Professional Documents
Culture Documents
Technician – Basic
Course Manual
Life Support Training International
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Life Support Training International
this course may be reproduced without the written permission of Life Support Training
Welcome to the first edition of the Emergency Medical Technician-Basic manual published by
Life Support Training International. The manual aims to help you on your journey to becoming a
competent EMT-B by providing you as much information as possible to supplement the lectures
provided by LSTI.
As you proceed through the manual, please note that all information was current at the time of
publishing. As new treatments and protocols are released, your lecturers will update you to keep
For the Philippines, the prehospital care system is about to undergo significant changes with the
passing of the EMS Bill by the Philippine Senate.
This book is dedicated to Aidan and Joann Tasker-Lynch, without whom the EMS industry in the
Philippines would still be poorly developed. It is their vision and dedication to prehospital care
and the Filipino EMT that gives us all hope for nation-wide professional EMS services, with
world-class Filipino EMTs providing the best possible care for the Filipino people.
On a final note, as a graduate of LSTI Batch 67, I congratulate you on your decision to become
an EMT. It is a difficult but immensely rewarding course you are to undertake, and hopefully it is
LSTI-Batch 67
Chapter Page
Appendices
Chapter 1:
EMS In The Philippines
Outline
L
ife Support Training International is the Philippines’ industry leader in all
levels of instruction in pre-hospital emergency medical care and is
dedicated to the spread of knowledge in handling all traumatic and
medical emergencies.
Our faculty is composed of only the most qualified and experienced instructors
ranging from trained Trauma Surgeons and fully registered Emergency Medical
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Emergency Medical Technician – Basic
Chapter 1: EMS In The Philippines
Technicians and Paramedics - WE GIVE YOU ONLY THE VERY BEST. Our
standards of training meet with the highest of international standards and
great care is taken to mould the courses to meet your specific requirements.
We will help students to develop the essential knowledge, skills and
confidence in order to be able to provide essential Emergency Life Support in
times of crisis.
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Emergency Medical Technician – Basic
Chapter 1: EMS In The Philippines
PSEMT Affiliations
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Emergency Medical Technician – Basic
Chapter 1: EMS In The Philippines
Australasian Registry of
Emergency Medical Technicians
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Emergency Medical Technician – Basic
Chapter 1: EMS In The Philippines
ASSOCIATE MEMBER
BASIC EMERGENCY MEDICAL TECHNICIAN - EMT (B)
EMERGENCY MEDICAL TECHNICIAN, DEFIBRILLATOR TRAINED - EMT (D)
EMERGENCY MEDICAL TECHNICIAN, INFUSION & INTUBATION TRAINED -
EMT (I & I)
ADVANCED EMERGENCY MEDICAL TECHNICIAN - EMT (A)
REGISTERED EMERGENCY MEDICAL TECHNICIAN, PARAMEDIC - REMT (P)
REGISTERED EMERGENCY MEDICAL SERVICES INSTRUCTOR - REMSI
Associate Membership
This level will allow entry to all that hold current First Aid and Basic Life Support
Provider certificates from a Recognized Training Agency. The minimum requirement
will be thirty-two hours of instruction in First Aid, with a further eight hours in Basic
Life Support.
This is the initial entry grade for all professional pre-hospital care providers. This
grade is inclusive of ambulance staff and nursing personnel who can demonstrate
appropriate training and experience in line with PSEMT/PBEMT published standards.
Entry may be afforded to applicants who are outside the full time professional
sector on achievement of the following requirements:
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Emergency Medical Technician – Basic
Chapter 1: EMS In The Philippines
Entry requirement must be that of EMT (I & I) with not less than six (6) months
post-certification experience. In addition to this, all applicants must have
successfully completed two hundred hours instruction in Advanced Cardiac
Life Support and Advanced Trauma Management and the examinations
thereof.
The minimum entry criteria for Paramedic training is EMT Advanced (A), in
accordance with the standards set out by the PSEMT/PBEMT, with at least six
(6) months post-certification experience. All applicants must have successfully
completed the three hundred and sixty (360) hour Advanced Clinical Training
modules. This level will only be available to those who complete a minimum of
seven hundred and fifty (750) hours actual operational experience per year.
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Emergency Medical Technician – Basic
Chapter 1: EMS In The Philippines
Exemptions
Training fees may be paid on an instalment basis, but must be paid in full,
whether or not the candidate chooses to complete the course - in other words,
all students who start the course are obliged to pay in full, irrespective of the
outcome thereof.
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Emergency Medical Technician – Basic
Chapter 1: EMS In The Philippines
LSTI meticulously enforces the payment schedule given to students on the first
day of the class. Students should follow the schedule diligently.
Life Support Training International reserves the right to terminate the training
of any student who fails to honor the set payment schedule.
Weekly Assessment
Final Examinations
The final examination is done under the strict supervision of the Philippine
Society of Emergency Medical Technicians (PSEMT) and the Australasian
Registry of Emergency Medical Technicians (AREMT).
The high standards of training shall not be compromised in any way, and as
such:
Students must settle all outstanding accounts before the Final Examination.
Non-payment or incomplete payment of tuition fees will result in forfeiture of
the student’s chance to take the examination.
Re-Sit/Re-Examination
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Emergency Medical Technician – Basic
Chapter 1: EMS In The Philippines
For the EMT Final Written Examination PSEMT/AREMT policy allows for a
maximum of two (2) sits only (1 exam and 1 re-sit).
For the Basic Life Support Written Examination, a maximum of three (3) sits are
allowed (1 exam and 2 re-sits). No EMT certification can be awarded to a
candidate without successful completion of both practical and theoretical
examinations in Basic Life Support.
Validity of the re-sit/re-examination is limited to within one (1) year from the
time the student finishes the course. If a student fails to re-sit or take the Final
Examination within this grace period, he/she shall forfeit their right to retake
said Final Examination.
Under no circumstances will a candidate who has failed the final examinations
and re-sit be accepted for retraining at LSTI.
Students who fail all the re-sits/re-examinations shall not be awarded any
certificate of proficiency.
Smoking is strictly
prohibited in and
around the
training facility at
all times.
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Emergency Medical Technician – Basic
Chapter 2: Roles and Responsibilities of the EMT
C h a p te r 2 :
Roles and
Responsibilities of the
E MT
Outline
J
ust as physicians have the caduceus, and pharmacists the mortar and
pestle, Emergency Medical Services have the ‘Star of Life’, a symbol
whose use is encouraged by both the American Medical Association
and the Advisory Council within the Department of Health and Human
Services. On road maps and highway signs, the Star of Life indicates the
location or access to qualified emergency care services.
The Star of Life was designed by Leo Schwartz, EMS Branch Chief at the
National Highway Traffic Safety Administration (NHTSA) USA. The star of life
was created in 1973 as a common symbol to be used by US emergency
medical services (EMS) and medical goods pertaining to EMS.
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Emergency Medical Technician - Basic
Chapter 2: Roles and Responsibilities of the EMT
Resource Management
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Sample Manual Template
Chapter 2: Roles and Responsibilities of the EMT
All personnel who ride ambulances should be trained at the minimum level
using a standardized curriculum.
Transportation
Communications
Efforts to educate the public about their role in the EMS system and
prevention of injuries.
Medical Direction
Trauma Systems
Development of more than one trauma center. Triage and transfer guidelines
for trauma patients, rehabilitation programs, data collection and means for
managing and assuring the quality of the system.
Evaluation
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Emergency Medical Technician - Basic
Chapter 2: Roles and Responsibilities of the EMT
Personal Safety
Patient Assessment
Patient Care
Preparation for action or a series of actions to take that will help the
patient deal with and survive illness or injury.
Transport
Patient Advocacy
Appearance
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Sample Manual Template
Chapter 2: Roles and Responsibilities of the EMT
Physical Demands
Good physical health and good eyesight to properly assess the patient and drive
safely.
A pleasant personality
Leadership ability
Good judgement
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Emergency Medical Technician - Basic
Chapter 2: Roles and Responsibilities of the EMT
Communication
Training
Manpower
Mutual Aid
Transportation
Accessibility
Facilities
Transfer of Care
Consumer Participation
Public Education
Disaster Linkages
The above design has proved proficient in many aspects, including medical direction and
accountability, prevention, rehabilitation, financing and operational and patient care
protocols. EMS systems continued to be refined in the 1980s and 1990s.
Successful EMS systems are designed to meet the needs of the communities they serve.
The state provides laws that broadly outline what is prudent, safe and acceptable. To be
effective, EMS systems must be planned and operated at the local level.
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Sample Manual Template
Chapter 2: Roles and Responsibilities of the EMT
Communities need to identify their individual needs and resources, develop funding
mechanisms, and become involved at all levels in structuring the system. A governing
body or council should be established to organize, direct and coordinate all system
components. The council consists of representatives from the local medical, EMS,
consumer and public safety agencies to ensure consensus in developing policies and
settling disputes. The EMS system must provide equal access to all, and remain
protected from forces that serve the interests of only one group.
Medical Direction
Physician input, leadership and oversight in ensuring that medical care provided is safe,
effective and in accordance with accepted standards. Physicians must be empowered and
imvolved in planning, implementing, overseeing and evaluating all components of the
system. Medical direction is characterized as either immediate (on-line) or organisational
(off-line).
On-line medical direction provides EMTs with consultation in the field, either in person or,
more commonly, via radio or telephone communication. This responsibility is delegated
medical director to physicians who staff local Emergency Departments. The base station
facility providing on-line control is required to monitor all advanced life support (ALS)
communications, provide field consultations, and notify receiving facilities of incoming
patients. Physicians providing on-line direction should be appropriately trained and
familiar with the operations and limitations of the system.
The medical director assumes authority and responsibility for off-line medical direction. In
cooperation with the local medical community, the medical director is responsible for
developing standards, protocols, policies and procedures; developing training programs;
issuing credentials and providing evaluations; and implementing a process for continuous
quality improvement.
Communications
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Emergency Medical Technician - Basic
Chapter 2: Roles and Responsibilities of the EMT
system, which automatically provide the dispatcher with the caller’s address and
telephone number. Using enhanced systems, callers can obtain services even if they are
unable to communicate with dispatch. Emergency medicine dispatch includes assessment
of patient location and status, as well as the provision of pre-arrival instructions.
On-line medical direction should be obtained in all calls that result in transport. This
includes:
Decision to transport;
Otherwise, the provider may be perceived as practicing without a licence, and could be
charged with an offence.
Transportation
Inter-facility transportation occurs once the patient has been examined and stabilized.
Patients are transported in compliance with regional protocols and federal, national or
state laws (e.g. Consolidated Omnibus Budget Reconciliation Act [COBRA] and Emergency
Medical Treatment and Active Labor Act [EMTALA] in the US). Legislation dictates that
medically unstable patients be transferred only when the transfer is expected to have a
positive effect on outcome.
Patients should be transported to the closest, most appropriate facility. Receiving facilities
are required to have the capabilities to treat the patients, stabilize their condition, and
improve their outcome. Stable patients may be transported to the hospital of their choice,
as long as the transport meets regional point-of-entry protocols, has the approval of on-
line medical control, and does not necessarily overburden the system.
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Emergency Medical Technician – Basic
Chapter 2: Roles and Responsibilities of the EMT
Specialized resources to care for the severely injured are not available in every hospital.
