Exam 5 (Chapters 16-19)

Chapter 16
Cardiovascular Emergencies

I. Introduction
A. Cardiovascular disease accounts for about 1 of every 3 deaths.
B. EMS can help reduce deaths by providing the following services:
1. Encouragement of people to follow a healthy lifestyle
2. Early access to medical care
3. More CPR training of laypeople
4. Increased use of evolving technology in dispatch and cardiac arrest response
5. Public access to defibrillation devices
6. Recognition of the need for ALS
7. The use of cardiac specialty centers when they are available

II. Anatomy and Physiology

ventricle A. The heart’s job is to pump blood to supply oxygen-enriched red blood cells to the
pumps tissues of the body.
atrium holds +
transfers to 1. The heart is divided down the middle into left and right sides, each with an upper
ventricle chamber (atrium) to receive incoming blood and a lower chamber (ventricle) to pump
outgoing blood.
one-way valves
↳ if blood returns through 2. Blood leaves each of the four chambers of the heart through one-way valves, which keep
this, it causes the the blood moving through the circulatory system in the proper direction.
heart to work harder
(regurgitation,very bad)
3. The aorta, the body’s main artery, receives blood ejected from the left ventricle and
LV ⇒ aorta ⇒ arteries in body delivers it to all other arteries that supply the body’s tissues.
B. The heart’s electrical system controls heart rate and coordinates the work of the atria
sinus node (atria) and ventricles.

ventricles 1. The heart generates its own electrical impulse, starting at the sinus node.
builds electricity to 2. The impulse passes from the atria to the ventricles.
the ventricle
contract C. Automaticity allows spontaneous contraction without a stimulus from a nerve source.
1. As long as impulses come from the sinoatrial node, the other myocardial cells will
contract when the impulse reaches them.

sinus node = sinoatrial node

impulses are generated by the atria

 2. If no impulse arrives, however, the other myocardial cells are capable of creating their
own impulses and stimulating a contraction.
D. The autonomic nervous system (ANS) controls involuntary activities of the body.
1. The ANS has two parts, which normally balance one another.
a. Sympathetic nervous system
i. The “fight-or-flight” system THR, PRR, dilate muscles, constrict digestive system
opposites ii. Speeds up heart rate, increases respiratory rate and depth, dilates blood vessels in the
muscle,; and constricts blood vessels in the digestive system
stress vs. relax
iii. In times of stress, this system takes control.
i b. Parasympathetic nervous system IHR, IRR, constrict muscles, dilate digestive system
ii. Slows heart and respiratory rates, constricts blood vessels in the muscles, and dilates
blood vessels in the digestive system
iii. In times of relaxation, this system takes control.
E. The myocardium must have a continuous supply of oxygen and nutrients to pump
myocardium blood.
muscle heart
heart needs constant 1. Increased oxygen demand during periods of physical exertion is supplied by the dilation
oxygenated blood (widening) of the coronary arteries.
F. Stroke volume describes the volume of blood ejected with each ventricular contraction.
1. Increased stroke volume results in increased cardiac output. 9SV= 900
G. The coronary arteries are blood vessels that supply blood to heart muscle.
coronary artery 1. They start at the first part of the aorta, just above the aortic valve.
triple R 2. The right coronary artery supplies blood to the right atrium and right ventricle and, in
triple L most people, the inferior wall of the left ventricle.
3. The left coronary artery supplies blood to the left atrium and left ventricle and divides
into two major branches just a short distance from the aorta.
H. The arteries supply oxygenated blood to different parts of the body.
carotid (meck) ⇒ brain 1. The right and left carotid arteries supply the head and brain.
subclavian ⇒ arms + hands 2. The right and left subclavian arteries supply the upper extremities.
funder/below clavicle)
brachial ⇒ arms 3. The brachial artery supplies the arms.
radial/ulnar ⇒ forearm + hands
+ ris + less 4.
In" thinkiniinist
The radial and ulnar arteries supply the lower arms and hands.

femoral (inner thigh) ⇒ legs 5. The right and left iliac arteries supply the groin, pelvis, and legs.
tibial + peroneal ⇒ lower legs 6. The right and left femoral arteries supply the legs.
(calves) + feet
7. The anterior and posterior tibial and peroneal arteries supply the lower legs and feet.
I. The arterioles and capillaries are smaller vessels that receive blood from the arteries.
1. Capillaries are one-cell thick.
 CAV caps connect arterioles to venules

a. Exchange nutrients and oxygen for waste at the cellular level

b. Connect arterioles to venules

VCR ⇒ vena caval J. The venules and veins receive blood from the capillaries.
returns 1. Venules are the smallest branches of the veins.
2. Vena cavae return oxygen-poor blood to the heart.
chest up a. Superior (upper) vena cava carries blood from the head and the arms back to the right atrium.
chest down b. Inferior (lower) vena cava carries blood from the abdomen, kidneys, and legs back to the
right atrium.
K. Blood consists of several types of cells and fluid.
RBCs ⇒ 02 + CO2
WBCs ⇒ immune system 1 Red blood cells carry oxygen and remove carbon dioxide.
Platelets ⇒ dotting mechanism 2. White blood cells fight infection.
Plasma ⇒ fluid part of blood
3. Platelets help blood to clot.
4. Plasma is the fluid that cells float in.

Drive ⇒ diastolicL.relaxes
Blood pressure is the force of circulating blood against artery walls.
1. Systolic blood pressure is the maximum pressure generated in the arms and legs during
Scoundrel ⇒ systolic contacts
the contraction of the left ventricle during the time period known as systole.
a. The top number in a blood pressure reading
2. Diastolic blood pressure is the pressure against artery walls while the left ventricle
relaxes.
a. The bottom number in a blood pressure reading
M. A pulse is felt when blood passes through an artery during systole.
1. Peripheral pulses are felt in the extremities (eg, radial and posterior tibial).
2. Central pulses are felt near the trunk of the body (eg, femoral and carotid).
N. Cardiac output is defined as the volume of blood that passes through the heart in 1
minute.
1. Calculated by multiplying the heart rate by the volume of blood ejected with each
contraction (stroke volume)
CO-SVX HR
a. In the field, stroke volume can be roughly determined by the heart rate and the strength of a
patient’s pulse.
O. Perfusion describes the constant flow of oxygenated blood to the tissues.
1. Good perfusion requires the following:
a. A well-functioning heart
i. Appropriate heart rate allows the proper volume of blood to be circulated
b. An adequate volume of ”fluid” or blood
 i. Reduced volume (eg, through hemorrhage) limits the amount of tissue that can be
perfused.
Dilated⇒ slower flow, reduced c. Blood vessels must be appropriately constricted to match the volume of blood available.
perfusion i. Dilated blood vessels mean reduced perfusion.
2. If perfusion fails, cellular death occurs, and, eventually, the patient will die.

III. Pathophysiology lack of blood flow, can cause tissue death

A. Heart-related chest pain usually stems from ischemia, which is decreased blood flow to
the heart or inefficient supply of oxygen and nutrients.
1. Ischemic heart disease involves a decrease in blood flow to one or more portions of the
heart muscle.
2. If the blood flow is not restored, the tissue dies.
B. Atherosclerosis is a disorder in which calcium and cholesterol build up and form a
plaque inside the walls of blood vessels.
Antherosclerosis 1. It can cause complete occlusion or blockage of a coronary artery and other arteries of the
↳ Ca + cholesterol body.
build up fams 2. Fatty material accumulates as a person ages, resulting in the narrowing of the lumen
plaque (inside diameter of the artery).
↳ Plaque can break a. The inner wall of the artery becomes rough and brittle.
off and form dot b. If a brittle plaque develops a crack (for unknown reasons), the ragged edge of the crack
activates the blood-clotting system, resulting in a blood clot that will partially or completely
block the lumen of the artery.
embolism-dot 3. A thromboembolism is a blood clot that floats through the blood vessels.
thrombo = blood vessels a. If it reaches an area too narrow for it to pass, it stops and blocks blood flow at that point.
b. Tissues downstream from the blood clot will suffer from hypoxia.
c. If too much time passes before blood flow is resumed, the tissues will die.
AM I ⇒ caused by d. This sequence of events is known as acute myocardial infarction (AMI), a classic heart attack.
thromboembolism
and can lead to i. “Infarction” means the death of tissue.
cardiac arrest
e. The death of heart muscle can severely diminish the heart’s ability to pump, called cardiac
arrest.
(CAD)
4. In the United States, coronary artery disease is the number one cause of death for men
CAD ⇒ #I cause of and women.
death in US
a. The peak incidence of heart disease is between 45 and 64 years, but it can strike in
individuals ranging from their teens to their 90s.
5. Risk factors place a person at higher risk for an AMI.
↳ acute myocardial infarction
a. Major controllable risk factors:
i. Cigarette smoking
 ii. High blood pressure
iii. Elevated cholesterol level
iv. Elevated blood glucose level (diabetes)
v. Lack of exercise
vi. Obesity
b. Major uncontrollable risk factors:
i. Older age
ii. Family history of atherosclerotic coronary artery disease
iv. Race
v. Ethnicity
vi. Male sex
C. Acute coronary syndrome (ACS) describes a group of symptoms caused by myocardial
ACS → caused by ischemia.
ischemia 1. This includes temporary myocardial ischemia, resulting in angina pectoris or a more
↳ damage/death of serious condition, an AMI.
cardiac tissue
D. Angina pectoris occurs when the heart’s need for oxygen exceeds the available supply,
usually during physical or emotional stress.
Angina = chest pain 1. It can result from a spasm of an artery, but is most often a symptom of atherosclerotic
pectoris due to d 02
coronary artery disease.
↳ treat with nitro
a. May be triggered by large meal or sudden fear
b. When increased oxygen demand goes away, the pain typically goes away
2. Angina pain is commonly described as crushing, squeezing, or “like somebody is
standing on my chest.”
a. Usually felt in the midportion of the chest, under the sternum
b. Can radiate to the jaw, arms (frequently the left arm), midback, or epigastrum (the upper-
middle region of the abdomen)
c. Usually lasts from 3 to 8 minutes but rarely longer than 15 minutes
d. May be associated with shortness of breath, nausea, or sweating
e. Usually disappears promptly with rest, supplemental oxygen, or nitroglycerin (NTG)
3. Although angina does not usually lead to death or permanent heart damage, it is a
warning sign that should be taken seriously.
4. Unstable angina occurs in response to fewer stimuli than ordinarily required to produce
angina.
5. Stable angina responds to rest or nitroglycerin (see Skill Drill 16-1 ).
6. Patients experiencing chest pain or discomfort should always be treated as if they are
having an AMI.
 AMI vs angina
d
pain caused by pain caused by
ischemia lack of 02
E. The pain of AMI signals the actual death of cells in the area of the heart where blood
flow is obstructed.
1. Once dead, the cells cannot be revived.
a. They will turn to scar tissue and become a burden to the beating heart.
30 mins ⇒ start
dying b. About 30 minutes after blood flow is cut off, some heart muscles begin to die.

24ns ⇒ It dead c. After about 2 hours, as many as half of the cells in the area may be dead.
d. After 4 to 6 hours, more than 90% of the cells will be dead.
4-61ns ⇒ 90%+ dead
2. Opening the coronary artery with either “clot-busting” (thrombolytic) drugs or
clear with thrombolytic angioplasty (mechanical clearing of the artery) can prevent permanent damage if it is
+ angioplasty done within the first few hours after the onset of symptoms.
3. Immediate transport is essential.
LV = more common 4. It is more likely to occur in the left ventricle.
5. Signs and symptoms of AMI include the following:
a. Sudden onset of weakness, nausea, and sweating
b. Chest pain, discomfort, or pressure that is often crushing or squeezing that does not change
with each breath
c. Pain, discomfort, or pressure in the lower jaw, arms, back, abdomen, or neck
d. Irregular heartbeat and syncope (fainting)
e. Shortness of breath (dyspnea)
f. Nausea/vomiting
g. Pink, frothy sputum
h. Sudden death
6. The pain of AMI differs from the pain of angina in three ways:
can treat with a. It may or may not be caused by exertion and can occur at any time, sometimes when a person
is sitting quietly or even sleeping.
nitro
b. It does not resolve in a few minutes; rather, it can last between 30 minutes and several hours.
c. It may or may not be relieved by rest or nitroglycerin.
7. Not all patients who are having an AMI experience pain or recognize when it occurs.
a. When called to a scene where the chief complaint is chest pain, complete a thorough
assessment, no matter what the patient says.
8. Physical findings of AMI and cardiac compromise include the following:
a. General appearance
i. Frightened
ii. Nausea, vomiting, and a cold sweat
iii. Pale or ashen gray skin
iv. Cyanosis ⇒ no blood flow as dot is preventing heart from pumping blood around body
 b. Pulse p
i. Pulse rate increases in response to pain, stress, fear, or injury to the myocardium
ii. Irregularity or slowing pulse
iii. Bradycardia due to damage to inferior area of the heart
c. Blood pressure And
i. May fall due to diminished cardiac output and left ventricle function
ii. Most AMI patients will have a normal or, possibly, elevated blood pressure.
d. Respirations normal
i. Usually normal
ii. If the patient has congestive heart failure (CHF), they may be rapid and labored with a
higher likelihood of cyanosis and possibly frothy sputum.
e. Mental status
i. Confusion, agitation or overwhelming feelings of impending doom: “I think I am going
to die.”
9. An AMI can have three serious consequences:
a. Sudden death
b. Cardiogenic shock
c. Congestive heart failure
⇒ pulmonary edema (fluid in lungs) → plasma enters lungs due to accumulation of blood
F. Dysrhythmia describes an abnormality of the heart rhythm. trying and not succeeding in entering the heart
1. Premature ventricular contractions are extra beats in a damaged ventricle.
a. Harmless and common among healthy as well as sick people
2.p Tachycardia describes rapid beating of the heart, at 100 beats/min or more.
3. Bradycardia describes unusually slow beating of the heart, at 60 beats/min or less.
V-tach is fast 4. Ventricular tachycardia describes a very rapid heart rhythm, at 150 to 200 beats/min.
a. May deteriorate into ventricular fibrillation
5. Ventricular fibrillation describes the disorganized, ineffective quivering of ventricles.
V-fib is quiv
a. No blood is pumped through the body, and the patient usually becomes unconscious within
seconds.
b. Defibrillation may convert this arrhythmia.
G. Defibrillation is the process of shocking the heart with a specialized electrical current to
restore normal cardiac rhythms.
1. It can save lives if shocks are delivered within the first few minutes of sudden death.
2. CPR must be initiated until a defibrillator is available.
3. Chances of survival diminish approximately 10% each minute until defibrillation is
accomplished.
 no

longterm H. Asystole is the absence of all heart electrical activity.

