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 EMTs 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 students 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 participants 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 students basic academic skills competence The students EMS knowledge and skills The faculty to student ratio The students motivation The students prior emergency/health care experience The students 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 groups 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 students abilities and the local EMS systems 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 participants performance. Pretest The use of a psychomotor pretest is the best measurement of an individuals 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 programs objectives or pass the evaluation process should have their performance reviewed by one of the instructional staff members. The participants 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 participants 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 patients 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 - Sellicks 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 patients 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 ringers 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 patients 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 have a natural fear of strangers; for stable patients, allow them to become accustomed to you before your hands-on assessment Give some control of what is going to happen to the patient (which arm to have their IV) When possible and practical, physically position your face at the same level as the patients face to facilitate communication and minimize fear Use age-appropriate vocabulary Keep patient warm Allow child to take their favorite toy/ blanket if possible Permit the child to express their feelings (e.g., fear, pain, crying,) Let the child know that certain physical actions (e.g., hitting, biting, spitting) are not permitted Specific pathophysiology, assessment and management Respiratory compromise Introduction Epidemiology Incidence Morbidity/ mortality Risk factors Prevention strategies Categories of respiratory compromise Upper airway obstruction Lower airway disease Pathophysiology Respiratory illnesses cause respiratory compromise in airway/ lung Severity of respiratory compromise depends on extent of respiratory illness Approach to treatment depends on severity of respiratory compromise Severity Respiratory distress Increased work of breathing Carbon dioxide tension in the blood initially decreases, then increases as condition deteriorates If uncorrected, respiratory distress leads to respiratory failure Respiratory failure Inadequate ventilation or oxygenation Respiratory and circulatory systems are unable to exchange enough oxygen and carbon dioxide Carbon dioxide tension in the blood increases, leading to respiratory acidosis Very ominous condition; patient is on the verge of respiratory arrest Respiratory arrest Cessation of breathing Failure to intervene will result in cardiopulmonary arrest Good outcomes can be expected with early intervention that prevents cardiopulmonary arrest Assessment Chief Complaint History Physical findings Signs and symptoms of respiratory distress Normal mental status => irritability or anxiety Tachypnea Retractions Nasal flaring Good muscle tone Tachycardia Head bobbing Grunting Cyanosis which improves with supplemental oxygen Signs and symptoms of respiratory failure Irritability or anxiety ==> lethargy Marked tachypnea ==> bradypnea Marked retractions ==> agonal respirations Poor muscle tone Marked tachycardia ==> bradycardia Central cyanosis Signs and symptoms of respiratory arrest Obtunded ==> coma Bradypnea ==> apnea Absent chest wall motion Limp muscle tone Bradycardia ==> asystole Profound cyanosis On-going assessment - improvement indicated by Improvement in color Improvement in oxygen saturation Increased pulse rate Increased level of consciousness Management Graded approach to treatment Consider separating parent and child Airway Manage upper airway obstructions as needed Insert airway adjunct if needed Ventilation and oxygenation Respiratory distress/ early respiratory failure Administer high flow oxygen Late respiratory failure/ respiratory arrest BVM - ventilate patient with 100% oxygen via age- appropriate sized bag ETT - intubate patient if positive pressure ventilation does not rapidly improve patient condition Consider gastric decompression if abdominal distention is impeding ventilation Consider needle decompression per medical direction if tension pneumothorax is present Consider cricothyroidotomy per medical direction only as a last resort if complete upper airway obstruction is present Circulation Supportive care Transport considerations Appropriate mode Appropriate facility Psychological support/ communication strategies Upper airway obstruction Croup Epidemiology Incidence Very common in infants and children (6 months to 4 years of age) Risk factors Prevention strategies Pathophysiology An inflammatory process of the upper respiratory tract involving the subglottic region Main cause is viral infection of the upper airway Another form is spasmodic croup Occurs mostly in the middle of the night Usually without prior upper respiratory infection Assessment Signs and symptoms of respiratory distress or failure, depending on severity, plus Appears sick Stridor Barking (seal or dog-like) or brassy cough Hoarseness Fever (+/-) History Usually with history of upper respiratory infection in classic croup (1-2 days) Rarely progresses to respiratory failure Management Airway and ventilation Humidified or nebulized oxygen Cool mist oxygen at 4-6 L/min Circulation Pharmacological Non-pharmacological Keep child in position of comfort Transport considerations Psychological support/ communication strategies Do not agitate the patient (no IVs, blood pressure, etc.) Keep the parent/ guardian/ caregiver with the infant or child if appropriate Foreign body aspiration Epidemiology Incidence Usually occurs in toddlers and pre-schoolers (1 to 4 years of age, but can occur at any age) Common Risk factors Prevention strategies Pathophysiology Partial or complete blockage of the upper airway by a foreign body Objects are usually food (hard candy, nuts, seeds, hot dog) or small objects (coins, balloons) If no interventions or if interventions are unsuccessful, respiratory arrest followed by cardiopulmonary arrest will ensue Assessment Partial obstruction Signs and symptoms of respiratory distress or failure, depending on severity, plus History - Usually a history of choking if observed by adult Complete obstruction Signs and symptoms of respiratory failure or arrest, depending on severity, plus History Management Airway and ventilation Partial obstruction Complete obstruction Circulation Pharmacological Transport considerations Notify hospital of patient status Transport expeditiously Psychological support/ communication strategies Do not agitate patient Keep caregiver with child, if appropriate Bacterial tracheitis Epidemiology Incidence Usually occurs in infants and toddlers (1-5 years old), but can occur in older children Very uncommon Risk factors Prevention strategies Pathophysiology Bacterial infection of the upper airway, subglottic trachea, usually following viral croup Assessment Signs and symptoms - respiratory distress or failure depending on severity, plus Appears agitated, sick High-grade fever Inspiratory and expiratory stridor Coughing up pus/ mucous Hoarse voice Pain in throat History Usually a history of croup in the preceding few days May progress to respiratory failure or arrest Management Assure airway and ventilation Administer oxygen by non-rebreather or blow-by Complete obstruction or respiratory failure/ arrest BVM ventilation May require high pressure to adequately ventilate Intubate patient Suction endotracheal tube to reduce pus or mucous Circulation Pharmacological Transport considerations Place patient in sitting position Notify hospital of patient status as early as possible Transport quickly Psychological support/ communication strategies DO NOT AGITATE THE PATIENT - no IVs, no BP, do not look in patients mouth Keep caregiver with child if appropriate Epiglottitis Epidemiology Incidence Usually occurs in pre-school and school-age children (3-7 years of age) but can occur at any age Extremely uncommon due to the H. flu vaccine Risk factors Prevention strategies Pathophysiology Rapidly forming cellulitis of the epiglottis and its surrounding structures Bacterial infection, usually Hemophilus influenza type B Can be a true life-threatening emergency Assessment Signs and symptoms of respiratory distress or failure depending on severity, plus Appears agitated, sick Stridor Muffled voice Drooling Sore throat Pain on swallowing High fever History Usually no previous history but a rapid onset of symptoms (6-8 hours) Can quickly progress to respiratory arrest Management Airway and ventilation NEVER ATTEMPT TO VISUALIZE THE AIRWAY IF THE PATIENT IS AWAKE Allow the parent to administer oxygen If airway becomes obstructed, two rescuer ventilation with BVM is almost always effective If BVM is not effective, attempt intubation with stylet in place Intubation should not be attempted in settings with short transport times Performing chest compression upon glottic visualization during intubation may produce a bubble at the tracheal opening Consider needle cricothyroidotomy per medical direction as a last resort if complete upper airway obstruction is present Circulation Pharmacological Transport considerations