Lsti Emt B Manual

Emergency Medical Technician Basic
Course Manual
Life Support Training International
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Emergency Medical Technician - Basic (EMT-B) Course Manual
This work is protected by copyright in The Philippines and internationally. No p
art of this course may be reproduced without the written permission of Life Supp
ort Training International (LSTI). All rights reserved.
This first edition produced 2010.
Edited by Craig Barrett, BA, PG Dip Ed, EMT-B
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Editors Note
Welcome to the first edition of the Emergency Medical Technician-Basic manual pu
blished by Life Support Training International. The manual aims to help you on y
our journey to becoming a competent EMT-B by providing you as much information a
s possible to supplement the lectures provided by LSTI.
As you proceed through the manual, please note that all information was current
at the time of publishing. As new treatments and protocols are released, your le
cturers will update you to keep you current with worldwide standards.
For the Philippines, the prehospital care system is about to undergo significant
changes with the passing of the EMS Bill by the Philippine Senate.
This book is dedicated to Aidan and Joann Tasker-Lynch, without whom the EMS ind
ustry in the Philippines would still be poorly developed. It is their vision and
dedication to prehospital care and the Filipino EMT that gives us all hope for
nation-wide professional EMS services, with world-class Filipino EMTs providing
the best possible care for the Filipino people.
On a final note, as a graduate of LSTI Batch 67, I congratulate you on your deci
sion to become an EMT. It is a difficult but immensely rewarding course you are
to undertake, and hopefully it is the beginning of a career you will be passiona
te about.
Craig Barrett, EMT-B LSTI-Batch 67 Quezon City 2010
Contents Chapter Page

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

Outline
Life Support Training International Philippine Society of Emergency Medical Tech

nicians PSEMT Affiliations PSEMT Membership Grades LSTI Academic Policies and Pr
ocedures
L
ife Support Training International is the Philippines industry leader in all leve
ls of instruction in pre-hospital emergency medical care and is dedicated to the
spread of knowledge in handling all traumatic and
medical emergencies. Our consultants have been involved in developing Emergency
Medical Services Systems (EMSS) in various parts of the world, ranging from the
United Kingdom to the Middle East, the Western Pacific Region and, indeed, here
in The Philippines. In the Philippines, we work closely with Emergency Medicine
Consultants from the University of the Philippines, Philippines General Hospital
, Department of Emergency Medicine. Life Support Training International is heavi
ly involved with the Philippine Heart Association, being active members of both
the Expanded Council on Resuscitation and the National Emergency Medical Service
s Council. We are also the founding executive members of the Philippine Society
of Emergency Medical Technicians, which is a society dedicated to developing a N
ational Emergency Medical Services System throughout The Philippines. Our facult
y is composed of only the most qualified and experienced instructors ranging fro
m trained Trauma Surgeons and fully registered Emergency Medical
Page 1 Emergency Medical Technician Basic

Technicians and Paramedics - WE GIVE YOU ONLY THE VERY BEST. Our standards of tr
aining meet with the highest of international standards and great care is taken
to mould the courses to meet your specific requirements. We will help students t
o develop the essential knowledge, skills and confidence in order to be able to
provide essential Emergency Life Support in times of crisis. Life Support Traini
ng International is currently The Philippines only fully certified training and
assessment center for the Philippine Society of Emergency Medical Technicians an
d, internationally, the Australasian Registry of Emergency Medical Technicians (
AREMT) and the Technical Education and Skills Development Authority (TESDA). WHE
N THEY DEPEND ON YOU YOU CAN ALWAYS DEPEND ON US!
Philippine Society of Emergency Medical Technicians
The Philippine Society of Emergency Medical Technicians (PSEMT) is a nonprofit,
non-political, non-union body which is dedicated to the cause of pushing for the
introduction of an effective National Ambulance System for all citizens of The
Philippines, irrespective of social status, cultural background, religious belie
fs or political affiliations. The development of a first-class Emergency Medical
Services System in The Philippines is our prime objective, as this is absolutel
y essential in order to form an integral link in the chain of delivering quality
care to the ill and injured. We must accept, however, that any chain is only as
strong as its weakest link, and with this in mind, the Philippine Society of Em
ergency Medical Technicians has recognized that excellence can only be achieved
through education, training and maintenance of the highest standards. Our Nation
al Training, Research and Development Council, has developed comprehensive train
ing guidelines which clearly outline the standards required of all those seeking
the implementation of truly professional standards of PreHospital Emergency Med
ical Care, and these standards will be required of anyone seeking membership of
the Society.