Local communities need to establish regional protocols to provide clear guidance for the
transport of unstable patients to categorized facilities. Unstable patients with special
problems, such as burns or trauma, can be transported to regionally designated hospitals,
bypassing closer facilities.
Training Standards
Providers must be trained to meet the expectations and requirements in programs that
comply with regional and national standards. Training includes didactic, clinical and field
components. Most states require that candidates pass written and practical examinations
prior to certification. Additionally, EMTs are required to receive continuing didactic and
clinical education to maintain certification.
Education is also used to reinforce proper patient care, update standards and protocols,
and remedy perceived deficiencies in patient care. Physician involvement is essential to
assure appropriate utilizations of skills and equipment. The EMS system also provides
community education, such as public courses in CPR, first aid, child safety and EMS access.
Protocols
Protocols are developed to deal with operational, administrative and patient care issues.
They define a standardized, acceptable approach to commonly encountered problems.
Protocols should reflect regional and national standards, as well as the uniqueness and
limitations of the local environment. The medical director has the responsibility to address
protocols dealing with patient care, such as triage and treatment.
Triage assesses the condition of each patient, sorts patients into treatment categories, and
optimizes use of field resources for treatment and transport. In addition, triage addresses
the level of provider during multiple casualty incidents to facilitate the screening,
prioritization, treatment and transport of patients.
Treatment protocols describe the authority and responsibilities of providers and offer
guidance for medical evaluation and care. Optimal care and medical accountability require
standardized protocols, algorithms and standing orders that outline specific actions
providers can take without contacting a physician for orders. Any deviation from these
standing orders must be considered a breach of duty and must result in an audit. On-line
medical direction is crucial in systems, requiring decision-making to provide guidance and
assume some of the patient-care responsibilities.
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Emergency Medical Technician – Basic
Chapter 2: Roles and Responsibilities of the EMT
Continuous quality improvement (CQI) is the sum of all activities undertaken to assess
and improve the products and services EMS provides. The goal is to influence patient
outcomes positively by delivering products timely, consistent, appropriate,
compassionate and cost-effective systems. CQI ensures that the field staff provides the
highest quality of care and that the system supports this goal. Quality should be
monitored from within the EMS system and by an external, independent and unbiased
body that involves the consumer, government and medical communities. Standardized
protocols, policies, performance and documentation are invaluable in constructing a
successful CQI process.
Disaster Preparedness
The EMS system is an integral part of disaster preparedness and planning. It plays an
important role in initial response and transportation, and is essential in establishing a
regional disaster preparedness plan in coordination with public safety agencies,
government and the medical community. The plan should address disaster
management, communication, treatment and designation of casualties. Periodic
disaster drills serve to assess performance, refine management and educate personnel
and the community.
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Emergency Medical Technician – Basic
Chapter 3: Medico-Legal and Ethical Issues in EMS
Chapter 3:
Medico-Legal and Ethical
Issues in EMS
Outline
Definitions
Patient Bill of Rights
Ethical Implications
Right of Refusal
Legal Aspects
Crime Scenes
EMS Code of Ethics
Definitions
ETHICS - The science of right and wrong, of moral duties and of ideal behaviour.
MEDICAL ETHICS - The part of ethics that deals with the health care of human
beings.
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Emergency Medical Technician – Basic
Chapter 3: Medico-Legal and Ethical Issues in EMS
In the Philippines, the Patient Bill of Rights is known as Title 111: Declaration of Rights.
Protects a person from liability for acts performed in good faith, unless those
acts constitute gross negligence.
Does not prevent one from being sued, although it may provide some
protection against losing a lawsuit if one has performed to the standard of
care for an EMT-B.
Different standards may be held in different legal jurisdictions.
Medical Direction
Duty to Act
IF ON-DUTY:
legally obligated
IF OFF-DUTY:
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Emergency Medical Technician – Basic
Chapter 3: Medico-Legal and Ethical Issues in EMS
Ethical Responsibilities
Serve the needs of the patients with respect for human dignity, without
regard to nationality, race, gender, creed or status.
Maintain skill mastery.
Keep abreast of changes in EMS which affect patient care.
Critically review performances.
Report with honesty.
Work harmoniously with others.
Types of Consent
Expressed consent
Implied consent
Consent to treat a minor or mentally incompetent adult
Advance Directives
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Emergency Medical Technician – Basic
Chapter 3: Medico-Legal and Ethical Issues in EMS
Refusal of Treatment
Competency
Protecting yourself:
Remember:
Try to persuade the patient to accept treatment or
transport to a hospital. A competent adult is
Make sure that the patient is able to make a defined as one who is lucid
rational informed decision. and capable of making an
Consult medical direction as required by local informed decision.
protocol.
If the patient still refuses, have them sign a refusal form.
Before you leave, encourage the patient to seek help if certain
symptoms develop.
Abandonment One stopped providing care for the patient without ensuring that
equivalent or better care would be provided
Negligence The care one provides deviates from the accepted standard of care
and this results in further injury to the patient
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Emergency Medical Technician – Basic
Chapter 3: Medico-Legal and Ethical Issues in EMS
Confidentiality
Do not speak to the press, your family, friends or other members of the public about
details of the emergency care you provided to a patient.
Another health care provider needs to know the information to continue medical
care;
As requested by the police as part of a potential criminal investigation;
As required on a third-party billing form;
As required by legal subpoena;
When a patient signs a release form.
Special Situations
A legal signed document is required, such as a signed donor care sticker affixed to a
driver’s licence or an organ donor card.
If the person is obviously dead, you may be required to leave the body at the scene if
there is any possibility that the police will have to investigate.
In other situations, you may be required to arrange for transport of the body so that a
physician can officially pronounce the patient dead.
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Emergency Medical Technician – Basic
Chapter 3: Medico-Legal and Ethical Issues in EMS
Crime Scenes
General guidelines - a potential crime scene is any scene that may require police
support.
If the crime is rape, do not wash the patient or allow the patient to wash,
change their clothing, use the bathroom or take anything by mouth.
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Emergency Medical Technician – Basic
Chapter 3: Medico-Legal and Ethical Issues in EMS
The Emergency Medical Technician provides services based on human need, with
respect for human dignity, unrestricted by consideration of nationality, race creed, color,
or status.
The Emergency Medical Technician does not use professional knowledge and skills in
any enterprise detrimental to the public wellbeing.
The Emergency Medical Technician respects and holds in confidence all information of a
confidential nature obtained in the course of professional work unless required by law
to divulge such information.
The Emergency Medical Technician, as a citizen, understands and upholds the law and
performs the duties of citizenship; as a professional, the Emergency Medical Technician
has the never-ending responsibility to work with concerned citizens and other health
care professionals in promoting a high standard of emergency medical care to all
people.
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Emergency Medical Technician – Basic
Chapter 3: Medico-Legal and Ethical Issues in EMS
The Emergency Medical Technician assumes responsibility for individual professional
actions and judgment, both in dependent and independent emergency functions, and
knows and upholds the laws which affect the practice of the Emergency Medical
Technician.
The Emergency Medical Technician has an obligation to protect the public by not
delegating to a person less qualified, any service which requires the professional
competence of an Emergency Medical Technician.
The Emergency Medical Technician will work harmoniously with and sustain confidence
in Emergency Medical Technician associates, the nurses, the physicians, and other
members of the Emergency Medical Services health care team.
The EMT Code of Ethics was written by Dr. Charles Gillespie and adopted by the
National Association of EMTs in 1978.
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Emergency Medical Technician – Basic
Chapter 4: Ambulance Vehicles and Equipment
Chapter 4:
Equipment
Outline
Introduction
Cleanliness
Emergency Driving
Ambulance Hygiene
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Emergency Medical Technician – Basic
Chapter 4: Ambulance Vehicles and Equipment
Introduction
M
odern ambulances have evolved into sophisticated vehicles, with modern
safety features such as ABS brakes and airbags. Many newer ambulances
look similar to older vehicles, with changes related to the use of new
lightweight materials and increased safety features. Ambulances now are often
equipped with GPS and computer dispatch systems. Ambulances are equipped
according to their role - basic transport, Intermediate Life Support (ILS), Advanced Life
Support (ALS), or Mobile Intensive Care Unit (MICU).
Ambulance vehicle designations in the USA are governed by federal laws and
standards.
A driver’s compartment.
A patient compartment to accommodate an emergency medical services provider
(EMSP) and one patient located on the primary cot so positioned that the primary
patient can be given intensive life-support during transit.
Equipment and supplies for emergency care at the scene as well as during
transport.
Safety, comfort, and avoidance of aggravation of the patient’s injury or illness.
Two-way radio communication.
Audible and Visual Traffic warning devices
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Emergency Medical Technician – Basic
Chapter 4: Ambulance Vehicles and Equipment
requirement basis. The general cab-chassis is similar to the North American Type II
vehicle but the interior is generally built to the customer’s specific requirements.
Fibreglass is used extensively in the manufacture of European vehicles - this promotes
vehicle handling characteristics as well as reducing overall weight and fuel
consumption.
These vehicles are utilized to deliver Advanced Life Support quickly and efficiently at
the scene of any emergency. The vehicle is either dispatched at the same time as an
ambulance unit or in advance of the ambulance unit when resources are limited and
demands on the service are high. Paramedic Fast Response Units are mobilized to
achieve early stabilization of the patient and rely heavily on ambulance follow-up for
transportation of the victim/s to the receiving medical facility.
Helicopter Emergency Medical Services (HEMS) units are basically used for trauma and
high-dependency transfers. HEMS are particularly useful for the pickup of patients in
isolated areas where access by other forms of air, sea or road transport is difficult or just
not possible at all. It should be said that HEMS units are extremely costly to set up and
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Emergency Medical Technician – Basic
Chapter 4: Ambulance Vehicles and Equipment
run. Due to the high cost factor, HEMS units are usually run on a regional or national
basis as opposed to local operations.
Monitoring Equipment:
BP Cuff / NIBP, Stethoscope, ECG Monitor Defibrillator, Vital Signs Monitor, Pulse
Oximeter, Thermometer.
Airway Equipment:
Scoop Stretcher, Vacuum Mattress, Extrication Device (KED), Cervical Collars, Head
Immobilizer, Extremity Splints, Traction Splint, Straps and harnesses.
Others:
Stretcher
Carry chair
Entonox
Medical Bag
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Emergency Medical Technician – Basic
Chapter 4: Ambulance Vehicles and Equipment
It is the duty of the driver and assistant to check the vehicle and equipment according to the
checklist when reporting for duty. As emergency care professionals, we are dealing with
people’s lives each time we respond to a call, and a faulty vehicle or equipment could result in
the loss of a life that could have been saved. When checking equipment it is also vital to ensure
that all the equipment on the ambulance is clinically clean. The safety of the crew also depends
on any faults with the vehicle being noted and corrected.
Duties of Driver
Check all fluid levels – fuel, engine oil, radiator coolant, automatic transmission fluid,
battery water levels before starting the vehicle. Also check for leaks under the vehicle.
Check lights – headlights, taillights, direction indicators, rotators, flashers, sirens, etc.
When checking the vehicle it is important to remember that the most engine wear occurs
during the first 30 seconds after start up, before the oil is circulated through the engine. DO
NOT rev the engine immediately on or after start up.
