LSTI EMT-B Manual

Emergency Medical
Technician – Basic
Course Manual
Life Support Training International
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Emergency Medical Technician - Basic (EMT-B) Course Manual
This work is protected by copyright in The Philippines and internationally. No part of
this course may be reproduced without the written permission of Life Support Training
International (LSTI). All rights reserved.
This first edition produced 2010.
Edited by Craig Barrett, BA, PG Dip Ed, EMT-B

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Editor’s Note
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
you current with worldwide standards.
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
the beginning of a career you will be passionate about.
Craig Barrett, EMT-B
LSTI-Batch 67
Quezon City 2010

Contents
Chapter Page
1 EMS In The Philippines 1

2 Roles and Responsibilities of the EMT 10
3 Medico-Legal and Ethical Issues in EMS 20
4 Ambulance Vehicles and Equipment 28
5 Medical Terminology in EMS 37
6 Infection Control and the EMT 48
7 Anatomy for EMTs 57
8 Health, Hygiene, Fitness and Safety of the EMT 71
9 Patient Assessment 75
10 Communication and Documentation 110
11 Airway Management 123
12 The Basic ECG 155
13 The Automated External Defibrillator 164
Appendices
Appendix 1 ERC Guidelines (2010)

Chapter 1: EMS In The Philippines
Chapter 1:
EMS In The Philippines
Outline
 Life Support Training International

 Philippine Society of Emergency Medical Technicians
 PSEMT Affiliations
 PSEMT Membership Grades
 LSTI Academic Policies and Procedures
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 consultants have been involved in developing Emergency Medical Services

Systems (EMSS) in various parts of the world, ranging from the United Kingdom
to the Middle East, the Western Pacific Region and, indeed, here in The
Philippines. In the Philippines, we work closely with Emergency Medicine
Consultants from the University of the Philippines, Philippines General Hospital,
Department of Emergency Medicine. Life Support Training International is
heavily involved with the Philippine Heart Association, being active members of
both the Expanded Council on Resuscitation and the National Emergency
Medical Services Council. We are also the founding executive members of the
Philippine Society of Emergency Medical Technicians, which is a society
dedicated to developing a National Emergency Medical Services System
throughout The Philippines.
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
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.
Life Support Training International is currently The Philippines only fully

certified training and assessment center for the Philippine Society of
Emergency Medical Technicians and, internationally, the Australasian Registry
of Emergency Medical Technicians (AREMT) and the Technical Education and
Skills Development Authority (TESDA).
WHEN THEY DEPEND ON YOU
YOU CAN ALWAYS DEPEND ON US!
Philippine Society of Emergency Medical Technicians
The Philippine Society of Emergency Medical Technicians (PSEMT) is a non-

profit, non-political, non-union body which is dedicated to the cause of
pushing for the introduction of an effective National Ambulance System for all
citizens of The Philippines, irrespective of social status, cultural background,
religious beliefs or political affiliations.
The development of a first-class Emergency Medical Services System in The

Philippines is our prime objective, as this is absolutely essential in order to
form an integral link in the chain of delivering quality care to the ill and
injured. We must accept, however, that any chain is only as strong as its
weakest link, and with this in mind, the Philippine Society of Emergency
Medical Technicians has recognized that excellence can only be achieved
through education, training and maintenance of the highest standards. Our
National Training, Research and Development Council, has developed
comprehensive training guidelines which clearly outline the standards required
of all those seeking the implementation of truly professional standards of Pre-
Hospital Emergency Medical Care, and these standards will be required of
anyone seeking membership of the Society.
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It is clearly recognized that any Pre-Hospital Care System involving EMTs

requires the support and clinical supervision of physicians. The Society has
established a National Executive Council composed of some of the foremost
physicians and experts in the field of Pre-Hospital Emergency Care. This
council will formulate the legal framework for pre-hospital care professionals
to carry out their vital role. As outline above, the Society has established a
National Training, Research and Development Council, which is tasked with,
not only setting the Society’s Training Standards, but also establishing a
National Examination System to ensure that these standards are achieved and
maintained. This council has also been tasked to carry out continuing research
and development in the field of Pre-Hospital Emergency Care to ensure that
members are keep abreast of advances in equipment and techniques.
We are pleased to announce that, due to our adherence to the highest of

international standards and practice, the Philippine Society of Emergency
Medical Technicians was, in March 2007, awarded direct and complete
reciprocity with the Australasian Registry of Emergency Medical Technicians
(AREMT). The AREMT is an Australian-based pre-hospital professional body,
which bases its standards on both the US Department of Transport and
European models of pre-hospital care. Due to this recognition, the Filipino
EMT is justifiably and proudly acknowledged as a world-standard professional.
PSEMT Affiliations
American College of Emergency Physicians
Page 3
Emergency Care and Safety

Institute
Australasian Registry of
Emergency Medical Technicians
International Liaison Committee

on Resuscitation
Philippine Heart Association
Page 4
PSEMT Membership Grades
The following are the grades of membership for the PSEMT:
 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.
Basic Emergency Medical Technician - EMT (B) “Certification”
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:
 Completion of a PSEMT/PBEMT approved 280 hour training course and the

achievement of the required pass mark in all sections of the National Final
Examination.
 Proof of a minimum of 250 hands-on patient management in the preceding
twelve months. This must be confirmed by the applicant’s Officer-In-Charge
and duly approved by the Society’s National Executive Committee.
 Completion of a minimum of 40 hours continuous medical education.
 Submission of a personal log of experience gained.
 Successful completion of National Examinations.
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The minimum age shall be 20 years.
Emergency Medical Technician, Defibrillator - EMT (D) “Certification”
All applicants must be a certified Emergency Medical Technician (EMT) with a

minimum of three (3) months full-time post-EMT (B) certification experience,
which must include emergency response duties. They must have successfully
completed the prescribed defibrillation module, and examinations thereof,
which will include all the content as outlined in the Society’s National Syllabus.
Re-registration will be required on an annual basis and all applications thereof

must be accompanied by a competency certificate duly countersigned by an
Emergency Medical Practitioner who has been approved by PSEMT/PBEMT.
Emergency Medical Technician Advanced - EMT (A) “Registration”
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.

Registered Emergency Medical Technician Paramedic - EMT (P)

“Registration”
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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Registered Emergency Medical Services Instructor - REMSI
This level has yet to be defined.
Exemptions
Exemptions from some requirements may be considered based on

alternative qualifications and experience. Requests for exemption will be
reviewed by the PSEMT National Training, Research and Development
Council and the PBEMT. Their decision will be considered final.
LSTI Academic Policies and Procedures
Course Performance Rating
Students’ overall performances are evaluated via the following:
 Weekly Examinations 10%

 Attendance and Timekeeping 10%
 Final Written Examination 45%
 Final Practical Examination 35%
Passing grade is set at 75% in all written and practical examinations. In

accordance with the Philippine Heart Association (PHA), a minimum passing
grade of 80% is required for the Basic Life Support (BLS) written examination.
BLS certification is a mandatory requirement for the issuance of EMT
certification.
Payment of Tuition Fees
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.
Page 7
Reservation fee - PHP5000 (Non-refundable)
Weekly payment - PHP3000 (Week 2-6 inclusive)
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
Every Monday morning, starting week 2, an assessment/examination shall be

conducted to gauge the student’s performance and knowledge. All policies
regarding examinations, payment of fees etc. are applicable.
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:
Any cheating, or perceived attempt to cheat, in the Final Examinations will

be subject to immediate disqualification, and those involved will forfeit
any chance to re-sit the exam.
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
In the case of failures, re-sit/re-examination shall be done at a time and date

designated by the PSEMT/AREMT. All students are obliged to follow the
scheduled examination date.
Page 8
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.
In accordance with PSEMT/AREMT policies, repetition of the EMT-Basic Course

is also not permitted.
Smoking is strictly
prohibited in and
around the
training facility at
all times.
Please put all your litter in the

numerous garbage receptacles
provided around the training
facility for student use.
Page 9
Chapter 2: Roles and Responsibilities of the EMT
C h a p te r 2 :
Roles and
Responsibilities of the
E MT
Outline
 The Star of Life

 The Emergency Medical Services System
 Components of the Emergency Medical Services System
 Roles and Responsibilities of the EMT
 Professional Attributes
The Star of Life
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
The symbol’s six-barred cross represents the six-system function of

Emergency Medical Services. The staff in the center of the symbol
represents medicine and healing. According to Greek mythology, the staff
belonged to Asclepius, the son of Apollo (god of light, truth and
prophesy), who learned the art of healing.
The Emergency Medical Services S
Regulation and Policy
Laws that allow the system to exist.
Resource Management
Centralized coordination of resources (i.e. hospitals) to have equal access to basic

emergency care and transport by certified personnel in a licenced and equipped
ambulance, to an appropriate facility.
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Sample Manual Template
Human Resources and Training
All personnel who ride ambulances should be trained at the minimum level
using a standardized curriculum.
Transportation
Safe, reliable ambulance transportation is a critical component.
Communications
There must be an effective ccommunications system, beginning with a

universal access number
Public Information and Education
Efforts to educate the public about their role in the EMS system and
prevention of injuries.
Medical Direction
Involvement of EMS physicians in all aspects of pre-hospital emergency

medical care practice.
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
Program for improving the EMS system.
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Roles and Responsibilities of the EMT
 Personal Safety
An EMT is no good if he or she becomes another victim.
 Safety of the Crew, Patient and Bystanders
 Patient Assessment
Finding out what is wrong with your patient to be able to undertake

emergency medical care.
 Patient Care
Preparation for action or a series of actions to take that will help the
patient deal with and survive illness or injury.
 Lifting and Moving
Effective and safe application of patient handling procedures to avoid

self-inflicted and career-ending injuries.
 Transport
A serious responsibility in ambulance operations, even more so with a

patient on board.
 Patient Advocacy
Moral responsibility to speak on behalf of the patient’s need of attention

for a particular cause. Must develop a rapport that will give understanding
of the patient’s condition.
Professional Attributes of the EMT
Appearance
Excellent personal grooming and a neat clean appearance to instil confidence

in patients.
Page 13
Knowledge and Skills
A successful completion of EMT-B training and the knowledge to know:
 The use and the maintenance of common emergency

equipment.
 How and when to assist the administration of medications

approved by medical direction or protocol.
 How to clean, disinfect and sterilize non-disposable equipment.
 Personal safety and security measures, as well as for other

rescuers, the patient and bystanders.
 The territory and terrain within the service area.
 Traffic laws and ordinances concerning emergency

transportation of the sick and injured.
Physical Demands
Good physical health and good eyesight to properly assess the patient and drive
safely.
Temperament and Abilities
 A pleasant personality
 Leadership ability
 Good judgement
 Good moral character
 Stability and adaptability
Page 14
Components of Emergency Medical Services Systems – In Depth
The following 15 components have been identified as essential to an EMS system:
 Communication
 Training
 Manpower
 Mutual Aid
 Transportation
 Accessibility
 Facilities
 Critical Care Units
 Transfer of Care
 Consumer Participation
 Public Education
 Public Safety Agencies
 Standard Medical Records
 Independent Review and Evaluation
 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.
Page 15
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
A comprehensive communications plan is essential to provide the community access to

system dispatch and to provide the EMT access to medical direction and additional
resources. The establishment of a universal access number (911 in the US and Canada or
999 in the UK for example) has greatly improved the system’s accessibility. Additional
advancements have been made with enhanced systems, such as the enhanced 911
Page 16
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.
Ground vehicles provide most EMS transportation. Ambulances should be constructed

according to federal or national standards, and be appropriately equipped to provide
basic or advanced level of care. Air transport, such as a helicopter or airplane, may also be
either BLS or ALS. Air transport is used to transport patients over greater distances,
decrease total pre-hospital time or to reach patients in poorly accessible locations.
Operational standards are established to delineate the equipment needed, the number of
personnel and the level of certification required, as well as the response-time criteria and
the destination for each transport.
On-line medical direction should be obtained in all calls that result in transport. This
includes:
 Decision to transport;
 Patient refusal of care; and
 Triage to a lower level of care.
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.
Page 17
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.
Page 18
Continuous Quality Improvement
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.
Quality evaluation is prospective, concurrent and retrospective. Prospective evaluation

is most effective process to ensure quality in EMS, because it has the potential to
prevent mistakes. The system must be scrutinized constantly to determine areas
requiring refinement and improvement. When goals and standards are not met, CQI
staff members must identify the problem, establish and implement a corrective course
of action, and measure the outcome. Concurrent evaluation occurs on scene or on-
line. Staff members observe performance, encourage positive behavior and correct
problems before bad habits develop. Retrospective evaluation is the least valuable and
most time-consuming. It includes critique sessions and reviews of patient encounter
tapes and charts.
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.
Public support is invaluable in constructing a successful EMS system; involvement is

required to plan a system that works for everyone. Consumers need to be well
informed of the benefits of having an EMS system and how to gain access to it.
Page 19
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.
Patient Bill of Rights
 The patient has the right to considerate and respectful care.