It is clearly recognized that any Pre-Hospital Care System involving EMTs requir
es the support and clinical supervision of physicians. The Society has establish
ed a National Executive Council composed of some of the foremost physicians and
experts in the field of Pre-Hospital Emergency Care. This council will formulate
the legal framework for pre-hospital care professionals to carry out their vita
l role. As outline above, the Society has established a National Training, Resea
rch and Development Council, which is tasked with, not only setting the Societys
Training Standards, but also establishing a National Examination System to ensur
e that these standards are achieved and maintained. This council has also been t
asked to carry out continuing research and development in the field of Pre-Hospi
tal Emergency Care to ensure that members are keep abreast of advances in equipm
ent and techniques. We are pleased to announce that, due to our adherence to the
highest of international standards and practice, the Philippine Society of Emer
gency Medical Technicians was, in March 2007, awarded direct and complete recipr
ocity with the Australasian Registry of Emergency Medical Technicians (AREMT). T
he AREMT is an Australian-based pre-hospital professional body, which bases its
standards on both the US Department of Transport and European models of pre-hosp
ital care. Due to this recognition, the Filipino EMT is justifiably and proudly
acknowledged as a world-standard professional.
PSEMT Affiliations
American College of Emergency Physicians

Emergency Care and Safety Institute
Australasian Registry of Emergency Medical Technicians
International Liaison Committee on Resuscitation
Philippine Heart Association
PSEMT Membership Grades

The following are the grades of membership for the PSEMT:
ASSOCIATE MEMBER BASI
EMERGENCY MEDICAL TECHNICIAN - EMT (B) EMERGENCY MEDICAL TECHNICIAN, DEFIBRILLA
TOR TRAINED - EMT (D) EMERGENCY MEDICAL TECHNICIAN, INFUSION & INTUBATION TRAINE
D EMT (I & I) ADVANCED EMERGENCY MEDICAL TECHNICIAN - EMT (A) REGISTERED EMERGEN
CY MEDICAL TECHNICIAN, PARAMEDIC - REMT (P) REGISTERED EMERGENCY MEDICAL SERVICE
S INSTRUCTOR - REMSI
Associate Membership This level will allow entry to all that hold current First
Aid and Basic Life Support Provider certificates from a Recognized Training Agen
cy. The minimum requirement will be thirty-two hours of instruction in First Aid
, with a further eight hours in Basic Life Support. Basic Emergency Medical Tech
nician - EMT (B) Certification This is the initial entry grade for all professiona
l pre-hospital care providers. This grade is inclusive of ambulance staff and nu
rsing personnel who can demonstrate appropriate training and experience in line
with PSEMT/PBEMT published standards. Entry may be afforded to applicants who ar
e outside the full time professional sector on achievement of the following requ
irements: Completion of a PSEMT/PBEMT approved 280 hour training course and the
achievement of the required pass mark in all sections of the National Final Exam
ination. Proof of a minimum of 250 hands-on patient management in the preceding
twelve months. This must be confirmed by the applicants Officer-In-Charge and dul
y approved by the Societys National Executive Committee.
Completion of a minimum
of 40 hours continuous medical education. Submission of a personal log of experi
ence gained. Successful completion of National Examinations.