It is also important to remember that diesel engines with a turbo need to idle before shut
down. NEVER rev a turbo engine before turning off the ignition, as it can cause damage to
the turbo bearings, loss of power and shorten the life of the engine.
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Emergency Medical Technician – Basic
Chapter 4: Ambulance Vehicles and Equipment
Duties of Attendant
Check equipment according to the checklist, making sure that all the equipment is
complete and in good working order.
Check oxygen cylinders are full, and that gauges and flowmeters are working.
Make sure batteries are charged for any battery powered equipment such as ECG
monitors, pulse oximeters, etc.
Make sure that the patient compartment, equipment and supplies are clinically
clean and thoroughly hygienic.
Make sure that you know exactly how each item of equipment works, and the
trouble-shooting procedures for that item of equipment.
Cleanliness
Cleanliness of the vehicle, both inside and out serves two purposes. The first is that a
clean vehicle portrays a professional image. The second and more important function is
to ensure that both the crew and patients are protected from the transmission of
infection and communicable diseases by contaminated surfaces, linen, equipment, etc. It
is vitally important to clean the interior surfaces with approved disinfectants, as a surface
which appears clean, can harbour bacteria and viruses.
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Emergency Medical Technician – Basic
Chapter 4: Ambulance Vehicles and Equipment
Ambulance equipment
Personnel
2. Dispatch
Location of call.
Nature of call.
4. At the scene.
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Emergency Medical Technician – Basic
Chapter 4: Ambulance Vehicles and Equipment
8. Post run.
Emergency Driving
Exceed the posted speed limit for the area as long as you are not
endangering lives or propery.
Drive the wrong way down a one-way street or drive down the opposite side
of the road.
Turn in any direction at an intersection.
Park anywhere as long as you do not endanger lives or property.
Leave the ambulance standing in the middle of a street or intersection.
Cautiously proceed through a red flashing signal.
Pass other vehicles in a no-passing zones.
Ambulance Hygiene
Strip used linens from the stretcher and place them in a plastic bag or designated
receptacle.
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Emergency Medical Technician – Basic
Chapter 4: Ambulance Vehicles and Equipment
Air out the ambulance with all doors and windows open for 15 minutes.
Scrub again with germicidal solution, then air out again to let everything dry.
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Emergency Medical Technician – Basic
Chapter 5: Medical Terminology in EMS
Chapter 5:
Medical Terminology in
EMS
Outline
Internal Inside
External Outside
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Emergency Medical Technician – Basic
Chapter 5: Medical Terminology in EMS
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Emergency Medical Technician – Basic
Chapter 5: Medical Terminology in EMS
Epistasis - nosebleed
Erythema - redness
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Emergency Medical Technician – Basic
Chapter 5: Medical Terminology in EMS
Rales - crackles
Emesis - vomiting
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Emergency Medical Technician – Basic
Chapter 5: Medical Terminology in EMS
Genitourinary (GU)
MS - Musculoskeletal
Ext - Extremities
Edema - swelling
Skin
Pruritic - itchy
Bumps:
Sacs:
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Emergency Medical Technician – Basic
Chapter 5: Medical Terminology in EMS
Erythema - redness
ASA Aspirin
BP Blood pressure
BVM Bag-valve-mask
c/o Complaining of
Ca Cancer/carcinoma
cc Cubic centimeter
CC Chief Complaint
CO Carbon monoxide
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Emergency Medical Technician – Basic
Chapter 5: Medical Terminology in EMS
chronic bronchitis)
d/c Discontinue
DM Diabetes mellitus
Dx Diagnosis
Fx Fracture
GI Gastrointestinal
gtt. Drop
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Emergency Medical Technician – Basic
Chapter 5: Medical Terminology in EMS
GU Genitourinary
GYN Gynecologic
h, hr. Hour
H/A Headache
Hg Mercury
h/o History of
hs At bedtime
HTN Hypertension
Hx History
IM Intramuscular
IO Intraosseous
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Emergency Medical Technician – Basic
Chapter 5: Medical Terminology in EMS
L Left or Liter
LAC Laceration
mcg Micrograms
NC Nasal cannula
NS Normal saline
NTG Nitroglycerin
O2 Oxygen
OB Obstetrics
OD Overdose
OR Operating room
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Emergency Medical Technician – Basic
Chapter 5: Medical Terminology in EMS
PCN Penicillin
po By mouth
PRN As needed
Pt Patient
R Right
Rx or Tx Treatment
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Emergency Medical Technician – Basic
Chapter 5: Medical Terminology in EMS
stat. immediately
x Times
w/o or s without
Symbols
Δ change
+ Positive
- Negative
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Emergency Medical Technician – Basic
Chapter 6: Infection Control and the EMT
Chapter 6:
Infection Control and the
EMT
Outline
Overview
The Chain of Infection
Stages of Infection
Methods of Transmission
Defenses against Infection
Diseases That Pose A Threat To EMS Workers
Body Substances Isolation (BSI)
Exposure Control Plan
Reservoirs – Portals of Exit
Susceptible Defenses of a Susceptible Host
Hand Washing
Recommended Use of Personal Protective Equipment by Situation
Overview
Infection Control
Infection
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Emergency Medical Technician – Basic
Chapter 6: Infection Control and the EMT
Communicable Disease
Any disease that can be spread from one person to another or to a person
from contaminated objects.
Stages of Infection
Incubation Period
Interval between entrance of pathogen into body and appearance of first symptoms (e.g.,
chickenpox, 2-3 weeks; common cold, 1-2 days; influenza, 1-3 days; mumps, 15-18 days).
Prodromal Stage
Interval from onset of nonspecific signs and symptoms (malaise, low-grade fever, fatigue) to
more specific symptoms (during this time, microorganisms grow and multiply, and client may
be more capable of spreading disease to others).
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Emergency Medical Technician – Basic
Chapter 6: Infection Control and the EMT
Illness Stage
Interval when client manifests signs and symptoms specific to type of infection (e.g., common
cold manifested by sore throat, sinus congestion, rhinitis; mumps manifested by earache, high
fever, parotid and salivary gland swelling).
Convalescence
Interval when acute symptoms of infection disappear (length of recovery depends on severity of
infection and client’s general state of health; recovery may take several days to months).
Methods of Transmission
Direct contact
Contact with contaminated materials
Inhalation of infected droplets (TB, Meningitis)
The bite of an infected animal, human or insect
Puncture by contaminated needle
Transfusion of contaminated blood products
Normal flora
Body system defenses
Inflammation
Immune response (acquired immunity)
HIV
Hepatitis B and C
Tuberculosis
Syphilis
Meningitis
Rabies (Philippines)
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Rabies
Rabies is a zoonotic disease (a disease that is transmitted to humans from animals) that is
caused by a virus. Rabies infects domestic and wild animals, and is spread to people through
close contact with infected saliva (via bites or scratches). The disease is present on nearly every
continent of the world but most human deaths occur in Asia and Africa (more than 95%). Once
symptoms of the disease develop, rabies is fatal.
Rabies is widely distributed across the globe. More than 55 000 people die of rabies each year.
About 95% of human deaths occur in Asia and Africa.
Wound cleansing and immunizations, done as soon as possible after suspect contact with an
animal and following WHO recommendations, can prevent the onset of rabies in virtually 100%
of exposures. Once the signs and symptoms of rabies start to appear, there is no treatment and
the disease is almost always fatal.
Hepatitis B
Hepatitis B is the most common serious liver infection in the world. It is caused by the hepatitis
B virus (HBV) that attacks the liver. This disease is more infectious than AIDS because it is very
easily transmitted by blood, a single virus particle can cause disease. It is transmitted through
infected blood and other body fluids like seminal fluid, vaginal secretions, breast milk, tears,
saliva and open sores. Once infected with the hepatitis B virus, approximately 10% of the people
develop a chronic permanent infection. It is very common in Asia, Africa and the Middle East.
The overall incidence of reported Hepatitis B is 2 per 10,000 individuals, but the true incidence
may be higher, because many cases do not cause symptoms and go undiagnosed and
unreported.
Tuberculosis
Left untreated, each person with active TB disease will infect on average between 10 and 15
people every year. But people infected with TB bacilli will not necessarily become sick with the
disease. The immune system “walls off” the TB bacilli which, protected by a thick waxy coat, can
lie dormant for years. When someone’s immune system is weakened, the chances of becoming
sick are greater.
• Overall, one-third of the world’s population is currently infected with the TB bacillus.
Globally, the Philippines’ rate of TB infection is ninth among 22 high burden countries and ranks
third in the Western Pacific region (WHO, 2004).
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Meningitis
Meningitis is inflammation of the thin tissue that surrounds the brain and spinal cord, called
the meninges. There are several types of meningitis. The most common is viral meningitis,
which you get when a virus enters the body through the nose or mouth and travels to the
brain. Bacterial meningitis is rare, but can be deadly. It usually starts with bacteria that cause a
cold-like infection. It can block blood vessels in the brain and lead to stroke and brain
damage. It can also harm other organs.
Meningitis is more common in people whose bodies have trouble fighting infections.
Meningitis can progress rapidly. Symptoms include:
• sudden fever
• severe headache
• stiff neck
Wear mask and protective eyewear in situations where droplets of body fluids may spray
onto mucus membranes.
Wear a gown in situations where it is likely that droplets of blood or body fluids will be
sprayed on your working clothes.
Immediately and thoroughly wash or other skin surfaces that come into contact with blood or
body fluids.
To prevent needle stick injuries, dispose of all use needles in a puncture-resistant container
with a secured lid.
Do not provide direct patient care when you have open and oxidative skin lesions.
A comprehensive plan that helps employees reduce their risk of exposure or acquisition
of communicable diseases.
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Determination of Exposure - this area should define who is at risk at comining in contact with
blood or body fluids.
Education and Training - this area should explain why a qualified individual has to answer
questions about CD and why infection control is required
Hepatitis Vaccination Program - outlines the immunization schedules for EMT personnel.
Personal Protective Equipment - should list the PPE and should be of good quality.
Changing and Disinfection Practices - should describe how to care for and maintain vehicle
and equipment.
Post-Exposure Management - should identify who to notify when you believe you have been
exposed.
Primary Risk
Blood
Semen
Vaginal Secretions
Secondary Risk
Synovial Fluid
CSF Fluid
Amniotic Fluid
No Risk
Sweat
Tears
Saliva
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Feces
Vomitus
Nasal Secretions
Sputum
Respiratory Tract
Gastro-Intestinal Tract
Urinary Tract
Reproductive Tract
Blood
Hygiene
Good personal hygiene and maintaining the intactness of the skin and mucus
membrane retains a barrier against microorganisms entering the body.
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Immunization
Nutrition
Adequate nutrition enhances the health of all body tissues, helps keep the skin intact
and promotes the skin’s ability to repel microorganisms.
Fluid
Adequate rest and sleep are essential to health and preserving energy.