Allow patient to assume position of comfort Notify hospital of patient status early Transport to the hospital without delay, keeping child warm Psychological support/ communication strategies DO NOT AGITATE THE PATIENT - no IVs, BP, do not look in patients mouth Keep the caregiver with the child if appropriate Lower airway disease Asthma Epidemiology Incidence Usually occurs in children older than 2 years of age Very common Risk factors Typically in child with known history of asthma Triggered by upper respiratory infections, allergies, changes in temperature, physical exercise and emotional response Children that experience prolonged asthma attacks tire easily; watch for signs of respiratory failure Prevention strategies Pathophysiology Bronchospasm Excessive mucous production Inflammation of the small airways Assessment Signs and symptoms - respiratory distress or failure depending on severity, plus Appears anxious Wheezes Prolonged expiratory phase A silent chest means danger History Usually follows exposure to known trigger Bronchiolitis and asthma may present very similarly Management Airway and ventilation Administer oxygen by tolerated method BVM ventilations for respiratory failure/ arrest (progressive lethargy, poor muscle tone, shallow respiratory effort) Endotracheal intubation for respiratory failure/ arrest with prolonged BVM ventilations, or inadequate response to BVM ventilations Circulation Pharmacological Albuterol nebulizer Subcutaneous epinephrine 1:1000 - only with severe respiratory distress or failure Medications can be repeated if no effect Transport considerations Allow patient to assume position of comfort Psychological support/ communication strategies Keep caregiver with child if appropriate Bronchiolitis Epidemiology Incidence Usually occurs in children less than 2 years of age Very common Risk factors Usually occurs in winter months Prevention strategies Pathophysiology An inflammatory process of the lower respiratory tract including the terminal airways Main cause is respiratory syncytial virus infection of the lower airway Assessment Signs and symptoms - respiratory distress or failure depending on severity, plus Appears anxious Wheezing Rales (diffuse) History Usually a history of upper respiratory infection symptoms Bronchiolitis and asthma may present very similarly Management Airway and ventilation Administer oxygen by tolerated method BVM ventilations for respiratory failure/ arrest (progressive lethargy, poor muscle tone, shallow respiratory effort) Endotracheal intubation for respiratory failure/ arrest with prolonged BVM ventilations, or inadequate response to BVM ventilations Circulation Pharmacological Albuterol nebulizer Transport considerations Allow patient to assume position of comfort Psychological support/ communication strategies Keep caregiver with child if appropriate Pneumonia Epidemiology Incidence Usually occurs in infants, toddlers and pre-schoolers (1-5 years of age), but can occur at any age Common Risk factors Prevention strategies Pathophysiology Infection of the lower airway and lung May be caused by bacteria or virus Assessment Signs and symptoms - respiratory distress or failure depending on the severity, plus Appears anxious Decreased breath sounds Rales Rhonchi (localized or diffuse) Pain in the chest Fever History Usually a history of lower respiratory infectious symptoms Management Airway and ventilation Administer oxygen by tolerated method BVM ventilations for respiratory failure/ arrest (progressive lethargy, poor muscle tone, shallow respiratory effort) Endotracheal intubation for respiratory failure, prolonged BVM ventilations, or inadequate response to BVM ventilations Circulation Pharmacological Transport considerations Allow patient to assume position of comfort Psychological support/ communication strategies Keep caregiver with child if appropriate Foreign body lower airway obstruction Epidemiology Incidence Usually occurs in toddlers and preschool age children (1-4 years of age), but can occur at any age Uncommon Risk factors Prevention strategies Pathophysiology Foreign body in the lower airway or lung Objects are usually food (nuts, seeds, etc.) or small objects Assessment Signs and symptoms - respiratory distress of failure depending on the severity, plus Appears anxious Decreased breath sounds Rales Rhonchi (localized or diffuse) Pain in the chest History May be a history of choking if witnessed by an adult Management Airway and ventilation Administer oxygen by tolerated method BVM ventilations for respiratory failure/ arrest (progressive lethargy, poor muscle tone, shallow respiratory effort) Endotracheal intubation for respiratory failure/ arrest with prolonged BVM ventilations, or inadequate response to BVM ventilations Do not attempt to retrieve foreign body as it is beyond the reach of Magill forceps Circulation Transport considerations Allow patient to assume position of comfort Psychological support/ communication strategies Keep caregiver with child if appropriate Shock Introduction Epidemiology Incidence Morbidity/ mortality Risk factors Prevention strategies Categories of shock Non-cardiogenic Cardiogenic Pathophysiology An abnormal condition characterized by inadequate delivery of oxygen and metabolic substrates to meet the metabolic demands of tissues Severity Compensated (early) Patients blood pressure is normal although signs of inadequate tissue perfusion are present Reversible Decompensated (late) Hypotension and signs of inadequate organ perfusion are present Often irreversible Assessment Chief complaint History Physical findings Signs and symptoms of compensated shock Irritability or anxiety Tachycardia Tachypnea Weak peripheral pulses, full central pulses Delayed capillary refill Cool, pale extremities Systolic blood pressure within normal limits Decreased urinary output Signs and symptoms of decompensated shock Lethargy or coma Marked tachycardia or bradycardia Marked tachypnea or bradypnea Absent peripheral pulses, weak central pulses Markedly delayed capillary refill Cool, pale, dusky, mottled extremities Hypotension Markedly decreased urinary output Management Graded approach to treatment Consider separating parent and child Airway Trauma - immobilize c-spine Ventilation and oxygenation Compensated shock Oxygen Decompensated shock BVM - consider ventilating patient with 100% oxygen via appropriate-sized bag ETT - consider intubating patient if positive pressure ventilation does not rapidly improve patients condition Circulation Compensated shock Oxygen Decompensated shock Non-cardiogenic Cardiogenic Supportive care Transport considerations Appropriate mode Appropriate facility Psychological support/ communication strategies Noncardiogenic Hypovolemia Epidemiology Common Pathophysiology Intravascular volume depletion Severe dehydration Blood loss Assessment Signs and symptoms of compensated or decompensated shock depending on severity, plus Blood loss Dehydration History Management Airway and ventilation Oxygen Trauma - immobilize c-spine Circulation Compensated shock Decompensated shock Supportive care Transport considerations Psychological support/ communication strategies Distributive Epidemiology Uncommon Etiology Septic Neurogenic Anaphylactic Pathophysiology Peripheral pooling due to loss of vasomotor tone Assessment Signs and symptoms of compensated or decompensated shock depending on severity, plus Septic Neurogenic Anaphylactic History Management Airway and ventilation Oxygen Trauma - immobilize c-spine Circulation Compensated shock Decompensated shock Supportive care Transport considerations Psychological support/ communication strategies Cardiogenic Cardiomyopathy Epidemiology Infection Congenital abnormalities Pathophysiology Mechanical pump failure Usually biventricular Assessment Signs and symptoms of compensated or decompensated shock, depending on severity, plus Rales Jugular venous distention Hepatomegaly Peripheral edema History Management Airway and ventilation Oxygen Circulation Compensated shock Decompensated shock Supportive care Transport considerations Psychological support/ communication strategies Dysrhythmias Epidemiology Bradydysrhythmias - common Supraventricular tachydysrhythmias - uncommon Ventricular tachydysrhythmias - very uncommon Pathophysiology Electrical pump failure Results in cardiogenic shock or cardiopulmonary arrest depending on type Assessment Signs and symptoms of cardiogenic shock (compensated or decompensated) or cardiopulmonary arrest, depending on type History Management Specific to each type Dysrhythmias Tachydysrhythmias Supraventricular tachycardia Epidemiology Incidence Usually in infants with no prior history Risk factors Prevention strategies Pathophysiology Stable (compensated shock) - patient will usually remain stable during transport with oxygen Unstable (decompensated shock) - PATIENT REQUIRES IMMEDIATE TREATMENT Children may be able to sustain increased rates for a while, but after several hours, they will decompensate Assessment Signs and symptoms - compensated or decompensated shock, depending on severity, plus Narrow complex tachycardia with rates of greater than 220 beats per minute (too fast to count) Poor feeding Hypotension History Management Stable - supportive care Unstable Airway and ventilation Circulation Pharmacological Non-pharmacological Transport considerations Psychological support/ communication strategies Ventricular tachycardia with a pulse Epidemiology Incidence Risk factors Prevention strategies Pathophysiology Stable (compensated shock) - patient will usually not tolerate for long periods of time Unstable (decompensated shock) - PATIENT REQUIRES IMMEDIATE TREATMENT