The minimum age shall be 20 years. Emergency Medical Technician, Defibrillator EMT (D) Certification All applicants must be a certified Emergency Medical Techni
cian (EMT) with a minimum of three (3) months full-time post-EMT (B) certificati
on experience, which must include emergency response duties. They must have succ
essfully completed the prescribed defibrillation module, and examinations thereo
f, which will include all the content as outlined in the Societys National Syllab
us. Re-registration will be required on an annual basis and all applications the
reof must be accompanied by a competency certificate duly countersigned by an Em
ergency Medical Practitioner who has been approved by PSEMT/PBEMT. Emergency Med
ical Technician Advanced - EMT (A) Registration Entry requirement must be that of
EMT (I & I) with not less than six (6) months post-certification experience. In
addition to this, all applicants must have successfully completed two hundred ho
urs instruction in Advanced Cardiac Life Support and Advanced Trauma Management
and the examinations thereof. Re-registration will be required on an annual basi
s and all applications thereof must be accompanied by a competency certificate d
uly countersigned by an Emergency Medical Practitioner who has been approved by
PSEMT/PBEMT. Registered Emergency Medical Technician Paramedic EMT (P)
Registration The minimum entry criteria for Paramedic training is EMT Advanced (A)
, in accordance with the standards set out by the PSEMT/PBEMT, with at least six
(6) months post-certification experience. All applicants must have successfully
completed the three hundred and sixty (360) hour Advanced Clinical Training mod
ules. This level will only be available to those who complete a minimum of seven
hundred and fifty (750) hours actual operational experience per year.

Re-registration will be required on an annual basis and all applications thereof
must be accompanied by a competency certificate duly countersigned by an Emerge
ncy Medical Practitioner who has been approved by PSEMT/PBEMT. Registered Emerge
ncy Medical Services Instructor - REMSI This level has yet to be defined. Exempt
ions
Exemptions from some requirements may be considered based on alternative qualifi
cations and experience. Requests for exemption will be reviewed by the PSEMT Nat
ional Training, Research and Development Council and the PBEMT. Their decision w
ill be considered final.
LSTI Academic Policies and Procedures
Course Performance Rating Students overall performances are evaluated via the fol
lowing:
Weekly Examinations 10% Attendance and Timekeeping 10% Final Written Exa
mination 45% Final Practical Examination 35%
Passing grade is set at 75% in all written and practical examinations. In accord
ance with the Philippine Heart Association (PHA), a minimum passing grade of 80%
is required for the Basic Life Support (BLS) written examination. BLS certifica
tion is a mandatory requirement for the issuance of EMT certification. Payment o
f Tuition Fees Training fees may be paid on an instalment basis, but must be pai
d in full, whether or not the candidate chooses to complete the course - in othe
r words, all students who start the course are obliged to pay in full, irrespect
ive of the outcome thereof.

Reservation fee - PHP5000 (Non-refundable) Weekly payment - PHP3000 (Week 2-6 in
clusive) LSTI meticulously enforces the payment schedule given to students on th
e first day of the class. Students should follow the schedule diligently. Life S
upport Training International reserves the right to terminate the training of an
y student who fails to honor the set payment schedule. Weekly Assessment Every M
onday morning, starting week 2, an assessment/examination shall be conducted to
gauge the students performance and knowledge. All policies regarding examinations
, payment of fees etc. are applicable. Final Examinations The final examination
is done under the strict supervision of the Philippine Society of Emergency Medi
cal Technicians (PSEMT) and the Australasian Registry of Emergency Medical Techn
icians (AREMT). The high standards of training shall not be compromised in any w
ay, and as such: Any cheating, or perceived attempt to cheat, in the Final Exami
nations will be subject to immediate disqualification, and those involved will f
orfeit any chance to re-sit the exam. Students must settle all outstanding accou
nts before the Final Examination. Non-payment or incomplete payment of tuition f
ees will result in forfeiture of the students chance to take the examination. ReSit/Re-Examination In the case of failures, re-sit/re-examination shall be done
at a time and date designated by the PSEMT/AREMT. All students are obliged to fo
llow the scheduled examination date.