Stress
Handwashing
Purposes:
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Starting an IV Yes No No No
line
Endotracheal Yes No No, unless No, unless
intubation splashing is splashing is
likely likely
Oral/nasal Yes No No, unless No, unless
suctioning, splashing is splashing is
manually likely likely
clearing airway
Handling and Yes No, unless No No
cleaning soiling is likely
instruments with
microbial
contamination
Measuring blood No No No No
pressure
Measuring No No No No
temperature
Giving an No No No No
injection
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Chapter 7: Anatomy for EMTs
Chapter 7:
Anatomy for EMTs
Outline
Body Organization
Anatomical Planes and Directions
Metabolism
Skeletal System
Circulatory System
Respiratory System
Nervous System
Muscular System
Body Cavities
The Abdomen
Body Organization
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Metabolism
Metabolism refers to the chemical and energy transformations which occur in the body.
In the human body, carbohydrates, proteins and fats are oxidised to produce CO2, H2O
and form available energy (adenosine triphosphate - ATP) which is essential for life
processes.
At the cellular level, the production of energy takes place in the mitochondria when
oxygen and pyruvate are combined.
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Aerobic Metabolism
In aerobic metabolism, there is sufficient oxygen entering the cell to react with and convert the
available pyruvate into ATP.
Anaerobic Metabolism
In anaerobic metabolism, there is no oxygen or insufficient oxygen entering the cell and little or
no utilisation of pyruvate. The remaining pyruvate converts into lactic acid and cellular acidosis
occurs, invariably leading to cell damage or death. As little as 10% of ATP is produced during
anaerobic metabolism.
Skeletal System
The Spine
The spine supports the skull and gives attachment to the ribs. It is a column of 33 irregular
bones called vertebrae.
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The circulatory system is a closed system which transports essential food, oxygen and
water to the cells of the body and removes the waste products they produce.
The heart
Blood vessels
Blood
Pump
Pipes
Fluid
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Heart contraction is controlled by nerve stimuli which originate in the sino-atrial node (the
‘pacemaker’), passing down the Bundle of His and radiating throughput the heart muscle.
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Pulse
The wave of blood through the arteries formed when the left ventricle contracts.
Can be felt where an artery passes near the skin surface and over a bone.
Blood Pressure
Perfusion
Blood Vessels
Arteries
Arterioles
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Veins
Venules
Capillaries
Arteries carry blood away from the heart. The blood is moved along by the heartbeat and
the artery walls. Arteries have a strong outer wall and a thick muscle layer to withstand
high pressure.
Veins carry blood to the heart by the action of the surrounding muscles and by the suction
of the heart. Veins have thinner walls and are provided with valves, to stop the blood
flowing in the wrong direction.
Arterioles and venules dilate or contract to control the blood flow into and out of the
capillary bed.
Capillaries allow for the interchange of gases and the transfer of nutrients and waste
products. Capillaries have very thin walls consisting of a single layer of cells only. They are
semi-permeable to permit the passage of substances between the blood and the tissues.
Respiratory System
Extracts oxygen from the atmosphere and transfer it to the bloodstream in the lungs
Excretes water vapour and CO2
Maintains the normal acid-base status of the blood
Ventilates the lungs
Adults 12 to 20 breaths/min
Children 15 to 30 breaths/min
Infants 25 to 50 breaths/min
Inspired Air
79% nitrogen
20% oxygen
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Expired Air
79% nitrogen
16% oxygen
4% carbon dioxide
1% inert gases
water vapour to saturation
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Exchange of Gases
External respiration
takes place in the lungs. Oxygen from inhaled air is absorbed into the blood via the
capillaries of the lung. Carbon dioxide is released from the blood into the lungs and
is exhaled.
Internal respiration
The Diaphragm
Mechanisms of Breathing
Inhalation
Diaphragm and intercostal muscles contract, increasing the size of the thoracic
cavity.
Pressure in the lungs decreases.
Air travels to the lungs.
Exhalation
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The nervous system controls the body’s voluntary and involuntary actions.
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The Brain
The brain is the highest level of the nervous system and is continuous with the spinal
cord. It is divided into three main parts:
Cerebrum
Cerebellum
responsible for the maintenance of balance, muscle coordination and muscle tone.
Brainstem
the nerve connections of the motor and sensory systems from the main part of the
brain to the rest of the body pass through the brain stem.
regulation of cardiac and respiratory function.
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Nerves
1. Cranial nerves connect the sense organs (eyes, ears, nose, mouth) to the brain.
2. Central nerves connect areas within the brain and spinal cord.
3. Peripheral nerves connect the spinal cord with the limbs.
4. Autonomic nerves connect the brain and spinal cord with the organs (heart, stomach, intestines,
blood vessels, etc.).
Muscular System
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Body Cavities
The Abdomen
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Chapter 8: Health, Hygiene, Fitness and Safety of the EMT
Chapter 8:
Health, Hygiene, Fitness
and Safety of the EMT
Outline
Nutrition - to perform efficiently, an EMT should eat nutritious food to fuel the
body and make it run. Physical exertion and stress are part of an EMT‟s job and
require high energy output.
Exercise and relaxation - a regular program of exercise will enhance the benefits of
maintaining nutrition and adequate hydration.
Balancing work, family and health - as an EMT you will often be called to assist the
sick and the injured any time of the day or night. Shift work may be required to be
apart from loved ones for long periods of time. Never let the job interfere
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excessively with your own needs. Find a balance between work and family. Make sure that you
have the time that you need to relax with family and friends.
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Body Mechanics
The efficient coordinated and safe use of the body to produce motion and maintain
balance during activity.
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Avoid twisting the spine by pushing or pulling an object, directly away from or
toward the body and squarely facing the direction of movement.
When lifting objects, distribute the weight between the large muscles of the
arms and legs.
5. Wear clothing that allows you to use good body mechanics and wear comfortable
low-heeled shoes that provide good foot support and will not cause you to slip,
stumble and turn your ankle.
“One in four EMS workers will suffer a career ending back injury within the first 4
years of service. The number one physical reason for leaving EMS,” (mytactical.com,
EMS Back Injury Facts, 2007).
“Back injury from improper lifting is the number one injury suffered by pre-hospital
care providers,” according to New Mexico‟s EMT training manual.
“Almost one in two workers(47%) have sustained a back injury while performing
EMS duties,” (National Association of Emergency Medical Technicians, 2005).
“Average cost for a „simple‟ sprain or strain of the lumbar spine is approximately
US$18,365 in direct costs per occurrence,” (Mitterre D., “Back Injuries in EMS,” EMS
Magazine, 1999).
Lifting caused just over 62% of back injuries for EMT‟s, and low back strain was the
cause of 78% of the compensation days in a 3.5 year period, (Hogya PT, Ellis L.,
University of Pittsburgh Affiliated Residency in Emergency Medicine, PA, 1990).
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Chapter 9: Patient Assessment
Chapter 9:
Patient Assessment
Outline
Overview
Purpose of Patient Assessment
Scene Size-Up
Body Substances Isolation
Scene Safety
Number of Patients
Additional Resources
Mechanism of Injury (MOI)
Nature of Illness (NOI)
Cervical-Spine Immobilization
Initial Assessment
Baseline Vital Signs
Priority Patients
Transport Decisions
Trauma Assessment
Focused Physical Examination
Significant Mechanism of Injury
Patient Assessment Definitions
OPQRST
The Full Assessment
Overview
Scene size-up
Initial assessment
Focused history and physical exam
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Vital signs
History
Detailed physical exam
Ongoing assessment
Your total patient care and transport decisions will be based on your assessment of
the patient’s condition as follows:
To determine whether the patient has suffered trauma or has a medical complaint.
To identify and manage immediately life threatening injuries or conditions.
To determine further assessment and care on the scene vs immediate transport with
assessment and care continuing en route.
To provide further emergency care.
To examine the patient and gather a patient medical history.
To monitor the patient’s condition, assessing and adjusting care as required.
To communicate patient information to the medical facility to ensure continuity of care.
Scene Size-Up
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Scene Safety
Potential hazards
Oncoming traffic
Unstable surfaces
Leaking gasoline
Downed electrical lines
Potential for violence
Fire or smoke
Hazardous materials
Other dangers at crash or rescue scenes
Crime scenes
Number of Patients
Additional Resources
Medical resources
Additional units
Advanced life support
Nonmedical resources
Fire suppression
Rescue
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Law enforcement
Evaluate:
Cervical-Spine Immobilization
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Chapter 9: Patient Assessment
Initial Assessment
A Airway
B Breathing
C Circulation
Airway
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Labored breathing
Breathing
Look for:
Choking
Rate
Depth
Cyanosis
Lung sounds
Air movement
Circulation
Presence
Rate
Rhythm
Strength
Assessing perfusion:
Color
Temperature
Skin condition
Capillary refill
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Check:
Breathing
Pulse
Skin
Pupils
Blood Pressure
Pulse Oximetry
Respirations
Breathing checklist:
Equal chest rise Shallow chest rise Increased breathing Snoring, wheezing,
Rhythm
Regular
Irregular
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Effort
Depth
Shallow
Normal
Deep
Pulse checklist:
Strength
Weak
Normal
Strong
Quality
Slow
Normal
Rapid
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Rhythm
Regular
Irregular
Skin
Color
Temperature
Moisture
Blood Pressure
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Blood pressure should be measured in all patients older than 3 years of age.
60 to 90 mmHg (d)
BP by Auscultation BP by Palpation
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Level of Responsiveness
Pupil Response
P - Pupils
E - Equal
A - And
R - Round
R - Regular in size
L - React to Light
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Priority Patients
Difficulty breathing
Complicated childbirth
Uncontrolled bleeding
Severe pain
Transport Decisions
Patient condition
Distance to transport
Local protocols
A 60-90 second head-to-toe exam that is quickly conducted on a patient who has
suffered or may have suffered severe injuries
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During the Rapid Trauma Assessment, the EMT is looking for signs of:
D Deformities
C Contusions
A Abrasions
P Punctures/Penetrations Remember:
DCAP - BTLS
B Burns
T Tenderness
L Lacerations
S Swelling
2. Inspect and palpate the head and face, including the ears, pupils, nose and mouth.
5. Expose and assess the chest. Perform a four-point auscultation of the chest to listen
for breath sounds.
6. Assess the abdomen. If the patient complains of pain or there is obvious trauma, do
not palpate.
8. Assess all four extremities, including pulses, motor function and sensation (PMS).
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Performed on:
SAMPLE History
A Allergies
M Medications Remember:
P Pertinent past history SAMPLE
L Last oral intake
Chest
Abdomen
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Pelvis
Extremities
Posterior Body
Vehicle rollover
High-speed collision
Vehicle-pedestrian collision
Motorcycle crash
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Assessment Summary
Assessment Steps for Significant MOI Assessment Steps for Trauma Patients
Without Significant MOI
• Rapid trauma assessment
• Focused assessment
• Baseline vital signs
• Baseline vital signs
• SAMPLE history
• SAMPLE history
• Re-evaluate transport decision
• Re-evaluate transport decision
identified problems?
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Ongoing
1. Is the treatment improving the patient’s condition?
Assessment
2. Are any known problems getting better or worse?
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OPQRST
O Onset
P Provocation
Q Quality
R Radiation/Region
S Severity
T Time
OPQRST Explained
Onset
The word “onset” should trigger questions regarding what the patient was doing just
prior to and during the onset of the specific symptom(s) or chief complaint.
It may be helpful to know if the patient was at rest when the symptoms began or if they
were involved in some form of activity. This is especially true with patients presenting
with suspected cardiac signs & symptoms.