 The patient has the right to refuse treatment to the extent permitted by law
and to be informed of the medical consequences of his or her action.
 The patient has the right to expect that all communications and records
pertaining to his or her care should be treated as confidential.
 The patient has the right to expect continuity of care.
Page 20
In the Philippines, the Patient Bill of Rights is known as Title 111: Declaration of Rights.
Good Samaritan Law
 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
The legal right to function as an EMT-B is contingent upon medical direction.

The EMT-B must:
 Follow standing orders and protocols

 Establish telephone and radio communications
 Communicate clearly and completely and follow orders given
in response
 Consult medical direction for any question about the scope
and direction of care
Duty to Act
The obligation to provide care. May be implied or formal.
IF ON-DUTY:
 legally obligated
IF OFF-DUTY:
 may stop and help; or

 may pass the scene and call for help; or
 may pass the scene and make no attempt to call for help.
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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.
Patient Consent and Refusal
Types of Consent
 Expressed consent
 Implied consent
 Consent to treat a minor or mentally incompetent adult
Advance Directives
 “Living Will”, DNR/DNAR

 Instructions written in advance documenting the wish of the chronically or
terminally ill patient not to be resuscitated and legally allows the EMT-B to
withhold resuscitation.
 Usually accompanied by a doctor’s written orders.
 Associated problems:
 More useful in an institutional setting.
 More than one physician may be required to verify the patient’s
condition.
 Scrutiny of an advance directive may be time consuming.
Page 22
Refusal of Treatment
Competency
A competent adult is defined as one who is lucid and capable of making

an informed decision.
Protecting yourself:
Do the following before you leave the scene:
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.
Other Legal Aspects
Abandonment and Negligence
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
In order to establish negligence, it must be proved that:
 The EMT-B had a duty to act;

 The patient was injured, either physically or psychologically;
 The EMT-B violated the standard of care expected.
 The EMT-B’s action or lack thereof caused or contributed to the
patient’s injury.
Page 23
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.
Releasing confidential information requires a written release form signed by the

patient or a legal guardian.
Instances when an EMT-B is allowed to release confidential information:
 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
Donors and Organ Harvesting
A legal signed document is required, such as a signed donor care sticker affixed to a
driver’s licence or an organ donor card.
To provide assistance in organ harvesting:
1. Identify the patient as a potential donor.

2. Communicate with medical direction regarding the possibility of organ
donation.
3. Provide emergency care that will maintain the vital organs.
Dying and Deceased Patients
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.
Page 24
Medical Identification Insignia
A patient with a serious medical condition may be wearing a medical identification

tag (bracelet, necklace or card).
Crime Scenes
General guidelines - a potential crime scene is any scene that may require police
support.
If you suspect a crime is in progress or a criminal is still active at a scene, do not

attempt to provide care to any patient. Try to avoid any item at the scene that may
be considered evidence.
Basic Guidelines for the EMT at a Crime Scene
 Touch only what you need to touch.
 Move only what you need to move.
 Do not use the phone unless authorised by the police.
 Observe and document anything unusual at the scene.
 If possible, do not cut through holes in the patient’s clothing.
 Do not cut through any knot in a rope or tie.
 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.
Page 25
The EMT Code of Ethics
Professional status as an Emergency Medical Technician and Emergency Medical

Technician-Paramedic is maintained and enriched by the willingness of the individual
practitioner to accept and fulfil obligations to society, other medical professionals, and
the profession of Emergency Medical Technician. As an Emergency Medical Technician-
Paramedic, I solemnly pledge myself to the following code of professional ethics:
A fundamental responsibility of the Emergency Medical Technician is to conserve life, to

alleviate suffering, to promote health, to do no harm, and to encourage the quality and
equal availability of emergency medical care.
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.
The Emergency Medical Technician shall maintain professional competence and

demonstrate concern for the competence of other members of the Emergency Medical
Services health care team.
An Emergency Medical Technician assumes responsibility in defining and upholding

standards of professional practice and education.
Page 26
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.
An Emergency Medical Technician has the responsibility to be aware of and participate

in matters of legislation affecting the Emergency Medical Service System.
The Emergency Medical Technician, or groups of Emergency Medical Technicians, who

advertise professional service, do so in conformity with the dignity of the profession.
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 Emergency Medical Technician refuses to participate in unethical procedures, and

assumes the responsibility to expose incompetence or unethical conduct of others to
the appropriate authority in a proper and professional manner.
The EMT Code of Ethics was written by Dr. Charles Gillespie and adopted by the
National Association of EMTs in 1978.
Page 27
Chapter 4: Ambulance Vehicles and Equipment
Chapter 4:
Ambulance Vehicles and
Equipment
Outline
 Introduction
 North American Ambulance Designs
 European Ambulance Designs
 Paramedic Fast Response Vehicles
 Helicopter Emergency Medical Services (HEMS)
 Standard Ambulance Equipment
 Daily Checks of Ambulance Equipment
 Cleanliness
 Phases of an Ambulance Call
 Emergency Driving
 Ambulance Hygiene
Page 28
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).
North American Ambulance Designs
Ambulance vehicle designations in the USA are governed by federal laws and
standards.
In America, an ambulance is defined as a vehicle used for emergency medical care

that provides:
 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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There are three basic ambulance specifications in North America:
 TYPE I AMBULANCE - a cab chassis furnished with a modular ambulance body.

 TYPE II AMBULANCE - a long wheelbase van, with integral cab-body.
 TYPE III AMBULANCE - a cutaway van with integrated modular ambulance body.
European Ambulance Designs
European ambulances are generally manufactured on an individual service
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.
Paramedic Fast Response Vehicles
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)
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
Page 30
run. Due to the high cost factor, HEMS units are usually run on a regional or national
basis as opposed to local operations.
Standard Ambulance Equipment
Monitoring Equipment:
BP Cuff / NIBP, Stethoscope, ECG Monitor Defibrillator, Vital Signs Monitor, Pulse
Oximeter, Thermometer.
Airway Equipment:
Oxygen Cylinder, Regulator, Flowmeter, Automated Transport Ventilator / Resuscitator,

Bag Valve Mask, Suction unit, Guedal Airways, Combitubes, Laryngeal Mask Airway,
Endotracheal Tubes.
Immobilisation / Splinting 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
Medical disposables according to checklist
Page 31
Daily Checks of Ambulance 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.
 Check communications equipment – vehicle radio and handheld radio
 Check tyres for pressure, wear and damage.
 Check brakes – both foot and handbrakes
 Check all windows and mirrors
 Check all door latches and handles
 Check all seatbelts / passenger restraints
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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Duties of Attendant
 Check equipment according to the checklist, making sure that all the equipment is
complete and in good working order.
 Check medical disposables according to checklist, noting expiry dates.
 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.
Phases of an Ambulance Call
1. Daily pre-run vehicle and equipment preparation
 Ambulance maintenance benefits:
• decreases vehicle downtime
Page 33
• improves response times to the scene
• safer emergency and non-emergency responses
• improves transport times to a medical facility
• safer patient transports to a medical facility
 Daily inspection of the vehicle
 Ambulance equipment
 Personnel
2. Dispatch
 Location of call.
 Nature of call.
 Name, location and callback number of the caller.
 Location of the patient.
 The number of patients and severity of the problem.
 Any other special problems or circumstances that may be pertinent.
3. En route to the scene.
4. At the scene.
5. En route to the receiving facility.
6. At the receiving facility.
7. En route to the station.
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8. Post run.
Emergency Driving
Emergency Driving Privileges
 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.
Warning and Emergency Lights
 Warning lights must be activated at all times when responding to an

emergency call.
 Lights should be used even when you are not using the siren.
 Ambulance emergency lights should be high enough to cast a beam above the
traffic.
Ambulance Hygiene
After every call
 Strip used linens from the stretcher and place them in a plastic bag or designated
receptacle.
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 In an appropriate receptacle, dispose of all disposable equipment used for

patient care.
 Disinfect all non-disposable equipment used for patient care.
 Clean the stretcher with germicidal solution.
 If there is any spoilage or contamination in the ambulance, clean it up.
 Air out the ambulance with all doors and windows open for 15 minutes.
At least once a day:
 Empty the ambulance of the stretcher and equipment boxes.
 Disinfect the oxygen humidifier and refill with clean water.
 Scrub all the interior surfaces with soap and water.
 Scrub again with germicidal solution, then air out again to let everything dry.
Page 36
Chapter 5: Medical Terminology in EMS
Chapter 5:
Medical Terminology in
EMS
Outline
 Words describing location

 Words describing position
 Medical terms by body systems
 Common medical abbreviations
Words Describing Location
Imaginary vertical line down the middle of the front

Midline surface of the body
Anterior Toward the front
Posterior Toward the back
Superior Above; toward the head
Inferior Below; toward the feet
Medial Nearer the midline of the body
Lateral Farther from the midline of the body
Proximal Nearer the point of attachment to the body

Farther from the point of attachment to the body
Distal (or the heart)
Internal Inside
External Outside
Page 37
Superficial Near the surface
Deep Remote from the surface
Words Describing Position
Erect Standing upright
Recumbent Lying down
Supine Lying face up
Prone Lying face down
Lateral Lying on the side
Page 38
Medical Terms By Body Systems
HEENT – Head, Ears, Eyes, Nose & Throat
Occipital - back of the head
Photophobia - intolerant of light
Phonophobia - intolerant of sounds
Diplopia - double vision
Epistasis - nosebleed
Rhinorrhea - runny nose or nasal discharge
Otorrhea - discharge from the ear
Tinnitus - ringing noise in the ear
NCAT - normocephalic, atraumatic
PERRL - Pupils Equal Round and Reactive to Light
Erythema - redness
Purulent - consisting of pus
Injected - blood vessel congestion, such as red eye
Page 39
Coronary & Pulmonary
Cor - Coronary (the heart)
Pulm - Pulmonary (respiratory system)
CTAB no rrw - Clear to auscultation bilaterally, no rales, ronchi or