For the EMT Final Written Examination PSEMT/AREMT policy allows for a maximum of
two (2) sits only (1 exam and 1 re-sit). For the Basic Life Support Written Exa
mination, a maximum of three (3) sits are allowed (1 exam and 2 re-sits). No EMT
certification can be awarded to a candidate without successful completion of bo
th practical and theoretical examinations in Basic Life Support. Validity of the
re-sit/re-examination is limited to within one (1) year from the time the stude
nt finishes the course. If a student fails to re-sit or take the Final Examinati
on within this grace period, he/she shall forfeit their right to retake said Fin
al Examination. Under no circumstances will a candidate who has failed the final
examinations and re-sit be accepted for retraining at LSTI. Students who fail a
ll the re-sits/re-examinations shall not be awarded any certificate of proficien
cy. In accordance with PSEMT/AREMT policies, repetition of the EMT-Basic Course
is also not permitted.
Smoking is strictly prohibited in and around the training facility at all times.
Please put all your litter in the numerous garbage receptacles provided around t
he training facility for student use.
Chapter 2: Roles and Responsibilities of the EMT

C h a p te r 2 : Roles and Responsibilities of the E MT
Outline
The Star of Life The Emergency Medical Services System Components of the Emergen
cy Medical Services System Roles and Responsibilities of the EMT Professional At
tributes
The Star of Life
J
ust as physicians have the caduceus, and pharmacists the mortar and pestle, Emer
gency Medical Services have the Star of Life, a symbol whose use is encouraged by
both the American Medical Association
and the Advisory Council within the Department of Health and Human Services. On
road maps and highway signs, the Star of Life indicates the location or access t
o qualified emergency care services.
The Star of Life was designed by Leo Schwartz, EMS Branch Chief at the National
Highway Traffic Safety Administration (NHTSA) USA. The star of life was created
in 1973 as a common symbol to be used by US emergency medical services (EMS) and
medical goods pertaining to EMS.
Page 10 Emergency Medical Technician - Basic

The symbols six-barred cross represents the six-system function of Emergency Medi
cal Services. The staff in the center of the symbol represents medicine and heal
ing. According to Greek mythology, the staff belonged to Asclepius, the son of A
pollo (god of light, truth and prophesy), who learned the art of healing.
The Emergency Medical Services S
Regulation and Policy Laws that allow the system to exist. Resource Management C
entralized coordination of resources (i.e. hospitals) to have equal access to ba
sic emergency care and transport by certified personnel in a licenced and equipp
ed ambulance, to an appropriate facility.
Page 11 Sample Manual Template

Human Resources and Training All personnel who ride ambulances should be trained
at the minimum level using a standardized curriculum. Transportation Safe, reli
able ambulance transportation is a critical component. Communications There must
be an effective ccommunications system, beginning with a universal access numbe
r Public Information and Education Efforts to educate the public about their rol
e in the EMS system and prevention of injuries. Medical Direction Involvement of
EMS physicians in all aspects of pre-hospital emergency medical care practice.
Trauma Systems Development of more than one trauma center. Triage and transfer g
uidelines for trauma patients, rehabilitation programs, data collection and mean
s for managing and assuring the quality of the system. Evaluation Program for im
proving the EMS system.

Roles and Responsibilities of the EMT
Personal Safety An EMT is no good if he or she becomes another victim.
Safety of the Crew, Patient and Bystanders Patient Assessment Finding out what i
s wrong with your patient to be able to undertake emergency medical care.
Patient Care Preparation for action or a series of actions to take that will hel
p the patient deal with and survive illness or injury.
Lifting and Moving Effective and safe application of patient handling procedures
to avoid self-inflicted and career-ending injuries.
Transport A serious responsibility in ambulance operations, even more so with a

patient on board.
Patient Advocacy Moral responsibility to speak on behalf of the patients need of

attention for a particular cause. Must develop a rapport that will give understa
nding of the patients condition.
Professional Attributes of the EMT
Appearance Excellent personal grooming and a neat clean appearance to instil con
fidence in patients.