Provocation
The word “provocation” should trigger questions regarding what makes the symptoms
better or worse.
• Does anything you do make the symptoms better or relieve them in any way?
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a cardiac origin whose pain is not made any better or worse with movement or
palpation.
Quality
The word “quality” should trigger questions regarding the character of the symptoms
and how they feel to the patient.
• Can you describe the symptom (pain/discomfort) that you are having right now?
• Is it sharp or dull?
This if often the most difficult question for the patient to understand and to articulate.
The key here is to allow the patient to use their own words and not try to feed the
patient with suggestions that they may choose simply because you have made it easy. It
is sometime helpful to offer the patient choices and allow them to decide which is most
appropriate for their situation. For instance, “is your pain sharp or is it dull” or “is your
pain steady or does it come and go”?
Region/Radiation
The words “region and radiation” should trigger questions regarding the exact location
of the symptoms.
• Can you point with one finger where it hurts the most?
Although it is not always easy for a patient to identify the exact point of pain, especially
with pediatric patients, it is important to ask. Asking if they can point with one finger to
where it hurts the most is a good start. From there you will want to know if the pain
“moves” or “radiates” anywhere from the point of origin. The patient may need you to
offer some suggestions such as, “does the pain radiate anywhere else such as your back,
neck, jaw or shoulders”? Always give them two or three choices and allow them to select
from the options that you give.
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Severity
The word “severity” should trigger questions relating to the severity of the symptoms.
• On a scale of 1 to 10, how would you rate your level of discomfort right now?
• Using the same scale, how would you rate your discomfort when it first began?
It’s not always just about how bad the pain or discomfort is when you arrive - this is a
common mistake made by many new EMTs. Once you have established the level of
discomfort that the patient is experiencing at that moment, you must follow this up with
how severe the discomfort was at onset. This will help you establish whether the
discomfort is getting better, worse or staying the same over time. You will want to
follow these two checkpoints up with an additional check once the patient has received
some of your care and reassurance. Often times with a little oxygen and reassurance the
symptoms may subside. Ask the patient a few minutes later how the discomfort is and if
it has changed at all since your arrival.
Time
The word “time” should trigger questions relating to the when the symptoms began.
Establishing an accurate duration of the symptoms will be very helpful to the hospital
staff that will be caring for the patient. This question has special importance when caring
for patients presenting with suspected cardiac signs and symptoms.
SCENE SIZE-UP
Ensure BSI (Body Substance Isolation) procedures and & personal protective gear is
being used.
Observe scene for safety of crew, patient, bystanders. Identify the mechanism of injury
or nature of illness.
Identify the number of patients involved.
Determine the need for additional resources including Advanced Life Support.
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INITIAL ASSESSMENT
General Impression
Mental Status
Airway
Breathing
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Quickly palpate the chest for unstable segments, crepitation (trauma), and equal
expansion of the chest.
Check pulse oximetry - if below 94% administer oxygen.
If the pt. is unresponsive and breathing is inadequate, use a BVM to maintain pulse
oximetry at 94% or above.
Circulation
If the pt. is unresponsive, assess for presence and quality of the carotid pulse.
If the pt. is responsive, assess the rate and quality of the radial pulse.
If radial pulse is weak or absent, compare it to the carotid pulse.
For patients 1 year old or less, assess the brachial pulse.
Is there life threatening hemorrhage?
Control life threatening hemorrhage
Assess the patient’s perfusion by evaluating skin for color, temperature and condition
(CTC);
can also check the conjunctiva and lips
Assess capillary refill in infant or child < 6 yrs. old
Cover with blanket and elevate the legs as needed for shock (hypoperfusion)
Is the patient:
Critical?
Unstable?
Potentially Unstable?
Stable?
Consider the need for Advanced Life Support
If the patient is CRITICAL, UNSTABLE or POTENTIALLY UNSTABLE , begin packaging the
patient during the rapid assessment while treating life threats and transport as soon as
possible.
In addition, perform the rapid trauma assessment for the trauma patient if he/she has
significant mechanism of injury and apply spinal immobilization as needed.
For the unresponsive medical patient perform the rapid medical assessment.
If the patient is or STABLE, perform the appropriate focused physical exam (for the
medical pt. perform the focused physical exam; for trauma patient perform the focused
trauma assessment.)
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Re-consider the mechanism of injury. If there is significant mechanism of injury, perform a Rapid
Trauma Assessment on-scene while preparing for transport and then a Detailed Assessment
during transport. If there is no significant mechanism of injury, perform the Focused Trauma
Assessment. Direct the focused trauma assessment to the patient’s chief complaint and the
mechanism of injury (perform it instead of the rapid trauma assessment).
HEAD
DCAP-BTLS
Blood & fluids from the head, including cerebrospinal fluid
NECK
DCAP-BTLS
JVD (Jugular Vein Distention)
Crepitation
Apply CSIC (Cervical Spinal Immobilization Collar) - if not already done
CHEST
DCAP-BTLS
Paradoxical movement
Crepitation
Breath sounds - bilateral assessment of the apices, mid-clavicular line;
midaxillary at the nipple line; and at the bases
ABDOMEN
DCAP-BTLS
Pain
Firm
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Soft
Distended
PELVIS
DCAP-BTLS
If no pain is noted, gently compress the pelvis to determine tenderness or unstable
movement.
EXTREMITIES
DCAP-BTLS
Crepitation
Distal pulses
Sensory function
Motor function
POSTERIOR
The specific injury they are complaining about – why they called EMS
Assess and treat injuries not found during your Initial Assessment
Reconsider your transport decision
Consider ALS intercept
Focused Assessment
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Respirations
RATE:
QUALITY:
Normal
Shallow
Any unusual pattern?
Labored?
Deep
Noisy breathing?
Pulse
RATE:
Check the radial pulse. If pulse is regular, count for 30 seconds and multiply x 2. If it is irregular,
count for a full 60 seconds.
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QUALITY:
Regular
Strong
Irregular
Weak
Skin (CTC)
COLOUR:
Normal (unremarkable)
Cyanotic
Pale
Flushed
Jaundice
TEMPERATURE:
Warm
Hot
Cool
Cold
CONDITION:
Wet
Dry
Blood Pressure
Pupils
Use a penlight to check reactivity of the pupils; also assess for size
equal or unequal
normal, dilated, or constricted
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During this phase of the patient assessment, the mnemonic OPQRST and SAMPLE will be used
to gather information about the chief complaint and history of the present illness. Baseline vital
signs and a focused physical exam or a rapid medical assessment will be performed. The order
in which you perform the steps of this focused history and physical exam varies depending on
whether the patient is responsive or unresponsive.
Performed on patients who are unconscious, confused, or unable to adequately relate their chief
complaint.
Perform a rapid assessment using DCAP-BTLS following the order of the Rapid Trauma
Assessment:
Performed on the conscious, alert patient who can adequately relate their chief complaint.
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Radiation - “Where do you feel the pain/discomfort?” “Does the pain/discomfort
travel anywhere else?”
Severity - “How bad is the pain?” “How would you rate the pain on a scale of 1-10,
with 10 being the worst pain you’ve felt in your life?”
Time - “How long has the problem been going on?”
Assess SAMPLE
o Seizures o Interventions
o Fever
o Time period o Loss of consciousness “Have you been feeling that life is not
worth living?”
o Interventions o Effects-general or local
“Have you been feeling like killing
o Estimated weight yourself?”
o Medical problem
o Interventions
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o How long have you been pregnant? o Any vomiting? If so, o Position
color/substance
o Pain or contraction o History
o Taking birth control
o Bleeding or discharge o Blood in vomit or stool
o Vaginal bleeding or discharge
o Has your water broke? o Trauma
o Abnormal vital signs
o Do you want to push? o Incontinence
- Respirations
- Pulse
- Blood Pressure
- Level of Consciousness
- Skin
- Pupils
Provide Treatment
The Detailed Physical Exam is used to gather additional information regarding the patient’s
condition only after you have provided interventions for life threats and serious conditions. Not
all patients will require a Detailed Physical Exam. It is performed in a systematic head-to-toe
order. You will examine the same body areas that you examined during your rapid assessment.
During the detailed physical exam, you will look more closely at each area to search for findings
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of lesser priority than life threats and/or signs of injury that have worsened. Do not delay
transport to perform a detailed physical exam; it is only performed while en route to the
hospital or while waiting for transport to arrive.
The Detailed Physical Exam is used to gather additional information regarding the patient’s
condition only after you have provided interventions for life threats and serious conditions.
Not all patients will require a Detailed Physical Exam. It is performed in a systematic head-to-
toe order. You will examine the same body areas that you examined during your rapid
assessment. During the detailed physical exam, you will look more closely at each area to
search for findings of lesser priority than life threats and/or signs of injury that have
worsened. Do not delay transport to perform a detailed physical exam; it is only performed
while en route to the hospital or while waiting for transport to arrive.
• DCAP-BTLS
• DCAP-BTLS
• DCAP-BTLS
• DCAP-BTLS
• Discoloration
• Unequal Pupils
• Foreign Bodies
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NOSE - inspect and palpate for signs of injury.
• DCAP-BTLS
• Drainage
• Bleeding
• DCAP-BTLS
• Damaged/Missing Teeth
• Obstructions
• Discoloration
• Unusual Odors
• DCAP-BTLS
• JVD
• Tracheal deviation
• Crepitation
• DCAP-BTLS
• Paradoxical movement
• Crepitation
• Breath sounds - bilateral assessment of the apices, midclavicular line; mid-axillary at the
nipple line; and at the bases
• Present
• Absent
• Equal
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• DCAP-BTLS
• Pain/Tenderness
• Firm
• Soft
• Distended
• DCAP-BTLS
EXTREMITIES - inspect and palpate the lower and upper extremities for signs of injury.
• DCAP-BTLS
• Crepitation
• Distal pulses
• Sensory function
• Motor function
POSTERIOR
• DCAP-BTLS
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ON-GOING ASSESSMENT
The On-Going Assessment will be performed on all patients while the patient is being
transported to the hospital. It is designed to reassess the patient for changes that may require
new intervention. You will also evaluate the effectiveness of earlier interventions, and reassess
earlier significant findings. You should be prepared to modify treatment as appropriate and
begin new treatment on the basis of your findings during the On-Going Assessment.
Check Interventions
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Chapter 10: Communication and Documentation
Chapter 10:
Communication and
Documentation
Outline
Overview
Types of Communication in EMS
Emergency Medical Dispatch
Response Times
Dispatch Life Support
EMT Communication
Triage
Verbal Communication
Communicating with Patients
Documentation
The Pre-hospital Care Report/Patient Care Report
Documenting Refusal
Special Reporting Situations
Overview
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- Range of 10 to 15 miles
Repeater-Based Systems
Digital Systems
• Some EMS systems use telemetry to send an ECG from the unit to the hospital.
• Telemetry is the process of converting electronic signals into coded, audible signals.
Cellular Telephones
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Others
• Simplex
- Push-to-talk communication
• Duplex
- Simultaneous talk-listen
• MED channels
Responsibilities
• Location of incident
• Number of patients
• Special information
• Time dispatched
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The output gives a main response category - A (Immediately Life Threatening), B (Urgent
Call), C (Routine Call). This may well be linked to a performance targeting system such as
ORCON where calls must be responded to within a given time period. For example, in
the United Kingdom, calls rated as „A‟ on AMPDS are targeted with getting a responder
on scene within 8 minutes.