wheezes
SOB - Shortness of Breath (dyspnea)
Productive cough - phlegm producing
Wheezing - high pitched sounds
Hemoptysis - coughing up blood
Pleuritic - worse with deep inspiration
Rales - crackles
Ronchi - wheezes/whistling sounds
Retractions - visible skin retractions with inspiration
Tachypnea - rapid breathing
Abdomen (Abd) or Gastrointestinal (GI)
Anorexia - loss or lack of appetite
Post-prandial - after eating
Emesis - vomiting
NBNB - non-bloody, non-bilious
Hematemesis - bloody emesis
Hematochezia - bloody stool
BRBPR - Bright Red Blood per Rectum
Melena - tarry black stool
Page 40
BS - bowel sounds (normoactive, hyperactive, hypoactive, absent)
TTP - tender to palpation, often more so in a single quadrant
Guarding - hard abdomen when palpated
Rebound - worse pain as examining hand is quickly pulled away
Genitourinary (GU)
Dysuria - painful urination
Hematuria - blood in the urine
Musculoskeletal & Extremities
MS - Musculoskeletal
Ext - Extremities
Myalgias - muscle aches
Arthralgias - joint aches
Edema - swelling
Skin
Pruritic - itchy
Macule - flat discoloration <10mm in diameter
Bumps:
Papule - bump 5mm or less
Nodule - well defined bump >5mm
Plaque - raised area
Sacs:
Vesicle - fluid filled sac <5mm
Bulla - fluid filled sac >5mm
Page 41
Pustule - sac filled with pus
Erythema - redness
Common Medical Abbreviations
AED Automated External Defibrillator
a.c. Before meals
ASA Aspirin
AMA Against medical advice
AMI Acute myocardial infarction
ASHD Arteriosclerotic heart disease
b.i.d. Twice a day
BP Blood pressure
BS Breath sounds, bowel sounds, or blood sugar
BVM Bag-valve-mask
c/o Complaining of
Ca Cancer/carcinoma
cc Cubic centimeter
CC Chief Complaint
CHF Congestive heart failure
CO Carbon monoxide
Page 42
COPD Chronic obstructive pulmonary disease (emphysema,
chronic bronchitis)
CPR Cardiopulmonary resuscitation
CSF Cerebrospinal fluid
CVA Cerebrovascular accident
CXR Chest X-ray
d/c Discontinue
DM Diabetes mellitus
DOA Dead on arrival
DOB Date of birth
Dx Diagnosis
ECG, EKG Electrocardiogram
e.g. For example
ETA Estimated time of arrival
ETOH Alcohol (ethanol)
Fx Fracture
GI Gastrointestinal
GSW Gun shot wound
gtt. Drop
Page 43
GU Genitourinary
GYN Gynecologic
h, hr. Hour
H/A Headache
HEENT Head, ears, eyes, nose, throat
Hg Mercury
h/o History of
hs At bedtime
HTN Hypertension
Hx History
ICP Intracranial pressure
ICU Intensive Care Unit
IM Intramuscular
IO Intraosseous
JVD Jugular venous distension
KVO Keep vein open
Page 44
L Left or Liter
LAC Laceration
LOC Level of consciousness
LR Lactated Ringers solution
mcg Micrograms
MS Morphine sulphate, multiple sclerosis
NAD No apparent distress
NC Nasal cannula
NKA No known allergies
npo Nothing by mouth
NRB Non-rebreather mask
NS Normal saline
NSR Normal sinus rhythm
NTG Nitroglycerin
N/V Nausea / vomiting
O2 Oxygen
OB Obstetrics
OD Overdose
OR Operating room
Page 45
PCN Penicillin
PEA Pulseless electrical activity
PERL Pupils equal and reactive to light
PID Pelvic inflammatory disease
PND Paroxysmal nocturnal dyspnea
po By mouth
PRN As needed
PSVT Paroxysmal supraventricular tachycardia
Pt Patient
PTA Prior to arrival
PVC Premature ventricular contraction
q.h. Every hour
q.i.d. Four times a day
R Right
r/o Rule out
Rx or Tx Treatment
SIDS Sudden Infant Death Syndrome
SOB Shortness of breath
Page 46
stat. immediately
SVT Supraventricular tachycardia
TIA Transient ischemic attack
t.i.d. Three times a day
TKO To keep open
V.S. Vital signs
x Times
w/o or s without
WNL Within normal limits
y/o or y.o. Years old
Symbols
Δ change
+ Positive
- Negative
Page 47
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
Procedures to reduce infection in patients and health care personnel.
Infection
The growth of an organism in a susceptible host with or without signs and

symptoms of illness.
Page 48
Communicable Disease
Any disease that can be spread from one person to another or to a person
from contaminated objects.
The Chain of Infection
1. Etiologic Agent/Causative Agent

2. Reservoir
3. Portal of exit from reservoir
4. Method of transmission
5. Portal of entry to the susceptible host
6. Susceptible host
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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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
Defenses against Infection
 Normal flora
 Body system defenses
 Inflammation
 Immune response (acquired immunity)
Diseases that pose a threat to Health Care Providers
 HIV
 Hepatitis B and C
 Tuberculosis
 Syphilis
 Meningitis
 Rabies (Philippines)
Page 50
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.
• Someone in the world is newly infected with TB bacilli every second.
• 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).
Page 51
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
Body Substances Isolation
Wear mask and protective eyewear in situations where droplets of body fluids may spray
onto mucus membranes.
Wear gloves when in contact with blood or bodily fluids.
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.
Use mouthpieces, resuscitation bags or ventilation equipment when providing resuscitation.
Do not provide direct patient care when you have open and oxidative skin lesions.
Exposure Control Plan
A comprehensive plan that helps employees reduce their risk of exposure or acquisition
of communicable diseases.
Page 52
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.
Body Fluids and the Risk of Hepatitis B/C or HIV
Primary Risk
Blood
Semen
Vaginal Secretions
Secondary Risk
Synovial Fluid
CSF Fluid
Amniotic Fluid
No Risk
Sweat
Tears
Saliva
Page 53
Feces
Vomitus
Nasal Secretions
Sputum
Reservoirs – Portals of Exit
Respiratory Tract
 nose, mouth, through sneezing, coughing, breathing, talking, ET tubes

and tracheostomies.
Gastro-Intestinal Tract
 mouth, saliva, vomitus, feces, anus, drainage tubes, ostomies
Urinary Tract
 urethral meatus, urine, urinary diversion, ostomies
Reproductive Tract
 vaginal discharges, vagine, semen, urine
Blood
 open wound, needle puncture site, any disruption of intact skin or

mucous membrane
Susceptible Defenses of a Susceptible Host
Hygiene
Good personal hygiene and maintaining the intactness of the skin and mucus
membrane retains a barrier against microorganisms entering the body.
Page 54
Immunization
The immunologic system is a major defense against infection.
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 fluid intake flushes the bladder and urethra
Rest and Sleep
Adequate rest and sleep are essential to health and preserving energy.
Stress
Predisposes people to infection.
Personnel Protective Equipment
 Vinyl latex gloves

 Heavy duty gloves for cleansing
 Protective eyewear
 Mask - including pocket mask for CPR
 Cover gown
 Ventilatory equipment
Handwashing
Purposes:
1. To reduce the number of microorganisms onto the hands.

2. To reduce the risk of transmission of infectious organisms to one’s self.
3. To reduce the risk of transmission of microorganisms and cross-contamination
to patients
Page 55
Recommended Use of Personal Protective Equipment by Situation
Task or Activity Disposable Gown Mask Protective

Gloves Eyewear
Bleeding control Yes Yes Yes Yes
with spurting
blood
Bleeding control Yes No No No
with minimal
blood
Emergency Yes Yes Yes, if splashing Yes, if splashing
childbirth is likely is likely
Blood drawing At certain times No No No
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
Page 56
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
Page 57
Anatomical Planes and Directions
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
 Gives form to the body

 Protects vital organs
 Consists of 206 bones
 Acts as a framework for attachment of muscles
 Designed to permit motion of the body
 The skeletal system can be divided into two parts: the axial skeleton and the
appendicular skeleton
The Spine
The spine supports the skull and gives attachment to the ribs. It is a column of 33 irregular
bones called vertebrae.
Discs of cartilage between the vertebrae:
 allow limited movement

 prevent friction
 act as shock absorbers.
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The Skeletal System
The Circulatory System
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 circulatory system consists of three parts:
 The heart
 Blood vessels
 Blood
These three parts are sometimes referred to as:
 Pump
 Pipes
 Fluid
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Normal Heart Rates
Adults 60 to 100 bpm
Children 70 to 150 bpm
Infants 100 to 160 bpm
Electrical Control Mechanism
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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Physiology of the Circulatory System
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
 Amount of force exerted against walls of arteries.

 Systole: Left ventricle contracts.
 Diastole: Left ventricle relaxes.
Perfusion
 Circulation of blood within an organ or tissue.

 If inadequate, the patient goes into shock.
Blood Vessels
There are five types of 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
Normal Breathing Rates
Adults 12 to 20 breaths/min
Children 15 to 30 breaths/min
Infants 25 to 50 breaths/min
Inspired Air
The air we breathe in contains approximately:
 79% nitrogen
 20% oxygen
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 0.04% carbon dioxide

 1% inert gases
 water vapour - variable
Expired Air
The air we breathe out contains approximately:
 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
 takes place in the tissues.
The Diaphragm
 Has characteristics of both voluntary and involuntary muscles

 Dome-shaped muscle
 Divides thorax from abdomen
 Contracts during inhalation
 Relaxes during exhalation
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
 Diaphragm and intercostal muscles relax.

 As the muscles relax, all dimensions of the thorax decrease.
 Pressure in the lungs increases.
 Air flows out of the lungs.
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Normal Breathing Characteristics
 Normal rate and depth

 Regular rhythm
 Good breath sounds in both lungs
 Regular rise and fall movements in the chest
 Easy, not labored
Infant and Child Anatomy
 Structures less rigid

 Airway smaller
 Tongue proportionally larger
 Dependent on diaphragm for breathing
The Nervous System
The nervous system controls the body’s voluntary and involuntary actions.
 Somatic nervous system - regulates voluntary actions

 Autonomic nervous system - controls involuntary body functions
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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
 motor centres control all the voluntary muscles.

 sensory centres receive sensory signals from the skin, muscles, bones and joints.
 control of the autonomic nervous system is buried deep in the cerebrum, in the
thalamus and hypothalamus
 regulates the central nervous system, and is pivotal in maintaining consciousness
and regulating the sleep cycle.
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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Divisions of the Nervous System
Central Nervous System
 Consists of the brain and the spinal cord
Peripheral Nervous System
 Links the organs of the body to the central nervous system.

 Sensory nerves carry information from the body to the central nervous system.
 Motor nerves carry information from the central nervous system to the muscles of
the body.
Nerves
There are four types of 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
 Gives the body shape

 Protects internal organs
 Provides for movement
 Consists of more than 600 muscles
Three Types of Muscles
1. Skeletal (voluntary) muscle

 Attached to the bones of the body.
2. Smooth (involuntary) muscle
 Carries out the automatic muscular functions of the body.
3. Cardiac muscle
 Involuntary muscle.
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 Has own blood supply and electrical system.

 Can tolerate interruptions of blood supply for only very short periods.
Body Cavities
The Abdomen
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Page 70
Chapter 8: Health, Hygiene, Fitness and Safety of the EMT
Chapter 8:
Health, Hygiene, Fitness
and Safety of the EMT
Outline
 Traits of a Good EMT

 Healthy Lifestyle of an EMT
 The Food Pyramid for Filipino Adults
 Body Mechanics
 Guidelines for Preventing Back Injuries
 EMS and Back Injuries
Traits of a Good EMT
 Neat and clean - to promote confidence in both patients and

bystanders and to reduce the possibility of contamination.
 Physically fit - should be in good health and fit to carry out duties.
 Emotionally and mentally fit - should be able to cope with stress at
work and able to overcome unpleasant aspects of any emergencies.
Healthy Lifestyle of an EMT
 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.
The Food Pyramid for Filipino Adults
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Body Mechanics
The efficient coordinated and safe use of the body to produce motion and maintain
balance during activity.
Proper movement promotes body musculoskeletal functioning, reduces the energy

required for a task, and maintains balance, thereby reducing fatigue and decreasing the
risk of injury.
Three Basic Elements of Body Mechanics
1. Body Alignment (Posture) - when the body is well-aligned, balance is achieved

without undue strain on the joints, muscles, tendons or ligaments. Proper body
alignment also enhances lung expansion and promotes efficient circulatory,
renal and gastrointestinal function.
2. Balance (Stability) - good body alignment is essential to body balance. A person
maintains balance as long as the line of gravity passes through the centre of
gravity and the base of support.
3. Coordinated Body Movement - body mechanics involves the integrated
functioning of the musculoskeletal and nervous system as well as joint mobility.
Guidelines for Preventing Back Injuries
1. Be consciously aware of your posture and body mechanics.