ischemia ↳ heartbeat
1. It usually reflects a long period of ischemia.
2. Nearly all patients with asystole will die.
I. Cardiogenic shock occurs when body tissues do not get enough oxygen, causing body
602
organs to malfunction.
1. It is often caused by a heart attack.
2. The heart lacks the power to force enough blood through the circulatory system.
3. It is more common in an AMI affecting the inferior and posterior regions of the left
ventricle.
4. It is important to recognize shock in its early stages.
J. Congestive heart failure (CHF) often occurs within the first few days after a myocardial
infarction.
1. CHF develops when increased heart rate and enlargement of the left ventricle no longer
make up for decreased heart function (eg, due to diseased heart valves or chronic
pulmonary edema hypertension).
↳ in lungs 2. It is called “congestive” because lungs become congested with fluid (pulmonary edema)
once the heart fails to pump effectively.
dependent edema a. Occurs suddenly or slowly over months
↳ in feet + legs
due to gravity b. In acute-onset CHF, severe pulmonary edema is accompanied by pink, frothy sputum and
severe dyspnea.
3. Fluid may also collect in other parts of the body (dependent edema), such as in the feet
and legs.
High BP-
K. Hypertensive emergencies involve any systolic blood pressure greater than 180 mm Hg
or a rapid increase in the systolic pressure.
1. Sudden, severe headache is a common sign.
2. Other symptoms include the following:
a. Strong, bounding pulse
b. Ringing in the ears
c. Nausea and vomiting
d. Dizziness
e. Warm skin (dry or moist)
f. Nosebleed
g. Altered mental status
tear in aorta ⇒ will
h. Sudden development of pulmonary edema cause death
can cause stroke if not treated
3. Untreated hypertensive emergencies can lead to stroke or dissecting aortic aneurysm.
or dissecting antic in time
aneurysm 4. Transport patients to the hospital as quickly and safely as possible.
aneurysm ⇒ weakening/bulging of an artery

a. Consider ALS assistance, depending on transport distance and time

L. Aortic aneurysm describes a weakness in the wall of the aorta.
1. It is susceptible to rupture.
a. If it ruptures, blood loss will cause the patient to die almost immediately.
2. A dissecting aneurysm occurs when inner layers of the aorta become separated, allowing
blood to flow at high pressure between the layers.
3. Uncontrolled hypertension is the primary cause.
4. Signs and symptoms include the following:
a. Very sudden chest pain located in the anterior part of the chest or in the back between the
shoulder blades
b. Pain that usually comes on full force from one minute to the next
c. Sometimes, a difference in blood pressure between arms or diminished pulses in the lower
extremities
5. Transport patients to the hospital as quickly and safely as possible.

IV. Patient Assessment

A. Scene size-up
1. Ensure scene safety.
a. Ensure the scene is safe for you, your partner, your patient, and bystanders.
b. Determine the necessary standard precautions and whether you will need additional
resources.
2. Determine the nature of illness (NOI).
a. Use information from the dispatcher, clues at scene, and the comments of family members
and bystanders.
B. Primary assessment
1. Form a general impression.
a. If the patient is unresponsive and is not breathing, begin CPR, starting with chest
compressions, and call for an AED.
2. Assess the patient’s airway and breathing.
a. If dizziness or fainting has occurred due to cardiac compromise, consider the possibility of a
spinal injury from a fall.
b. Assess breathing to determine whether the ailing heart is receiving adequate oxygen.
i. Shortness of breath, with no signs of respiratory distress
(a) If oxygen saturation is less than 95%, administer oxygen at 4 L/min via nasal
cannula.
new (b) If they do not improve quickly, apply oxygen with a nonrebreathing mask at 15 L/min
L/min.
info

need to need to ensure patient is receiving enough 02

know
 ii. Not breathing or inadequate breathing
(a) Apply 100% oxygen with a bag-valve mask (BVM)
iii. Pulmonary edema
(a) Positive-pressure ventilation with BVM or continuous positive airway pressure
(CPAP)
3. Assess the patient’s circulation.
a. Pulse rate and quality
b. Skin color, moisture, and temperature
c. Capillary refill time
d. Consider treatment for cardiogenic shock early to reduce the workload of the heart.
e. Position the patient in a comfortable position, usually sitting up and well supported.
4. Make a transport decision based on whether you were able to stabilize life threats during
the primary assessment.
a. Remainder of the assessment can be performed en route, if time allows.
i. Most patients with chest pain should be transported immediately.
ii. Follow local protocol for determining what receiving facility is most appropriate (ie, the
nearest facility or a medical center with special capabilities).
b. Determine whether to use the lights and siren for each patient, partially based on estimated
transport time.
c. As a general rule, patients with cardiac problems should be transported in the most gentle,
stress-relieving manner possible.
C. History taking
1. Investigate the chief complaint.
a. Because patients experiencing AMI will have different signs and symptoms, seriously
consider all complaints of chest pain or discomfort, shortness of breath, and dizziness.
b. If the patient is experiencing dyspnea:
i. Is it due to exertion or related to the patient’s position?
ii. Is it continuous or does it change (eg, with deep breathing)?
c. If the patient has a cough:
i. Does it produce sputum?
d. Does the patient have nausea and vomiting, fatigue, headache, and/or palpitations?
e. Ask about recent past trauma.
2. Obtain the SAMPLE history from a responsive patient.
a. Ask the following questions:
i. Have you ever had a heart attack?
ii. Have you been told that you have heart problems?
cardiac
medical
history
if present
 iii. Do you have any risk factors for coronary artery disease?
b. In addition, ask:
i. What allergies does the patient have?
ii. Is the patient taking medications?
(a). Prescribed: For what condition?
(b) Over the counter
(c) Home remedies
3. Include the OPQRST questions when obtaining the symptoms as part of the SAMPLE
history.
a. Using OPQRST helps you to understand the details of specific complaints (see Table 16-
2).
D. Secondary assessment
1. Focus on the cardiac and respiratory systems.
a. Circulation
i. Assess pulses at various locations.
ii. Skin color
iii. Skin temperature
iv. Skin condition
b. Respirations
i. Are lung sounds clear?
ii. Are breath sounds equal?
iii. Are neck veins distended?
iv. Is the trachea deviated or midline?
2. Measure and record the patient’s vital signs.
a. Pulse
b. Respirations
c. Systolic and diastolic blood pressures in both arms
d. If available, use pulse oximetry.
e. If continuous blood pressure monitoring is available, use it as well.
f. Repeat at appropriate intervals and note the time that each set of vital signs is taken and
recorded.
g. In patients with chest pain, it is very valuable to have a 12-lead ECG tracing from as early as
possible after the onset of pain.
i. EMTs may assist with the placement of electrodes.
E. Reassessment
 1. Repeat the primary assessment by checking to see whether the patient’s chief complaint
and condition have improved or are deteriorating.
2. Reassess vital signs at least every 5 minutes or any time significant changes in the
patient’s condition occur.
3. Sudden cardiac arrest is always a risk with patients experiencing a cardiovascular
emergency.
a. If cardiac arrest occurs:
i. If an AED is immediately available, use it
ii. If not, perform CPR immediately until an AED is available.
4. Reassess your interventions.
5. Provide transport if not performed already.
6. Communication and documentation
a. Alert the emergency department about the patient’s condition and estimated time of arrival.
b. Follow the instructions of medical control.
c. Document your assessment and treatment of the patient.

V. Emergency Medical Care for Chest Pain or Discomfort

A. Ensure a proper position of comfort.
1. Allow patients to sit up if most comfortable.
2. Loosen tight clothing.
B. Give oxygen if indicated.
1. Continually reassess oxygen saturation and patient’s respiratory status.
a. Use nasal cannula for patients with mild dyspnea.
b. Use nonrebreathing face mask for patients with more serious respiratory difficulty.
i. Titrate the oxygen to obtain an oxygen saturation between 95% to 99%.
c. Assist unconscious patients with breathing as well as those with obvious respiratory distress.
i. Use BVM or positive-pressure ventilation device, according to local protocols.
C. Depending on local protocol, prepare to administer low-dose aspirin and assist with
prescribed nitroglycerin.
1. Aspirin
review a. Effects:
i. Prevents blood clots from forming or getting bigger
of skills
ii. 81-mg chewable tablets
exam iii. Recommended dose: 162 mg (two tablets) to 324 mg (four tablets)
2. Nitroglycerin
 a. Available forms:
i. Sublingual pill
ii. Sublingual spray
iii. Skin patch applied to chest
b. Mechanism of action:
i. Relaxes blood vessel wall muscles
ii. Increases blood flow and oxygen supply to heart
iii. Decreases workload of heart
( iv. Dilates blood vessels
c. Side effects:
i. Can cause a severe headache
ii. May cause change in patient’s pulse rate (eg, tachycardia or bradycardia)
d. Contraindications:
i. After administering nitroglycerin, if the patient’s systolic blood pressure is less than 100
mm Hg, do not administer more medication.
ii. Presence of head injury
iii. Use of erectile dysfunction drugs within 24 to 48 hours
iv. Maximum prescribed dose has already been given (usually 3 doses)
D. Administering nitroglycerin
1. Make sure medications are neither expired nor contaminated before administering them
to the patient.
2. Make sure prescription medications are prescribed for the patient.
3. Wear gloves when administering medication.
4. Follow the steps in Skill Drill 16-1 .

VI. Cardiac Monitoring

A. For an ECG to be reliable and useful, the electrodes must be placed in consistent
positions on each patient.
B. Certain basic principles should be followed to achieve the best skin contact and
minimize artifact in the signal.
1. Artifact refers to an ECG tracing that is the result of interference, such as patient
movement, rather than the heart’s electrical activity.
C. Guiding principles:
1. It may occasionally be necessary to shave body hair from the electrode site.
2. Rub the electrode site briskly with an alcohol swab before application to remove oils and
dead tissues from the surface of the skin.
3. Attach the electrodes to the ECG cables before placement.
a. Confirm that the appropriate electrode now attached to the cable is placed at the correct
location on the patient’s chest or limbs.
 4. Once all electrodes are in place, switch on the monitor.
a. Print a sample rhythm strip.
b. If the strip shows any artifact, verify that the electrodes are firmly applied to the skin and the
monitor cable is plugged in correctly.
5. Follow the steps in Skill Drill 16-2 .

VI. Heart Surgeries and Cardiac Assistive Devices

A. Over the last 30 years, hundreds of thousands of open-heart operations have been
performed to bypass damaged segments of coronary arteries in the heart.

place other B. In a coronary artery bypass graft, a blood vessel from the chest or leg is sewn directly
blood vessel from the aorta to a coronary artery beyond the point of obstruction.
so that heart can C.
continue doing its Percutaneous transluminal coronary angioplasty involves the following steps:
job
1. A tiny balloon is attached to the end of a long, thin tube.
opening up a 2. The tube is threaded into the narrowed coronary artery and inflated.
blocked blood 3. The balloon is then deflated, and the tube and balloon are removed.
vessel
4. Sometimes a stent in placed inside the artery.
D. Patients who have had a bypass procedure may or may not have a long scar on the
chest.
E. Treat chest pain in a patient who has had any of these procedures in the same way you
would treat chest pain in patients who have not had heart surgery.
F. Some people have cardiac pacemakers.
1. Pacemakers help maintain a regular cardiac rhythm and rate.
2. They are inserted when the electrical system of the heart is so damaged that it cannot
function properly.
3. These battery-powered devices deliver an electrical impulse through wires that are in
direct contact with the myocardium.
4. The generating unit typically resembles a silver dollar and is usually placed under a
heavy muscle or fold of skin in the left upper portion of the chest.
5. EMTs normally do not need to be concerned about problems with pacemakers.
6. When they do not function properly, pacemakers can cause a patient to experience
syncope, dizziness, or weakness due to an excessively slow heart rate.
7. The pulse will ordinarily be less than 60 beats/min.
8. A patient with a malfunctioning pacemaker should be promptly transported to the
emergency department.
9. When an AED is used, the patches should not be placed directly over the pacemaker.

pacemaker delivers impulses

comparison
automated cardiac defibrillators deliver shocks
 G. Automatic implantable cardiac defibrillators are sometimes used by patients who have
survived cardiac arrest due to ventricular fibrillation.
1. These devices continuously monitor the heart rhythm and deliver shocks as needed.
2. Treat these patients like all other patients having an AMI, including performing CPR and
using an AED if the patient goes into cardiac arrest.
3. The electricity from an automatic implantable cardiac defibrillator is so low that it will
have no effect on rescuers.
H. External defibrillator vest → delivers shocks
1. This device is a vest with built-in monitoring electrodes and defibrillation pads, which is
worn by the patient under his or her clothing.
2. The vest is attached to a monitor worn on a belt or hung from a shoulder strap.
3. This device uses high-energy shocks similar to an AED, so you should avoid contact with
the patient if the device warns that it is about to deliver a shock.
4. The vest should remain in place while CPR is being performed unless it interferes with
compressions.
a. If it is necessary to remove the vest, simply remove the battery from the monitor and then
remove the vest.
I. Left ventricular assist devices (LVADs) helps LV pump blood
1. These devices are used to enhance the pumping of the left ventricle in patients with
severe heart failure or in patients who need a temporary boost due to an MI.
2. May be pulsatile or continuous
↳ does it at pulse intervals
3. The patient or family may be able to tell you more about the device.
4. Unless the device malfunctions, you should not have to deal with it.
5. Contact medical control if there is any doubt in what to do.
6. Transport all LVAD supplies and battery packs with the patient.