Response Times
Most countries have adopted a response time of 8 to 10 minutes for the most critical
cases, and a longer response time for non-acute calls.
Toronto, Canada
Within 9 minutes in 90% of critical, life-threatening and serious cases; and within 21
minutes in 90% of non-acute cases.
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London, UK
Queensland, Australia
Within 10 minutes in 68% of Emergency Transport cases; no target set for non-
urgent cases.
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EMT Communication
The physician bases his or her instructions on the report received from the
EMT-B.
Never use codes while communicating.
Repeat all orders received.
Do not blindly follow an order that does not make sense to you - ask the
physician to clarify his or her orders.
Notify as early as possible.
Estimate the potential number of patients.
Identify special needs of patient.
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Reporting Requirements
Patient Report
Triage
Triage Priorities
Triage is the sorting of patients according to the urgency of their need for care.
It occurs both in the field and at the hospital.
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Priority Two
Priority 3 (Lowest)
Verbal Communication
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If the patient is hearing impaired, speak clearly and face him or her.
Allow time for the patient to answer questions.
Act and speak in a calm, confident manner.
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Documentation
Patient information:
Chief complaint
Mental status
Systolic BP (patients older than 3 years)
Capillary refill (patients younger than 6 years)
Skin color and temperature
Pulse
Respirations and effort
Time incident was reported
Time that EMS unit was notified
Time EMS unit arrived on scene
Time EMS unit left scene
Time EMS unit arrived at facility
Time that patient care was transferred
The Pre-hospital Care Report (or Patient Care Report) serves six functions:
Continuity of care
Legal documentation
Education
Administrative
Research
Evaluation and quality improvement
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Written forms
Computerized versions
Narrative sections of the form:
Use only standard abbreviations.
Spell correctly.
Record time with assessment findings.
Report is considered confidential.
Reporting Errors
Remember:
Gunshot wounds
Animal bites
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Chapter 11:
Airway Management
Outline
Anatomy Review
Normal Breathing Rates
Recognizing Adequate Breathing
The Patent Airway
Recognizing Inadequate Breathing
Hypoxia
Different Types of Abnormal Respirations
Abnormal Lung Sounds
Conditions Resulting in Hypoxia
Opening the Airway
Assessing the Airway
Suctioning
Basic Airway Adjuncts
Ventilation Devices
Oxygen Therapy
Article: 10 Things Every Paramedic Should Know About
Capnography
Reading a Capnograph Wave
Oxygen Delivery Equipment
Pressure Regulation Devices
Article: The Oxygen Myth
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Anatomy Review
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Hypoxia
- Breathing inadequately
- Not breathing
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Signs of Hypoxia
Crackles
Crackles (or rales) are caused by fluid in the small airways or atelectasis. Crackles
are referred to as discontinuous sounds; they are intermittent, nonmusical and
brief. Crackles may be heard on inspiration or expiration. The popping sounds
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produced are created when air is forced through respiratory passages that are
narrowed by fluid, mucus, or pus. Crackles are often associated with inflammation
or infection of the small bronchi, bronchioles, and alveoli. Crackles that don’t clear
after a cough may indicate pulmonary edema or fluid in the alveoli due to heart
failure or adult respiratory distress syndrome (ARDS).
Wheezes
Wheezes are sounds that are heard continuously during inspiration or expiration,
or during both inspiration and expiration. They are caused by air moving through
airways narrowed by constriction or swelling of airway or partial airway
obstruction.
• Wheezes that are relatively high pitched and have a shrill or squeaking
quality may be referred to as sibilant rhonchi. They are often heard
continuously through both inspiration and expiration and have a musical
quality. These wheezes occur when airways are narrowed, such as may
occur during an acute asthmatic attack.
• Wheezes that are lower-pitched sounds with a snoring or moaning quality
may be referred to as sonorous rhonchi. Secretions in large airways, such
as occurs with bronchitis, may produce these sounds; they may clear
somewhat with coughing.
Stridor
• their loudness.
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• timing in the respiratory cycle.
• whether or not the sounds clear after a cough or a few deep breaths:
- secretions from bronchitis may cause wheezes, (or rhonchi), that clear with
coughing.
- crackles may be heard when atelectatic alveoli pop open after a few deep
breaths.
• Myocardial infarction
• Pulmonary edema
• Acute narcotic overdose
• Smoke inhalation
• Stroke
• Chest injury
• Shock
• Lung disease
• Asthma
• Premature birth
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1. Look
2. Listen
3. Feel
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Suctioning
Suctioning Technique
Oropharyngeal airways
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Nasopharyngeal Airways
Airway Kits
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Ventilation Devices
The EMT is equipped with a range of devices to assist ventilation. Some of these
devices are not authorized for use by EMT-Bs, but the EMT-B may be called upon to
assist with the use of these devices.
Pocket Mask
A pocket mask may be used to provide artificial ventilations when no other equipment
is available. Pocket masks may be disposable or reusable. Some pocket masks have a
nozzle for the attachment of oxygen tubing. A pocket mask should be equipped with a
one-way valve to prevent body fluids from transferring from the patient to the EMT.
Bag-Valve Mask
The bag-valve mask should be the EMTs primary method of delivering ventilations.
Supplemental oxygen may be attached to the bag-valve if needed. Bag-valve masks
can also be used in conjunction with airway adjuncts and advanced airways such as the
endotracheal tube. Three different sizes are available - adult, child and infant. The child
and infant BVM have a pressure valve to prevent overinflation of the lungs.
Ventilation Techniques
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Oxygen Therapy
Medical Oxygen
The chemical symbol for the element oxygen is O. As a medicinal gas, oxygen contains
not less than 99.0% by volume of O2.
Whereas previously oxygen tended to be given to a majority of patients, research has led
to the prescription of oxygen when and as needed, using pulse oximetry and end-tidal
CO2 capnography to guide the EMT.
Pulse Oximeters
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Capnography
A study in the March 2005 Annals of Emergency Medicine, comparing field intubations that
used continuous capnography to confirm intubations versus non-
use showed zero unrecognized misplaced intubations in the
monitoring group versus 23% misplaced tubes in the
unmonitored group. The American Heart Association (AHA)
affirmed the importance of using capnography to verify tube
placement in their 2005 CPR and ECG Guidelines.
Paramedics are also now beginning to monitor the ETCO2 status of nonintubated patients
by using a special nasal cannula that collects the carbon dioxide. A high ETCO2 reading in a
patient with altered mental status or severe difficulty breathing may indicate
hypoventilation and a possible need for the patient to be intubated.
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Adapted from an Article from JEMS (Journey of Emergency Medical Services), by Peter Canning,
EMT-P, December 29, 2007
By tracking the carbon dioxide in a patient’s exhaled breath, capnography enables paramedics
to objectively evaluate a patient’s ventilatory status (and indirectly circulatory and metabolic
status), as the medics utilize their clinical judgement to assess and treat their patients.
Definitions:
End Tidal CO2 (ETCO2 or PetCO2) – the level of (partial pressure of) carbon dioxide released at
end of expiration.
Oxygenation is how we get oxygen to the tissue. Oxygen is inhaled into the lungs where gas
exchange occurs at the capillary-alveolar membrane. Oxygen is transported to the tissues
through the blood stream. Pulse oximetry measures oxygenation.
At the cellular level, oxygen and glucose combine to produce energy. Carbon dioxide, a waste
product of this process (The Krebs cycle), diffuses into the blood.
Ventilation (the movement of air) is how we get rid of carbon dioxide. Carbon dioxide is carried
back through the blood and exhaled by the lungs through the alveoli. Capnography measures
ventilation.
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ETCO2 35-45 mm Hg is the normal value for capnography. However, some experts say
30 mm HG – 43 mm Hg can be considered normal.
The normal wave form appears as straight boxes on the monitor screen but the wave
form appears more drawn out on the print out because the monitor screen is
compressed time while the print out is in real time.
The capnogram wave form begins before exhalation and ends with inspiration. Breathing
out comes before breathing in.
1. Monitoring Ventilation
Hyperventilation
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Note: Ventilation equals tidal volume X respiratory rate. A patient taking in a large tidal
volume can still hyperventilate with a normal respiratory rate just as a person with a small
tidal volume can hypoventilate with a normal respiratory rate.
Hypoventilation
Some diseases may cause the CO2 to go down, then up, then down. (See asthma below).
Pay more attention to the ETCO2 trend than the actual number.
A steadily rising ETCO2 (as the patient begins to hypoventilate) can help a paramedic
anticipate when a patient may soon require assisted ventilations or intubation.
Heroin Overdoses – Some EMS systems permit medics to administer narcan only to
unresponsive patients with suspected opiate overdoses with respiratory rates less than 10.
Monitoring ETCO2 provides a better gauge of ventilatory status than respiratory rate.
ETCO2 will show a heroin overdose with a respiratory rate of 24 (with many shallow
ineffective breaths) and an ETCO2 of 60 is more in need of arousal than a patient with a
respiratory rate of 8, but an ETCO2 of 35.
Continuous end-tidal CO2 monitoring can confirm a tracheal intubation. A good wave
form indicating the presence of CO2 ensures the ET tube is in the trachea.
A 2005 study comparing field intubations that used continuous capnography to confirm
intubations versus non-use showed zero unrecognized misplaced intubations in the
monitoring group versus 23% misplaced tubes in the unmonitored group. -Silverstir,
Annals of Emergency Medicine, May 2005
Paramedics can attach the capnography filter to the ET tube prior to intubation and, in
cases where it is difficult to visualize the chords, use the monitor to assist placement. This
includes cases of nasal tracheal intubation.
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Paramedics should encourage their services to equip them with continuous wave form
capnography.
Monitoring ETC02 measures cardiac output, thus monitoring ETCO2 is a good way to
measure the effectiveness of CPR.
With the new American Heart Association Guidelines calling for quality compressions
(”push hard, push fast, push deep”), rescuers should switch places every two minutes.
Set the monitor up so the compressors can view the ETCO2 readings as well as the ECG
wave form generated by their compressions. Encourage them to keep the ETCO2
number up as high as possible.
“Reductions in ETCO2 during CPR are associated with comparable reductions in cardiac
output….The extent to which resuscitation maneuvers, especially precordial
compression, maintain cardiac output may be more readily assessed by measurements
of ETCO2 than palpation of arterial pulses.” -Max Weil, M.D., Cardiac Output and End-
Tidal carbon dioxide, Critical Care Medicine, November 1985
Note: Patients with extended down times may have ETCO2 readings so low that quality
of compressions will show little difference in the number.
ETCO2 can be the first sign of return of spontaneous circulation (ROSC). During a
cardiac arrest, if you see the CO2 number shoot up, stop CPR and check for pulses.
End-tidal CO2 will often overshoot baseline values when circulation is restored due to
carbon dioxide washout from the tissues.
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A recent study found the ETCO2 shot up on average 13.5 mmHg with sudden ROSC before
settling into a normal range
In a resuscitated patient, if you see the stabilized ETCO2 number significantly drop in a
person with ROSC, immediately check pulses. You may have to restart CPR.
End tidal CO2 monitoring can confirm the futility of resuscitation as well as forecast the
likelihood of resuscitation.