Most VT with a pulse is secondary to structural heart disease and responds poorly to lidocaine Assessment Signs and symptoms - signs of compensated or decompensated shock, depending on severity, plus Rapid, wide complex tachycardia Poor feeding Hypotension History Management Stable - supportive care Unstable Airway and ventilation Circulation Pharmacological Non-pharmacological Transport considerations Psychological support/ communication strategies Bradydysrhythmias Epidemiology Incidence - most common dysrhythmia in children Risk factors Prevention strategies Pathophysiology Usually develops as a result of hypoxia May develop due to vagal stimulation (rare) Assessment Signs and symptoms - compensated or decompensated shock, depending on severity, plus Bradycardia Slow, narrow complex heart rhythm, QRS duration may be normal or prolonged History Management Stable - supportive care Unstable Airway and ventilation Ventilate patient with 100% oxygen via BVM Intubate patient if poor response to BVM ventilations Circulation Perform chest compressions if oxygen does not increase heart rate Pharmacological Medications can be given down the endotracheal tube Administer epinephrine Administer atropine for vaguely induced bradycardia Non-pharmacological Transport considerations Psychological support/ communication strategies Absent rhythm Asystole Epidemiology Incidence - may be the initial cardiac arrest rhythm Risk factors Prevention strategies Pathophysiology Bradycardias may degenerate into asystole High mortality rate Assessment Signs and symptoms Pulseless Apneic Cardiac monitor indicating no electrical activity History Management Confirm in two leads Airway and ventilation Ventilate the patient with 100% oxygen via BVM Intubate patient if poor response to BVM ventilations Circulation Perform chest compressions Pharmacological Medications can be given down the endotracheal tube Administer epinephrine Non-pharmacological Transport considerations Psychological support/ communication strategies Ventricular fibrillation/ pulseless ventricular tachycardia Epidemiology Incidence - rare Risk factors Prevention strategies Pathophysiology Possibly due to electrocution and drug overdoses High mortality rate Assessment Signs and symptoms Pulseless Apneic Cardiac monitor indicating no organized electrical activity or rapid wide complex tachycardia History Management Unmonitored - perform basic life support Monitored - defibrillate up to three consecutive shocks Airway and ventilation Ventilate the patient with 100% oxygen via BVM Intubate patient if poor response to BVM ventilations Circulation Perform chest compressions Pharmacological Medications can be given down the endotracheal tube Administer epinephrine Administer lidocaine Administer bretylium After administration of a medication, allow it to circulate for one minute before repeat defibrillation Non-pharmacological Transport considerations Psychological support/ communication strategies Pulseless electrical activity Epidemiology Incidence - look for a treatable cause Risk factors Prevention strategies Pathophysiology Pneumothorax Cardiac tamponade Hypovolemia Hypoxia Acidosis Hypothermia Hypoglycemia Assessment Signs and symptoms Pulseless Apneic Cardiac monitor indicating organized electrical activity History Management Resuscitation should be directed toward relieving cause Airway and ventilation Ventilate the patient with 100% oxygen Intubate patient Circulation Perform chest compressions Pharmacological Medications can be given down the endotracheal tube Administer epinephrine Non-pharmacological Transport considerations Psychological support/ communication strategies Pediatric trauma Pathophysiology Blunt Thinner body wall allows forces to be readily transmitted to body contents Predominant cause of injury in children Penetrating Becoming an increasing problem in adolescents Higher incidence in the inner city (mostly intentional), but significant incidence in other areas (mostly unintentional) Mechanism of injury Fall Single most common cause of injury in children Serious injury or death resulting from truly accidental falls is relatively uncommon unless from a significant height Prevention strategies Motor vehicle crash Leading cause of permanent brain injury and new cases of epilepsy Leading cause of death and serious injury in children Prevention strategies Pedestrian vehicle crash Particularly lethal form of trauma in children Initial injury due to impact with vehicle (extremity/ trunk) Child is thrown from force of impact causing additional injury (head/ spine) upon impact with other objects (ground, another vehicle, light standard, etc.) Prevention strategies Near-drowning Third leading cause of injury or death in children between birth and 4 years of age Causes approximately 2000 deaths annually Severe, permanent brain damage occurs in 5-20% of hospitalized children for near drowning Prevention strategies Penetrating injuries Risk of death from firearm injuries increase with age Stab wounds and firearm injuries account for approximately 10-15% of all pediatric trauma admissions Visual inspection of external injuries can not evaluate the extent of internal involvement Prevention strategies Burns The leading cause of accidental death in the home for children under the age of 14 years Burn survival is a function of burn size and concomitant injuries Modified "rule of nines" is utilized to determine percentage of surface area involved Prevention strategies Physical abuse Has been classified into four categories - physical abuse, sexual abuse, emotional abuse and child neglect Social phenomena such as increased poverty, domestic disturbance, younger aged parents, substance abuse, and community violence have been attributed to increase of abuse Document all pertinent findings, treatments and interventions Prevention strategies Special considerations Airway control Maintain in-line stabilization in neutral, not sniffing position Administer 100% oxygen to all trauma patients Patent airway must be maintained via suctioning and jaw thrust Be prepared to assist ineffective respirations Intubation should be performed when the airway remains inadequate Gastric tube should be placed after intubation Needle cricothyroidotomy is rarely indicated for traumatic upper airway obstruction Immobilization Indications for stabilization and immobilization of cervical spine Utilize appropriate sized pediatric immobilization equipment Rigid cervical collar Towel/ blanket roll Child safety seat Pediatric immobilization device Vest-type/ short wooden backboard Long backboard Straps, cravats Tape Padding Maintain supine neutral in-line position for infants, toddlers, and pre-schoolers by placing padding from the shoulders to the hips Fluid management Management of the airway and breathing take priority over management of circulation because circulatory compromise is less common in children than adults Vascular access Large-bore intravenous catheter should be inserted into a large peripheral vein Do not delay transport to gain access Intraosseous access in children < 6 years of age if intravenous access fails Initial fluid bolus of 20 ml/kg of an lactated ringers or NS Reassess vital signs and rebolus with 20 ml/kg if no improvement If improvement does not occur after the second bolus, there is likely to be significant blood loss and the need for rapid surgical intervention Traumatic brain injury Early recognition and aggressive management can reduce mortality and morbidity Severity Mild - GCS is 13 to 15 Moderate - GCS is 9 to 12 Severe - GCS is less than or equal to 8 Signs of increased intracranial pressure Elevated blood pressure Bradycardia Rapid deep respirations (Kussmaul) progressing to slow, deep respirations alternating with rapid deep respirations (Cheyne-Stokes) Bulging fontanelle (infant) Signs of herniation Asymmetrical pupils Posturing Specific management Administer high concentration of oxygen for mild to moderate head injuries (GCS 9-15) Intubate and ventilate at normal breathing rate with 100% oxygen for severe head injuries (GCS 3-8) Use of lidocaine may blunt rise in ICP (controversial) Consider RSI per medical direction Indications for hyperventilation Asymmetric pupils Active seizures Neurologic posturing Specific injuries Head and neck injury Larger relative mass of the head and lack of neck muscle strength provides increased momentum in acceleration-deceleration injuries and a greater stress to the cervical spine region Fulcrum of cervical mobility in the younger child is at the C2-C3 level 60% to 70% of pediatric fractures occur in C1 or C2 Head injury is the most common cause of death in pediatric trauma victim Diffuse injuries are common in children, focal injuries are rare Soft tissues, skull and brain are more compliant in children than in adults Due to open fontanelles and sutures, infants up to an average age of 16 months may be more tolerant to an increase of intracranial pressure and can have delayed signs Subdural bleeds in a infant can produce hypotension (extremely rare) Significant blood loss can occur through scalp lacerations and should be controlled immediately The Modified Glasgow Coma scale should be utilized for infants and young children Chest injury Chest injuries in children under 14 years of age are usually the result of blunt trauma Due to the compliance of the chest wall, severe intrathoracic injury can be present without signs of external injury Tension pneumothorax is poorly tolerated and is an immediate threat to life Flail segment is an uncommon injury in children; when noted without a significant mechanism of injury, suspect child abuse Many children with cardiac tamponade