VII. Cardiac Arrest

A. Cardiac arrest is the complete cessation of cardiac activity—electrical, mechanical, or
both.
no pulse 1. It is indicated in the field by the absence of a carotid pulse.
2. Cardiac arrest was almost always terminal until the advent of CPR and external
defibrillation in the 1960s.
B. Automated external defibrillation involves the use of a small computer (an automated
external defibrillator [AED]) that analyzes electrical signals from the heart.
1. It identifies ventricular fibrillation and is extremely accurate.
2. It administers a shock to the heart when needed.
3. AEDs come in different models.
a. All models require some operator interaction (ie, applying the pads, turning on the machine).
b. The operator must push a button to deliver an electrical shock.
c. Many use a computer voice synthesizer to advise the EMT which steps to take.
d. Most of the AEDs are semiautomated.
4. Advantages of AED use include the following:
a. Quick delivery of an electrical shock
b. Easy to operate
c. No need for ALS providers to be on the scene
d. Remote, adhesive defibrillator pads are safe to use
e. Larger pad area than manual paddles, which means that the transmission of electricity is more
efficient
5. Other considerations when using AEDs include the following:
a. Not all patients in cardiac arrest require electrical shock.
b. All patients in cardiac arrest should be analyzed with an AED; some do not have shockable
rhythms.
c. Asystole (flatline) indicates that no electrical activity remains.
d. Pulseless electrical activity usually refers to a state of cardiac arrest that exists despite an
organized electrical complex.
7. Early defibrillation is an essential intervention for patients experiencing cardiac arrest.
a. Few patients who experience sudden cardiac arrest outside of a hospital survive unless a rapid
sequence of events takes place.
b. Links in the chain of survival include:
i. Recognition of early warning signs and immediate activation of EMS
ii. Immediate CPR with emphasis on high-quality chest compressions
iii. Rapid defibrillation
iv. Basic and advanced EMS
v. ALS and postarrest care
c. CPR helps patients in cardiac arrest by prolonging the period during which defibrillation can
be effective.
d. Rapid defibrillation has successfully resuscitated many patients in cardiac arrest due to
ventricular fibrillation.
e. Defibrillation works best if it takes place within 2 minutes of the onset of the cardiac arrest.
f. Nontraditional first responders are being trained to use AED.
8. The final step in the chain of survival is ALS and postarrest care.
a. Continue ventilation at less than 12 breaths/min to achieve an ETCO2 of 35 to 40 mm Hg.
b. Maintain oxygen saturation between 94% and 99%
c. Assure blood pressure is above 90 mm Hg.
d. Maintain glucose levels in the patient who is hypoglycemic.
e. It also includes cardiopulmonary and neurologic support at the hospital as well as other
advanced assessment techniques and interventions when indicated.
9. When integrating the AED and CPR into patient care, keep the following in mind:
a. It is important to work the AED and CPR in sequence.
b. Do not touch the patient while the AED is analyzing the heart rhythm and delivering shocks.
c. CPR must stop while the AED is performing its job.
10. AED maintenance is important.
a. Become familiar with the maintenance procedures required for the brand of AED your
service uses.
b. Read the operator’s manual.
c. Three most common errors in using certain AEDS:
i. Failure of the machine to shock fine V fib
ii. Applying the AED to a patient who is moving, squirming, or being transported
iii. Turning off the AED before analysis or shock is complete.
d. Operator errors include:
i. Failing to apply the AED to a patient in cardiac arrest
ii. Not pushing the analyze or shock buttons when the machine advises you to do so
iii. Pushing the power button instead of pushing the shock button when a shock is advised.
e. Make sure the battery is properly maintained.
f. Check your equipment, including your AED, daily at the beginning of each shift.
g. Ask the manufacturer for a checklist of items that should be checked daily, weekly, or less
often.
h. Report any AED failure that occurs while caring for a patient to the manufacturer and to the
US Food and Drug Administration.
i. Be sure to follow the appropriate EMS procedures for notifying these organizations.
11. Medical direction should approve the written protocol that you will follow in caring for
patients in cardiac arrest.
a. The EMT team and your service’s medical director or quality improvement officer should
review each incident in which the AED is used.
b. Quality improvement involves both the individuals using AEDs and the responsible EMS
system managers.
c. Reviews should focus on speed of defibrillation (ie, the time from the call to the shock).
d. Shocks should be delivered within 1 minute of the call.
 e. Mandatory continuing education with skill competency review is generally required for EMS
providers.

VII. Emergency Medical Care for Cardiac Arrest

A. When preparing to use an AED, it is the EMT’s job to make sure that the electricity
from the AED injures no one.
1. Do not defibrillate patients in pooled water; electricity will diffuse through the pooled
water.
a. You can defibrillate a soaking wet patient, but dry the patient’s chest.
2. Do not defibrillate patients who are touching metal that others are touching.
3. Carefully remove a nitroglycerin patch from a patient’s chest, and wipe the area with a
dry towel before defibrillation to prevent ignition of the patch.
4. It is often helpful to shave a hairy patient’s chest before pad placement to increase
conductivity.
5. Determine the patient’s NOI and/or MOI.
a. Perform spinal immobilization for trauma patients during the primary assessment.
6. Call for ALS assistance if in a tiered system with a patient in cardiac arrest.
7. Use a well-organized team approach.
B. If you witness a patient’s cardiac arrest, begin CPR starting with chest compressions
and attach the AED as soon as it is available. See Skill Drill 16-3 for the steps of using
an AED.
C. Follow local protocols for patient care following AED use.
1. After the AED protocol is completed, one of the following is likely:
a. Pulse is regained (ROSC).
b. No pulse, and the AED indicates that no shock is advised.
c. No pulse, and the AED indicates that a shock is advised.
2. If ALS is responding to the scene, stay where you are and continue the sequence of
shocks and CPR.
3. If ALS is not responding to the scene and protocols agree, begin transport when one of
the following occurs:
a. The patient regains a pulse.
b. Six to nine shocks are delivered (or as directed by local protocol).
c. The machine gives three consecutive messages (separated by 2 minutes of CPR) that no
shock is advised (or as directed by local protocol).
D. Cardiac arrest during transport

during transport, if no pulse → stop vehicle and do CPR + use AED

 1. If you are traveling to the hospital with an unconscious patient and the patient becomes
pulseless:
a. Stop the vehicle.
b. Begin CPR if the AED is not immediately ready.
c. Call for ALS support or other available resources based on circumstances and local
protocol.
d. Analyze the rhythm.
e. Deliver one shock, if indicated, and immediately resume CPR.
f. Continue resuscitation according to your local protocol.
2. If you are en route with a conscious adult patient who is having chest pain and becomes
unconscious:
a. Check for a pulse.
b. Stop the vehicle.
c. Begin CPR if the AED is not immediately ready.
d. Analyze the rhythm.
e. Deliver one shock, if indicated, and immediately resume CPR.
f. Begin compressions and continue resuscitation according to your local protocol,
including transporting the patient.
E. Coordinate with ALS personnel according to your local protocols.
1. If you have an AED available, do not wait for paramedics to arrive.
2. Notify ALS personnel as soon as possible after you recognize a cardiac arrest.
3. Do not delay defibrillation.
4. When paramedics arrive, inform them of your actions to that point and then interact with
them according to your local protocols.
F. Management of return of spontaneous circulation
1. Monitor for spontaneous respirations.
2. Provide oxygen via BVM at 10 to 12 breaths/min.
3. Maintain an oxygen saturation between 95% and 99%.
4. Assess the patient’s blood pressure.
5. See if the patient can follow simple commands.
6. If ALS is not on scene or en route, immediately begin transport to the closest appropriate
hospital depending on local protocol.

Chapter 17
Neurologic Emergencies
 I. Introduction
A. Stroke is the fifth-leading cause of death and the leading cause of adult disability in the
United States, according to the American Stroke Association.

1. It is common in geriatric patients.

2. Contributing factors for stroke include family history and race.

a. African Americans, Hispanics, and Asians have a higher risk of stroke.

3. Treatments are available for stroke.

a. Many hospitals are certified stroke centers.
b. Rapid transport is vital.
B. Seizures and altered mental status may also occur when there is a disorder in the brain.

1. Seizures may occur as a result of:

a. A recent or prior head injury
b. A brain tumor
c. A metabolic problem
d. Fever
e. A genetic disposition

2. Altered mental status is a common presentation in patients with a wide variety of medical
problems.
a. Possible causes include:
i. Intoxication
ii. Head injury
iii. Hypoxia
iv. Stroke
v. Metabolic disturbances
b. Treatment varies widely.

II. Anatomy and Physiology

A. The brain is the body’s computer.

1. It controls breathing, speech, and all other body functions.

cerebrum = largest2. There are three major parts: brain stem, cerebellum, and cerebrum.
a. The cerebrum is the largest part.
brain stem = basic
fins b. The brain stem controls the most basic functions.
i. Breathing, blood pressure, swallowing, pupil constriction
cerebellum = coordination
c. The cerebellum controls muscle and body coordination.
 cerebrum
↳ controls opposite side of brain fine. stroke in RH will cause issue on left side of body)
↳ emotion + thought
↳ sensation + movement
↳ sight
↳ speech i. Walking, writing, picking up a coin, playing the piano
d. The cerebrum, located above the cerebellum, is divided into right and left hemispheres.
i. Each controls activities on the opposite side of the body.
ii. The front of the cerebrum controls emotion and thought.
iii. The middle part controls sensation and movement.
iv. The back part processes sight.
v. In most people, speech is controlled on the left side of the brain near the middle of the
cerebrum.
B. Messages sent to and from the brain travel through nerves.

12 facial nerves 1. Twelve cranial nerves run directly from the brain to parts of the head.
a. Eyes, ears, nose, and face

2. The rest of the nerves join in the spinal cord and exit the brain through a large opening in
the base of the skull called the foramen magnum.
↳ hole/opening ↳ large
3. At each vertebra in the neck and back, two nerves branch out.
2 spinal nerves branch
out of each vertebrae a. These are called spinal nerves.
b. They carry signals to and from the body.

III. Pathophysiology
A. Many different disorders may cause brain dysfunction and may affect the patient’s:

1. Level of consciousness

2. Speech

3. Voluntary muscle control sugar tem

B. The brain is most sensitive to changes in oxygen, glucose, and temperature levels.

1. A significant change in any one of these levels will result in a neurologic change.
issue with heart or 2. General rule:
lungs will directly
affect brain a. If a problem is caused primarily by disorders in the heart and lungs, the entire brain will be
affected.
b. If the primary problem is in the brain, only part of the brain is affected.
if issue stems from brain,
it will remain a localized issue
IV. Headache
A. One of the most common complaints you will hear from your patients in terms of pain
is headache.
 1. Headache can be a symptom of another condition or it can be a neurologic condition on
its own.

2. Only a small percentage of headaches are caused by a serious medical condition.

B. Tension headaches, migraines, and sinus headaches are the most common types.

1. These are not life threatening.

tension = muscle
d contraction2. Tension headaches
tense neck a. These headaches are caused by muscle contractions in the head and neck and are attributed to
stress.
b. The pain is usually described as squeezing, dull, or as an ache.
c. Usually do not require medical attention
C. Migraine headaches

1. They are thought to be caused by changes in the blood vessel size in the base of the brain.
dilated blood vessels
2. Both adults and children can experience migraines.
reason caffeine helps
migraines is due to 3. Women are three times as likely as men to experience migraines.
blood vessel constriction
4. The pain is usually described as pounding, throbbing, and pulsating.

5. Migraines are often associated with nausea and vomiting and may be preceded by visual
warning signs such as flashing lights or partial vision loss.

6. Migraine headaches can last for several hours to days.

D. Sinus headaches are caused by pressure that is the result of fluid accumulation in the
sinus cavities.
caused by
1. Patients may also have cold-like signs and symptoms of nasal congestion, cough, and
blocked sinuses fever.

2. Prehospital emergency care is not required.

E. Serious conditions that include headache as a symptom are hemorrhagic stroke
(bleeding in the brain), brain tumor, and meningitis.
↳ swelling of meninges in brain
1. You should be concerned if the patient complains of a sudden-onset, severe headache or a
sudden-onset headache that has associated symptoms.