“An end-tidal carbon dioxide level of 10 mmHg or less measured 20 minutes after the
initiation of advanced cardiac life support accurately predicts death in patients with cardiac
arrest associated with electrical activity but no pulse. Cardiopulmonary resuscitation may
reasonably be terminated in such patients.” -Levine R, End-tidal Carbon Dioxide and
Outcome of Out-of-Hospital Cardiac Arrest, New England Journal of Medicine, July 1997
Likewise, case studies have shown that patients with a high initial end tidal CO2 reading
were more likely to be resuscitated than those who didn’t. The greater the initial value, the
likelier the chance of a successful resuscitation.
“No patient who had an end-tidal carbon dioxide of level of less than 10 mm Hg survived.
Conversely, in all 35 patients in whom spontaneous circulation was restored, end-tidal
carbon dioxide rose to at least 18 mm Hg before the clinically detectable return of vital
signs….The difference between survivors and nonsurvivors in 20 minute end-tidal carbon
dioxide levels is dramatic and obvious.” – ibid.
“An ETCO2 value of 16 torr or less successfully discriminated between the survivors and
the nonsurvivors in our study because no patient survived with an ETCO2 less than 16 torr.
Our logistic regression model further showed that for every increase of 1 torr in ETCO2,
the odds of surviving increased by 16%.” –Salen, Can Cardiac Sonography and
Capnography Be Used Independently and in Combination to Predict Resuscitation
Outcomes?, Academic Emergency Medicine, June 2001
Caution: While a low initial ETCO2 makes resuscitation less likely than a higher initial
ETCO2, patients have been successfully resuscitated with an initial ETCO2 >10 mmHg.
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Capnography can also be utilized to differentiate the nature of the cardiac arrest.
A 2003 study found that patients suffering from asphyxic arrest as opposed to primary
cardiac arrest had significantly increased initial ETCO2 reading that came down within a
minute. These high initial readings, caused by the buildup of carbon dioxide in the lungs
while the nonbreathing/nonventilating patient’s heart continued pump carbon dioxide to
the lungs before the heart bradyed down to asystole, should come down within a minute.
The ETCO2 values of asphyxic arrest patients then become prognostic of ROSC
“End-tidal carbon dioxide monitoring of patients undergoing PSA detected many clinically
significant acute respiratory events before standard ED monitoring practice did so. The
majority of acute respiratory events noted in this trial occurred before changes in SP02 or
observed hypoventilation and apnea.” – -Burton, Does End-Tidal Carbon Dioxide
Monitoring Detect Respiratory Events Prior to Current Sedation Monitoring Practices,
Academic Emergency Medicine, May 2006
Capnography is also essential in sedated, intubated patients. A small notch in the wave
form indicates the patient is beginning to arouse from sedation, starting to breathe on
their own, and will need additional medication to prevent them from “bucking” the tube.
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Hypoxic Drive
Capnography will show the hypoxic drive in COPD “retainers.” ETCO2 readings will steadily
rise, alerting you to cut back on the oxygen before the patient becomes obtunded. Since it
has been estimated that only 5% of COPDers have a hypoxic drive, monitoring capnography
will also allow you to maintain sufficient oxygen levels in the majority of tachypneic COPDers
without worry that they will hypoventilate.
It has been suggested that in wheezing patients with CHF (because the alveoli are still, for
the most part, emptying equally), the wave form should be upright. This can help assist your
clinical judgement when attempting to differentiate between obstructive airway wheezing
such as COPD and the “cardiac asthma” of CHF.
Capnography can help paramedics avoid hyperventilation in intubated head injured patients.
In a study of 291 intubated head injured patients, 144 had ETCO2 monitoring. Patients with
ETCO2 monitoring had lower incidence of inadvertant severe hyperventilation (5.6%) than
those without ETCO2 monitoring (13.4%). Patients in both groups with severe
hyperventilation had significantly higher mortality (56%) than those without (30%). –Davis,
The Use of Quantitative End-Tidal Capnometry to Avoid Inadvertant Severe Hyperventilation
in Patients with Head Injury After Paramedic Rapid Sequence Intubation, Journal of Trauma,
April 2004
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End tidal CO2 monitoring can provide an early warning sign of shock. A patient with a
sudden drop in cardiac output will show a drop in ETCO2 numbers that may be regardless
of any change in breathing. This has implications for trauma patients, cardiac patients –
any patient at risk for shock.
9. Other Issues
DKA – Patients with DKA hyperventilate to lessen their acidosis. The hyperventilation
causes their PAC02 to go down.
“End-tidal C02 is linearly related to HC03 and is significantly lower in children with DKA. If
confirmed by larger trials, cut-points of 29 torr and 36 torr, in conjunction with clinical
assessment, may help discriminate between patients with and without DKA, respectively.”
–Fearon, End-tidal carbon dioxide predicts the presence and severity of acidosis in
children with diabetes, Academic Emergency Medicine, December 2002
Pulmonary Embolus – Pulmonary embolus will cause an increase in the dead space in the
lungs decreasing the alveoli available to offload carbon dioxide. The ETCO2 will go down.
Trauma – A 2004 study of blunt trauma patients requiring RSI showed that only 5 percent
of patients with ETCO2 below 26.25 mm Hg after 20 minutes survived to discharge. The
median ETCO2 for survivors was 30.75. - Deakin CD, Sado DM, Coats TJ, Davies G.
“Prehospital end-tidal carbon dioxide concentration and outcome in major trauma.”
Journal of Trauma. 2004;57:65-68.
Field Disaster Triage – It has been suggested that capnography is an excellent triage tool
to assess respiratory status in patients in mass casualty chemical incidents, such as those
that might be caused by terrorism.
“Capnography…can serve as an effective, rapid assessment and triage tool for critically
injured patients and victims of chemical exposure. It provides the ABCs in less than 15
seconds and identifies the common complications of chemical terrorism. EMS systems
should consider adding capnography to their triage and patient assessment toolbox and
emphasize its use during educational programs and MCI drills.”- Krauss, Heightman, 15
Second Triage Tool, JEMS, September 2006
Anxiety- ETCO2 is being used on an ambulatory basis to teach patients with anxiety
disorders as well as asthmatics how to better control their breathing. Try (it may not
always be possible) to get your anxious patient to focus on the monitor, telling them that
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as they slow their breathing, their ETCO2 number will rise, their respiratory rate number will fall
and they will feel better.
Anaphylaxis- Some patients who suffer anaphylactic reactions to food they have ingested (nuts,
seafood, etc.) may experience a second attack after initial treatment because the allergens
remain in their stomach. Monitoring ETCO2 may provide early warning to a reoccurrence. The
wave form may start to slope before wheezing is noticed.
Accurate Respiratory Rate – Studies have shown that many medical professionals do a poor job
of recording a patient’s respiratory rate. Capnography not only provides an accurate respiratory
rate, it provides an accurate trend or respirations.
Capnography should be the prehospital standard of care for confirmation and continuous
monitoring of intubation, as well as for monitoring ventilation in sedated patients. Additionally,
it should see increasing use in the monitoring of unstable patients of many etiologies. As more
research is done, the role of capnography in prehospital medicine will continue to grow and
evolve.
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Segment II (B to C) of the wave represents exhalation upstroke where dead space gas
mixes with alveolar gas.
Segment III (C to D) of the wave represents a continuance of exhalation and is also called
the plateau.
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The height of the wave should be compared to the scale on the page/screen to determine
ETCO2 levels.
• The number of wave forms per minute can be counted to get an accurate respiratory rate.
• The waves should be analyzed to see if there is any difference from the expected squared-
off wave form.
• Changes in the height of the waves during monitoring should also be evaluated.
Nasal Cannula
Has an oxygen reservoir bag attached to the mask with a one-way valve between them that
prevents the patient’s exhaled air from mixing with the oxygen in the reservoir bag. Oxygen
requirement = 15 LPM.
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Has an oxygen reservoir bag attached to the mask with a one-way valve between them
that prevents the patient’s exhaled air from mixing with the oxygen in the reservoir bag.
Oxygen requirement = 8 LPM.
Similar to a nonrebreather mask but is equipped with a two-way valve that allows the
patient to rebreathe about 1/3 of their exhaled air. Can provide an oxygen concentration
of about 35% to 60%.
Venturi Mask
A low flow oxygen system that provides precise concentrations of oxygen through an
entertainment valve connected to the face mask.
Mouth-to-Mask 10 50%
reservoir
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Oxygen Cylinders
Safety Precautions
Oxygen is a gas that acts as an accelerant for combustion, and oxygen cylinders are under
high pressure.
Never allow combustible materials, such as oil and grease, touch the cylinder, regulator
fittings, valves or hoses.
Never smoke or allow others to smoke in any area where oxygen cylinders are in use or on
standby.
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1 120ml
2 156ml
3-4 170ml
5-6 200ml
7-10 270ml
11-12 380ml
13-14 420ml
15 as adult
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• When you are working with oxygen cylinders, never put any body parts over
the cylinder valve.
Pressure Regulators
Pressure regulators are devices that control gas flow and reduce the high pressure in the
cylinder to a safe range (from 2000psi to around 50psi), and controls the flow of oxygen
from 1-15 liters per minute.
High-pressure regulator
This type of regulator has one gauge that registers the content of the cylinder and that,
through a step-down regulator, can provide 50psi to power a flow restricted oxygen
powered automatic transport ventilator (ATV).
Therapy regulator
This type of regulator has two gauges, one indicating the pressure in the tank and a
flowmeter indicating the measured flow of oxygen being delivered to the patient (0-15
LPM).
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(http://www.jems.com/news_and_articles/columns/Bledsoe/the_oxygen_myth.html)
In EMS, we’ve always emphasized two things: airway and oxygenation. In reality, we should
be emphasizing ventilation. Without an airway, your patient cannot ventilate. Without
ventilation, you cannot assess the airway. They’re inseparably linked.
Likewise, without ventilation, oxygenation is impossible. But ventilation involves much more
than oxygenation. It involves the elimination of carbon dioxide and toxins and plays a role in
other important biological processes.
We’ve always taught that a little oxygen is good and a lot of oxygen is better. We adopted
pulse oximeters and really only use them to document oxygen saturations -- especially low
thresholds. The closer to 100%, the better -- or so we thought. But is doing this in the best
interest of the patients?
Several years ago we saw a change in practice in the neonatology community to limit
supplemental oxygenation given to newborns and neonates. We had always known that
high-concentration oxygen was associated with the development of retinopathy of
prematurity (ROP), formerly called retrolental fibroplasia, in premature infants. Later,
clinicians found that neonates resuscitated with high-concentration oxygen had worse
outcomes than those resuscitated with room air. For example, infants resuscitated with 100%
oxygen have a greater delay to first cry and a greater delay to first respiration.(1) In one
study of depressed infants, mortality was 13% for those resuscitated with 100% oxygen and
only 8% for those resuscitated with room air.(2) Further, neonates resuscitated with room air
had a lower mortality at one week compared to those resuscitated with 100% oxygen.(3) The
American Heart Association now recommends starting with room air and increasing oxygen
concentration as needed to maintain an adequate oxygen saturation.(4)
Next, the phenomenon of reperfusion injury was noted. Reperfusion injury occurs when
oxygen is reintroduced to ischemic tissues. Stated another way, the injury does not occur
during periods of hypoxia. It occurs after oxygen is restored to the affected tissues.