2. Minimize lumbar lordosis as much as possible:
 when standing for a period of time, periodically flex one hip
and knee and rest your foot on an object if possible.
 when sitting, keep your knees slightly higher than your hips.
 unless you have a pillow or other support beneath your
abdomen, avoid sleeping in the prone position.
3. Exercise regularly to maintain overall physical condition, including
exercises that strengthen the pelvic, abdominal and lumbar muscles.
4. Apply principles of body mechanics when moving objects:
 Spread your feet apart to provide a wide base of support.
 Place your feet appropriately in the direction in which the
movement will occur.
 Push, pull, roll or slide objects rather than lifting them
whenever possible.
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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.
EMS and Back Injuries
 “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
Purpose of Patient 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
 Review dispatch information

 Inspection of scene
 Scene hazards
 Safety concerns
 Mechanism of injury
 Nature of illness/chief complaint
 Number of patients
 Additional resources needed
Body Substances Isolation
 Assumes all body fluids present a possible risk for infection

 Protective equipment:
 Latex or vinyl gloves should always be worn
 Eye protection
 Mask
 Gown
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Scene Safety
 Park in a safe area.

 Speak with law enforcement first if present.
 The safety of you and your partner comes first!
 Next concern is the safety of patient(s) and bystanders.
 Request additional resources if needed to make scene safe.
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
 Determine the number of patients and their condition.

 Assess what additional resources will be needed.
 Triage to identify severity of each patient’s condition.
Additional Resources
Medical resources
 Additional units
 Advanced life support
Nonmedical resources
 Fire suppression
 Rescue
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 Law enforcement
Mechanism of Injury (MOI)
Helps determine the possible extent of injuries on trauma patients
Evaluate:
 Amount of force applied to body

 Length of time force was applied
 Area of the body involved
Nature of Illness (NOI)
Search for clues to determine the nature of illness.
Often described by the patient’s chief complaint
Gather information from the patient and people on scene.
Observe the scene.
The Importance of MOI/NOI
 Guides preparation for care of the patient

 Suggests equipment that will be needed
 Prepares for further assessment
 Fundamentals of assessment are the same whether the emergency appears to be
related to trauma or a medical cause.
Cervical-Spine Immobilization
 Consider early during assessment.

 Do not move without immobilization.
 Err on the side of caution
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Initial Assessment
1. Develop a general impression.

2. Assess mental status.
3. Assess airway.
4. Assess the adequacy of breathing.
5. Assess circulation.
6. Identify patient priority.
Forming a General Impression
 Occurs as you approach the scene and the patient

 Assessment of the environment
 Patient’s chief complaint
 Presenting signs and symptoms of patient
Assessing Mental Status/Level of Consciousness
A Alert - awake and oriented
V Verbal - responds to verbal stimuli
P Painful: responds to painful stimuli
U Unresponsive: does not respond to stimuli
Assessing the ABCs
A Airway
B Breathing
C Circulation
Airway
Look for signs of airway compromise:
 Two- to three-word dyspnea

 Use of accessory muscles
 Nasal flaring and use of accessory muscles in children
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 Labored breathing
Breathing
Look for:
 Choking
 Rate
 Depth
 Cyanosis
 Lung sounds
 Air movement
Circulation
Assessing the pulse:
 Presence
 Rate
 Rhythm
 Strength
Assessing and controlling external bleeding
 Assess after clearing the airway and stabilizing breathing

 Look for blood flow or blood on floor/clothes
 Controlling bleeding
 Direct pressure
 Elevation
 Pressure points
Assessing perfusion:
 Color
 Temperature
 Skin condition
 Capillary refill
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Baseline Vital Signs
Check:
 Breathing
 Pulse
 Skin
 Pupils
 Blood Pressure
 Pulse Oximetry
Respirations
Normal ranges for respiration:
Adult 12-20 breaths/min
Children 15-30 breaths/min
Infants 25-50 breaths/min
Breathing checklist:
Normal Shallow Laboured Noisy
Equal chest rise Shallow chest rise Increased breathing Snoring, wheezing,
effort. Use of gurgling and
accessory muscles; grunting noises
gasping, nasal flaring
Rhythm
 Regular
 Irregular
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Effort
 Effortless - Talks normally

 Difficulty breathing - Can only speak few words at a time
Depth
 Shallow
 Normal
 Deep
Pulse checklist:
Normal ranges for pulse rates:
Adult 60-100 60 – 100 beats/min
Children 80-120 80-120 beats/min
Toddlers 90-150 beats/min
Newborn 120-160 beats/min
Tachycardia >100 beats/min
Bradycardia <60 beats/min
Strength
 Weak
 Normal
 Strong
Quality
 Slow
 Normal
 Rapid
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Rhythm
 Regular
 Irregular
Skin
Color
Pale/grey/waxy Blue/grey Red/flushed
Fever, poisoning, sunburn,

Poor peripheral perfusion; Blood not properly
heatstroke, high blood
Abnormally cold/frozen saturated with oxygen
pressure
Temperature
Cold Cool Normal Hot
Early shock, mild

hypothermia, Hyperthermia, fever,
Shock, hypothermia
inadequate sunburn
perfusion
Moisture
Dry/Normal Moist Wet
Early Shock Shock
Capillary Refill in Children
CRT=2 secs Normal
CRT>2 secs Poor peripheral circulation
Blood Pressure
 Blood pressure is a vital sign.

 Pressure of circulating blood against the walls of the arteries.
 A drop in blood pressure may indicate:
 Loss of blood
 Loss of vascular tone
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 Cardiac pumping problem
 Blood pressure should be measured in all patients older than 3 years of age.
Normal ranges for blood pressure:
Adults 90 to 140 mmHg (s)
60 to 90 mmHg (d)
Children (1-8) 80 to 110 mmHg (s)
Infants (up to 1 yr) 50 to 90 mmHg (s)
The amount of pressure exerted against the walls

Systolic pressure
of the arteries when the left ventricle contracts.
The pressure exerted against the wall of the

Diastolic pressure
arteries when the left ventricle is at rest.
Pulse pressure Systolic pressure minus diastolic pressure.
BP by Auscultation BP by Palpation
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Level of Responsiveness
A Alert - awake and oriented
V Verbal - responds to verbal stimuli
P Painful: responds to painful stimuli
U Unresponsive: does not respond to stimuli
Pupil Response
P - Pupils
E - Equal
A - And
R - Round
R - Regular in size
L - React to Light
Abnormal pupil reaction
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Priority Patients
‘Stay and Play’ vs. ‘Scoop and Run’
 Difficulty breathing
 Poor general impression
 Unresponsive with no gag reflex
 Severe chest pain
 Signs of poor perfusion
 Complicated childbirth
 Uncontrolled bleeding
 Responsive but unable to follow commands
 Severe pain
 Inability to move any part of the body
Transport Decisions
 Patient condition
 Availability of advanced care
 Distance to transport
 Local protocols
Rapid Trauma Assessment
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
Stages of the Rapid Trauma Assessment
1. Maintain spinal immobilization while checking patient’s ABCs.
2. Inspect and palpate the head and face, including the ears, pupils, nose and mouth.
3. Assess the neck.
4. Apply a cervical spine immobilization collar.
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.
7. Assess the pelvis, checking for stability and crepitus.
8. Assess all four extremities, including pulses, motor function and sensation (PMS).
9. Roll the patient with spinal precautions.
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Focused Physical Exam
Used to evaluate patient’s chief complaint.
Performed on:
• Trauma patients without significant MOI
• Responsive medical patients
SAMPLE History
S Signs and Symptoms
A Allergies
M Medications Remember:
P Pertinent past history SAMPLE
L Last oral intake
E Events leading to injury or illness
Stages of the Focused Physical Exam
Head, Neck, and Cervical Spine
 Feel head and neck for deformity, tenderness, or crepitation.

 Check for bleeding.
 Ask about pain or tenderness.
Chest
 Watch chest rise and fall with breathing.

 Feel for grating bones as patient breathes.
 Listen to breath sounds.
Abdomen
 Look for obvious injury, bruises, or bleeding.

 Evaluate for tenderness and any bleeding.
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 Do not palpate too hard.
Pelvis
 Look for any signs of obvious injury, bleeding, or deformity.

 Press gently inward and downward on pelvic bones.
Extremities
 Look for obvious injuries.

 Feel for deformities.
 Assess PMS:
 Pulse
 Motor function
 Sensory function
Posterior Body
 Feel for tenderness, deformity, and open wounds.

 Carefully palpate from neck to pelvis.
 Look for obvious injuries.
Significant Mechanism of Injury
 Ejection from vehicle
 Death in passenger compartment
 Fall greater than 15’-20’
 Vehicle rollover
 High-speed collision
 Vehicle-pedestrian collision
 Motorcycle crash
 Unresponsiveness or altered mental status
 Penetrating trauma to the head, chest, or abdomen
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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
Responsive Medical Patients Unresponsive Medical Patients
• History of illness • Rapid medical assessment
• SAMPLE history • Baseline vital signs
• Focused assessment • SAMPLE history
• Vital signs • Re-evaluate transport decision
Ongoing Assessment Steps of the Ongoing Assessment
• Is treatment improving the patient’s • Repeat the initial assessment.
condition? • Reassess and record vital signs.
• Has an already identified problem gotten • Repeat focused assessment.
better? Worse? • Check interventions.
• What is the nature of any newly
identified problems?
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Patient Assessment Definitions
Steps taken by EMS providers when approaching the

scene of an emergency call; determining scene
safety, taking BSI precautions, noting the mechanism
Scene Size-Up of injury or patient’s nature of illness, determining
the number of patients, and deciding what, if any
additional resources are needed including Advanced
Life Support.
The process used to identify and treat life-

threatening problems, concentrating on Level of
Consciousness, Cervical Spinal Stabilization, Airway,
Breathing, and Circulation. You will also be forming a
Initial Assessment General Impression of the patient to determine the
priority of care based on your immediate assessment
and determining if the patient is a medical or trauma
patient. The components of the initial assessment
may be altered based on the patient presentation.
In this step you will reconsider the mechanism of

injury, determine if a Rapid Trauma Assessment or a
Focused History Focused Assessment is needed, assess the patient’s
chief complaint, assess medical patients complaints
and Physical
and signs and symptoms using OPQRST, obtain a
Exam baseline set of vital signs, and perform a SAMPLE
history. The components of this step may be altered
based on the patient’s presentation.
This is performed on patients with significant

mechanism of injury to determine potential life
threatening injuries. In the conscious patient,
symptoms should be sought before and during the
Rapid Trauma Rapid Trauma assessment. You will estimate the
severity of the injuries, re-consider your transport
Assessment decision, reconsider Advanced Life Support, consider
the platinum 10 minutes and the Golden Hour,
rapidly assess the patient from head to toe using
DCAP-BTLS, obtain a baseline set of vital signs, and
perform a SAMPLE history.
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This is performed on medical patients who are

unconscious, confused, or unable to adequately
relate their chief complaint. This assessment is used
Rapid Medical to quickly identify existing or potentially life-

threatening conditions. You will perform a head to
History
toe rapid assessment using DACP-BTLS, obtain a
baseline set of vital signs, and perform a SAMPLE
history
This is used for patients, with no significant

mechanism of injury, that have been determined to
have no life-threatening injuries. This assessment
Focused History would be used in place of your Rapid Trauma
and Physical Assessment. You should focus on the patient’s chief

complaint. An example of a patient requiring this
Exam - Trauma
assessment would be a patient who has sustained a
fractured arm with no other injuries and no life-
threatening conditions.
This is used for patients with a medical complaint

who are conscious, able to adequately relate their
chief complaint to you, and have no life-threatening
Focused History
conditions. This assessment would be used in place
and Physical
of your Rapid Medical Assessment. You should focus
Exam - Medical on the patient’s chief complaint using OPQRST,
obtain a baseline set of vital signs, and perform a
SAMPLE history.
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This is a more in-depth assessment that builds on the