2. You should suspect a stroke in patients with a severe headache, seizures, and altered
mental status.
3. Signs of increased intracranial pressure (ICP) include headache, vomiting, altered mental
status, and seizures.
4. Increasing ICP may be caused by a hemorrhagic stroke, tumor, or recent head trauma.

headaches need special attention

as they can cause death if misdiagnosed
 5. Your patient assessment should include asking the patient if he or she has experienced
any recent head trauma.

6. Consider not using lights and siren during transport.

V. Stroke
A. A cerebrovascular accident (CVA), or stroke, is an interruption of blood flow to an area
interrupted within the brain that results in the loss of brain function.
blood flow in
brain (i.e. from a 1. Lacking oxygen, brain cells stop functioning and begin to die within minutes.
clot)
2. Once brain cells die, not much can be done.

causes ischemia3. Brain cells develop ischemia, the reduction in blood supply that results in inadequate
oxygen being supplied to the cells, causing those cells to stop functioning properly.
and if cells die
4. It may take several hours or more for cell death to occur, because small trickles of blood
they cannot be may be keeping ischemic cells alive.
restored
5. With prompt restoration of blood flow, the cells will not die, and function can be
preserved or restored.
can be debilitating
or cause death B. Types of stroke blocks blood
a flow
brain bleed +
causes pressure
1. There are two main types of stroke: ischemic and hemorrhagic.
a. An ischemic stroke occurs when blood flow through the cerebral arteries is blocked.
b. In hemorrhagic stroke, a blood vessel ruptures and the accumulated blood causes increased
pressure in the brain.

2. Ischemic stroke → blockage (i. e. clot)

more common a. Most common, according to the American Stroke Association, accounting for more than 80%
of strokes
b. When blood flow to a particular part of the brain is stopped by a blockage (blood clot) inside
a blood vessel
c. This blockage can be due to thrombosis, where a clot forms at the site of blockage, or due to
an embolus, where the clot forms in a remote area and then travels to the site of blockage.
d. Symptoms may range from nothing at all to complete paralysis.
e. Atherosclerosis in the blood vessels is often the cause of ischemic stroke.
plaque breaks
i. Disorder in which calcium and cholesterol build up, forming a plaque inside the walls of
off + creates dot
the blood vessels
ii. This plaque may obstruct blood flow and interfere with the vessel’s ability to dilate.
iii. Eventually, it causes complete occlusion of an artery.
iv. Even if the blockage in the carotid artery is not complete, smaller pieces of the clot may
embolize deep into the brain and become lodged in a smaller branch of a blood vessel,
blocking blood flow.

3. Hemorrhagic stroke ⇒ brain bleed that causes clots to fam to stop the bleeding, and in
doing so, blocking blood flow to that area
 less
common a. Accounts for 13% of strokes, according to the American Stroke Association.
b. Results from bleeding inside the brain
i. Blood forms a clot, which compresses the brain tissue next to it.
ii. This compression prevents oxygenated blood from getting into the area, and the brain
cells begin to die.
c. Cerebral hemorrhages are often fatal.
d. People at high risk include those experiencing stress or exertion.
e. People at highest risk are those who have very high blood pressure or long-term elevated
blood pressure that is not treated.
i. Blood vessels in the brain weaken.
ii. If a vessel ruptures, the bleeding in the brain will increase the pressure inside the
cranium.
f. An aneurysm is a swelling or enlargement of the wall of an artery resulting from a defect or
weakening of the arterial wall.
g. A symptom may be the sudden onset of a severe headache.
h. When a hemorrhagic stroke occurs in an otherwise healthy young person, it is likely caused
by a weakness in a blood vessel called a berry aneurysm.
i. Surgical repair may be possible if care is sought immediately.

4. Transient ischemic attack (TIA) → brain's blood flow is obstructed by clot

a. When blood flow to the brain is obstructed due to atherosclerosis or a small blood clot, the
temporary patient may exhibit signs of a stroke.
b. When stroke-like symptoms go away on their own in less than 24 hours, the event is called a
no tissue death transient ischemic attack.
i. Some patients call these mini-strokes.
c. No actual death of tissue occurs with a TIA.
warning sign d. Because symptoms of a TIA can last up to 24 hours, you may not be able to differentiate
for future stroke between a stroke and a TIA.
e. Although most patients with TIAs do well, every TIA is an emergency.
f. It may be a warning sign that a more significant stroke may occur in the future.
i. About one third of patients who have a TIA will experience a stroke soon after.
ii. All patients with a TIA should be evaluated by a physician.
C. Signs and symptoms of stroke

1. General signs and symptoms include the following:

Weakness/unable to a. Facial drooping
use one side of the b. Sudden weakness or numbness in the face, arm, leg, or one side of the body
body c. Decreased or absent movement and sensation on one side of the body
d. Lack of muscle coordination (ataxia) or loss of balance
e. Sudden vision loss in one eye, or blurred and double vision
f. Difficulty swallowing
g. Decreased level of responsiveness
 unable to express
yourself
h. Speech disorders
i. Aphasia: difficulty expressing thoughts or inability to use the right words (expressive
aphasia) or difficulty understanding spoken words (receptive aphasia)
j. Slurred speech (dysarthria)
k. Sudden and severe headache
l. Confusion
m. Dizziness
n. Weakness
o. Combativeness
p. Restlessness
q. Tongue deviation
r. Coma

2. Left hemisphere ⇒ R body

a. Stroke in the left cerebral hemisphere may cause aphasia.
i. Aphasia is the inability to produce or understand speech.
ii. Speech problems can vary widely.
b. Strokes that affect the left side of the brain can also cause paralysis of the right side of the
body.

3. Right hemisphere ⇒ L body

a. Strokes that affect the right side of the brain can cause paralysis of the left side of the body.
oblivious ⇒ neglect b. Usually, patients will understand language and be able to speak, but their words may be
slurred and hard to understand.
c. Patients may be oblivious to their problem; this symptom is called neglect.
i. Patients with a problem affecting the back part of the cerebrum may neglect certain parts
of their vision.
d. Neglect and lack of pain cause many patients to delay seeking help.

4. Bleeding in the brain

IBP a. Patients may have very high blood pressure.
i. May be the cause of the bleeding
if BPJ, condition
ii.May be caused by the bleeding, as a compensatory response
worsened
b. A trend of increasing blood pressure is an important sign, as the body must increase the blood
pressure to get blood to the brain’s tissues.
c. Significant drops in blood pressure may occur as the patient’s condition worsens.
d. Monitoring the blood pressure for changes in these patients is very important.
D. Conditions that may mimic stroke

1. Hypoglycemia ⇒ low blood glucose levels

a. Not enough blood glucose

2. Postictal state→ after seizure, as patient regains consciousness

↳ labored breathing
↳ altered
 a. Period following seizure that lasts between 5 and 30 minutes, characterized by labored
respirations and some degree of altered mental status

3. Subdural or epidural bleeding

a. A collection of blood near the skull that presses on the brain

VI. Seizures
A. A seizure is a neurologic episode caused by a surge of electrical activity in the brain.
Un coordination
+ alter. of consciousness 1. Can take the form of a convulsion, characterized by generalized uncoordinated muscle
activity, and/or can be associated with a temporary alteration in consciousness.

2. In the United States, it is estimated that 2 to 3 million people have epilepsy, a common
cause of seizures.

3. Seizures are classified into two basic groups: generalized and partial (focal).
gin and tonic 4. Generalized (tonic-clonic) seizure
a. This type of seizure results from abnormal electrical discharges from large areas of the brain,
genteralized usually involving both hemispheres.
tonic-clonic b. Typically characterized by unconsciousness and a generalized severe twitching of all muscles
that lasts several minutes or longer.
unconscious c. In other cases, the seizure may simply be characterized by a brief lapse of consciousness in
severe twitching which the patient seems to stare and not respond to anyone.
i. This type of seizure does not involve any changes in motor activity.
ii. Called a petit mal or absence seizure

5. Partial (focal) seizure

Simple a. Begins in one part of the brain and is classified as simple or complex
→ no change in consciousmeSS b. Simple partial seizure
→ some twitching i. No change in the patient’s level of consciousness
ii. Patients may have numbness, weakness, dizziness, visual changes, or unusual smells and
tastes
complex iii. May also cause some twitching or brief paralysis
→ altered mental status c. Complex partial seizure
→ abnormal discharges from i. The patient has an altered mental status and does not interact normally with his or her
temporal lobe (near forehead)
→ lip smacking + isolated jerking environment.
→ smells + hallucinations + ii. Results from abnormal discharges from the temporal lobe of the brain
fear etc. iii. Other characteristics may be lip smacking, eye blinking, and isolated jerking.
iv. Patients also may experience unpleasant smells and visual hallucinations, exhibit
uncontrollable fear, or perform repetitive physical behavior.
6. Patients may experience an aura prior to a seizure.
may have an auraa. Can include visual changes (flashing lights or blind spots in the field of vision) or
hallucinations (seeing, hearing, or smelling things that are not actually present).
pride ⇒ visual changes
or hallucinations

some may feel it coming

 b. People with a history of seizures recognize their auras and usually take steps to minimize
injury, such as sitting or lying down.
c. Auras do not occur prior to every seizure, and not all patients with a seizure disorder
experience an aura.
7. Generalized seizure
a. Characterized by sudden loss of consciousness followed by chaotic muscle
movement
and tone, and apnea.
b. During a generalized seizure, a patient may exhibit bilateral muscle movement characterized by a
cycle of muscle rigidity and relaxation usually lasting 1 to 3 minutes.
i. The patient exhibits tachycardia, hyperventilation, sweating, and intense
salivation.
THR PRR ii. Most seizures last 3 to 5 minutes.
iii. A postictal state (5 to 30 minutes) follows, in which the patient is unresponsive at
first and gradually regains consciousness.
8. In contrast, an absence (formerly called petit mal) seizure may last for just seconds, after
which the patient fully recovers with only a brief lapse of memory of the event.
9. Seizures lasting more than 5 minutes are likely to progress to status epilepticus.
a. Seizures that continue every few minutes without the person regaining consciousness or last
longer than 30 minutes are referred to as status epilepticus.
B. Causes of seizures
present from birth
1. Some seizure disorders, such as epilepsy, are congenital.

2. Others may be caused by:

a. High fever
b. Structural problems in the brain
c. Metabolic or chemical problems in the body
d. Idiopathic (cause cannot be determined)

3. Epileptic seizures usually can be controlled with medications.

a. Medications used most often to treat seizures include:

i. Levetiracetam (Keppra)

ii. Phenytoin (Dilantin)

iii. Phenobarbital

iv. Carbamazepine (Tegretol)

v. Valproate (Depakote)

vi. Topiramate (Topamax)

 vii. Clonazepam (Klonopin)
scar tissue
4. Seizures may also be caused by an abnormal area in the brain (structural cause), such as:
SIT → tuma 0
a. A benign or cancerous tumor
infection b. An infection (brain abscess,
- meningitis)
c. Scar tissue from some type of injury

5. Seizures from a metabolic cause can result from:

a. Abnormal levels of certain blood chemicals
b. Hypoglycemia ⇒ d blood glucose
c. Poisons
d. Drug overdoses
e. Sudden withdrawal from routine heavy alcohol or sedative drug use
f. Prescribed medications

6. Seizures can also result from sudden high fevers, particularly in children.
febrile-fever a. Known as febrile seizures
b. Always transport a child who has had a febrile seizure for evaluation at a hospital; it is
possible a second seizure may occur.
C. The importance of recognizing seizures
cyphosis 1. You must recognize when a seizure is occurring and whether this episode differs from
previous ones. -
may have trouble breathing
a. Patient may turn cyanotic from a lack of oxygen in the blood.
blood glucose may drop
b. Seizures may prevent the patient from breathing normally.
hypoglycemia c. In a patient with diabetes, the blood glucose level may decrease.
i. If your local protocol allows, closely monitor blood glucose levels after a patient with
diabetes has a seizure.

2. You must look at other problems associated with the seizure.

a. Patients who have fallen during a seizure may have a head injury.
b. Patients having a generalized seizure also may experience incontinence. ⇒ loss of control over urination or defecation
D. The postictal state

after seizure 1. Once a seizure has stopped, the patient’s muscles relax, becoming almost flaccid, or
floppy, and the breathing becomes labored (fast and deep).
↳ muscles relax
↳ labored breathing a. This breathing pattern helps the body balance the acidity in the bloodstream.
b. With normal circulation and liver function, the patient will begin to breathe more normally
within minutes.

2. In some situations, the postictal state may be characterized by hemiparesis, or weakness

on one side of the body, resembling a stroke.

hemiparesis
half weakness/
partial paralysis
 3. The postictal state is most commonly characterized by lethargy and confusion.
a. The patient may be combative.
b. You must be prepared for these circumstances.

4. If the patient’s condition does not improve, you should consider other possible
underlying conditions.
a. Hypoglycemia ⇒ I BGL
b. Infection
E. Syncope
1. Seizures are often mistaken for syncope (fainting).
a. Fainting typically occurs while the patient is standing.
b. Seizures may occur in any position.
c. Fainting is not associated with a postictal state.

VII. Altered Mental Status

A. Aside from stroke and seizures, the most common type of neurologic emergency that
you will encounter is a patient with an altered mental status.