The primary mechanism is thought to be the development of toxic chemicals called “reactive
oxygen species” or “free radicals.” These chemicals have an unpaired electron in their outer
shell and are very unstable. They occur normally, to a limited degree, but the body has
enzyme systems that process the free radicals into less toxic substances, thus avoiding
significant cellular damage. But following a period of hypoxia, a large number of free radicals
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are produced that overwhelm the protective enzyme systems (antioxidants) and cellular
damage occurs. This damage is called “oxidative stress . “
The effects of aging are often due to oxidative stress. Also, some diseases such as
atherosclerosis, Alzheimer’s disease, Parkinson’s disease, and others have been linked to
oxidative stress and free radical induction. Thus, the evolving thought is that, in some
conditions, high concentrations of oxygen can be harmful.
So, what does this mean to the future evolution of EMS practice? Well, there are several
disease processes we must consider.
Stroke: The brain is very vulnerable to the effects of oxidative stress. The brain has fewer
antioxidants than other tissues. Thus, should we give oxygen to non-hypoxic stroke patients?
Studies have shown that patients with mild-moderate strokes have improved mortality when
they receive room air instead of high-concentration oxygen.
The data on patients with severe strokes is less clear.(5) Current research indicates that
supplemental oxygen should not be routinely given to patients with stroke and can, in some
cases, be detrimental.(6)
Acute Coronary Syndrome: The myocardium is highly oxygen dependent and vulnerable to
the effects of oxidative stress. Thus far, there’s no evidence that giving supplemental oxygen
to acute coronary syndrome patients is helpful, but there’s no evidence it’s harmful.(7)
Post-Cardiac Arrest: Here, too, the evidence is too scant to tell. We do know that virtually all
current therapies for cardiac arrest (drugs, airway) are of little, if any, benefit. The primary
therapies remain CPR (often with limited ventilation initially) and defibrillation followed by
induced hypothermia. The whole purpose of induced hypothermia is to prevent the
detrimental effects of oxidative stress and the other harmful effects of reperfusion injury.
Trauma: What role should oxygen play in non-hypoxic trauma patients? Little research exists,
but an interesting study out of New Orleans demonstrated that there was no survival benefit
to the use of supplemental oxygen in the prehospital setting in traumatized patients who do
not require mechanical ventilation or airway protection.(8)
Carbon Monoxide (CO) Poisoning: We have learned a lot about carbon monoxide poisoning
in the past few years. We know that the mechanism of CO poisoning is a lot more complex
than once thought. We also know that there’s no reliable evidence that hyperbaric oxygen
(HBO) therapy improves outcome (although it’s still widely used).(9) But when you think
about it, the goal of treatment in CO poisoning is to eliminate CO through ventilation -- not
hyperoxygenation. Although oxygen can displace some CO from hemoglobin, the induction
of free-radicals may be worse than the effects of CO. Again, the science here is in a state of
flux.
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Again, this is a discussion of the changing science. Always continue to follow the direction of
your medical director and local protocols. That said, it’s clear that we need to use every tool
possible to support, but not replace, our physical exam skills. We should use pulse oximetry
and waveform capnography. Although, individually, each technology has its limitations,
together they provide important information about the patient.
The goal of therapy is to avoid hypoxia and hyperoxia. If the patient’s oxygen saturation and
ventilation are adequate, supplemental oxygen is probably not required. If the patient is
hypoxic or hypercapnic, then you must determine whether the problem can be remedied
through increased ventilation, increased oxygenation, or both. Thus, you have to assess the
problem, recognize and understand the pathophysiological processes involved, plan an
appropriate therapy (within the scope of your protocols), and provide the needed therapy.
That is what prehospital care is all about.
References
1. Martin RJ, Bookatz GB, Gelfand SL, et al: “Consequences of neonatal resuscitation with
supplemental oxygen.” Semin Perinatol. 32:355-366, 2008.
2. Davis PG, Tan A, O’Donnell CP, et al: “Resuscitation of newborn infants with 100% oxygen
or air: A systematic review and meta-analysis.” Lancet. 364:1329-1333, 2004.
3. Rabi Y, Rabi D, Yee W: “Room air resuscitation of the depressed newborn: A systematic
review and meta-analysis.” Resuscitation. 72:353-363, 2007.
5. Ronning OM, Guldvog B: “Should stroke victims routinely receive supplemental oxygen? A
quasi-randomized controlled trial.” Stroke. 30:2033-2037, 1999.
6. Pancioli AM, Bullard MJ, Grulee ME, et al: “Supplemental oxygen use in ischemic stroke
patients: Does utilization correspond to need for oxygen therapy.” Archives of Internal
Medicine. 162:49-52, 2002.
8. Stockinger ZT, McSwain NE: “Prehospital supplemental oxygen in trauma patients: Its
efficacy and implications for military medical care.” Military Medicine. 169:609-612, 2004.
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Chapter 12: The Basic ECG
Chapter 12:
The Basic ECG
Outline
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Chapter 12: The Basic ECG
A heartbeat is a complex series of events that take place in the heart. A heartbeat is a single
cycle in which the heart’s chambers relax and contract to pump blood. This cycle includes
the opening and closing of the inlet and outlet valves of the right and left ventricles of the
heart.
Each heartbeat has two basic parts: diastole and atrial and ventricular systole. During
diastole, the atria and ventricles of the heart relax and begin to fill with blood.
At the end of diastole, the heart’s atria contract (atrial systole) and pump blood into the
ventricles. The atria then begin to relax. The heart’s ventricles then contract (ventricular
systole) pumping blood out of the heart.
Each beat of the heart is set in motion by an electrical signal from within the heart muscle. In
a normal, healthy heart, each beat begins with a signal from the SA node. This is why the SA
node is sometimes called the heart’s natural pacemaker. The pulse, or heart rate, is the
number of signals the SA node produces per minute. The signal is generated as the two vena
cavae fill the heart’s right atrium with blood from other parts of the body. The signal spreads
across the cells of the heart’s right and left atria. This signal causes the atria to contract. This
action pushes blood through the open valves from the atria into both ventricles.
The signal arrives at the AV node near the ventricles. It slows for an instant to allow the
heart’s right and left ventricles to fill with blood. The signal is released and moves along a
pathway called the bundle of His, which is located in the walls of the heart’s ventricles.
From the bundle of His, the signal fibers divide into left and right bundle branches through
the Purkinje fibers that connect directly to the cells in the walls of the heart’s left and right
ventricles. The signal spreads across the cells of the ventricle walls, and both ventricles
contract. However, this doesn’t happen at exactly the same moment. The left ventricle
contracts an instant before the right ventricle. This pushes blood through the pulmonary
valve (for the right ventricle) to the lungs, and through the aortic valve (for the left ventricle)
to the rest of the body.
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As the signal passes, the walls of the ventricles relax and await the next signal. This process
continues over and over as the atria refill with blood and other electrical signals come from
the SA node.
The Electrocardiogram
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• Consistent P waves
• Consistent P-R interval
• 60–100 beats/min
Sinus Bradycardia
• Consistent P waves
• Consistent P-R interval
• Less than 60 beats/min
Sinus Tachycardia
• Consistent P waves
• Consistent P-R interval
• More than 100 beats/min
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Ventricular Tachycardia
Ventricular Fibrillation
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Asystole
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Chapter 13: The Automated External Defibrillator
Chapter 13:
The Automated External
Defibrillator
Outline
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Chapter 13: The Automated External Defibrillator
The Chain of Survival was developed by the American Heart Association in 1990 in
recognition of the fact that the vast majority of sudden cardiac arrests (SCA) occur outside of
hospitals, and that failure to defibrillate early results in a high rate of failure to resuscitate
patients. In response to the development of the chain of survival, public awareness of the
importance of its components has increased, particularly in western countries, where AEDs
are often located readily in public places. To provide the best opportunity for survival, each
of these four links must be put into motion within the first few minutes of SCA onset:
Early Access to Emergency Care must be provided by calling 911 (US) or a
universal access number.
Early CPR should be started and maintained until emergency medical services
(EMS) arrive.
Early Defibrillation is the only one that can re-start the heart function of a
person with ventricular fibrillation (VF). If an automated external defibrillator
(AED) is available, a trained operator should administer defibrillation as quickly
as possible until EMS personnel arrive.
Early Advanced Care, the final link, can then be administered as needed by
EMS personnel.
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0%
No care after collapse
20%
CPR and defibrillation within 8 minutes
In certain environments, where the Chain is strong and when defibrillation occurs within the
first few minutes of cardiac arrest, survival rates can approach 80% to 100%.
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Defibrillation does not „jump start‟ the heart. The purpose of the shock is to produce
temporary aystole. The shock attempts to completely depolarize the myocardium and
provide an opportunity for the natural pacemaker centers of the heart to resume normal
activity.
Defibrillation is the single most important factor in determining the survival from cardiac
arrest.
The most common initial rhythm in witnessed sudden cardiac arrest is ventricular
fibrillation.
The most effective treatment for ventricular fibrillation is electrical defibrillation.
The probability of successful defibrillation diminishes rapidly over time.
VF tends to convert to asystole within a few minutes.
Types of Defibrillators
Manual defibrillators
Automated internal defibrillators
Automated external defibrillators
fully automated
semi-automated
Shockable Rhythms
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Non-Shockable Rhythms
Asystole
Pulseless Electrical Activity (PEA) - (any heart rhythm observed on the ECG that
should be producing a pulse, but is not)
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Medical Direction
The earliest defibrillators were monophasic, which means that they passed an electrical
current in just one direction to try to reset the heart. Biphasic defibrillators use an
electrical current that flows in two directions to shock the heart. The advantage of using
biphasic defibrillators is that less electrical current is needed to successfully shock the
heart, which makes these devices more effective to restore the heart‟s regular rhythm
more quickly.
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Step 1
Assess responsiveness.
Stop CPR if in progress.
Check breathing and pulse.
If patient is unresponsive and not breathing adequately, give two slow
ventilations.
Step 2
If there is a delay in obtaining an AED, have your partner start or resume CPR.
If an AED is close at hand, prepare the AED pads.
Turn on the machine.
Step 3
Remove clothing from the patient‟s chest area. Apply pads to the chest.
Stop CPR.
State aloud, “Clear the patient.”
Step 4
Step 5
After the shock is delivered, immediately resume CPR. Perform 5 cycles of CPR.
Reanalyze the rhythm.
If the machine advises a shock, deliver a shock then perform 5 cycles of CPR.
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Step 6
Step 7
If the patient is not breathing adequately, use necessary airway adjuncts and proper
positioning to open airway.
Provide artificial ventilations with high concentration oxygen.
Transport.
Step 8
Check pulse.
No pulse, no shock advised
No pulse, shock advised
If a patient is breathing independently:
Administer oxygen if needed.
Check pulse.
If a patient has a pulse, but breathing is inadequate, assist ventilations.
Transport
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Appendix 1
Appendix 1:
Updated 2010 European
Resuscitation Council
Guidelines
Changes in basic life support (BLS) since the 2005 guidelines include:
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Appendix 1
Electrical therapies
The most important changes in the 2010 ERC Guidelines for electrical therapies include:
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