Focused Physical Exam. Many of your patients may
not require a Detailed Physical Exam because it is
either irrelevant or there is not enough time to
complete it. This assessment will only be performed
while en route to the hospital or if there is time on
scene while waiting for an ambulance to arrive.
Detailed Physical Patients who will have this assessment completed are
patients with significant mechanism of injury,
Exam
unconscious, confused, or unable to adequately relate
their chief complaint. In the Detailed Physical Exam
you will perform a head to toe assessment using
DCAP-BTLS to find isolated and non-life-threatening
problems that were not found in the Rapid
Assessment and also to further explore what you
learned during the Rapid Assessment.
This assessment is performed during transport on all

patients.
The Ongoing Assessment will be repeated every 15

minutes for the stable patient and every 5 minutes for
the unstable patient.
This assessment is used to answer the following

questions:
Ongoing
1. Is the treatment improving the patient’s condition?
Assessment
2. Are any known problems getting better or worse?
3. What is the nature of any newly identified

problems?
You will continue to reassess mental status, ABCs, re-

establish patient priorities, reassess vital signs, repeat
the focused assessment, and continually recheck your
interventions.
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OPQRST
Used to assess a patient’s chief complaint during a medical exam.
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.
• What were you doing when the symptoms started?
• Was the onset sudden or gradual?
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?
• Does anything you do make the symptoms worse in any way?
This is sometimes helpful in ruling in or out a possible musculoskeletal cause. A patient

with a broken rib or pulled muscle will most likely have pain that is easily provoked by
palpation and/or movement. This is often in contrast to the patient having chest pain of
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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?
• What does it feel like?
• Is it sharp or dull?
• Is it steady or does it come and go?
• Has it changed since it began?
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?
• Does the pain radiate or move anywhere else?
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.
• When did the symptoms first begin?
• Have you ever experienced these symptoms before? If so, when?
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.
The Full Assessment
SCENE SIZE-UP
Steps taken when approaching the scene.
 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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 Consider C-Spine stabilization
INITIAL ASSESSMENT
Assessment & treatment (life-threats)
General Impression
 Mechanism of injury or nature of illness

 Age, sex, race
 Find and treat life threatening conditions (any obvious problems that may
kill the patient within seconds). Problems with Airway, Breathing, or
Circulation
 Verbalize general impression of patient
Mental Status
 If the pt. appears to be unconscious, check for responsiveness, (“Hey! Are

you OK”?)
 Evaluate mental status using AVPU.
 Obtain a chief complaint, if possible.
Airway
 Is the pt. talking or crying?

 Do you hear any noise?
 Will the airway stay open on its own?
 Does anything endanger it?
 Open the airway - head-tilt-chin-lift or jaw thrust – as needed
 Clear the airway – as needed
 Suction - as needed
 Insert an OPA/NPA - as needed
Breathing
 Do you see any signs of inadequate respirations?

 Is the rate and quality of breathing adequate to sustain life?
 Is the patient complaining of difficulty breathing?
 Quickly inspect the chest for impaled objects, open chest wounds, and
bruising (trauma).
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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)
Identify Priority Patients
 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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FOCUSED HISTORY AND PHYSICAL EXAM - TRAUMA
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).
Rapid Trauma Assessment
Performed on patients with significant MOI.
 Continue spinal stabilization

 Re-consider ALS back-up
Inspect and palpate the body for injuries to the following:
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
 Logroll the patient. Maintain c-spine stabilization.

 Inspect and palpate for injuries or signs of injury.
 DCAP-BTLS
FOCUSED TRAUMA ASSESSMENT
Performed on patients with no significant MOI.
Assess the patient’s chief complaint
 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
 Follow order of the Rapid Assessment

 Focus assessment on the specific area of injury or complaint
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 Obtain a full set of vital signs including:

 Respirations
 Pulse
 Blood Pressure
 Level of Consciousness
 Skin
 Pupils
 Assess SAMPLE History
 Signs & Symptoms
 Pertinent Past Medical History
 Allergies
 Last oral intake
 Medications
 Events leading up to the injury/illness
Respirations
RATE:
 Watch the chest/abdomen and count for no less than 30 seconds.

 If abnormal respirations are present count for a full 60 seconds.
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
 Blood pressure should be measured in all patients over the age of 3.

 Auscultate the blood pressure. In a high noise environment, palpate (only the systolic
reading can be obtained).
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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 reactive - change when exposed to light

 non-reactive - do not change when exposed to light
 equally or unequally reactive when exposed to light
FOCUSED HISTORY AND PHYSICAL EXAM - MEDICAL
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.
RAPID MEDICAL ASSESSMENT
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:
 Assess the head

 Assess the neck
 Assess the chest
 Assess the abdomen
 Assess the pelvis
 Assess the extremities
 Assess the posterior
 Obtain baseline set of vital signs
 Position patient to protect the airway
 Obtain the SAMPLE history from bystander, family, or friends.
FOCUSED MEDICAL ASSESSMENT
Performed on the conscious, alert patient who can adequately relate their chief complaint.
 Obtain the history of the present illness

 Onset - “What were you doing when the symptoms started?”
 Provocation - “Is there anything that makes the symptoms better or worse?”
 Quality - “What does the pain/discomfort feel like?”
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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
Examples of questions to ask a conscious medical patient and assessment elements
according to the patient’s chief complaint
Altered Mental Status Allergic Reaction Cardiac/Respiratory
o Description of episode o History of allergies o Onset
o Duration o Exposed to what? o Provocation
o Onset o How exposed o Quality
o Associated symptoms o Effects o Radiation
o Evidence of trauma o Progression o Severity
o Interventions o Interventions o Time
o Seizures o Interventions
o Fever
Poisoning & OD Environmental Behavioral
o Substance o Source o How do you feel?
o When exposed/ingested o Environment o Determine if suicidal:
o Amount o Duration “Were you trying to hurt yourself?”
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 Threat to self or others
o Medical problem
o Interventions
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Obstetrics Acute Abdomen Loss of Consciousness
o Are you pregnant? o Location of pain o Length of time unconscious
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
o Last menstrual period? o Abnormal vital signs
Obtain a full set of vital signs including:
- Respirations
- Pulse
- Blood Pressure
- Level of Consciousness
- Skin
- Pupils
Provide Treatment
Provide emergency medical care based on signs and symptoms.
DETAILED PHYSICAL EXAM
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.
Detailed Physical Exam – Trauma or Medical
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.
HEAD - inspect and palpate for signs of injury.
• DCAP-BTLS
• Blood & fluids from the head
FACE - inspect and palpate for signs of injury.
• DCAP-BTLS
EARS - inspect and palpate for signs of injury.
• DCAP-BTLS
• Drainage (blood or any other fluid)
EYES - inspect for signs of injury.
• DCAP-BTLS
• Discoloration
• Unequal Pupils
• Foreign Bodies
• Blood in Anterior Chamber
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NOSE - inspect and palpate for signs of injury.
• DCAP-BTLS
• Drainage
• Bleeding
MOUTH - inspect for signs of injury.
• DCAP-BTLS
• Damaged/Missing Teeth
• Obstructions
• Swollen or Lacerated Tongue
• Discoloration
• Unusual Odors
NECK - inspect and palpate for signs of injury.
• DCAP-BTLS
• JVD
• Tracheal deviation
• Crepitation
CHEST - inspect and palpate for signs of injury.
• 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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ABDOMEN - inspect and palpate for signs of injury.
• DCAP-BTLS
• Pain/Tenderness
• Firm
• Soft
• Distended
PELVIS - inspect and palpate for signs of injury.
• DCAP-BTLS
• If no pain is noted, gently compress the pelvis to determine tenderness or

unstable movement.
EXTREMITIES - inspect and palpate the lower and upper extremities for signs of injury.
• DCAP-BTLS
• Crepitation
• Distal pulses
• Sensory function
• Motor function
POSTERIOR
• Log roll the patient. Maintain c-spine stabilization.
• Inspect and palpate for injuries or signs of injury.
• 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.
Repeat Initial Assessment
• Reassess mental status.
• Maintain an open airway.
• Monitor breathing for rate and quality.
• Reassess pulse for rate and quality.
• Monitor skin color and temperature (CTC).
• Re-establish patient priorities.
Reassess and Record Vital Signs
Repeat Focused Assessment
Check Interventions
• Assure adequacy of oxygen delivery/artificial ventilation.
• Assure management of bleeding.
• Assure adequacy of other interventions
UNSTABLE PATIENTS – repeat On-Going

Assessment at least every 5 minutes.
STABLE PATIENTS – repeat On-Going

Assessment at least every 15 minutes.
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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
Essential components of pre-hospital care:
• Verbal communications are vital.
• Adequate reporting and accurate records ensure continuity of patient care.
• Reporting and record keeping are essential aspects of patient care.
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Types of Communication in EMS
Base Station Radios
• Transmitter and receiver located in a fixed place
• Power of 100 watts or more
• A dedicated line (hot line) is always open.
• Immediately “on” when you lift up the receiver
Mobile and Portable Radios
• Mobile radios installed in vehicle
- Range of 10 to 15 miles
• Portable radios hand-held
- Operate at 1 to 5 watts of power
Repeater-Based Systems
• Receives radio messages and retransmits
• A repeater is a base station able to receive low-power signals.
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.
• Signals can be decoded by the hospital.
Cellular Telephones
• Low-powered portable radios that communicate through interconnected repeater stations
• Cellular telephones can be easily scanned.
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Others
• Simplex
- Push-to-talk communication
• Duplex
- Simultaneous talk-listen
• MED channels
- Reserved for EMS
Emergency Medical Dispatch
Responsibilities
• Screen and assign priorities
• Select and alert appropriate units to respond
• Dispatch and direct units to the location
• Coordinate response with other agencies
• Provide pre-arrival instructions to the caller
Information Received From Dispatch
• Nature and severity of injury, illness, or incident
• Location of incident
• Number of patients
• Responses by other agencies
• Special information
• Time dispatched
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Advanced Medical Priority Dispatch System (AMPDS)
The Advanced Medical Priority Dispatch System (AMPDS), is a medically-approved,

unified system used to dispatch appropriate aid to medical emergencies including
systematized caller interrogation and pre-arrival instructions. AMPDS is developed and
marketed by Priority Dispatch Corporation which also has similar products for police and
fire.
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.
Positive Benefits of AMPDS
 Decreased EMV accidents

 Decreased burn-out of field personnel
 Decreased lights-and-siren runs
 Improved medical control at dispatch
 Improved medical dispatcher professionalism
 Improved standardization of care, interrogation and decision making
 Increased appropriateness of medical care through correct response
 Increased resource availability, especially ALS
 Increased safety of response personnel in the field
 Increased knowledge at arrival of response personnel
 Increased cooperation with associated public safety systems, law enforcement
and fire departments
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
Within 8 minutes in 75% of immediately life-threatening cases; no target set for
cases that are not serious or life-threatening.
Queensland, Australia
Within 10 minutes in 68% of Emergency Transport cases; no target set for non-
urgent cases.
Dispatch Life Support
An Emergency Medical Dispatcher (EMD) is trained to dispatch EMTs based on

the information given during the initial emergency call. They are trained to
mobilise resources based on these essential guidelines:
 A seizure or convulsion may be a sympton of the onset of cardiac arrest.