Knowledge and Skills A successful completion of EMT-B training and the knowledge
to know:
The use and the maintenance of common emergency equipment. How and whe
n to assist the administration of medications approved by medical direction or p
rotocol.
How to clean, disinfect and sterilize non-disposable equipment. Persona
l safety and security measures, as well as for other rescuers, the patient and b
ystanders.
The territory and terrain within the service area. Traffic laws and o
rdinances concerning emergency
transportation of the sick and injured. Physical Demands Good physical health an
d good eyesight to properly assess the patient and drive safely. Temperament and
Abilities
A pleasant personality Leadership ability Good judgement Good moral c
haracter Stability and adaptability

Components of Emergency Medical Services Systems In Depth
The following 15 components have been identified as essential to an EMS system:
Communication Training Manpower Mutual Aid Transportation Accessibility Faciliti
es Critical Care Units Transfer of Care Consumer Participation Public Education
Public Safety Agencies Standard Medical Records Independent Review and Evaluatio
n Disaster Linkages
The above design has proved proficient in many aspects, including medical direct
ion and accountability, prevention, rehabilitation, financing and operational an
d patient care protocols. EMS systems continued to be refined in the 1980s and 1
990s. Successful EMS systems are designed to meet the needs of the communities t
hey serve. The state provides laws that broadly outline what is prudent, safe an
d acceptable. To be effective, EMS systems must be planned and operated at the l
ocal level.

Communities need to identify their individual needs and resources, develop fundi
ng mechanisms, and become involved at all levels in structuring the system. A go
verning body or council should be established to organize, direct and coordinate
all system components. The council consists of representatives from the local m
edical, EMS, consumer and public safety agencies to ensure consensus in developi
ng policies and settling disputes. The EMS system must provide equal access to a
ll, and remain protected from forces that serve the interests of only one group.
Medical Direction Physician input, leadership and oversight in ensuring that me
dical care provided is safe, effective and in accordance with accepted standards
. Physicians must be empowered and imvolved in planning, implementing, overseein
g and evaluating all components of the system. Medical direction is characterize
d as either immediate (on-line) or organisational (off-line). On-line medical di
rection provides EMTs with consultation in the field, either in person or, more
commonly, via radio or telephone communication. This responsibility is delegated
medical director to physicians who staff local Emergency Departments. The base
station facility providing on-line control is required to monitor all advanced l
ife support (ALS) communications, provide field consultations, and notify receiv
ing facilities of incoming patients. Physicians providing on-line direction shou
ld be appropriately trained and familiar with the operations and limitations of
the system. The medical director assumes authority and responsibility for off-li
ne medical direction. In cooperation with the local medical community, the medic
al director is responsible for developing standards, protocols, policies and pro
cedures; developing training programs; issuing credentials and providing evaluat
ions; and implementing a process for continuous quality improvement. Communicati
ons A comprehensive communications plan is essential to provide the community ac
cess to system dispatch and to provide the EMT access to medical direction and a
dditional resources. The establishment of a universal access number (911 in the
US and Canada or 999 in the UK for example) has greatly improved the systems acce
ssibility. Additional advancements have been made with enhanced systems, such as
the enhanced 911