will have no physical signs of tamponade other then hypotension Abdominal injury Musculature is minimal and poorly protects the viscera Organs most commonly injured are liver, kidney and spleen Onset of symptoms may be rapid or gradual Due to the small size of the abdomen, be certain to palpate only one quadrant at a time Any child who is hemodynamically unstable without evidence of obvious source of blood loss should be considered as having an abdominal injury until proven otherwise Extremity Relatively more common in children than adults Growth plate injuries are common Compartment syndrome is an emergency in children Any sites of active bleeding must be controlled Splinting should be performed to prevent further injury and blood loss PASG may be useful in unstable pelvic fractures with hypotension Burns Thermal burns in children Chemical burns in children Electrical burns in children Management priorities Prompt management of the airway is required as swelling can develop rapidly If intubation is required, an endotracheal tube up to two sizes smaller than what would normally be used may be required Thermally burned children are very susceptible to hypothermia; maintain normal body temperature Module VI: Other Recommended Content Areas Operations NREMT PRACTICE ANALYSIS TASK ITEMS Prepare the emergency vehicle and equipment before responding to a call Drive the emergency vehicle in an emergency situation Assess scene safety Provide for safety of self, patient and fellow workers Take infection control precautions (body substance isolation), Dispose of sharps (needles, auto-injector, etc...), Dispose of materials contaminated with body fluids Use body mechanics when lifting and moving a patient COGNITIVE OBJECTIVES At the completion of this unit, the paramedic will be able to: 6.1Discuss the importance of completing an ambulance equipment/ supply checklist. (C-1) 6.2Given a scenario involving arrival at the scene of a motor vehicle collision, assess the safety of the scene and propose ways to make the scene safer. (C-3) / 1-2.11 6.3List factors that contribute to safe vehicle operations. (C-1) / 1-2.12 6.4Describe the considerations that should be given to: (C-1) / 1-2.13 Using escorts Adverse environmental conditions Using lights and siren Proceeding through intersections Parking at an emergency scene 6.5Discuss the concept of "due regard for the safety of all others" while operating an emergency vehicle. (C-1) / 1-2.14 6.6Explain how EMS providers are often mistaken for the police. (C-1) / 8-5.1 6.7Explain specific techniques for risk reduction when approaching the following types of routine EMS scenes: (C-1) / 8-5.2 Highway encounters Violent street incidents Residences and "dark houses" 6.8Describe warning signs of potentially violent situations. (C-1) / 8-5.3 6.9Explain emergency evasive techniques for potentially violent situations, including: (C-1) / 8-5.4 Threats of physical violence. Firearms encounters Edged weapon encounters 6.10Explain EMS considerations for the following types of violent or potentially violent situations: (C-1) / 8-5.5 Gangs and gang violence Hostage/ sniper situations Clandestine drug labs Domestic violence Emotionally disturbed people Hostage/ sniper situations 6.11Explain the following techniques: (C-1) / 8-5.6 Field "contact and cover" procedures during assessment and care Evasive tactics Concealment techniques 6.12Describe police evidence considerations and techniques to assist in evidence preservation. (C-1) 8-5.7 6.13Describe the problems that a paramedic might encounter in a hostile situation and the techniques used to manage the situation. (C-1) / 1-2.10 6.14Describe the equipment available for self-protection when confronted with a variety of adverse situations. (C-1) / 1-2.15 6.15Differentiate proper from improper body mechanics for lifting and moving patients in emergency and non-emergency situations. (C-3) / 1-2.9 AFFECTIVE OBJECTIVES At the completion of this unit, the paramedic will be able to: 6.16Assess personal practices relative to ambulance operations, which may affect the safety of the crew, the patient and bystanders. (A-3) / 8-1.6 6.17Serve as a role model for others relative to the operation of ambulances. (A-3) / 8-1.7 6.18Advocate and practice the use of personal safety precautions in all scene situations. (A-3) / 1-2.43 6.19Discuss the importance of universal precautions and body substance isolation practices. (C-1) / 1-2.30 6.20Describe the steps to take for personal protection from airborne and bloodborne pathogens. (C-1) / 1-2.31 6.21Given a scenario, in which equipment and supplies have been exposed to body substances, plan for the proper cleaning, disinfection, and disposal of the items. (C-3) / 1-2.32 6.22Explain what is meant by an exposure and describe principles for management. (C-1) / 1-2.33 6.23Advocate and serve as a role model for other EMS providers relative to body substance isolation practices. (A-3) 1-2.43 PSYCHOMOTOR OBJECTIVES At the completion of this unit, the paramedic will be able to: 6.24Demonstrate the following techniques: (P-1) / 8-5.8 Field "contact and cover" procedures during assessment and care Evasive tactics Concealment techniques 6.25Demonstrate the proper procedures to take for personal protection from disease. (P-2) / 1-2.46 6.26Demonstrate safe methods for lifting and moving patients in emergency and non-emergency situations. (P-2) / 1-2.45 6.27Demonstrate how to place a patient in, and remove a patient from, an ambulance. (P-1) / 8-1.9 Other Suggested Topic Areas Diagnostic ECG EMS Agenda for the Future issues (such as prevention) Geriatrics Local clinical & technology / equipment update Local quality improvement issues Nationally recognized guidelines / programs for out-of-hospital care (ACLS, AMLS, BTLS, PALS, PEPP, PHTLS, etc) Skills updates / maintenance AppendixES Appendix A NREMT Practice Analysis (1999) NREMT Practice Analysis (1999) Below is a list of the tasks extracted from the 1999 NREMT Practice Analysis. Each participant involved in the random survey was asked to indicate the frequency in which they utilized an identified task. In addition to frequency, the participants were asked to provide input on the potential of harm and difficulty they experienced in accomplishing each task. The chart below identifies those task, based on either frequency and/or potential for harm, that was used in the creation of this document. The task force utilized those task that were identified as having low frequency of performance and a high potential for harm along with the tasks that had a high frequency of performance and a high potential for harm. 24 of the 123 tasks were identified as meeting the above criteria and were utilized as the basis for the mandatory portion of this refresher curriculum. TaskFrequencyPotential for Harm Assess a patient experiencing an allergic reactions s Assess a patient with possible overdoses s Assess a near-drowning patients s Assess an infant or child with cardiac arrests s Assess an infant or child with respiratory distresss s Assess an infant or child with shock (hypoperfusion)s s Assess an infant or child with traumas s Assess a patient with a head injurys s Assess a patient with a suspected spinal injurys s Perform a rapid trauma assessments s Provide ventilatory support for a patients s Attempt to resuscitate a patient in cardiac arrests s Provide care to a patient experiencing cardiovascular compromises s Provide post-resuscitation care to a cardiac arrest patients s Provide care to the patient experiencing an allergic reactions s Provide care to a near-drowning patients s Provide care to an infant or child with cardiac arrests s Provide care to an infant or child with respiratory distresss s Provide care to an infant or child with shock (hypoperfusion)s s Provide care to an infant or child with traumas s Provide care to a patient with a chest injurys s Provide care to a patient with an open abdominal injurys s Provide care to a patient with shock (hypoperfusion)s s Provide care to a patient with suspected spinal injurys s Appendix B Practice Scenario and Scenario Template Scenario Template Lectures have traditionally been the backbone for most educational endeavors. While this type of education process has been used in the past, todays students are seeking greater challenges in the classroom. One alternative method for education is the use of scenario based education. Scenario based education allows the instructor and student to achieve a more realistic approach to patient care situations. This refresher curriculum can be delivered to the experienced provider through the use of scenarios. This scenario template has been included for use during the refresher course. The template was designed by the NREMT for use with their oral scenario station. The recommendation would be for the instructor to develop scenarios that met the objectives of this curriculum for use in the classroom portion as well as the skill labs. BACKGROUND INFORMATION EMS System description (including urban/rural setting) Vehicle type/response capabilities Proximity to and level/type of facilities DISPATCH INFORMATION Nature of the call Location Dispatch time Weather Personnel on scene SCENE SURVEY INFORMATION Scene considerations Patient location Visual appearance Age, gender, weight Immediate surroundings (bystanders, family members present, etc.) PATIENT ASSESSMENT Chief complaint History of present illness/injury Patient responses, symptoms, and pertinent negatives PAST MEDICAL HISTORY Past medical history Medications and allergies Social/family concerns EXAMINATION FINDINGS Initial vital signsB/P P R SpO2 Respiratory Cardiovascular Gastrointestinal