Any person 35 years or older who presents with a seizure as a chief
complaint should be assumed to be in cardiac arrest until proven
otherwise.
 Cardiac arrest in a previously healthy child should be considered to be
caused by a foreign body obstructing the airway until proven otherwise.
 Dispatchers should be trained to identify obvious death situations (as
defined by medical control), mobilize response accordingly and give
limited pre-arrival instructions.
 If the caller is a third-party who cannot identify if the victim is
unconscious and not breathing, the victim should be assumed to be in
cardiac arrest until proven otherwise.
 EMDs should assume that bystanders have inappropriately placed a pillow
under the head of an unconscious victim, until proven otherwise, and
ensure it is removed.
 BLS protocol for a choking victim should be modified to reflect EMDs
recommend a specific number of thrusts, rather than stating a range of
thrusts.
 The Heimlich manoeuvre should be the primary treatment of infants,
children and adults who are choking.
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Remember that Emergency Medical Dispatchers are not usually EMT-trained.

They are trained to ask specific questions and give basic life support advice over
the telephone. Because people calling emergency services rarely have medical
training, EMDs are trained to err on the side of caution and cater for the worst
case scenario.
EMT Communication
EMT Communication with Dispatch
 Report any problems during run.

 Advise of arrival.
 Communicate scene size-up.
 Keep communications brief.
EMT Communication with Medical Control
 Radio communications facilitate contact between providers and medical

control.
 Consult with medical control to:
- Notify hospital of incoming patient.
- Request advice or orders.
- Advise hospital of special circumstances.
 Organize your thoughts before transmitting.
Calling Medical Control
 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
 Acknowledge dispatch information.

 Notify arrival at scene.
 Notify departure from scene.
 Notify arrival at hospital or facility.
 Notify you are clear of the incident.
 Notify arrival back in quarters.
Patient Report
 Identification and level of services

 Receiving hospital and ETA
 Patient‟s age and gender
 Chief complaint
 History of current problem
 Other medical history
 Physical findings
 Summary of care given and patient response
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.
Priority One (Highest)
 Airway or breathing difficulties

 Uncontrolled or severe bleeding
 Decreased or altered mental status
 Severe medical problems
 Signs and symptoms of shock
 Severe burns with airway compromise
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Priority Two
 Burns without airway compromise

 Multiple or major bone or joint injuries
 Back injuries with or without spinal cord damage
Priority 3 (Lowest)
 Minor bone or joint injuries

 Minor soft-tissue injuries
 Prolonged cardiac arrest
 Cardiopulmonary arrest
 Death
Verbal Communication
 Essential part of quality patient care.

 You must be able to find out what the patient needs and then tell others.
 You are a vital link between the patient and the health care team.
Components of an Oral Report
 Patient‟s name, chief complaint, nature of illness, mechanism of injury

 Summary of information from radio report
 Any important history not given earlier
 Patient‟s response to treatment
 The vital signs assessed
 Any other helpful information
Communicating with Patients
 Make and keep eye contact.

 Use the patient‟s proper name.
 Tell the patient the truth.
 Use language the patient can understand.
 Be careful of what you say about the patient to others.
 Be aware of your body language.
 Always speak slowly, clearly, and distinctly.
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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.
Communicating With Geriatric Patients
 Determine the person‟s functional age.

 Do not assume that an older patient is senile or confused.
 Allow patient ample time to respond.
 Watch for confusion, anxiety, or impaired hearing or vision.
 Explain what is being done and why.
Communicating With Hearing-Impaired Patients
 Always assume that the patient has normal intelligence.

 Make sure you have a paper and pen.
 Face the patient and speak slowly, clearly and distinctly.
 Never shout!
 Learn simple phrases used in sign language.
Communicating With Children
 Children are aware of what is going on.

 Allow people or objects that provide comfort to remain close.
 Explain procedures to children truthfully.
 Position yourself on their level.
Communicating With Vision-Impaired Patients
 Ask the patient if he or she can see at all.

 Explain all procedures as they are being performed.
 If a guide dog is present, transport it also, if possible.
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Communicating With Non-English-Speaking Patients
 Use short, simple questions and answers.

 Point to specific parts of the body as you ask questions.
 Learn common words and phrases in the non-English languages
used in your area.
Documentation
Minimum Data Set for Written 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 (PCR)
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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Types of PCR Forms
 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
 Do not write false statements on report.

 If error made on report then:
 Draw a single horizontal line through error.
 Initial and date error.
 Write the correct information.
Remember:
 A PCR is a legal document.

 If you didn‟t do something - don‟t write it down.
 If you don‟t write it down - it didn‟t happen.
Documenting Right of Refusal
 Document assessment findings and care given.

 Have the patient sign the form.
 Have a witness sign the form.
 Include a statement that you explained the possible consequences of
refusing care to the patient
Special Reporting Situations
Be familiar with required reporting in your jurisdiction, including:
 Gunshot wounds
 Animal bites
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 Certain infectious diseases

 Suspected physical, sexual, or substance abuse
 Multiple-casualty incidents (MCI)
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Chapter 11: Airway Management
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
Normal Breathing Rates
Adult 12-20 breaths per minute
Child 15-30 breaths per minute
Infant 25-50 breaths per minute
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Recognizing Adequate Breathing
• Normal rate and depth

• Regular pattern
• Regular and equal chest rise and fall
• Adequate depth
The Patent Airway
0-1 minute without oxygen Cardiac irritability
0-4 minutes without oxygen Brain damage not likely
4-6 minutes without oxygen Brain damage possible
6-10 minutes without oxygen Brain damage very likely
More than 10 minutes without oxygen Irreversible brain damage
Recognizing Inadequate Breathing
• Fast or slow rate

• Irregular rhythm
• Abnormal lung sounds
• Reduced tidal volumes
• Use of accessory muscles
• Cool, damp, pale or cyanotic skin
Hypoxia
• Not enough oxygen for metabolic needs

• Develops when patient is:
- Breathing inadequately
- Not breathing
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Signs of Hypoxia
• Nervousness, irritability, and fear

• Tachycardia
• Mental status changes
• Use of accessory muscles for breathing
• Difficulty breathing, possible chest pain
Different Types of Abnormal Respirations
• BRADYPNEA - rate of breathing is abnormally slow < 10 bpm.

• TACHYPNEA - rate of breathing is abnormally rapid > 24 bpm.
• HYPERNEA - respirations are increased in depth and rate (occurs normally with
exercise).
• APNEA - respirations cease for several seconds.
• HYPERVENTILATION - rate of ventilation exceeds normal metabolic requirements
for exchange of respiratory gases. Rate and depth of respiration is increased.
• HYPOVENTILATION - rate of ventilation is insufficient for metabolic requirements.
Respiratory rate is below normal and depth of ventilations is depressed.
• CHEYNE-STOKES RESPIRATION - respiratory rhythm is irregular, characterised by
alternating periods of apnoea and hyperventilation. The respiratory cycle begins
with slow and shallow respiration and gradually increases to abnormal depth and
rapidity.
• KUSSMAUL RESPIRATION - respirations are abnormally deep but regular. Similar
to hyper ventilation.
• ORTHOPNEA - respiratory condition in which the person must sit or stand to
breathe deeply and comfortably.
• BIOT’S RESPIRATION - condition of the central nervous system which causes
shallow breathing interrupted by irregular periods of apnoea.
Abnormal Lung Sounds
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).
• Crackles are often described as fine, medium, and coarse.

• Fine crackles are soft, high-pitched, and very brief. You can simulate this
sound by rolling a strand of hair between your fingers near your ear, or by
moistening your thumb and index finger and separating them near your
ear.
• Coarse crackles are somewhat louder, lower in pitch, and last longer than
fine crackles. They have been described as sounding like opening a Velcro
fastener.
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
Stridor refers to a high-pitched harsh sound heard during inspiration. Stridor is

caused by obstruction of the upper airway, is a sign of respiratory distress and
thus requires immediate attention.
If abnormal lungs sounds are heard, it is important to assess:
• their loudness.
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• timing in the respiratory cycle.
• location on the chest wall.
• persistence of the pattern from breath to breath, and.
• 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.
Conditions Resulting In Hypoxia
• Myocardial infarction
• Pulmonary edema
• Acute narcotic overdose
• Smoke inhalation
• Stroke
• Chest injury
• Shock
• Lung disease
• Asthma
• Premature birth
Opening the Airway
Head Tilt-Chin Lift Method
Used when cervical spine injury is not suspected.
1. Kneel beside patient’s head.

2. Place one hand on forehead.
3. Apply backward pressure.
4. Place tips of finger under lower jaw.
5. Lift chin.
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Jaw Thrust Maneuver
Used when cervical spine injury is suspected.
1. Kneel above patient’s head.

2. Place fingers behind angle of jaw.
3. Use thumbs to keep mouth open
Assessment of the Airway
1. Look
2. Listen
3. Feel
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Suctioning
Suctioning of a patient’s airway may be necessary when:
• Blood, other liquids and food particles block the airway.

• A gurgling sound is heard when performing artificial ventilation.
Suctioning Technique
• Check the unit and turn it on.
• Select and measure proper catheter to be used.
• Open the patient’s mouth and insert tip.
• Suction as you withdraw the catheter.
• Never suction adults for more than 15 seconds.
Basic Airway Adjuncts
Oropharyngeal airways
• Keep the tongue from blocking the upper airway
• Allow for easier suctioning of the airway
• Used in conjunction with BVM device
• Used on unconscious patients without a gag reflex
Inserting an oropharyngeal airway
1. Select the proper size airway.

2. Open the patient’s mouth.
3. Hold the airway upside down and insert it in the patient’s mouth.
4. Rotate the airway 180° until the flange rests on the patient’s lips.
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Nasopharyngeal Airways
• Used on conscious patients who cannot maintain airway
• Can be used with intact gag reflex
• Should not be used with head injuries or nosebleeds
Inserting a nasopharyngeal airway
1. Select the proper size airway.

2. Lubricate the airway.
3. Gently push the nostril open.
4. With the bevel turned toward the septum, insert the airway.
Airway Kits
A typical EMS airway kit
Basic airways Advanced airways
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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
Mouth to Mask Technique
1. Kneel at patient’s head and open airway.

2. Place the mask on the patient’s face.
3. Take a deep breath and breathe into the patient for 1 1/2 to 2 seconds.
4. Remove your mouth and watch for patient’s chest to fall.
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1 Person BVM Technique
1. Insert an oral airway.

2. Establish and maintain an adequate seal with one hand while using the other
hand to delivers ventilations.
3. Place mask on patient’s face.
4. Squeeze bag to deliver ventilations.
2 Person BVM Technique
1. Insert an oral airway.

2. One caregiver maintains seal while the other delivers ventilations.
3. Place mask on patient’s face.
4. Squeeze bag to deliver ventilations.
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Oxygen Therapy
Medical Oxygen
Oxygen is a colourless, odourless gas normally present in the atmosphere at

concentrations of approximately 21%.
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
• Used to measure the oxygen saturation of hemoglobin.