1. The patient is not thinking clearly or is incapable of being aroused.

2. In some cases, the patient will be unconscious; in others, the patient may be alert but
confused.
3. Causes include:
a. Hypoglycemia ⇒ d BGL
b. Hypoxemia ⇒ 102
c. Intoxication
d. Delirium
e. Drug overdose
f. Unrecognized head injury
g. Brain infection
h. Body temperature abnormality
i. Brain tumor
j. Overdose and/or poisoning
B. Causes of altered mental status

1. Hypoglycemia
a. Patients can have signs and symptoms that mimic stroke and seizures.
i. In these cases, the patient may have hemiparesis, similar to what occurs as a result of a stroke.
altered
ii. The principal difference is that a patient who has had a stroke may be alert and attempting to
communicate normally, whereas a patient with hypoglycemia almost always has an altered or
decreased level of consciousness.
can have b. Patients with hypoglycemia commonly, but not always, take medications that lower the blood
glucose level.
a seizure
c. Patients with hypoglycemia can also experience seizures.
i. The mental status of a patient with hypoglycemia is not likely to improve, even after several
minutes.
d. Consider hypoglycemia in a patient who has altered mental status after an injury such as a
motor vehicle crash.

2. Delirium

a. Delirium is a symptom, not a disease.

b. Presents as a new complaint, rather than a long-standing alteration in behavior.

c. Temporary state that often has a physical or mental cause

i. Infection

ii. Changes in medications

iii. Hypoxia

d. May be reversed with proper treatment

e. Signs and symptoms include:

i. Confusion and disorientation

ii. Disorganized thoughts

iii. Inattention

iv. Memory loss

v. Striking changes in personality and affect

vi. Hallucinations
vii. Delusions
viii. Decreased level of consciousness

f. The patient may experience rapid alteration between mental states such as lethargy and
agitation.

g. Symptoms of delirium may mimic intoxication, drug abuse, or severe psychological disorders
such as schizophrenia.

h. Delirium is discussed in detail in Chapter 35, Geriatric Emergencies.

3. Other causes of altered mental status

 a. Consideration of other possibilities becomes important because a patient with altered mental
status may be combative and refuse treatment and transport.
b. Unrecognized head injury
c. In most cases, a patient who appears intoxicated is just that; however, you must consider
other problems.
d. Psychological disorders and medication complications are also possible causes.
e. Infections may cause altered mental status, particularly those involving the brain or
bloodstream.

VIII. Patient Assessment

A. Scene size-up

1. Scene safety
a. In some calls to the dispatcher, the description of the patient’s signs and symptoms will
provide a fairly good idea of what the problem may be and the dispatcher will be able to
convey this information to the responding crew.
b. Patients with altered mental status may exhibit a wide range of signs and symptoms and
behaviors.
c. The most significant difference between an altered mental status and other emergencies is
that your patient cannot tell you reliably what is wrong.
d. Do not be distracted by the seriousness of the situation or by frightened family members.
e. Look first for threats to your safety, and follow standard precautions.
f. Consider the need for spinal immobilization based on dispatch information and your
assessment of the scene.
g. Call for additional resources early.

2. Mechanism of injury/nature of illness

a. Look for clues to help you determine the nature of illness.
b. There are special considerations for a patient with a suspected neurologic emergency:
i. An evaluation of the environment, assessing for any signs of potential trauma
ii. Indications of a previous medical condition
iii. Evidence of a seizure
iv. Ask family when was the last time the patient appeared normal.
B. Primary assessment

1. Remember that your first priority is to look for and treat life-threatening conditions.

2. Perform a rapid exam.

3. As you approach the patient:

a. Gather information from the scene.
b. Note the patient’s body position and level of consciousness.
c. This initial impression will help you determine the severity of the situation
 d. You should be able to tell if a seizure is still taking place.
i. Unless you are stationed extremely close to the scene, most seizures will be over by the time
you arrive.
ii. If the seizure is still occurring, status epilepticus may be present.
e. Use the AVPU scale.

4. Airway and breathing

a. Stroke patients may have difficulty swallowing and are at risk for choking on their own
saliva.
b. Evaluate the airway of an unresponsive patient to make sure it is patent and will remain so.
c. Be prepared to provide suction.
d. Position the patient to prevent aspiration.
e. Check for foreign body obstruction.
f. Assess the patient’s breathing.
i. All patients with an altered mental status, regardless of the cause, should receive
high-flow oxygen.
g. It is important to ventilate the patient at the appropriate rate with the proper
volume.
i. Deliver each breath during a period of 1 second at a rate of 10 to 12
breaths/min.
ii. Do not hyperventilate the patient.
try to prevent h. Hyperventilation may have several negative consequences.
ho
r
ypersvteonpn
tilatio i. Overinflates the lungs, which can impair blood return to the right atrium and cause a
decrease in cardiac output
ii. Increases the risks of regurgitation and aspiration.
iii. May cause severe injury in patients with intracerebral bleeding and increased intracranial
pressure, causing cerebral vasoconstriction, which shunts blood (and oxygen) away from the
brain, causing further injury to the brain.

5. Circulation
a. Begin by checking the pulse if the patient is unresponsive.
b. If no pulse is found, immediately begin CPR and attach an AED.
c. If the patient is responsive, determine if the pulse is fast or slow, weak or strong.
d. Evaluate the patient quickly for external bleeding.

6. Transport decision
a. Establish your priorities based on your assessment of the patient’s level of consciousness and
ABCs.
b. If you suspect the patient is having a stroke, you should rapidly transport the patient to an
appropriate facility.
C. History taking

1. Investigate the chief complaint.

Recognize
a. If the patient is unresponsive, gather any history of the present illness from family or
stroke ⇒ one side bystanders.
weakness
b. If no one is around, quickly look for explanations for the altered mental status, such as a
Seizure ⇒ incontinence or stroke (hemiparalysis or one-sided weakness) or seizure (incontinence or bitten tongue).
bitten tongue c. In a responsive patient, ask him or her what happened.
d. Evaluate the patient’s speech.
e. Gather a SAMPLE history.
i. Remember that time can be critical in a neurologic emergency.
ii. Make a special effort to determine the exact time that the patient last appeared to be healthy.
iii. Collect or list all medications the patient has taken.
iv. Patients who have had a stroke may appear to be unconscious and unable to speak, but they
may still be able to hear and understand what is taking place.
v. Try to establish effective communication.
vi. Your history should reveal if the patient has a history of seizures.
vii. Find out if this episode differs from previous episodes and what medications the patient takes.
(a) Note medications used to treat a seizure disorder.
viii. If the patient does not have a history, a serious condition should be suspected.
D. Secondary assessment

1. Physical examinations
a. Your assessment should continue with a secondary assessment of the entire body, paying
special attention to the system involved.
b. If you suspect your patient is having a stroke, direct particular attention to your neurologic
assessment.

2. Vital signs
a. Patients with significant intracranial bleeding may have a great deal of pressure in the skull
that is compressing the brain.
TBP i. This slows the pulse and causes respirations to be erratic.
unequal pupils
ii. Blood pressure is usually high to compensate for poor perfusion in the brain.
altered → check BGL iii. Unequal pupil size and reactivity indicate significant bleeding and pressure on the brain.
b. If the patient has an altered mental status, you should check the glucose level if you have the
equipment available.
c. During most active seizures, it is impossible to evaluate vital signs and this should not be
your priority.
d. In most cases, vital signs of a patient in a postictal state will be close to normal limits.
e. Monitoring devices
i. Use a portable blood glucose monitor to check blood glucose levels.
ii. You may also use noninvasive blood pressure methods to monitor blood pressure.

3. Stroke assessment
a. Rapidly identify stroke in the field with a stroke scale.
b. Stroke scales evaluate the face, arms, and speech.
 c. The Cincinnati Prehospital Stroke Scale and the Los Angeles Prehospital Stroke Screen are
commonly used.
i. To test speech, ask the patient to repeat a simple phrase. "the sky is blue"
ii. To test facial movement, ask the patient to smile, showing his or her teeth.
iii. To test arm movement, ask the patient to hold both arms in front of his or her body, palms up
toward the sky, with eyes closed and without moving.
d. 3-Item Stroke Severity Scale (LAG)
i. Looks specifically at three items—level of consciousness, arm drift (motor function), and
gaze.
e. FAST mnemonic
Face
i. Facial droop
Arms
ii. Arm drift Speech
iii. Speech Time to call 9-1-1
iv. Time (the time the patient last acted normally)
f. All patients with an altered mental status should also have a Glasgow Coma Scale (GCS)
score calculated.
E. Reassessment

1. Focus on reassessing the ABCs, vital signs, and interventions provided so far.
a. Patients who have had a stroke can lose their airway or stop breathing without warning.

2. Interventions
a. Multiple interventions may be necessary.
i. Airway adjuncts
ii. Positive-pressure ventilations
iii. Other treatments
iv. If an intervention is not working, try something else.
b. Compare baseline information with updated information.
call stroke alert c. Notify the receiving facility of your patient’s chief complaint and your assessment findings.
so hospital is ready i. Local protocol will tell you if the designated stroke centers in your call area want you to call
for patient in a “stroke alert” for patients you have assessed and found to be having a stroke.
ii. Report the time the patient last appeared to be healthy.
iii. Report the findings of your neurologic examination and the time you anticipate arriving at the
hospital.
d. For patients who have had a seizure, give a description of the seizure activity if known.
i. If the patient has a history of seizure activity, determine how often the seizures occur and
if there is any history of status epilepticus.
e. Document interventions and the patient’s response.

IX. Emergency Medical Care

A. General
 1. Some conditions are easier to identify with treatment options that are readily available.
2. The cause of other neurologic emergencies may not always be obvious to you.
a. This may make it difficult for you to provide definitive treatment in the field.
3. In most patients with a suspected stroke, physicians in the emergency department need to
determine whether there is bleeding in the brain.
a. The only reliable way to tell is with a CT scan of the head.
no bleed ⇒ blood thinner i. If there is no bleeding, the patient may be a candidate for blood clot–dissolving
medication.
bleed present ⇒DO NOT give blood
thinner, will worsen ii. If bleeding is present, this medication will increase bleeding with disastrous
bleeding consequences.
b. Some EMS systems designate specific hospitals, typically accredited stroke hospitals, for
patients who may be having a stroke.
c. Notify the hospital staff as early as possible if you have a “stroke alert” patient.
try to find out last timed. Only a limited number of treatments are available that are effective if started more than 3
hours after the stroke began.
patient was/felt normal
i. Notify the hospital regarding the last time the patient was known to be without their
current signs and symptoms of stroke.
4. Patients who have had a seizure require definitive evaluation and treatment in the
hospital.
a. Supplemental oxygen is strongly advised.
b. Most seizures will not require a significant amount of intervention on your part.
c. For patients who are having a seizure:
i. Protect them from harm.
ii. Maintain a clear airway by suctioning.
iii. Provide oxygen as quickly as possible.
iv. If head or neck trauma is suspected, provide spinal immobilization
d. For patients who continue to have a seizure, as in status epilepticus:
i. Suction the airway. → patient may drool
ii. Provide positive-pressure ventilations.
iii. Transport quickly to the hospital.
iv. Rendezvous with ALS, if possible.
B. Headache

1. Most headaches are harmless and do not require emergency medical care.

2. You should be concerned if the patient complains of:

a. A sudden-onset, severe headache
b. A sudden headache with fever, seizures, altered mental status, or following trauma

3. Migraine
a. Always assess the patient for other signs and symptoms that might indicate a more serious
high-flow Or condition.
b. Apply high-flow oxygen, if tolerated.
 c. Provide a darkened and quiet environment.
d. Do not use lights and sirens during transport.
B. Stroke

1. Support the ABCs and provide rapid transport to a stroke center.

2. The patient may require manual airway positioning.

3. Use suction as needed and monitor the patient’s oxygen saturation with a pulse oximeter.

a. Maintain a Spo2 level of at least 94%.

giving Oz is not 4. Routine use of oxygen therapy is not recommended unless the patient is experiencing
recommended respiratory distress or is showing signs of hypoxia.
unless you really have to
5. A patient’s paralyzed extremities will require protection from harm.

p can stop stroke 6. Continuously talk to the patient and inform him or her of what is going on.
thrombolytic 7. Thrombolytic therapy (blood clot–dissolving drugs) and methods to mechanically remove
given within 3hr the blood clot may reverse stroke symptoms and even stop the stroke if given within 3
(drugs) or 6 hours hours (drugs) or 6 hours (mechanical methods).
↳ the sooner the better
8. Comprehensive stroke centers are able to offer advanced stroke care and in some cases
may be able to provide thrombolytic therapy even after the 3- and 6-hour window.
a. Proceed under the assumption that an area of the brain can still be saved.
b. The sooner the treatment is done, the better the patient’s prognosis.

9. Spend as little time at the scene as possible.

a. Stroke is an emergency, and “time is brain.”
b. If possible, transport to a designated stroke center.
C. Seizure

1. The patient may be in postictal state upon your arrival.

2. Alternatively, the patient may still be having the seizure.

a. Continue to assess and treat ABCs.
b. Try administering oxygen.
c. It is difficult to safely prepare a patient for transport who is having a seizure.
i. Assess for trauma.
ii. Use spinal immobilization if indicated.
iii. Never attempt to restrain a patient having a seizure.