Genitourinary Musculoskeletal Neurologic Integumentary Hematologic Immunologic Endocrine Psychiatric PATIENT MANAGEMENT Initial stabilization Treatments Monitoring Additional resources Patient response to interventions TRANSPORT DECISION Lifting and moving the patient Mode Facilities CONCLUSION Field impression Rationale for field impression Related pathophysiology Verbal report MANDATORY ACTIONS POTENTIALLY HARMFUL/DANGEROUS ACTIONS ORDERED/PERFORMED Practice Scenario BACKGROUND INFORMATION EMS System description (including urban/rural setting)Suburban EMS that responds to both emergency and non-emergency calls Vehicle type/response capabilities2 person paramedic level transporting service Proximity to and level/type of facilities30 minutes to the attending physicians office 15 minutes to the community hospital DISPATCH INFORMATION Nature of the callWoman cant walk, requests transport to her physicians office, non-emergent LocationWell kept walk-up single family dwelling Dispatch time1512 hours Weather68 F, clear spring day Personnel on sceneDaughter who is serving as primary care giver SCENE SURVEY INFORMATION Scene considerations10 cement steps up to the front door No access for stretcher from any other doorway Patient location1st floor, back bedroom, narrow hallways & doorways Visual appearancePatient sitting in bed with multiple pillows holding her in an upright position, pale in color, does not respond to your presents in the room Age, gender, weight58 year old female, 200 pounds Immediate surroundings (bystanders, family members present, etc.)Clean, neat, well-kept surroundings Daughter is only family member present PATIENT ASSESSMENT Chief complaintAltered level of consciousness History of present illness/injuryDaughter states "My Mother just passed out a couple of minutes ago from the pain." Patient woke this morning with a painful left leg that has increased in pain, unable to walk without sever pain. Daughter states that her mother, "Has a small score on her left inner thigh that has gotten bigger over the past few hours and her doctor wants to see her in his office." Patient responses, symptoms, and pertinent negativesPatient opens her eyes to loud verbal stimulus but does not verbally respond PAST MEDICAL HISTORY Past medical historyAdult onset of diabetes controlled with diet and oral medication, hypertension, hernia repair several years ago Medications and allergiesGlucophage bid, Lasix 20 mg qid, dilitazem qid, and Colace qid NKA Social/family concernsPatient lives alone after death of husband two years ago, daughter comes to her home each day to help mother with daily chores EXAMINATION FINDINGS Initial vital signsB/P 100/pa;pation P 130, rapid and weak R 8 RespiratoryLung sounds are diminished bilaterally CardiovascularTachycardia, hypotensive Gastrointestinal----- Genitourinary----- Musculoskeletal----- NeurologicOpens her eyes to loud verbal stimulus and withdraws to pain Utters incomprehensible sounds Pupils equal and responds sluggishly to light IntegumentaryLarge ecchymotic area over the patients entire left inner thigh extending into the groin, pelvis, and left lower abdomen Area is hot to touch with crepitation under the skin Skin is pale, hot, and moist to the touch Hematologic---- Immunologic---- EndocrineBlood glucose 370 mg/dL Psychiatric---- PATIENT MANAGEMENT Initial stabilizationAssisted ventilations with high flow oxygen TreatmentsAssisted ventilations with high flow oxygen, IV enroute MonitoringECG sinus tachycardia, SpO2 85% Additional resourcesConsider transportation to facility with immediate surgical capabilities and hyperbarics Patient response to interventionsNo change TRANSPORT DECISION Lifting and moving the patientPlace in Reeves stretcher to ambulance stretcher ModeRapid FacilitiesEmergency department CONCLUSION Field impressionSeptic shock Rationale for field impressionRapidly extending extremity infection, febrile, hypotension, and tachycardia with altered LOC Related pathophysiology"What is the basis for septic shock in this case?" Sever bacterial infection Verbal report"Please provide me with a verbal report on this patient." Must include chief complaint, interventions, current patient condition, and ETA MANDATORY ACTIONS Rapid identification of life-threat and immediate transportation to the emergency department High flow oxygen POTENTIALLY HARMFUL/DANGEROUS ACTIONS ORDERED/PERFORMED Delayed transportation for on scene interventions Taking the patient to the doctors office BACKGROUND & DISPATCH INFORMATION You are a paramedic on a transporting paramedic unit. You are working with a paramedic partner in a suburban EMS system. You are thirty (30) minutes away from the attending physicians office and fifteen (15) minutes from the community hospital. At 1512 hours, you are dispatched to a residence for a non-emergent transport of a woman to her doctors office. It is a clear spring day with temperature of 68o F. A woman who identifies herself as the patients daughter meets you at the door. Appendix C Practical Evaluation Skill Sheets (Modeled after the NREMT Practical Skill Sheets) The practical skill sheets included in this appendix were modeled after the National Registry of Emergency Medical Technicians (NREMT) Advanced Level Practical Examination for the 1998 EMT-Paramedic National Standard Curriculum. These skill sheets should not be used as a substitute during a NREMT Advanced Level Practical Examination. The sheets were designed to be used as a standarized evaluation instrument for determining an individuals competency for an identified psychomotor skill. Worksheets Patient Assessment - TraumaIntravenous Therapy Ventilatory Management - AdultPediatric (<2 yrs.) Ventilatory Management Dual Lumen Airway Device (Combitube or PTL )Pediatric Intraosseous Infusion Dynamic CardiologySpinal Immobilization (Seated Patient) Static CardiologySpinal Immobilization (Supine Patient) Oral StationBleeding Control / Shock Management Modeled after the National Registry of Emergency Medical Technicians Advanced Level Practical Examination Patient Assessment - Trauma Candidate: ___________________________________________________Examiner: ______________________________________________________________ Date: _________________________________________________________Signature: _____________________________________________________________ Scenario # _________________________________________________________________________________________________________________________ Time Start: __________________Possible PointsPoints Awarded Takes or verbalizes body substance isolation precautions1 SCENE SIZE_UP Determines the scene/situation is safe1 Determines the mechanism of injury/nature of illness1 Determines the number of patients1 Requests addition help if necessary1 Considers stabilization of spine1 INITIAL ASSESSMENT/RESUSCITATION Verbalizes general impression of the patient1 Determines responsiveness/level of consciousness1 Determines chief complaint/apparent life-threats1 Airway Opens and assesses airway (1 point) -Inserts adjunct as indicated (1 point)2 Breathing -Assesses breathing (1 point) -Assures adequate ventilation (1 point) -Initiates appropriate oxygen therapy (1 point) -Manages any injury which may compromise breathing/ventilation (1 point) 4 Circulation -Checks pulse (1 point) -Assess skin [either skin color, temperature, or condition] (1 point) -Assesses for and controls major bleeding if present (1 point) -Initiates shock management (1 point) 4 FOCUSED HISTORY AND PHYSICAL EXAMINATION/RAPID TRAUMA ASSESSMENT Selects appropriate assessment1 Obtains or directs assistant to obtain baseline vital signs1 Obtains SAMPLE history1 DETAILED PHYSICAL EXAMINATION Head -Inspects mouth**, nose**, and assesses facial area (1 point) -Inspects and palpates scalp and ears (1 point) -Assesses eyes for PERRL** (1 point)3 Neck** -Checks position of trachea (1 point) -Checks jugular veins (1 point) -Palpates cervical spine (1 point)3 Chest** -Inspects chest (1 point) -Palpates chest (1 point) -Auscultates chest (1 point)3 Abdomen/pelvis** -Inspects and palpates abdomen (1 point) -Assesses pelvis (1 point) -Verbalizes assessment of genitalia/perineum as needed (1 point)3 Lower extremities** -Inspects, palpates, and assesses motor, sensory, and distal circulation functions (1 point/leg)2 Upper extremities -Inspects, palpates, and assesses motor, sensory, and distal circulation functions (1 point/arm)2 Posterior thorax, lumbar, and buttocks** -Inspects and palpates posterior thorax (1 point) -Inspects and palpates lumbar and buttocks area (1 point)2 Manages secondary injuries and wounds appropriately1 Performs ongoing assessment1 Time End: TOTAL 43 CRITICAL CRITERIA Failure to initiate or call for transport of the patient within 10 minute time limit Failure to take or verbalize body substance isolation precautions Failure to determine scene safety Failure to assess for and provide spinal protection when indicated Failure to voice and ultimately provide high concentration of oxygen Failure to assess/provide adequate ventilation Failure to find or appropriately manage problems associated with airway, breathing, hemorrhage or shock [hypoperfusion] Failure to differentiate patients need for immediate transportation versus continued assessment/treatment at the scene Does other detailed/focused history or physical exam before assessing/treating threats to airway, breathing, and circulation Orders a dangerous or inappropriate intervention You must factually document your rational for checking any of the above critical items on the reverse side of this form. Modeled after the National Registry of Emergency Medical Technicians Advanced