant or child more comfortable as appropriate. Interacting with parents and family Normal responses to acute illness and injury Parent/ guardian and child interaction Intervention techniques Physical exam Scene survey Observe the scene for hazards or potential hazards Observe the scene for mechanism of injury/ illness Ingestion ills, medicine bottles, household chemicals, etc. Child abuse Injury and history do not coincide, bruises not where they should be for mechanism of injury, etc. Position patient found Observe the parent/ guardian/ caregiver interaction with the child Do they act appropriately Is parent/ guardian/ caregiver concerned Is parent/ guardian/ caregiver angry Is parent/ guardian/ caregiver indifferent Initial assessment General impression General impression of environment General impression of parent/ guardian and child interaction General impression of the patient/ Pediatric Assessment Triangle A structure for assessing the pediatric patient Focuses on the most valuable information for pediatric patients Used to ascertain if any life-threatening condition exists Components Appearance Work of breathing Circulation Initial triage decisions Urgent - proceed with rapid ABC assessment, treatment and transport Non urgent - proceed with focused history, detailed physical exam after initial assessment Vital functions Determine level of consciousness AVPU scale Alert Responds to verbal stimuli Responds to painful stimuli Unresponsive Modified Glasgow Coma Scale Signs of inadequate oxygenation Airway Determine patency Breathing Adequate chest rise and fall Use of accessory muscles Nasal flaring Tachypnea Bradypnea Irregular breathing pattern Head bobbing Grunting Absent breath sounds Abnormal sounds Circulation Pulse Central Peripheral Quality of pulse Blood pressure Measuring blood pressure is not necessary in children < 3 years of age Skin color Active hemorrhage Vital signs Infant Toddler Preschool School aged Adolescent Transition phase - Utilized to allow the infant or child to become familiar with you and your equipment Use of transition phase depends on the seriousness of the patient's condition For the conscious, non-acutely ill child For the unconscious, acutely ill child do not perform the transition phase but proceed directly to the treatment and transport Focused history Approach For infant, toddler, and preschool age patient, obtain from parent/guardian For school age and adolescent patient, most information may be obtained from the patient For older adolescent patient question the patient in private regarding sexual activity, pregnancy, illicit drug and alcohol use Content Chief complaint Nature of illness/injury How long has the patient been sick/injured Presence of fever Effects on behavior Bowel/ urine habits Vomiting/ diarrhea Frequency of urination Past medical history Infant or child under the care of a physician Chronic illnesses Medications Allergies Detailed physical exam Examine all body regions Head-to-toe in older child Toe-to-head in younger child Some or all of the following may be appropriate, depending on the situation Pupils Capillary refill Normal - two seconds or less Valuable to assess on patients less than six years of age Less reliable in cold environment Blanch nailbed, base of the thumb, sole of the feet Hydration Skin turgor Sunken or flat fontanelle in an infant Presence of tears and saliva Pulse oximetry Should be utilized on any moderately injured or ill infant or child Hypothermia and shock can alter reading Cardiac monitor On-going exam - continually monitor the following Respiratory effort Color Mental status Pulse oximetry Vital signs Patient temperature General management Airway management in pediatric patients Basic airway management Manual positioning Allow medical patients to assume position of comfort Support under the torso for trauma patients less than 3 year old Occipital elevation for supine medical patients 3 years of age or older Foreign body airway obstruction - basic clearing methods Infants Back blows Chest thrusts Children Abdominal thrusts Suction Avoid hypoxia Avoid upper airway stimulation Decrease suction negative pressure (100 mm/Hg) in infants Oxygenation Non-rebreather mask Blow-by oxygen if mask is not tolerated Utilize the parent or guardian to deliver oxygen if (patient condition warrants Maintain proper head position Oropharyngeal airway Sizing Preferred method of insertion uses the tongue blade to depress the tongue and jaw Nasopharyngeal airway Sizing No major differences in sizing or use compared to adults Ventilation Bag size Proper mask fit Proper mask position and seal (E-C clamp) Ventilate at age appropriate rate (squeeze-release-release) Obtain chest rise with each breath Allow adequate time for exhalation Assess BVM ventilation Apply cricoid pressure to minimize gastric inflation and passive regurgitation Advanced airway management Foreign body airway obstruction - advanced clearing methods Direct laryngoscopy with Magill forceps Attempt intubation around foreign body Consider needle cricothyroidotomy per medical direction only as a last resort if complete upper airway obstruction is present Endotracheal intubation in pediatric patients Laryngoscope and appropriate size blade Length based resuscitation tape to determine size Straight blade is preferred Appropriate size endotracheal tube and stylet Sizing methods Length based resuscitation tape Stylet placement Technique for pediatric intubation Depth of insertion Endotracheal tube securing device Needle cricothyroidotomy in pediatric patients Circulation Vascular access Intraosseous access in children < 6 years of age in cardiac arrest or if intravenous access fails Fluid resuscitation 20 ml/kg of lactated ringer’s or normal saline bolus as needed Pharmacological Rapid sequence intubation per medical direction Non-pharmacological C-spine immobilization for traumatic cause Transport considerations Appropriate mode Transport should not be delayed to perform procedures that can be done en route Proper BLS care must be performed prior to any ALS interventions Appropriate facility The availability of a receiving hospital with expertise in pediatric care may improve the patient’s outcome Psychological support/ communication strategies Utilize the parent/ guardian to assist in making the infant or child more comfortable Encourage parents to help calm the child during painful procedures Infants, toddlers, preschool and school aged patients do not like to be separated from parent/ guardian Infants and children hav