system, which automatically provide the dispatcher with the callers address and t
elephone number. Using enhanced systems, callers can obtain services even if the
y are unable to communicate with dispatch. Emergency medicine dispatch includes
assessment of patient location and status, as well as the provision of pre-arriv
al instructions. Ground vehicles provide most EMS transportation. Ambulances sho
uld be constructed according to federal or national standards, and be appropriat
ely equipped to provide basic or advanced level of care. Air transport, such as
a helicopter or airplane, may also be either BLS or ALS. Air transport is used t
o transport patients over greater distances, decrease total pre-hospital time or
to reach patients in poorly accessible locations. Operational standards are est
ablished to delineate the equipment needed, the number of personnel and the leve
l of certification required, as well as the response-time criteria and the desti
nation for each transport. On-line medical direction should be obtained in all c
alls that result in transport. This includes:
Decision to transport; Patient ref
usal of care; and Triage to a lower level of care.
Otherwise, the provider may be perceived as practicing without a licence, and co
uld be charged with an offence. Transportation Inter-facility transportation occ
urs once the patient has been examined and stabilized. Patients are transported
in compliance with regional protocols and federal, national or state laws (e.g.
Consolidated Omnibus Budget Reconciliation Act [COBRA] and Emergency Medical Tre
atment and Active Labor Act [EMTALA] in the US). Legislation dictates that medic
ally unstable patients be transferred only when the transfer is expected to have
a positive effect on outcome. Patients should be transported to the closest, mo
st appropriate facility. Receiving facilities are required to have the capabilit
ies to treat the patients, stabilize their condition, and improve their outcome.
Stable patients may be transported to the hospital of their choice, as long as
the transport meets regional point-of-entry protocols, has the approval of onlin
e medical control, and does not necessarily overburden the system.

Specialized resources to care for the severely injured are not available in ever
y hospital. Local communities need to establish regional protocols to provide cl
ear guidance for the transport of unstable patients to categorized facilities. U
nstable patients with special problems, such as burns or trauma, can be transpor
ted to regionally designated hospitals, bypassing closer facilities. Training St
andards Providers must be trained to meet the expectations and requirements in p
rograms that comply with regional and national standards. Training includes dida
ctic, clinical and field components. Most states require that candidates pass wr
itten and practical examinations prior to certification. Additionally, EMTs are
required to receive continuing didactic and clinical education to maintain certi
fication. Education is also used to reinforce proper patient care, update standa
rds and protocols, and remedy perceived deficiencies in patient care. Physician
involvement is essential to assure appropriate utilizations of skills and equipm
ent. The EMS system also provides community education, such as public courses in
CPR, first aid, child safety and EMS access. Protocols Protocols are developed
to deal with operational, administrative and patient care issues. They define a
standardized, acceptable approach to commonly encountered problems. Protocols sh
ould reflect regional and national standards, as well as the uniqueness and limi
tations of the local environment. The medical director has the responsibility to
address protocols dealing with patient care, such as triage and treatment. Tria
ge assesses the condition of each patient, sorts patients into treatment categor
ies, and optimizes use of field resources for treatment and transport. In additi
on, triage addresses the level of provider during multiple casualty incidents to
facilitate the screening, prioritization, treatment and transport of patients.
Treatment protocols describe the authority and responsibilities of providers and
offer guidance for medical evaluation and care. Optimal care and medical accoun
tability require standardized protocols, algorithms and standing orders that out
line specific actions providers can take without contacting a physician for orde
rs. Any deviation from these standing orders must be considered a breach of duty
and must result in an audit. On-line medical direction is crucial in systems, r
equiring decision-making to provide guidance and assume some of the patient-care
responsibilities.