Level Practical Examination Ventilatory Management - Adult Candidate: _____________________________________________________________Examiner: _________________________________________________ Date: __________________________________________________________________Signature: ________________________________________________ NOTE: If candidate elects to ventilate initially with BVM attached to reservoir and oxygen, full credit must be awarded for steps denoted by "*" so long as first ventilation is delivered within 30 seconds Possible PointsPoints Awarded Takes or verbalizes body substance isolation precautions1 Opens the airway manually1 Elevates tongue, inserts simple adjunct {oropharyngeal or nasopharyngeal airway]1 Note: Examiner now informs candidate no gag reflex is present and patient accepts adjunct "*" Ventilates patient immediately with bag-valve-mask devise unattached to oxygen1 "*" Hyperventilates patient with room air1 Note: Examiner now informs candidate that ventilation is being performed without difficulty and that pulse oximetry indicates the patients blood oxygen saturation is 85% Attaches oxygen reservoir to bag-mask device and connects to high flow oxygen regulator [12-15 L/min]1 Ventilates patient at a rate of 10-20/minute with appropriate volumes1 Note: After 30 seconds, examiner auscultates and reports breath sounds are present, equal bilaterally and medical direction has ordered intubation. The examiner must now take over ventilation Directs assistant to pre-oxygenate patient1 Identifies/selects proper equipment for intubation1 Checks equipment for: -Cuff leaks (1 point) -Laryngoscope operational with bulb tight (1 point)2 Note: Examiner to remove OPA and move out of the way when candidate is prepared to intubate Positions head properly1 Inserts blade while displacing tongue1 Elevates mandible with laryngoscope1 Introduces ET tube and advances to proper depth1 Inflates cuff to proper pressure and disconnects syringe1 Confirms proper placement by auscultation bilaterally over each lung and over epigastrium1 Note: Examiner to ask "If you had proper placement, what should you expect to hear?" Secures ET tube (may be verbalized)1 Note: Examiner now asks candidate, "Please demonstrate one additional method of verifying proper tube placement in this patient." Identifies/selects proper equipment1 Verbalizes findings and interpretations [compares indicator color to the colorimetric scale and states reading to examiner]1 Note: Examiner now states, "You see secretions in the tube and hear gurgling sounds with the patients exhalations." Identifies/selects a flexible suction catheter1 Pre-oxygenates patient1 Marks maximum insertion length with thumb and forefinger1 Inserts catheter into ET tube leaving catheter port open1 At proper insertion depth, covers catheter port and applies suction while withdrawing catheter1 Ventilates/directs ventilation of patient as catheter is flushed with sterile water1 Total27 CRITICAL CRITERIA Failure to initiate ventilations within 30 seconds after applying gloves or interrupts ventilations for grater than 30 seconds at any time Failure to take or verbalize body substance isolation precautions Failure to voice and ultimately provide high oxygen concentration [at least 85%] Failure to ventilate patient at a rate of at least 10/minute Failure to provide adequate volumes per breath [maximum 2 errors/minute permissible] Failure to pre-oxygenate patient prior to intubation and suctioning Failure to successfully intubate within 3 attempts Failure to disconnect syringe immediately after inflating cuff of ET tube Uses teeth as a fulcrum Failure to assure proper tube placement by auscultation bilaterally and over the epigastrium If used, stylet extends beyond end of ET tube Inserts any adjunct in a manner dangerous to the patient Suctions the patient for more than 15 seconds Does not suction the patient You must factually document your rational for checking any of the above critical items on the reverse side of this form. Modeled after the National Registry of Emergency Medical Technicians Advanced Level Practical Examination Dual Lumen Airway Device (Combitube or PTL ) Candidate: ______________________________________________________________Examiner: __________________________________________________________ Date: ___________________________________________________________________Signature: __________________________________________________________ NOTE: If candidate elects to ventilate initially with BVM attached to reservoir and oxygen, full credit must be awarded for steps denoted by "*" so long as first ventilation is delivered within 30 seconds Possible PointsPoints Awarded Takes or verbalizes body substance isolation precautions1 Opens the airway manually1 Elevates tongue, inserts simple adjunct {oropharyngeal or nasopharyngeal airway]1 Note: Examiner now informs candidate no gag reflex is present and patient accepts adjunct "*" Ventilates patient immediately with bag-valve-mask devise unattached to oxygen1 "*" Hyperventilates patient with room air1 Note: Examiner now informs candidate that ventilation is being performed without difficulty Attaches oxygen reservoir to bag-mask device and connects to high flow oxygen regulator [12-15 L/min]1 Ventilates patient at a rate of 10-20/minute with appropriate volumes1 Note: After 30 seconds, examiner auscultates and reports breath sounds are present, equal bilaterally and medical direction has ordered insertion of a dual lumen airway. The examiner must now take over ventilation Directs assistant to pre-oxygenate patient1 Checks/prepares airway device1 Lubricates distal tip of the device [may be verbalized]1 Note: Examiner to remove OPA and move out of the way when candidate is prepared to insert device Positions head properly1 Performs a tongue-jaw lift Uses Combitube Uses PTL Inserts device in mid-line and to depth so printed ring is at level of teethInserts device in mid-line until bite block flange is at level of teeth1 Inflates pharyngeal cuff with proper volume and removes syringeSecures strap1 Inflates distal cuff with proper volume and removes syringeBlows into tube #1 to adequately inflate both cuffs1 Attaches/directs attachment of BVM to the first [esophageal placement] lumen and ventilates1 Confirms placement and ventilation through correct lumen by observing chest rise, auscultation over the epigastrium, and bilaterally over each lung1 Note: The examiner states, "You do not see rise and fall of the chest and you only hear sounds over the epigastrium." Attaches/directs attachment of BVM to the second [endotracheal placement] lumen and ventilates1 Confirms placement and ventilation through correct lumen by observing chest rise, auscultation over the epigastrium, and bilaterally over each lung1 Note: The examiner confirms adequate chest rise, absent sounds over the epigastrium, and equal bilateral breath sounds. Secures device or confirms that the device remains properly secured1 Total20 CRITICAL CRITERIA Failure to initiate ventilations within 30 seconds after applying gloves or interrupts ventilations for grater than 30 seconds at any time Failure to take or verbalize body substance isolation precautions Failure to voice and ultimately provide high oxygen concentration [at least 85%] Failure to ventilate patient at a rate of at least 10/minute Failure to provide adequate volumes per breath [maximum 2 errors/minute permissible] Failure to pre-oxygenate patient prior to insertion of the dual lumen airway device Failure to insert the dual lumen airway device at a proper depth or at either proper place within 3 attempts Failure to inflate both cuffs properly Combitube failure to remove the syringe immediately after inflation of each cuff PTL - failure to secure the strap prior to cuff inflation Failure to confirm that the proper lumen of the device is being ventilated by observing chest rise, auscultation over the epigastrium, and bilaterally over each lung Inserts any adjunct in a manner dangerous to the patient You must factually document your rational for checking any of the above critical items on the reverse side of this form. Modeled after the National Registry of Emergency Medical Technicians Advanced Level Practical Examination Dynamic Cardiology Candidate: __________________________________________________________________Examiner: ____________________________________________ Date:_______________________________________________________________________ Signature: ____________________________________________ Level of testing: NREMT-Intermediate/99 NREMT-Paramedic Time start: ___________________Possible PointsPoints Awarded Takes or verbalizes infection control precautions1 Checks level of responsiveness1 Checks ABCs1 Initiates CPR if appropriate [verbally]1 Attaches ECG monitor in a timely fashion or applies paddles for "Quick Look"1 Correctly interprets initial rhythm1 Appropriately manages initial rhythm2 Notes change in rhythm1 Checks patient condition to include pulse and, if appropriate, BP1 Correctly interprets second rhythm1 Appropriately manages second rhythm2 Notes change in rhythm1 Checks patient condition to include pulse and, if appropriate, BP1 Correctly interprets third rhythm1 Appropriately manages third rhythm2 Notes change in rhythm1 Checks patient condition to include pulse and, if appropriate, BP1 Correctly interprets fourth rhythm1 Appropriately manages fourth rhythm2 Orders high percent of supplemental oxygen at proper times1 Time end: Total24 CRITICAL CRITERIA Failure to deliver first shock in a timely manner due to operator delay in machine use or providing treatments other than CPR with simple adjuncts Failure to deliver second or