3. Not every patient who has had a seizure wants to be transported.

a. It is usually in the patient’s best interest to be evaluated by a physician.
 b. Your goal is to encourage the patient to be seen by a physician.
c. Be prepared to discuss the situation with the hospital staff.
d. If the patient still refuses transport, ask yourself the following questions:
i. Is the patient awake and completely oriented after a seizure (GCS score of 15)?
ii. Does your assessment reveal no indication of trauma or complications from the seizure?
iii. Has the patient ever had a seizure before?
iv. Was this seizure the “usual” seizure in every way (length, activity, recovery)?
v. Is the patient currently being treated with medications and receiving regular evaluations
by a physician?
D. Altered mental status

1. Signs and symptoms vary from simple confusion to coma.

2. Regardless of the signs and symptoms, altered mental status is always an emergency that
requires immediate attention, even if the cause appears to be intoxication or minor head
trauma.

Chapter 18
Gastrointestinal and Urologic Emergencies

I. Introduction
A. Abdominal pain is a common complaint.
1. The cause of abdominal pain is often difficult to identify.
B. As an EMT:
1. You do not need to determine the exact cause of abdominal pain.
2. You should be able to recognize a life-threatening problem and act swiftly in response.
3. The patient in pain is probably anxious, requiring your skills of rapid assessment and
emotional support.

II. Anatomy and Physiology

A. Abdominal cavity
1. Contains solid and hollow organs that make up three systems:
a. Gastrointestinal system
GOG b. Genital system
c. Urinary system
2. Injury to a solid organ can cause shock and bleeding.
3. If perforation of these hollow organs occurs, the contents will leak and contaminate the
abdominal cavity.
↳ ex: gallbladder, stomach,etc.
 B. Gastrointestinal system
1. Responsible for digestion process
2. Digestion begins when food is put into the mouth and chewed.
3. The stomach is the main organ of the digestive system.
a. Gastric juices break down food.
4. The liver assists in digestion.
a. Secretes bile
b. Filters toxic substances produced by digestion
c. Creates glucose stores
d. Produces substances necessary for blood clotting and immune function
5. The gallbladder is a reservoir for bile.
6. Food then travels to the small intestine, which consists of three sections:
a. Duodenum
b. Jejunum
c. Ileum
7. Colon (large intestine)
a. Food not broken down and used moves into the colon as waste product.
b. Water is absorbed and stool is formed.
8. The spleen is located in the abdomen but has no digestive function.
D. Genital system
1. The abdominal space also holds reproductive organs.
E. Urinary system
kidney 1. Controls discharge of certain waste materials filtered from blood by the kidneys
2. There are two kidneys, one on each side of the body.
so
bladder 3. Ureters join each kidney to the bladder.
4. The urinary bladder is located immediately behind the pubic symphysis.
EE 5. The bladder empties to the outside of the body through the urethra.
6. A normal adult forms 1.5 to 2 L of urine per day.

III. Pathophysiology
A. The abdominal cavity is lined by a membrane called the peritoneum.
1. The peritoneum also covers the organs of the abdomen.
Vico Pawa a. Parietal peritoneum: lines the walls of the abdominal cavity
b. Visceral peritoneum: covers the organs
2. The presence of foreign material (blood, pus, bile, pancreatic juice, amniotic fluid) can
irritate the peritoneum, causing peritonitis.
B. Acute abdomen refers to the sudden onset of abdominal pain.
 1. Often associated with severe, progressive problems requiring medical attention
C. Peritonitis (inflammation of peritoneum)
1. Can cause ileus, which is paralysis of muscular contractions that normally propel material
through the intestine
⇒ condition in which bulging pouches develop in the digestive tract
2. Diverticulitis
3. Cholecystitis → inflammation of gallbladder
4. Acute appendicitis
D. Abdominal pain
1. Two types of nerves supply the peritoneum:
a. Parietal peritoneum: supplied by the same nerves that supply the skin of the abdomen
b. Visceral peritoneum: supplied by the autonomic nervous system
2. Referred pain
E. Common causes of acute abdomen
1. Ulcers: protective layer of the mucus lining erodes, allowing acid to eat into the organ
a. Common causes → meds, stress, etc.
b. Signs and symptoms → pain
c. Complications
2. Gallstones
a. May form and block the outlet from the gallbladder
b. If the blockage is not relieved, inflammation of the gallbladder (cholecystitis) can occur.
c. Common causes
d. Signs and symptoms
e. Complications
3. Pancreatitis: inflammation of the pancreas
a. Common causes
b. Signs and symptoms
c. Complications
4. Appendicitis: inflammation or infection in the appendix
a. Common causes
b. Signs and symptoms
c. Complications
5. Gastrointestinal hemorrhage ⇒ bleeding
a. Symptom of another disease, not a disease itself
b. May be acute or chronic
c. Can occur in upper or lower gastrointestinal tract
d. Common causes
e. Signs and symptoms
6. Esophagitis
 a. Occurs when the lining of the esophagus becomes inflamed by infection or acids from the
stomach
b. Gastroesophageal reflux disease (GERD)
c. Common causes
d. Signs and symptoms
7. Esophageal varices abnormal, enlarged veins
a. Amount of pressure within blood vessels surrounding the esophagus increases
b. Common causes
c. With a gradual disease process, patients will initially shows signs of liver disease.
i. Signs and symptoms
d. Rupture of varices is far more sudden.
i. Signs and symptoms
ii. Complications
8. Mallory-Weiss syndrome: junction between the esophagus and the stomach tears
a. Common causes
b. Signs and symptoms
9. Gastroenteritis
a. Infection combined with diarrhea, nausea, and vomiting
b. Can also be caused by noninfectious conditions
c. Common causes
d. Signs and symptoms
e. Complications
10. Diverticulitis
a. First recognized around 1900, when the amount of processed foods eaten increased
b. The consistency of stools became more solid, requiring more intestinal contractions and
increasing pressure in the colon.
c. Bulges in the colonic walls result from increased intestinal contractions.
i. Fecal matter becomes caught in the bulges, allowing bacteria to collect, and
resulting in inflammation and infection.
d. Signs and symptoms
e. Complications
11. Hemorrhoids: created by swelling and inflammation of blood vessels surrounding rectum
a. Common causes
b. Signs and symptoms
F. Urinary system
1. Cystitis (bladder inflammation)
a. Also called urinary tract infection (UTI)
b. Common causes
c. Signs and symptoms
d. Complications
G. Kidneys
 1. Play a major role in maintaining homeostasis
2. When the kidneys fail, uremia results. abnormally high levels of waste products in the blood (area,etc.)
3. Kidney stones can grow over time and cause blockage.
4. Acute kidney failure
a. Sudden decrease in function
b. Common causes
c. Reversible with prompt diagnosis and treatment
5. Chronic kidney failure
a. Progressive and irreversible damage
b. Common causes
c. Signs and symptoms
d. Will eventually require treatment with dialysis
H. Female reproductive organs
1. Gynecologic problems are a common cause of acute abdominal pain.
2. Lower quadrant pain may relate to the ovaries, fallopian tubes, or uterus.
3. Chapter 23, “Gynecologic Emergencies,” covers gynecologic emergencies in depth.
I. Other organ systems
1. The aorta lies immediately behind the peritoneum.
a. Weak areas can result in abdominal aortic aneurysm (AAA).
i. AAA is difficult to detect.
ii. Signs and symptoms
iii. Use extreme caution when trying to assess or detect AAA.
iv. If an aneurysm tears or ruptures, massive hemorrhage may occur.
2. Pneumonia, especially in the lower lungs, can cause ileus and abdominal pain.
3. Hernia
a. Protrusion of an organ or tissue through a hole or opening into a body cavity where it does not
belong
i. Common causes
b. Hernias may not always produce a noticeable mass or lump.
c. Reducible hernias pose little risk and can be pushed back into the body cavity.
d. Incarcerated hernias cannot be pushed back in and are compressed by surrounding body tissue.
e. Strangulation of an incarcerated hernia is a serious medical emergency.
i. Blood supply is compromised by the compressed surrounding tissue.
f. Serious hernia signs and symptoms:
i. A formerly reducible mass that is no longer reducible
ii. Pain at the hernia site
iii. Tenderness when the hernia is palpated
iv. Red or blue skin discoloration over the hernia
IV. Patient Assessment
A. Scene size-up
1. Scene safety and standard precautions
3. Mechanism of injury/nature of illness
a. Acute abdomen can be the result of violence, such as blunt or penetrating trauma.
b. Use assessment results to develop an early index of suspicion for life threats.
B. Primary assessment
1. The first priority to identify and treat life-threatening conditions.
2. Form a general impression.
3. Airway and breathing
a. May present with shallow or inadequate respirations due to pain
4. Circulation indicates bleeding
a. Ask the patient about blood in vomit or black, tarry stools.
b. Pulse rate, quality, and skin condition may indicate shock.
c. Check pulses in both arms.
i. A difference in pulse strength may indicate an aortic dissection.
5. Transport decision
a. Immediate transport is warranted if there are signs of significant illness.
C. History taking
1. SAMPLE history:
a. Nausea and vomiting
b. Changes in bowel habits
c. Urination
d. Weight loss
e. Belching or flatulence
f. Pain
g. Other signs or symptoms
h. Concurrent chest pain
D. Secondary assessment
1. Positioning of the patient may give clues to the nature of illness.
2. Physical examination
a. The normal abdomen is soft and not tender to the touch.
b. Pain and tenderness are the most common symptoms of an acute abdomen.
i. Localized pain may give clues to the problem organ.
ii. Muscles of the abdominal wall may become rigid involuntarily (guarding).
c. The following steps will help in the abdominal assessment:
i. Explain the procedure to the patient.
 ii. Place the patient in supine position, with legs drawn up and flexed at the
knees.
iii. Expose and visually assess the abdomen.
iv. Ask the patient where the pain is most intense.
v. Palpate the abdomen very gently.
vi. Gently palpate all four regions of the abdomen to determine softness or
guarding.
vii. Note whether the pain is localized or widespread.
viii. Look for the patient’s response after palpating.
ix. Determine whether the patient exhibits rebound tenderness.
x. Determine whether the patient can relax the abdominal wall on command.
xi. Guarding and rigidity may be present.
3. Vital signs
a. A high respiratory rate with a normal pulse rate and blood pressure may indicate improper
ventilations.
PHR and PRR ⇒ can b. A high respiratory rate and pulse rate with signs of shock may indicate septic or hypovolemic
indicate septic/hypovolemic shock shock.
c. If a patient has a dialysis shunt in his or her arm, avoid taking a blood pressure in the same arm
as the shunt to avoid damaging it.
E. Reassessment
1. Because it is often difficult to determine the cause of abdominal pain, frequent
reassessment is important.
2. Assess the effects of interventions, including treatment for shock and emotional support.
a. Transport the patient in the most comfortable position for him or her.
b. Consider ALS support.
3. Communication and documentation

V. Emergency Medical Care

A. Although you cannot treat the causes of acute abdomen, you can take steps to provide
comfort and lessen the effects of shock.
1. Treat the patient for shock even when obvious signs of shock are not apparent.
B. Position patients who are vomiting to maintain a patent airway.
1. Contain the vomitus to prevent spread of infections (use a biohazard bag).
C. Wear gloves, eye protection, a gown, and a mask.
D. When the patient has been released to hospital staff, clean the ambulance and
equipment.
E. Wash your hands even though you were wearing gloves.
F. Providing low-flow oxygen may decrease nausea and anxiety.
VI. Dialysis Emergencies
A. In patients with end-stage renal disease or chronic renal failure, dialysis is the only
definitive treatment.
1. Dialysis filters the blood, cleanses it of toxins, and returns it to the body.
2. If a patient misses a dialysis treatment, weakness and pulmonary edema can be the first in
a series of conditions that become progressively more serious.
3. Some services transport patients to and from dialysis centers.
4. A dialysis machine functions much like normal kidneys do.
a. Patients undergoing long-term hemodialysis have a shunt that connects a vein and an artery,
allowing blood flow from the body to the dialysis machine.
-
b. Peritoneal dialysis allows large amounts of dialysis fluid to be infused into the abdominal
cavity.
i. The fluid stays in the cavity for 1 to 2 hours.
ii. Carries a high risk of peritonitis
5. Adverse effects of dialysis:
a. Hypotension ⇒ dBP
b. Muscle cramps
c. Nausea and vomiting
d. Hemorrhage from the access site
e. Infection at the access site
6. Management of a dialysis patient
7. Some dialysis patients also have urinary catheters.

Chapter 19
Endocrine and Hematologic Emergencies

I. Introduction
A. The human endocrine system directly or indirectly influences nearly every:
1. Cell
2. Organ } cob
3. Bodily function
B. Endocrine disorders are often seen with a multiple of signs and symptoms.
C. Hematologic emergencies
1. Difficult to assess and treat in a prehospital setting
2. Your actions may save a patient’s life.
 endocrine system communicates through hormones

II. Anatomy and Physiology

A. The endocrine system is a communication system that controls functions inside the
body.
B. Endocrine glands secrete messenger hormones.
C. Hormones are chemical substances produced by a gland. (pituitary gland)
1. Travel through the blood to end organs, tissues, or cells that they affect
2. When it arrives, the message is received and an action takes place.
D. Endocrine disorders are caused by an internal communication problem.
1. If a gland is not functioning normally, it may produce
a. More hormone (hypersecretion) than needed
b. Not enough hormone (hyposecretion)
2. A gland may be functioning correctly, but the receiving organ may not be responding.
E. Glucose metabolism
02
1. The brain needs two things to survive: glucose and oxygen.
insulin opens the a. Insulin is necessary for glucose to enter cells.
door of the cell to b. Without enough insulin, the cells do not get fed.
allow glucose to come in
2. The pancreas produces and stores two hormones:
a. Glucagon ⇒ triggers a release of stored glucose from liver (when blood sugars are low)
b. Insulin → allows cells to absorb glucose from blood (when blood sugars are high)
3. Islets of Langerhans are found in a small portion of the pancreas.
a. Within the islets are alpha and beta cells.
i. Alpha cells produce glucagon. GABI
ii. Beta cells produce insulin.
4. The pancreas stores and secretes insulin and glucagon in response to the level of glucose
in the blood.