• May give false readings with CO absorption because it cannot distinguish between
O2 and CO.
• Takes several minutes to give an accurate reading.
A pulse oximetry of 94% O2 saturation or

above means the patient is receiving
adequate oxygen for metabolism.
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Capnography
Capnography is increasingly being used by paramedics to aid in their assessment and

treatment of patients in the prehospital environment. These uses include verifying and
monitoring the position of an endotracheal tube. A properly positioned tube in the trachea
guards the patient’s airway and enables the paramedic to breathe for the patient. A
misplaced tube in the esophagus can lead to death.
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.
The AHA also notes in their new guidelines that capnography,

which indirectly measures cardiac output, can also be used to
monitor the effectiveness of CPR and as an early indication of
return of spontaneous circulation (ROSC). Studies have shown
that when a person doing CPR tires, the patient’s end-tidal CO2
(ETCO2, the level of carbon dioxide released at the end of
expiration) falls, and then rises when a fresh rescuer takes over.
Other studies have shown when a patient experiences return of
spontaneous circulation, the first indication is often a sudden rise in the ETCO2 as the rush
of circulation washes untransported CO2 from the tissues. Likewise, a sudden drop in
ETCO2 may indicate the patient has lost pulses and CPR may need to be initiated.
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.
Capnography, because it provides a breath by breath measurement of a patient’s

ventilation, can quickly reveal a worsening trend in a patient’s condition by providing
paramedics with an early warning system into a patient’s respiratory status. As more clinical
studies are conducted into the uses of capnography in asthma, congestive heart failure,
diabetes, circulatory shock, pulmonary embolus, acidosis, and other conditions, the
prehospital use of capnography will greatly expand.
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Article: 10 Things Every Paramedic Should Know About Capnography
Adapted from an Article from JEMS (Journey of Emergency Medical Services), by Peter Canning,
EMT-P, December 29, 2007
10 Things Every Paramedic Should Know About Capnography
Capnography is the vital sign of ventilation.
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.
Part One: The Science
Definitions:
Capnography – the measurement of carbon dioxide (CO2) in exhaled breath.
Capnometer – the numeric measurement of CO2.
Capnogram – the wave form.
End Tidal CO2 (ETCO2 or PetCO2) – the level of (partial pressure of) carbon dioxide released at
end of expiration.
Oxygenation Versus Ventilation
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.
Capnography versus Pulse Oximetry
Capnography provides an immediate picture of patient condition. Pulse oximetry is delayed.

Hold your breath. Capnography will show immediate apnea, while pulse oximetry will show a
high saturation for several minutes.
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Circulation and Metabolism
While capnography is a direct measurement of ventilation in the lungs, it also indirectly

measures metabolism and circulation. For example, an increased metabolism will
increase the production of carbon dioxide increasing the ETCO2. A decrease in cardiac
output will lower the delivery of carbon dioxide to the lungs decreasing the ETCO2.
Normal Capnography Values
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.
Cautions: Imperfect positioning of nasal cannula capnofilters may cause distorted

readings. Unique nasal anatomy, obstructed nares and mouth breathers may skew
results and/or require repositioning of cannula. Also, oxygen by mask may lower the
reading by 10% or more.
Capnography Wave Form
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.
Abnormal Values and Wave Forms
ETCO2 Less Than 35 mmHg = “Hyperventilation/Hypocapnia”
ETC02 Greater Than 45 mmHg = “Hypoventilation/Hypercapnia”
Part Two: Clinical Uses of Capnography
1. Monitoring Ventilation
Capnography monitors patient ventilation, providing a breath by breath trend of

respirations and an early warning system of impending respiratory crisis.
Hyperventilation
When a person hyperventilates, their CO2 goes down.
Hyperventilation can be caused by many factors from anxiety to bronchospasm to

pulmonary embolus. Other reasons C02 may be low: cardiac arrest, decreased cardiac
output, hypotension, cold, severe pulmonary edema.
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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
When a person hypoventilates, their CO2 goes up.
Hypoventilation can be caused by altered mental status such as overdose, sedation,

intoxication, postictal states, head trauma, or stroke, or by a tiring CHF patient. Other
reasons CO2 may be high: Increased cardiac output with increased breathing, fever, sepsis,
pain, severe difficulty breathing, depressed respirations, chronic hypercapnia.
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.
2. Confirming, Maintaining , and Assisting Intubation
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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Continuous Wave Form Capnography Versus Colorimetric Capnography
In colorimetric capnography a filter attached to an ET tube changes color from purple

to yellow when it detects carbon dioxide. This device has several drawbacks when
compared to waveform capnography. It is not continuous, has no waveform, no
number, no alarms, is easily contaminated, is hard to read in dark, and can give false
readings.
Paramedics should encourage their services to equip them with continuous wave form
capnography.
3. Measuring Cardiac Output During CPR
Monitoring ETC02 measures cardiac output, thus monitoring ETCO2 is a good way to
measure the effectiveness of CPR.
In 1978, Kalenda “reported a decrease in ETC02 as the person performing CPR

fatigued, followed by an increase in ETCO2 as a new rescuer took over, presumably
providing better chest compressions.” –Gravenstein, Capnography: Clinical Aspects,
Cambridge Press, 2004
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.
Return of Spontaneous Circulation (ROSC)
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
.-Grmec S, Krizmaric M, Mally S, Kozelj A, Spindler M, Lesnik B.,Resuscitation. 2006 Dec 8
Loss of Spontaneous Circulation
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.
4. End Tidal CO2 As Predictor of Resuscitation Outcome
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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Asphyxic Cardiac Arrest versus Primary Cardiac Arrest
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
.-Grmec S, Lah K, Tusek-Bunc K,Crit Care. 2003 Dec
5. Monitoring Sedated Patients
Capnography should be used to monitor any patients receiving pain management or

sedation (enough to alter their mental status) for evidence of hypoventilation and/or
apnea.
In a 2006 published study of 60 patients undergoing sedation, in 14 of 17 patients who

suffered acute respiratory events, ETCO2 monitoring flagged a problem before changes in
SPO2 or observed changes in respiratory rate.
“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
Sedated, Intubated Patients
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.
6. ETCO2 in Asthma, COPD, and CHF
End-tidal CO2 monitoring on non-intubated patients is an excellent way to assess the

severity of Asthma/COPD, and the effectiveness of treatment. Bronchospasm will produce
a characteristic “shark fin” wave form, as the patient has to struggle to exhale, creating a
sloping “B-C” upstroke. The shape is caused by uneven alveolar emptying.
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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.
CHF: Cardiac Asthma
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.
7. Ventilating Head Injured Patients
Capnography can help paramedics avoid hyperventilation in intubated head injured patients.
“Recent evidence suggests hyperventilation leads to ischemia almost immediately…current

models of both ischemic and TBI suggest an immediate period during which the brain is
especially vulnerable to secondary insults. This underscores the importance of avoiding
hyperventilation in the prehospital environment.” –Capnography as a Guide to Ventilation in
the Field, D.P. Davis, Gravenstein, Capnography: Clinical Perspectives, Cambridge Press, 2004
Hyperventilation decreases intracranial pressure by decreasing intracranial blood flow. The

decreased cerebral blood flow may result in cerebral ischemia.
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
8. Perfusion Warning Sign
“A target value of 35 mmHg is recommended…The propensity of prehospital personnel to

use excessively high respiratory rates suggests that the number of breaths per minute
should be decreased. On the other hand, the mounting evidence against tidal volumes in
excessive of 10cc/kg especially in the absence of peep, would suggest the hypocapnia be
addressed by lower volume ventilation.” – –Capnography as a Guide to Ventilation in the
Field, D.P. Davis, Gravenstein, Capnography: Clinical Perspectives, Cambridge Press, 2004
Page 142
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.
Hyperthermia – Metabolism is on overdrive in fever, which may cause ETCO2 to rise.

Observing this phenomena can be live-saving in patients with malignant hyperthermia, a
rare side effect of RSI (Rapid Sequence Induction).
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.
10. The Future
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.
The normal range for exhaled CO2 is 35-45mmHg

Reading a Capnograph Wave
Segment I (A to B) of the wave represents post inspiration / dead space expiration.
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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.
Segment IV (D to E) of the wave represents inspiration washout.
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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.
Oxygen Delivery Devices
Nasal Cannula
An oxygen tube that provides only a very limited oxygen concentration.
Adult or Pediatric Simple Face Mask
No reservoir and can only deliver up to 60% oxygen.
Adult Nonrebreather Mask
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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Pediatric Nonrebreather Mask
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.
Partial Rebreather Mask
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.
Ventilatory Devices and Oxygen Concentration
Device Liter Flow (LPM) Oxygen Delivered
Nasal Cannulae 1-6 24-26%
Mouth-to-Mask 10 50%
Simple face mask 8-10 40-60%
BVM without reservoir 8-10 40-60%
Partial rebreather mask 6 60%
Simple mask with reservoir 6 60%
BVM with reservoir 15 100%
Nonrebreathing mask with 15 90-100%
reservoir
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Oxygen Cylinders
In emergency medical care, the following sizes of

oxygen cylinders are commonly used:
D cylinder 350 liters
E Cylinder 625 liters
M Cylinder 3000 liters
G cylinder 5300 liters
H cylinder 6900 liters
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.
Calculation of Oxygen Cylinder Contents in Liters
D cylinder - Lbs per in2 x 0.16 = contents in liters
E cylinder - Lbs per in2 x 0.28 = contents in liters
G cylinder - Lbs per in2 x 2.41 = contents in liters
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H cylinder - Lbs per in2 x 3.14 = contents in liters
M cylinder - Lbs per in2 x 1.56= contents in liters
Calculation of Oxygen Required for Transport
Breaths per minute x tidal volume x travel time = ɵ
ɵ + ɵ/2 = total requirement of oxygen for transport

(Note: 50% of the estimated need is added in order to cater for emergencies or unforeseen
circumstances)
Minimum Volume Requirements for Pediatrics
Age in Years Minimum Volume Required
1 120ml
2 156ml
3-4 170ml
5-6 200ml
7-10 270ml
11-12 380ml
13-14 420ml
15 as adult
Safety with Oxygen Cylinders
• Store cylinders below 50 degrees Celsius.

• Never use an oxygen cylinder without a safe, properly fitting
regulator valve.
• Keep all valves closed when the cylinder is not in use, even if the
tank is empty.
• Keep oxygen cylinders secured to prevent them from toppling
over.
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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.
There are two types of regulators:
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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Article: The Oxygen Myth?
The Oxygen Myth?
An article by Bryan E. Bledsoe, DO, FACEP, Mar 5 2009, JEMS
(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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Neonates: The science is clear in regard to supplemental oxygen in neonates. It should be

used only when room air ventilation fails.
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.
4. American Heart Association: “2005 American Heart Association guidelines for

cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) of pediatric
and neonatal patients: Pediatric basic life support.” Circulation.13:IV1-203, 2005.
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.
7. Mackway-Jones K: “Oxygen in uncomplicated myocardial infarction.” Emergency Medicine

Journal. 21:75-81, 2004.
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.
Page 153
9. Gilmer B, Kilkenny J, Tomaszewski C, et al: “Hyperbaric oxygen does not improve

neurologic sequelae after carbon monoxide poisoning.” Academic Emergency Medicine. 9:1-
8, 2002.
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Chapter 12: The Basic ECG
Chapter 12:
The Basic ECG
Outline
 Electrical Conduction System of the Heart

 The Electrocardiogram
 The ECG Complex
 An In-depth Look at the ECG and Its Generation
 ECG Rhythm Interpretation
Electrical Conduction System of the Heart
 A network of specialized tissue in the heart.

 Conducts electrical current throughout the heart.
 The flow of electrical current causes contractions that produce pumping of
blood.
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The heart’s electrical system is made up of three main parts:

 The sinoatrial (SA) node, located in the right atrium of the heart.
 The atrioventricular (AV) node, located on the interatrial septum close to the tricuspid
valve.
 The His-Purkinje system, located along the walls of the heart’s ventricles.
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
 Records potential (voltage) differences between a ‘neutral’ ground and recording

electrodes.
 3 lead ECG used for monitoring purposes.
 12 lead ECG used for diagnostic purposes.
 Lead II shows life-threatening rhythms.
 Most ECG recordings are obtained with paper speeds of 25mm/sec and signal
calibration of 1.0mV/1cm.
 The P-QRS-T complex of the normal ECG represents electrical activity over one cardiac
cycle.
 The dominant pacemaker of the heart is the sinus node in the right atrium. It normally
fires between 60 and 100 times a minute. Should the sinus node fail, the AV node is a
potential pacemaker but it only fires at 40-60 beats per minute.
The ECG Complex
• One complex represents one beat in the heart.