third shocks without delay other than the time required to reassess rhythm and recharge paddles Failure to verify rhythm before delivering each shock Failure to ensure the safety of self and others [verbalizes "All Clear" and observes] Inability to deliver DC shock [does not use machine properly] Failure to demonstrate acceptable shock sequence Failure to order initiation or resumption of CPR when appropriate Failure to order correct management of airway [ET when appropriate] Failure to order administration of appropriate oxygen at proper time Failure to diagnose or treat 2 or more rhythms correctly Orders administration of an inappropriate drug or lethal dosage Failure to correctly diagnose or adequately treat v-fib, v-tach, or asystole You must factually document your rational for checking any of the above critical items on the reverse side of this form. Modeled after the National Registry of Emergency Medical Technicians Advanced Level Practical Examination Static Cardiology Candidate: _________________________________________________________________Examiner: ___________________________________________________________ Date: _____________________________________________________________________Signature: ___________________________________________________________ Set # _______________________ Level of testing: NREMT-Intermediate/99 NREMT-Paramedic Note: No points for treatment may be awarded if the diagnosis is incorrect. Only document incorrect responses in space provided Time start: ___________________Possible PointsPoints Awarded STRIP #1 Diagnosis:1 Treatment:2 STRIP #2 Diagnosis:1 Treatment:2 STRIP #3 Diagnosis:1 Treatment:2 STRIP #4 Diagnosis:1 Treatment:2 Time end: ______________________________________________Total12 Modeled after the National Registry of Emergency Medical Technicians Advanced Level Practical Examination Oral Station Candidate: _____________________________________________Examiner:_______________________________________ Date: _________________________________________________Signature: ______________________________________ Scenario: _______________________________ Time start: ___________Possible PointsPoints Awarded Scene Management Thoroughly assessed and took deliberate actions to control the scene3 Assessed the scene, identified potential hazards, did not put anyone in danger2 Incompletely assessed or managed the scene1 Did not assess or manage the scene0 Patient Assessment Completed an organized assessment and integrated findings to expand further assessment3 Completed initial, focused, and ongoing assessments2 Performed an incomplete or disorganized assessment1 Did not complete an initial assessment0 Patient Management Managed all aspects of the patients condition and anticipated further needs3 Appropriately managed the patients presenting condition2 Performed an incomplete or disorganized management1 Did not manage life-threatening conditions0 Interpersonal Relations Established rapport and interacted in an organized, therapeutic manner3 Interacted and responded appropriately with patient, crew, and bystanders2 Used inappropriate communication techniques1 Demonstrated intolerance for patient, bystanders, and crew0 Integration (verbal report, field impression, and transport decision) Stated correct field impression and pathophysiology basis, provided succinct and accurate verbal report including social/psychological concerns, and considered alternate transport destinations3 Stated correct field impression, provided succinct and accurate verbal report, and appropriately stated transport decision2 Stated correct field impression, provided inappropriate verbal report or transport decision1 Stated incorrect field impression or did not provide verbal report0 Time end: _______________________Total15 CRITICAL CRITERIA Failure to appropriately address any of the Scenarios "Mandatory Actions" Performs or orders any harmful or dangerous action or intervention You must factually document your rational for checking any of the above critical items on the reverse side of this form. Modeled after the National Registry of Emergency Medical Technicians Advanced Level Practical Examination Intravenous Therapy Candidate: ___________________________________________________________________Examiner: _______________________________________ Date: ________________________________________________________________________Signature: ______________________________________ Level of testing: NREMT-Intermediate/99 NREMT-Paramedic Time start: ___________________Possible PointsPoints Awarded Checks selected IV fluid for: -Proper fluid (1 point) -Clarity (1 point)2 Selects appropriate catheter1 Selects proper administration set1 Connects IV tubing to the bag1 Prepares administration set [fills drip chamber and flushes tubing]1 Cuts or tears tape [at any time before venipuncture]1 Takes/verbalizes body substance isolation precautions {prior to venipuncture]1 Applies tourniquet1 Palpates suitable vein1 Cleanses site appropriately1 Performs venipuncture -Inserts stylet (1 point) -Notes or verbalizes flashback (1 point) -Occludes vein proximal to catheter (1 point) -Removes stylet (1 point) -Connects IV tubing to catheter (1 point) 5 Disposes/verbalizes disposal of needle in proper container1 Releases tourniquet1 Runs IV for a brief period to assure patent line1 Secures catheter [tapes securely or verbalizes]1 Adjusts flow rate as appropriate1 Time end: Total21 CRITICAL CRITERIA Failure to establish a patent and properly adjusted IV within 6 minute time limit Failure to take or verbalize body substance isolation precautions prior to performing venipuncture Contaminates equipment or site without appropriately correcting situation Performs any improper technique resulting in the potential for uncontrolled hemorrhage, catheter shear, or air embolism Failure to successfully establish IV within 3 attempts during 6 minute time limit Failure to dispose/verbalize disposal of needle in proper container Note: Check here ( ) if candidate did not establish a patent IV and do not evaluate IV Bolus Medications Intravenous Bolus Medications Time start:___________________________________Possible PointsPoints Awarded Asks patient for known allergies1 Selects correct medication1 Assures correct concentration of drug1 Assembles prefilled syringe correctly and dispels air1 Continues body substance isolation precautions1 Cleanses injection sit [Y-port or hub]1 Reaffirms medication1 Stops IV flow [pinches tubing or shuts off]1 Administers correct dose at proper push rate1 Disposes/verbalizes proper disposal of syringe and needle in proper container1 Flushes tubing [runs wide open for a brief period]1 Adjusts drip rate to TKO/KVO1 Verbalizes need to observe patient for desired effect/adverse side effects1 Time end: _____________________________________Total13 CRITICAL CRITERIA Failure to begin administration of medication within 3 minute time limit Contaminates equipment or site without appropriately correcting situation Failure to adequately dispel air resulting in potential for air embolism Injects improper drug or dosage [wrong drug, incorrect amount, or pushes at inappropriate rate] Failure to flush IV tubing after injecting medication Recaps needle or failure to dispose/verbalize disposal of syringe and needle in proper container You must factually document your rational for checking any of the above critical items on the reverse side of this form. Modeled after the National Registry of Emergency Medical Technicians Advanced Level Practical Examination Pediatric (<2 yrs.) Ventilatory Management Candidate: ___________________________________________________________Examiner: ______________________________________________________________ Date:________________________________________________________________Signature: ______________________________________________________________ NOTE: If candidate elects to ventilate initially with BVM attached to reservoir and oxygen, full credit must be awarded for steps denoted by "*" so long as first ventilation is delivered within 30 seconds Possible PointsPoints Awarded Takes or verbalizes body substance isolation precautions1 Opens the airway manually1 Elevates tongue, inserts simple adjunct {oropharyngeal or nasopharyngeal airway]1 Note: Examiner now informs candidate no gag reflex is present and patient accepts adjunct "*" Ventilates patient immediately with bag-valve-mask devise unattached to oxygen1 "*" Hyperventilates patient with room air1 Note: Examiner now informs candidate that ventilation is being performed without difficulty and that pulse oximetry indicates the patients blood oxygen saturation is 85% Attaches oxygen reservoir to bag-mask device and connects to high flow oxygen regulator [12-15 L/min]1 Ventilates patient at a rate of 20-30/minute and assures adequate chest expansion1 Note: After 30 seconds, examiner auscultates and reports breath sounds are present, equal bilaterally and medical direction has ordered intubation. The examiner must now take over ventilation Directs assistant to pre-oxygenate patient1 Identifies/selects proper equipment for intubation1 Checks laryngoscope to assure operational with bulb tight1 Note: Examiner to remove OPA and move out of the way when candidate is prepared to intubate Places patient in neutral or sniffing position1 Inserts blade while displacing tongue1 Elevates mandible with laryngoscope1 Introduces ET tube and advances to proper depth1 Directs ventilation of patient1 Confirms proper placement by auscultation bilaterally over each lung and over epigastrium1 Note: Examiner to ask "If you had proper placement, what should you expect to hear?" Secures ET tube (may be verbalized)1 