III. Pathophysiology
A. Diabetes mellitus is a disorder of glucose metabolism, such that the body has an
impaired ability to get glucose into the cells to be used for energy.
1. It affects about 9.3% of the population.
2. Without treatment, blood glucose levels become too high.
a. In severe cases, may cause life-threatening illness, or coma and death.
3. If not managed well, it can have severe complications such as:
a. Blindness
b. Cardiovascular disease
c. Kidney failure
B. There are three types of diabetes.
 1. Diabetes mellitus type 1
2. Diabetes mellitus type 2
3. Pregnancy-induced gestational diabetes
C. Treatments for diabetes
1. Medications and injectable hormones that lower blood glucose level.
a. If administered correctly or incorrectly, can create a medical emergency for the patient with
diabetes.
b. Low blood glucose level (hypoglycemia), if unrecognized and untreated, can be life
threatening.
D. You must also recognize the signs and symptoms of
1. High blood glucose level (hyperglycemia)
a. Can result in coma or death
b. If treatment exceeds a patient’s need, it can cause a life-threatening state of hypoglycemia.
2. Low blood glucose level (hypoglycemia)
E. Hyperglycemia and hypoglycemia can occur with both diabetes mellitus type 1 and type
2.
1. You will encounter many patients displaying the signs and symptoms of high and low
blood glucose levels.
2. Hyperglycemia and hypoglycemia can be quite similar in their presentation.
a. Patients present with altered mental status.
b. Can often mimic alcohol intoxication; intoxicated patients often have abnormal glucose levels
3. Hypoglycemia can develop:
either from too little a. If a person takes his or her medications but fails to eat enough food.
meds or food intake b. If a person takes too much medication, resulting in low blood glucose levels despite normal
dietary intake
4. All hypoglycemic patients require prompt treatment.
a. Oral glucose paste (if alert and able to protect their airway)
b. Injection of glucose (dextrose) or glucagon by an ALS provider
F. Diabetes mellitus type 1

body attacks beta 1. An autoimmune disorder in which the immune system produces antibodies against the
cells (makes insulin) pancreatic beta cells
a. Missing the pancreatic hormone insulin
b. Without insulin, glucose cannot enter the cell, and the cell cannot produce energy.
2. Onset usually happens from early childhood through the fourth decade of life.
0-40 year olds a. The immune system destroys the ability of the pancreas to produce insulin.
b. The patient must obtain insulin from an external source.
inject themselves c. Patients with type 1 diabetes cannot survive without insulin.
with insulin to d. Patients who inject insulin often need to check blood glucose levels up to six times or more a
survive day.
 3. Many people with type 1 diabetes have an implanted insulin pump.
always ask if they a. Continuously measures glucose levels and provides insulin and correction doses of insulin
have one and based on carbohydrate intake at mealtimes
whether it's working b. Limits the number of times patients have to check their fingerstick glucose level
properly c. Can malfunction and diabetic emergencies can develop
i. Always inquire about the presence of an insulin pump.
ii. Ask if it is working properly.
4. Type 1 diabetes is the most common metabolic disease of childhood. A patient with new-
onset type 1 diabetes will have symptoms related to eating and drinking:
a. Polyuria ⇒ produce too much urine
b. Polydipsia ⇒ great thirst
c. Polyphagia ⇒ excessive/extreme hunger
d. Weight loss
e. Fatigue
5. When a patient’s blood glucose level is above normal, the kidney’s filtration system
becomes overwhelmed and glucose spills into the urine.
a. Polyuria: frequent urination
b. Polydipsia: increase in fluid consumption
c. Polyphagia: severe hunger and increased food intake
6. When glucose is unavailable to cells, the body turns to burning fat.
a. When the body burns fat rather than glucose, it produces acid waste (ketones).
i. As ketone levels go up in the blood, they spill into the urine.
ii. Kidneys become saturated with glucose and ketones, and cannot maintain acid–base
balance in the body.
iii. The patient breathes faster and deeper, as the body attempts to reduce the acid level by
releasing more carbon dioxide through the lungs.
(a) Known as Kussmaul respirations
iv. If fat metabolism and ketone production continue, a life-threatening illness called diabetic
ketoacidosis (DKA) can develop.
v. DKA may present as generalized illness along with:
(a) Abdominal pain
(b) Body aches
(c) Nausea
(d) Vomiting
(e) Altered mental status or unconsciousness (if severe)
vi. If not rapidly recognized and treated, DKA can result in death.
vii. When a patient with DKA has altered mental status, ask family or friends about the
patient’s history and presentation.
viii. Obtain a glucose level with a fingerstick using a lancet and a glucometer.
(a) Generally higher than 400 mg/dL
G. Diabetes mellitus type 2
1. Caused by resistance to the effects of insulin at the cellular level
a. There is an association between obesity and increased resistance to the effects of insulin.
insulin resistance ⇒ when I BGL and T insulin production does not reduce those levels

b. The pancreas produces more insulin to make up for the increased levels of blood glucose and
dysfunction of cellular insulin receptors.
i. This response becomes inefficient.
ii. The blood glucose levels continue to rise and do not respond when the pancreas secretes
insulin, a process called insulin resistance.
c. Insulin resistance can sometimes be improved by exercise and dietary modification.
2. Oral medications used to treat type 2 diabetes
a. Some increase secretion of insulin and pose a high risk of hypoglycemic reaction.
b. Some stimulate receptors for insulin.
c. Others decrease the effects of glucagon and decrease the release of glucose stored in the liver.
3. Injectable medications and insulin are also used for type 2 diabetes.
4. Often diagnosed at a yearly medical examination from complaints related to high blood
glucose levels, including:
a. Recurrent infection
b. Change in vision
c. Numbness in the feet
H. Symptomatic hyperglycemia
1. Occurs when blood glucose levels are very high; the patient is in a state of altered mental
status resulting from several combined problems.
a. In type 1 diabetes, leads to ketoacidosis with dehydration from excessive urination
b. In type 2 diabetes, leads to a nonketotic hyperosmolar state of dehydration due to the
discharge of fluids from all of the body systems and eventually out through the kidneys,
leading to fluid imbalance
c. If an individual has hyperglycemia for a protracted length of time, consequences of diabetes
may present:
i. Wounds that do not heal
ii. Numbness in the hands and feet
iii. Blindness
iv. Renal failure
v. Gastric motility problems
2. When blood glucose levels are not controlled in diabetes mellitus type 2, a condition
known as hyperosmolar hyperglycemic nonketotic syndrome (HHNS) can develop.
a. Key signs and symptoms of HHNS include:
i. Hyperglycemia ⇒ TBGL
ii. Altered mental status, drowsiness, lethargy
iii. Severe dehydration, thirst, dark urine
iv. Visual or sensory deficits
v. Partial paralysis or muscle weakness
vi. Seizures
3. Higher glucose levels in the blood cause the excretion of glucose in the urine.
a. Patients respond by increasing their fluid intake, which causes polyuria.
 b. In HHNS, the patient cannot drink enough fluid to keep up with the exceedingly high glucose
levels in the blood.
c. The urine becomes dark and concentrated.
d. The patient may become unconscious or have seizure activity due to severe dehydration.
I. Symptomatic hypoglycemia
1. An acute emergency in which a patient’s blood glucose level drops and must be corrected
swiftly
a. Can occur in patients who inject insulin or use oral medications that stimulate the pancreas to
produce more insulin
i. When insulin levels remain high, glucose is rapidly taken out of the blood.
ii. If glucose levels fall, there may be an insufficient amount to supply the brain.
2. The mental status of the patient declines and he or she may become aggressive or display
unusual behavior.
a. Unconsciousness and permanent brain damage can quickly follow.
3. Common reasons for a low blood glucose level to develop:
a. Correct dose of insulin with change in routine (the patient exercised more, consumed a meal
later than usual, or skipped the meal)
b. More insulin than necessary
c. Correct dose of insulin without the patient eating a sufficient amount
d. Correct dose of insulin and the patient developed an acute illness
happens faster 4. Hypoglycemia develops much more quickly than hyperglycemia.
a. In some instances, it can occur in a matter of minutes.
5. Signs and symptoms of hypoglycemia:
a. Normal to shallow or rapid respirations
b. Pale, moist (clammy) skin
c. Diaphoresis (sweating)
d. Dizziness, headache
e. Rapid pulse
f. Normal to low blood pressure
g. Altered mental status (aggressive, confused, lethargic, or unusual behavior)
h. Anxious or combative behavior
i. Seizure, fainting, or coma
j. Weakness on one side of the body (may mimic stroke)
k. Rapid changes in mental status
can cause 6. Hypoglycemia is quickly reversed by giving the patient glucose.
permanent brain a. Without the glucose, however, the patient can sustain permanent brain damage.
damage b. Minutes count.

IV. Patient Assessment of Diabetes

A. Scene size-up
 1. Evaluate scene safety and ensure all hazards are addressed.
a. Be careful of the presence of syringes, used by patients with diabetes for insulin.
b. Be alert for clues (eg, syringes, insulin bottles, plate of food, glass of orange juice) that may
help you decide what is possibly wrong with the patient.
c. Use standard precautions.
d. Question bystanders on events leading to your arrival.
e. Keep open the possibility that trauma may have occurred.
2. Determine the mechanism of injury (MOI)/nature of illness (NOI).
B. Primary assessment
1. Form a general impression.
a. How does the patient look?
i. Anxious, restless, or listless?
ii. Apathetic or irritable?
iii. Interacting appropriately with environment?
b. Identify life threats and provide lifesaving interventions, particularly airway management.
c. Determine level of consciousness using the AVPU scale.
i. If unresponsive and you suspect the patient has diabetes:
(a) Call for ALS.
(b) Patient may have undiagnosed diabetes.
ii. If patient has altered mental status:
(a) Assess blood glucose level if you have proper equipment and training.
d. Perform cervical spine immobilization, when necessary, and provide rapid transport.
e. Remember: Always carry out a thorough, careful primary assessment, paying attention to the
ABCs.
2. Assess the patient’s airway and breathing.
a. Patients showing signs of inadequate breathing, a pulse oximetry level less than or equal to
94%, or altered mental status should receive high-flow oxygen (12 to 15 L/min via
nonrebreathing mask).
b. Hyperglycemic patients may have rapid, deep (Kussmaul) respirations and sweet, fruity
breath.
c. Hypoglycemic patients will have normal or shallow to rapid respirations.
d. If the patient is not breathing or having difficulty breathing:
i. Open the airway; insert airway adjunct.
ii. Administer oxygen.
iii. Assist ventilations.
iv. Continue to monitor ventilations throughout patient care.
3. Assess the patient’s circulatory status.
a. Dry, warm skin: hyperglycemia
b. -
Moist, pale skin: hypoglycemia
c. Rapid, weak pulse: symptomatic hypoglycemia
4. Make a transport decision.
 a. Patients with altered mental status and impaired ability to swallow should be transported
promptly.
b. Patients capable of swallowing and conscious enough to maintain their own airway may be
further evaluated on scene and interventions can be performed.
C. History taking
1. Investigate the chief complaint.
a. Obtain a history of the present illness from responsive patients, family, or bystanders.
i. Responsive, diabetic patients will often know what is wrong.
b. If patient has eaten but -
not taken insulin, hyperglycemia is more likely.
c. If patient has taken insulin but not eaten, hypoglycemia is more likely.
d. Observe physical signs and symptoms to determine whether the patient is hyperglycemic or
hypoglycemic.
2. Obtain the SAMPLE history from a responsive patient or a family member or bystander.
a. For a known patient with diabetes, ask:
i. Do you take insulin or pills that lower your blood sugar?
ii. Do you wear an insulin pump? Is it working properly?
iii. Have you taken your usual insulin dose (or pills) today?
iv. Have you eaten normally today?
v. Have you had any illness, unusual amount of activity, or stress?
b. Look for an emergency medical identification device (eg, wallet card, necklace, or bracelet).
D. Secondary assessment
1. Physical examination
a. Assess unresponsive patients from head to toe with a secondary assessment of the entire body
i. Look for clues about the patient’s condition.
ii. Be alert for secondary injury/illness (eg, trauma due to altered level of consciousness).
b. When you suspect a diabetes-related problem, focus on mental status, ability to swallow, and
ability to protect the airway.
i. Obtain a Glasgow Coma Scale (GCS) score.
2. Vital signs, including blood glucose level.
a. Use a glucometer, if available and protocols allow.
b. Overall Mam-ARR, THR, pale + clammy, IBP
i. Hypoglycemia: Respirations are normal to rapid, pulse is weak and rapid, and skin is
typically pale and clammy with a low blood pressure
ii. Hyperglycemia: Respirations may be deep and rapid; pulse may be rapid, weak, and
thready; and skin may be warm and dry with a normal blood pressure
c. Portable glucometer TRR, THR, warm + dry, mam. BP
i. Study the operator’s manual for proper use in the field.
ii. Know the upper and lower ranges at which your glucometer functions.
iii. Normal nonfasting adult and child blood glucose level range: 80 to 120 mg/dL; neonates
should be above 70 mg/dL
E. Reassessment
 1. Reassess the patient with diabetes frequently to assess changes.
a. Improved mental status?
b. Are ABCs intact?
c. How is patient reacting to interventions performed?
d. How must you adjust or change interventions?
e. Base administration of glucose on serial glucometer readings or a deteriorating level of
consciousness.
2. Provide the indicated interventions.
a. For hypoglycemic, conscious patients who can swallow without the risk of aspiration
(inhalation of a substance):
i. Encourage patient to take glucose tablets, if available, or drink juice containing sugar.
ii. Administer gel preparation or sugar drink, if local protocol permits.
iii. Provide rapid transport to hospital.
b. For unconscious, hypoglycemic patients, or patients with risk of aspiration:
i. Intravenous (IV) glucose or intramuscular (IM) or intranasal (IN) glucagon is needed,
which most EMTs are not permitted to give.
(a) AEMTs and paramedics can start an IV line and administer IV glucose.
c. If in doubt whether that patient has symptomatic hyperglycemia or hypoglycemia, most
protocols will err on the side of giving glucose.
i . When in doubt, consult medical control.
3. Determining blood glucose level in a patient with diagnosed diabetes can be difficult
when signs and symptoms are confusing and you have no way to test for a blood glucose
value. In these situations:
a. Perform a thorough assessment.
b. Contact the hospital to help sort out the signs and symptoms.
4. Coordinate communication and documentation.
a. Inform receiving hospital about the patient’s history, the present situation, your assessment
findings, and your interventions and their results.
b. Patients who refuse transport because their symptoms improve after taking oral glucose may
require even more thorough documentation.