Continuous Quality Improvement
Continuous quality improvement (CQI) is the sum of all activities undertaken to
assess and improve the products and services EMS provides. The goal is to influe
nce patient outcomes positively by delivering products timely, consistent, appro
priate, compassionate and cost-effective systems. CQI ensures that the field sta
ff provides the highest quality of care and that the system supports this goal.
Quality should be monitored from within the EMS system and by an external, indep
endent and unbiased body that involves the consumer, government and medical comm
unities. Standardized protocols, policies, performance and documentation are inv
aluable in constructing a successful CQI process. Quality evaluation is prospect
ive, concurrent and retrospective. Prospective evaluation is most effective proc
ess to ensure quality in EMS, because it has the potential to prevent mistakes.
The system must be scrutinized constantly to determine areas requiring refinemen
t and improvement. When goals and standards are not met, CQI staff members must
identify the problem, establish and implement a corrective course of action, and
measure the outcome. Concurrent evaluation occurs on scene or online. Staff mem
bers observe performance, encourage positive behavior and correct problems befor
e bad habits develop. Retrospective evaluation is the least valuable and most ti
me-consuming. It includes critique sessions and reviews of patient encounter tap
es and charts.
Disaster Preparedness
The EMS system is an integral part of disaster preparedness and planning. It pla
ys an important role in initial response and transportation, and is essential in
establishing a regional disaster preparedness plan in coordination with public
safety agencies, government and the medical community. The plan should address d
isaster management, communication, treatment and designation of casualties. Peri
odic disaster drills serve to assess performance, refine management and educate
personnel and the community. Public support is invaluable in constructing a succ
essful EMS system; involvement is required to plan a system that works for every
one. Consumers need to be well informed of the benefits of having an EMS system
and how to gain access to it.
Chapter 3: Medico-Legal and Ethical Issues in EMS

Outline
Definitions Patient Bill of Rights Ethical Implications Right of Refusal Legal A

spects Crime Scenes EMS Code of Ethics
Definitions
ETHICS - The science of right and wrong, of moral duties and of ideal behaviour.
MEDICAL ETHICS - The part of ethics that deals with the health care of human be
ings.
Patient Bill of Rights
The patient has the right to considerate and respectful care. The patient has th
e right to refuse treatment to the extent permitted by law and to be informed of
the medical consequences of his or her action. The patient has the right to exp
ect that all communications and records pertaining to his or her care should be
treated as confidential. The patient has the right to expect continuity of care.

In the Philippines, the Patient Bill of Rights is known as Title 111: Declaratio
n of Rights.
Good Samaritan Law
Protects a person from liability for acts performed in good faith, unless those
acts constitute gross negligence. Does not prevent one from being sued, although
it may provide some protection against losing a lawsuit if one has performed to
the standard of care for an EMT-B.
Different standards may be held in different legal jurisdictions.

Medical Direction
The legal right to function as an EMT-B is contingent upon medical direction. Th
e EMT-B must:
Follow standing orders and protocols Establish telephone and radio
communications Communicate clearly and completely and follow orders given in re
sponse Consult medical direction for any question about the scope and direction
of care
Duty to Act
The obligation to provide care. May be implied or formal. IF ON-DUTY:
IF OFF-DUT
Y:
may stop and help; or may pass the scene and call for help; or may pass the s
cene and make no attempt to call for help. legally obligated

Ethical Responsibilities
Serve the needs of the patients with respect for human dignity, without regard t
o nationality, race, gender, creed or status. Maintain skill mastery. Keep abrea
st of changes in EMS which affect patient care. Critically review performances.
Report with honesty. Work harmoniously with others.
Patient Consent and Refusal
Types of Consent
Expressed consent Implied consent Consent to treat a minor or mentally incompete

nt adult
Advance Directives
Living Will, DNR/DNAR Instructions written in advance documenti
ng the wish of the chronically or terminally ill patient not to be resuscitated
and legally allows the EMT-B to withhold resuscitation.
Usually accompanied by a
doctors written orders. Associated problems:
More useful in an institutional set
ting. More than one physician may be required to verify the patients condition. S
crutiny of an advance directive may be time consuming.

Refusal of Treatment
Competency A competent adult is defined as one who is lucid and capable of makin
g an informed decision. Protecting yourself: Do the following before you leave t
he scene:
Try to persuade the patient to accept treatment or transport to a hospital. Make

sure that the patient is able to make a rational informed decision. Consult med
ical direction as required by local protocol. If the patient still refuses, have
them sign a refusal form.
Remember: A competent adult is defined as one who is lucid and capable of making
an informed decision.
Before you leave, encourage the patient to seek help if certain symptoms develop
.
Other Legal Aspects
Abandonment and Negligence Abandonment One stopped providing care for the patien
t without ensuring that equivalent or better care would be provided Negligence T
he care one provides deviates from the accepted standard of care and this result
s in further injury to the patient In order to establish negligence, it must be
proved that:
The EMT-B had a duty to act; The patient was injured, either physically or psych
ologically; The EMT-B violated the standard of care expected. The EMT-Bs action o
r lack thereof caused or contributed to the patients injury.