Total17 CRITICAL CRITERIA Failure to initiate ventilations within 30 seconds after applying gloves or interrupts ventilations for grater than 30 seconds at any time Failure to take or verbalize body substance isolation precautions Failure to pad under the torso to allow neutral head position or sniffing position Failure to voice and ultimately provide high oxygen concentration [at least 85%] Failure to ventilate patient at a rate of at least 20/minute Failure to provide adequate volumes per breath [maximum 2 errors/minute permissible] Failure to pre-oxygenate patient prior to intubation Failure to successfully intubate within 3 attempts Uses teeth as a fulcrum Failure to assure proper tube placement by auscultation bilaterally and over the epigastrium Inserts any adjunct in a manner dangerous to the patient Attempts to use any equipment not appropriate for the pediatric patient You must factually document your rational for checking any of the above critical items on the reverse side of this form. Modeled after the National Registry of Emergency Medical Technicians Advanced Level Practical Examination Pediatric Intraosseous Infusion Candidate: _____________________________________________________________Examiner: __________________________________________________________ Date: __________________________________________________________________Signature:__________________________________________________________ Time start:___________________________Possible PointsPoints Awarded Checks selected IV fluid for: -Proper fluid (1 point) -Clarity (1 point)2 Selects appropriate equipment to include: -IO needle (1 point) -Syringe (1 point) -Saline (1 point) -Extension set (1 point) 4 Selects proper administration set1 Connects administration set to bag1 Prepares administration set [fills drip chamber and flushes tubing]1 Prepares syringe and extension tubing1 Cuts or tears tape [at any time before IO puncture]1 Takes or verbalizes body substance isolation precautions [prior to IO puncture]1 Identifies proper anatomical site for IO puncture1 Cleanses site appropriately1 Performs IO puncture: -Stabilizes tibia (1 point) -Inserts needle at proper angle (1 point) -Advances needle with twisting motion until "pop" is felt (1 point) -Unscrews cap and removes stylet from needle (1 point) 4 Disposes of needle in proper container1 Attaches syringe and extension set to IO needle and aspirates1 Slowly injects saline to assure proper placement of needle1 Connects administration set and adjusts flow rate as appropriate1 Secures needle with tape and supports with bulky dressing1 Time end: ________________________________________Total23 CRITICAL CRITERIA Failure to establish a patent and properly adjusted IO within 6 minute time limit Failure to take or verbalize body substance isolation precautions prior to performing IO puncture Contaminates equipment or site without appropriately correcting situation Performs any improper technique resulting in the potential for air embolism Failure to assure correct needle placement before attaching administration set Failure to successfully establish IO infusion within 2 attempts during 6 minute time limit Performing IO puncture in an unacceptable manner [improper site, incorrect needle angle, etc.] Failure to dispose of needle in proper container Orders or performs any dangerous or potentially harmful procedure You must factually document your rational for checking any of the above critical items on the reverse side of this form. Modeled after the National Registry of Emergency Medical Technicians Advanced Level Practical Examination Spinal Immobilization (Seated Patient) Candidate: _____________________________________________________________Examiner:__________________________________________________________ Date: __________________________________________________________________Signature: _________________________________________________________ Time start: __________________________Possible PointsPoints Awarded Takes or verbalizes body substance isolation precautions1 Directs assistant to place/maintain head in the neutral, in-line position1 Directs assistant to maintain manual immobilization of the head1 Reassesses motor, sensory, and circulation function in each extremity1 Applies appropriately sized extrication collar1 Positions the immobilization device behind the patient1 Secures the device to the patients torso1 Evaluates torso fixation and adjusts as necessary1 Evaluates and pads behind the patients head as necessary1 Secures the patients head to the device1 Verbalizes moving the patient to a long backboard1 Reassesses motor, sensory, and circulation function in each extremity1 Time end: _____________________________Total12 CRITAL CRITERIA Did not immediately direct or take manual immobilization of the head Did not properly apply appropriately sized cervical collar before ordering release of manual immobilization Released or ordered release of manual immobilization before it was maintained mechanically Manipulated or moved patient excessively causing potential spinal compromise Head immobilized to the device before device sufficiently secured to torso Device moves excessively up, down, left, or right on the patients torso Head immobilization allows for excessive movement Torso fixation inhibits chest rise, resulting in respiratory compromise Upon completion of immobilization, head is not in a neutral, in-line position Did not reassess motor, sensory, and circulation functions in each extremity after voicing immobilization to the long backboard You must factually document your rational for checking any of the above critical items on the reverse side of this form. Modeled after the National Registry of Emergency Medical Technicians Advanced Level Practical Examination Spinal Immobilization (Supine Patient) Candidate: ___________________________________________________________Examiner:__________________________________________________________ Date:________________________________________________________________Signature:__________________________________________________________ Time start: ____________________Possible PointsPoints Awarded Takes or verbalizes body substance isolation precautions1 Directs assistant to place/maintain head in the neutral, in-line position1 Directs assistant to maintain manual immobilization of the head1 Reassesses motor, sensory, and circulation function in each extremity1 Applies appropriately sized extrication collar1 Positions the immobilization device appropriately1 Directs movement of the patient onto the device without compromising the integrity of the spine1 Applies padding to the voids between the torso and the device as necessary1 Immobilizes the patients torso to the device1 Evaluates and pads behind the patients head as necessary1 Secures the patients head to the device1 Secures the patients legs to the device1 Secures the patients arms to the device1 Reassesses motor, sensory, and circulation function in each extremity1 Time end: _______________________Total14 CRITICAL CRITERIA Did not immediately direct or take manual immobilization of the head Did not properly apply appropriately sized cervical collar before ordering release of manual immobilization Released or ordered release of manual immobilization before it was maintained mechanically Manipulated or moved patient excessively causing potential spinal compromise Head immobilized to the device before device sufficiently secured to torso Device moves excessively up, down, left, or right on the patients torso Head immobilization allows for excessive movement Upon completion of immobilization, head is not in a neutral, in-line position Did not reassess motor, sensory, and circulation functions in each extremity after voicing immobilization to the device You must factually document your rational for checking any of the above critical items on the reverse side of this form. Modeled after the National Registry of Emergency Medical Technicians Advanced Level Practical Examination Bleeding Control / Shock Management Candidate: __________________________________________________________Examiner:_________________________________________________________ Date:_______________________________________________________________Signature:_________________________________________________________ Time Started: ___________________________Possible PointsPoints Awarded Takes or verbalizes body substance isolation precautions1 Applies direct pressure to the wound1 Elevates the extremity1 NOTE: The examiner must now inform the candidate that the wound continues to bleed. Applies an additional dressing to the wound1 NOTE: The examiner must now inform the candidate that the wound still continues to bleed. The second dressing does not control the bleeding. Locates and applies pressure to appropriate pressure point1 NOTE: The examiner must now inform the candidate that the bleeding is controlled Bandages the wound1 NOTE: The examiner must now inform the candidate that the patient is exhibiting signs and symptoms of hypoperfusion. Properly positions the patient1 Administers high concentration oxygen1 Initiates steps to prevent heat loss from the patient1 Indicates the need for immediate transport1 Time End: __________________________________________TOTAL10 CRITICAL CRITERIA Did not take or verbalize body substance isolation precautions Did not apply high concentration of oxygen Applied a tourniquet before attempting other methods of bleeding control Did not control hemorrhage in a timely manner Did not indicate a need for immediate transportation You must factually document your rational for checking any of the above critical items on the reverse side of this form.