• Complex consists of P, QRS, and T waves.
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Parts of the ECG Complex
 P Wave - Atrial depolarization - 0.04-0.12 seconds - 1-2 small squares

 PR Interval - SA Node-AV Node conduction time - 0.12-0.20 seconds - 3-5
small squares
 QRS Complex - Ventricular depolarization - 0.04-0.10 seconds - 1-2 small
squares
 ST Segment - Plateau phase ventricular depolarization - isoelectric (baseline)
 T Wave - Ventricular repolarization - 0.5mV/5mm
 QT Interval - Total duration of ventricular depolarization - 0.33-0.42 seconds -
8-10 small squares
An In-depth Look at the ECG and Its Generation
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ECG Rhythm Interpretation
Normal Sinus Rhythm
• Consistent P waves
• Consistent P-R interval
• 60–100 beats/min
Sinus Bradycardia
• Less than 60 beats/min
Sinus Tachycardia
• More than 100 beats/min
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Remember - A sinus rhythm is a rhythm that has

a P Wave present.
Ventricular Tachycardia
• Three or more ventricular complexes in a row

• More than 100 beats/min
Ventricular Fibrillation
• Rapid, completely disorganized rhythm

• Deadly arrhythmia that requires immediate treatment
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Asystole
• Complete absence of electrical cardiac activity

• Patient is clinically dead.
• Decision to terminate resuscitation efforts depends on local protocol.
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Chapter 13: The Automated External Defibrillator
Chapter 13:
The Automated External
Defibrillator
Outline
 The Chain of Survival

 The Purpose of Defibrillation
 The Importance of Early Defibrillation
 Types of Defibrillators
 Shockable Rhythms
 Non-Shockable Rhythms
 Advantages of the AED
 Medical Direction
 Energy Levels for AEDs
 Monophasic vs. Biphasic
 Indications for AED Use
 Contraindications for AED Use
 Preparing to Operate an AED
 Using an AED - 3 Simple Steps
 AED Treatment Algorithm
 Using an AED – Detailed Steps
 After AED shocks
 Transport
 Cardiac Arrest During Transport
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The Chain of Survival
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.
Time After the Onset of Attack Survival Chances

With every minute Chances are reduced by 7-10%
Within 4-6 minutes Brain damage and permanent death

start to occur
After 10 minutes Few attempts at resuscitation succeed
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Type of Care for SCA Victims Chance of Survival

after Collapse
0%
No care after collapse
No CPR and delayed defibrillation (after 10 0-2%

minutes)
CPR from a non-medical person (such as a

2-8%
bystander or family member) begun within
2 minutes, but delayed defibrillation
20%
CPR and defibrillation within 8 minutes
CPR and defibrillation within 4 minutes; 43%

paramedic help 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%.
ILCOR AED Symbol
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The Purpose of Defibrillation
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.
The Importance of Early Defibrillation
Defibrillation is the single most important factor in determining the survival from cardiac
arrest.
Rationale for Early Defibrillation
 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
Ventricular fibrillation (VF)
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Ventricular Tachycardia (V-Tach) - (if the patient is pulseless and unconscious)
Non-Shockable Rhythms
Asystole
Pulseless Electrical Activity (PEA) - (any heart rhythm observed on the ECG that
should be producing a pulse, but is not)
Advantages of the AED
 ALS providers do not need to be on scene.

 Remote, adhesive defibrillator pads are used.
 Efficient transmission of electricity
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Medical Direction
 Should approve protocols.

 Should review AED usage.
 Should review speed of defibrillation.
 Should provide review of skills every 3 to 6 months.
Energy Levels of the AED
 Electrical current is measured in joules (J)

 Manual defibrillators - 5 or 10 to 360J
 Fully or semi-automated defibrillators - preset values of 200 and 360J
programmed.
Monophasic vs. Biphasic
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.
Indications for AED Use
 The patient is unresponsive, and;

 The patient demonstrates no effective breathing, and;
 The patient has no signs of circulation.
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Contraindications for AED Use
 The patient is under 1 year old;

 The patient suffered cardiac arrest as a result of trauma (except electrocution);
 The patient has a detectable pulse or respirations;
 The patient demonstrates response to external stimulus.
Preparing to Operate an AED
 Make sure the electricity injures no one.

 Do not defibrillate a patient lying in pooled water.
 Dry a soaking wet patient‟s chest first.
 Do not defibrillate a patient who is touching metal.
 Remove nitroglycerin patches.
 Shave a hairy patient‟s chest if needed.
AED pads for adults (left) and children (right)
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Using an AED – 3 Simple Steps
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AED Treatment Algorithm
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Using an AED - Detailed Steps
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
 Push the analyze button, if there is one.

 Wait for the computer.
 If shock is not needed, start CPR.
 If shock is advised, make sure that no one is touching the patient.
 Push the shock button
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
 Check for pulse.

 If the patient has a pulse, check breathing.
 If the patient is breathing adequately, provide oxygen via non-rebreathing mask if
needed and transport.
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
 If the patient has no pulse, perform 1 minute of CPR.

 Gather additional information on the arrest event.
 After 1 minute of CPR, make sure no one is touching the patient.
 Push the analyze button again (as applicable).
 Transport and check with medical control.
 Continue to support the patient as needed.
After AED Shocks
 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
 When patient regains pulse; or

 After delivering six to nine shocks; or
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 After receiving three consecutive “no shock advised” messages.

 Keep AED attached.
 Check pulse frequently.
 Stop ambulance to use an AED.
Cardiac Arrest During Transport
 Check unconscious patient‟s pulse every 30 seconds.

 If pulse is not present:
 Stop the vehicle.
 Perform CPR until AED is available.
 Analyze rhythm.
 Deliver shock(s).
 Continue resuscitation according to local protocol
 If patient becomes unconscious during transport:
 Check pulse.
 Stop the vehicle.
 Perform CPR until AED is available.
 Analyze rhythm.
 Deliver up to three shocks.
 Continue resuscitation according to local protocol.
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Appendix 1
Appendix 1:
Updated 2010 European
Resuscitation Council
Guidelines
Basic life support
Changes in basic life support (BLS) since the 2005 guidelines include:
 Dispatchers should be trained to interrogate callers with strict protocols to elicit

information. This information should focus on the recognition of unresponsiveness
and the quality of breathing. In combination with unresponsiveness, absence of
breathing or any abnormality of breathing should start a dispatch protocol for
suspected cardiac arrest. The importance of gasping as sign of cardiac arrest is
emphasised.
 All rescuers, trained or not, should provide chest compressions to victims of cardiac
arrest. A strong emphasis on delivering high quality chest compressions remains
essential. The aim should be to push to a depth of at least 5 cm at a rate of at least
100 compressions min-1, to allow full chest recoil, and to minimise interruptions in
chest compressions. Trained rescuers should also provide ventilations with a
compression–ventilation (CV) ratio of 30:2. Telephone-guided chest compression-only
CPR is encouraged for untrained rescuers.
 The use of prompt/feedback devices during CPR will enable immediate feedback to
rescuers and is encouraged. The data stored in rescue equipment can be used to
monitor and improve the quality of CPR performance and provide feedback to
professional rescuers during debriefing sessions.
Page a
Appendix 1
Electrical therapies
The most important changes in the 2010 ERC Guidelines for electrical therapies include:
 The importance of early, uninterrupted chest compressions is emphasized

throughout these guidelines.
 Much greater emphasis on minimizing the duration of the pre-shock and post-
shock pauses; the continuation of compressions during charging of the defibrillator
is recommended.
 Immediate resumption of chest compressions following defibrillation is also
emphasised; in combination with continuation of compressions during defibrillator
charging, the delivery of defibrillation should be achievable with an interruption in
chest compressions of no more than 5 seconds.
 Safety of the rescuer remains paramount, but there is recognition in these
guidelines that the risk of harm to a rescuer from a defibrillator is very small,
particularly if the rescuer is wearing gloves. The focus is now on a rapid safety
check to minimise the preshock pause.
 When treating out-of-hospital cardiac arrest, emergency medical services (EMS)
personnel should provide good-quality CPR while a defibrillator is retrieved,
applied and charged, but routine delivery of a pre-specified period of CPR (e.g.,
two or three minutes) before rhythm analysis and a shock is delivered is no longer
recommended. For some EMS that have already fully implemented a pre-specified
period of chest compressions before defibrillation, given the lack of convincing
data either supporting or refuting this strategy, it is reasonable for them to
continue this practice.
 The use of up to three-stacked shocks may be considered if VF/VT occurs during
cardiac catheterization or in the early post-operative period following cardiac
surgery. This three shock strategy may also be considered for an initial, witnessed
VF/VT cardiac arrest when the patient is already connected to a manual
defibrillator.
 Further development of AED programmes is encouraged – there is a need for
further deployment of AEDs in both public and residential areas.
Page b
Appendix 1
Page c
Appendix 1
Page d
Appendix 1
Page e
Appendix 1
Page f

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Emergency Medical

Emergency Medical Technician - Basic (EMT-B) Course Manual

This work is protected by copyright in The Philippines and internationally. No part of

International (LSTI). All rights reserved.

This first edition produced 2010.

Edited by Craig Barrett, BA, PG Dip Ed, EMT-B

you current with worldwide standards.

the beginning of a career you will be passionate about.

Craig Barrett, EMT-B

Quezon City 2010

1 EMS In The Philippines 1

Appendix 1 ERC Guidelines (2010)

 Life Support Training International

Life Support Training International

Our consultants have been involved in developing Emergency Medical Services

Life Support Training International is currently The Philippines only fully

WHEN THEY DEPEND ON YOU

YOU CAN ALWAYS DEPEND ON US!

Philippine Society of Emergency Medical Technicians

The Philippine Society of Emergency Medical Technicians (PSEMT) is a non-

The development of a first-class Emergency Medical Services System in The

It is clearly recognized that any Pre-Hospital Care System involving EMTs

We are pleased to announce that, due to our adherence to the highest of

American College of Emergency Physicians

Emergency Care and Safety

International Liaison Committee

Philippine Heart Association

PSEMT Membership Grades

The following are the grades of membership for the PSEMT:

Basic Emergency Medical Technician - EMT (B) “Certification”

 Completion of a PSEMT/PBEMT approved 280 hour training course and the

The minimum age shall be 20 years.

Emergency Medical Technician, Defibrillator - EMT (D) “Certification”

All applicants must be a certified Emergency Medical Technician (EMT) with a

Re-registration will be required on an annual basis and all applications thereof

Emergency Medical Technician Advanced - EMT (A) “Registration”

Re-registration will be required on an annual basis and all applications thereof

Registered Emergency Medical Technician Paramedic - EMT (P)

Re-registration will be required on an annual basis and all applications thereof

Registered Emergency Medical Services Instructor - REMSI

This level has yet to be defined.

Exemptions from some requirements may be considered based on

LSTI Academic Policies and Procedures

Course Performance Rating

Students’ overall performances are evaluated via the following:

 Weekly Examinations 10%

Passing grade is set at 75% in all written and practical examinations. In

Payment of Tuition Fees

Reservation fee - PHP5000 (Non-refundable)

Weekly payment - PHP3000 (Week 2-6 inclusive)

Every Monday morning, starting week 2, an assessment/examination shall be

Any cheating, or perceived attempt to cheat, in the Final Examinations will

In the case of failures, re-sit/re-examination shall be done at a time and date

In accordance with PSEMT/AREMT policies, repetition of the EMT-Basic Course

Please put all your litter in the

 The Star of Life

The Star of Life

The symbol’s six-barred cross represents the six-system function of

The Emergency Medical Services S

Regulation and Policy

Laws that allow the system to exist.

Centralized coordination of resources (i.e. hospitals) to have equal access to basic

Human Resources and Training

Safe, reliable ambulance transportation is a critical component.