V. Emergency Medical Care for Diabetic Emergencies

A. Giving oral glucose
1. Three types of oral glucose preparations available commercially
a. Rapidly dissolving gel
b. Large chewable tablets
c. Liquid formulation
2. The only contraindications are the inability to swallow and unconsciousness.
a. Aspiration can occur.
3. Wear gloves before putting anything in the patient’s mouth.
4. Follow local protocols for glucose administration (See Skill Drill 19-1 ).
 5. Reassess the patient frequently.
a. You may see rapid response to your treatment; you may also see rapid deterioration.
6. Provide transport to the next level of care.

VI. The Presentation of Hypoglycemia

A. Seizures
1. Should be considered very serious, even in patients with a history of chronic seizures.
2. Possible causes:
a. Infection
b. Poisoning
c. Hypoglycemia ⇒ WBGL
d. Trauma
e. Decreased levels of oxygen
f. Idiopathic (unknown cause)
g. Fever (children)
h. Undiagnosed epilepsy (children)
3. Though brief seizures are not harmful, they may indicate a potentially life-threatening
underlying condition.
4. Management
a. Ensure that the airway is clear.
b. Place the patient on his or her side if there is no possibility of cervical spine trauma.
c. Do not place anything in the patient’s mouth (eg, bite stick or oral airway).
d. Have suctioning equipment ready in case the patient vomits.
e. If the patient is cyanotic or appears to be breathing inadequately, provide oxygen or artificial
ventilations.
f. Transport promptly. Acidosis/Alcohol
B. Altered mental status Epilepsy
1. May be from other conditions Infection
a. Poisoning
Overdose
b. Head injury
c. Postictal state Uremia
d. Decreased perfusion to the brain
2. May be caused by complications of diabetes Trauma/Tumor
a. Hypoglycemia → d BGL Insulin
b. Ketoacidosis → excess ketones Psychosis
3. Use the mnemonic AEIOU-TIPS. Stroke
a. Always suspect and check for low blood glucose in a patient with altered mental status.
4. Management
a. Ensure that the airway is clear.
 b. Be prepared to provide artificial ventilations.
c. Be prepared to suction if the patient vomits.
d. Provide prompt transport.
C. Misdiagnosis of neurologic dysfunction
1. Occasionally patients with diabetic emergencies are thought to be intoxicated.
2. A diabetic patient confined by police is at risk.
3. An emergency medical identification bracelet, necklace, or card may help to save the
patient’s life in such situations.
4. A blood glucose test performed at the scene (if protocols allow) or in the ED will identify
the real problem.
5. Be alert to the potential for diabetes and alcoholism to coexist in a patient.
D. Relationship to airway management
1. May not have a gag reflex and vomit or tongue may obstruct the airway.
2. Carefully monitor the airway.
3. Place the patient in a lateral recumbent position.
4. Make sure that suction is readily available.

VII. Hematologic Emergencies

A. Hematology is the study of blood-related diseases.
1. Three disorders that can create a prehospital emergency:
a. Sickle cell disease ⇒ misshapen RBCs
b. Hemophilia A ⇒ Keeps blood from clotting normally
c. Thrombophilia ⇒ imbalance of naturally occurring blood-clotting proteins

VIII. Anatomy and Physiology

A. Blood is made up of four components: erythrocytes, leukocytes, platelets, and plasma.
1. Each of the components of the blood serves a purpose in maintaining the body’s
homeostatic balance.
a. Transports oxygen and carbon dioxide into and out of tissues.
2. Red blood cells (RBCs or erythrocytes) contain hemoglobin, which carries oxygen to the
tissues.
a. Red blood cells make up 42% to 47% of blood volume.
3. White blood cells (WBCs or leukocytes) make up 0.1% to 0.2% of a person’s blood cell
volume.
a. Collect dead cells and provide for their correct disposal
b. Respond to infection
4. Platelets make up 4% to 7% of a person’s blood cell volume.
a. Essential for clot formation
 b. Respond to skin or blood vessel damage
c. Assist in forming a clot to stop bleeding
5. Plasma serves as the transportation medium for blood components, proteins, and
minerals.

IX. Pathophysiology
A. Sickle cell disease, also called hemoglobin S disease
1. An inherited blood disorder that affects RBCs
2. Found predominantly in people of African, Caribbean, and South American ancestry
a. Present but less common in Mediterranean and Middle Eastern people
b. All newborns in the United States are tested for sickle cell disease shortly after birth.
3. People with sickle cell disease have misshapen RBCs that lead to dysfunction in oxygen
binding and unintentional clot formation.
a. Clots may result in a blockage known as vasoocclusive crisis.
b. Can result in hypoxia, substantial pain, and organ damage
4. Sickled cells have a short life span, resulting in more cellular waste products in the
bloodstream and contributing to sludging (clumping) of the blood.
a. Maintaining hydration is important, as insufficient hydration leads to increased clumping.
5. Complications associated with sickle cell disease include:
a. Anemia
b. Gallstones
c. Jaundice
d. Splenic dysfunction
e. Vascular occlusion with ischemia:
i. Acute chest syndrome (hypoxia, dyspnea, chest discomfort, and fever)
ii. Stroke
iii. Joint necrosis (specifically the head of the femur and the humerus)
iv. Pain crises
v. Acute and chronic organ dysfunction/failure
vi. Retinal hemorrhages
vii. Increased risk of infection
6. Many of these complications are very painful and potentially life threatening.
a. The patient is also more susceptible to infections.
B. Clotting disorders
1. Hemophilia
a. Rare: only about 20,000 Americans have the disorder.
i. Hemophilia A affects mostly males.
b. People with hemophilia A have a decreased ability to create a clot after an injury, which can
be life threatening.
 c. Patients with hemophilia A typically have intravenous factor VIII replacement infusions,
which help the blood clot, either close at hand or with them.
d. Common complications of hemophilia A include:
i. Long-term joint problems that may require a joint replacement
ii. Bleeding in the brain (intracerebral hemorrhage)
iii. Thrombosis due to treatment
2. Thrombophilia
a. A disorder in the body’s ability to maintain the smooth flow of blood through the venous and
arterial systems
b. The concentration of particular elements in the blood creates clogging or blockage issues.
c. Thrombophilia is a general term for many different conditions that result in the blood clotting
more easily than normal.
i. Inherited (genetic) disorders
ii. Medications or other factors
iii. Patients with cancer
d. Clots can spontaneously develop in the blood of the patient.
3. Deep vein thrombosis (DVT) spending too much time seated/inactive
a. A common medical problem in sedentary patients and in patients who have had recent injury
or surgery
b. You may encounter several methods to prevent blood clot formation, including:
i. Blood-thinning medications
ii. Compression stockings
iii. Mechanical devices
c. Risk factors include
i. Recent history of joint replacement and complaints of leg swelling
ii. Travelers, truck and long-distance bus drivers
iii. Bedridden nursing home patients
d. Treatment
i. Anticoagulation therapy
(a) In-hospital IV medications transitioned to oral medications before discharge
(b) Self-administered subcutaneous injectable or oral medications
ii. Oral medications are typically administered for at least 3 months after diagnosis of a
DVT.
e. Patients prescribed medications to treat DVT are at increased risk of bleeding complications
(ie, gastrointestinal bleeding), and minor trauma is more likely to produce severe internal or
external hemorrhage.
f. A clot from the DVT can travel from the patient’s lower extremity to the lung, causing a
pulmonary embolus.
i. Pulmonary emboli can cause chest pain, difficulty breathing, or sudden cardiac arrest.

X. Patient Assessment of Hematologic Disorders

A. Scene size-up
 1. Ensure scene safety.
a. Most sickle cell patients will have had a crisis before.
b. Wear gloves and eye protection at a minimum.
c. Determine the number of patients involved.
d. Be alert for possible trauma.
e. Consider ALS support (eg, analgesic administration for vasoocclusive crisis pain).
B. Primary assessment
1. Is the patient in pain and of African American or Mediterranean descent?
a. If yes, may have undiagnosed sickle cell disease
2. Perform cervical spine immobilization, if necessary.
3. Form a general impression.
a. Is the patient anxious, restless, or listless?
b. Is the patient apathetic or irritable?
c. Determine level of consciousness.
4. Assess the patient’s airway and breathing.
a. For patients with inadequate breathing or altered mental status:
i. Provide high-flow oxygen at 12 to 15 L/min via nonrebreathing mask.
b. Patients experiencing a sickle cell crisis may have increased respirations or exhibit signs of
ARR pneumonia.
c. For patients with breathing difficulty:
i. Open the airway; insert airway adjunct.
ii. Administer oxygen; assist ventilations.
5. Assess the patient’s circulatory status.
PHR a. Sickle cell crisis patients will have increased heart rate to “force” sickled cells through
smaller blood vessels.
b. For suspected hemophilia patients:
i. Be alert for signs of acute blood loss:
(a) Pallor
(b) Weak pulse
(c) Hypotension ⇒ IBP
ii. Note bleeding of unknown origin:
(a) Nosebleeds
(b) Bloody sputum
(c) Blood in urine or stool
iii. Be alert for signs of hypoxia, which is due to blood loss.
6. Make a transport decision.
a. Transport to an ED should always be recommended to any patient who is experiencing a
sickle cell crisis or hemophilia.
C. History taking
1. Investigate the chief complaint.
a. Obtain a history of the present illness from responsive patients, family, or bystanders.
 b. Be alert for physical signs indicating sickle cell crisis:
i. Swelling of the fingers and toes
ii. Priapism → prolonged erection
iii. Jaundice
2. You should also ask following questions:
a. Is pain isolated to a single location or felt throughout the body?
b. Is the patient having visual disturbances?
c. Is the patient experiencing nausea, vomiting, or abdominal cramping?
d. Is the patient experiencing chest pain or shortness of breath?
3. Obtain the SAMPLE history from a responsive patient or family member.
a. Have you had a crisis before?
b. When was the last time you had a crisis?
c. How did your last crisis resolve?
d. Have you had any illnesses, unusual amount of activity, or stress lately?
D. Secondary assessment
1. Systematically examine the patient.
a. Focus on major joints at which cells congregate.
b. Evaluate and document mental status using the AVPU scale.
2. Obtain a complete set of vital signs, including oxygen saturation level.
a. Normal sickle cell crisis vital signs:
i. Normal to rapid respirations norm- MRR
ii. Weak, rapid pulse PHR
iii. Pale, clammy skin
iv. Low blood pressure LBP
b. Use pulse oximeter, if available, to monitor oxygen saturation.
i. Reading may be inaccurate due to patient’s anemic state.
E. Reassessment
1. Reassess vital signs frequently to determine changes in the patient’s condition.
a. Are there changes in mental status?
b. Are the ABCs intact?
2. How is the patient responding to the interventions performed?
a. Adjust or change the interventions as needed.
b. Document each assessment, your findings, the time of the interventions, and any changes in
the patient’s condition.
3. Administer supplemental oxygen via nonrebreathing mask at 12 to 15 L/min to attempt to
compensate for decreased cellular oxygenation related to the sickled cells or hemophilia.
4. Hospital care for sickle cell crises may include:
a. Analgesics for pain
b. Penicillin to treat infection
c. IV fluid for hydration
 d. Blood transfusion, depending on severity of condition
5. Hospital care for hemophilia may include:
a. IV therapy to treat hypotension
b. Transfusion of plasma
6. Communicate with hospital staff for continuity of care and document clearly.

XI. Emergency Medical Care for Hematologic Disorders

A. Emergency care is mainly supportive and symptomatic.
B. For patients with inadequate breathing or altered mental status:
1. Administer high-flow oxygen 12 to 15 L/min via nonrebreathing mask.
2. Place in position of comfort.
3. Transport rapidly to hospital.