Confidentiality Do not speak to the press, your family, friends or other members
of the public about details of the emergency care you provided to a patient. Re
leasing confidential information requires a written release form signed by the p
atient or a legal guardian. Instances when an EMT-B is allowed to release confid
ential information:
Another health care provider needs to know the information to continue medical c
are; As requested by the police as part of a potential criminal investigation; A
s required on a third-party billing form; As required by legal subpoena; When a
patient signs a release form.
Special Situations
Donors and Organ Harvesting A legal signed document is required, such as a signe
d donor care sticker affixed to a drivers licence or an organ donor card. To prov
ide assistance in organ harvesting: 1. Identify the patient as a potential donor
. 2. Communicate with medical direction regarding the possibility of organ donat
ion. 3. Provide emergency care that will maintain the vital organs. Dying and De
ceased Patients If the person is obviously dead, you may be required to leave th
e body at the scene if there is any possibility that the police will have to inv
estigate. In other situations, you may be required to arrange for transport of t
he body so that a physician can officially pronounce the patient dead.

Medical Identification Insignia A patient with a serious medical condition may b
e wearing a medical identification tag (bracelet, necklace or card).
Crime Scenes
General guidelines - a potential crime scene is any scene that may require polic
e support. If you suspect a crime is in progress or a criminal is still active a
t a scene, do not attempt to provide care to any patient. Try to avoid any item
at the scene that may be considered evidence. Basic Guidelines for the EMT at a
Crime Scene
Touch only what you need to touch. Move only what you need to move. Do not use t
he phone unless authorised by the police. Observe and document anything unusual
at the scene. If possible, do not cut through holes in the patients clothing. Do
not cut through any knot in a rope or tie. If the crime is rape, do not wash the
patient or allow the patient to wash,
change their clothing, use the bathroom or take anything by mouth.

The EMT Code of Ethics
Professional status as an Emergency Medical Technician and Emergency Medical Tec
hnician-Paramedic is maintained and enriched by the willingness of the individua
l practitioner to accept and fulfil obligations to society, other medical profes
sionals, and the profession of Emergency Medical Technician. As an Emergency Med
ical TechnicianParamedic, I solemnly pledge myself to the following code of prof
essional ethics: A fundamental responsibility of the Emergency Medical Technicia
n is to conserve life, to alleviate suffering, to promote health, to do no harm,
and to encourage the quality and equal availability of emergency medical care.
The Emergency Medical Technician provides services based on human need, with res
pect for human dignity, unrestricted by consideration of nationality, race creed
, color, or status. The Emergency Medical Technician does not use professional k
nowledge and skills in
any enterprise detrimental to the public wellbeing.
The Emergency Medical Technician respects and holds in confidence all informatio
n of a confidential nature obtained in the course of professional work unless re
quired by law to divulge such information. The Emergency Medical Technician, as
a citizen, understands and upholds the law and performs the duties of citizenshi
p; as a professional, the Emergency Medical Technician has the never-ending resp
onsibility to work with concerned citizens and other health care professionals i
n promoting a high standard of emergency medical care to all people. The Emergen
cy Medical Technician shall maintain professional competence and demonstrate con
cern for the competence of other members of the Emergency Medical Services healt
h care team. An Emergency Medical Technician assumes responsibility in defining
and upholding standards of professional practice and education.

The Emergency Medical Technician assumes responsibility for individual professio
nal actions and judgment, both in dependent and independent emergency functions,
and knows and upholds the laws which affect the practice of the Emergency Medic
al Technician. An Emergency Medical Technician has the responsibility to be awar
e of and participate in matters of legislation affecting the Emergency Medical S
ervice System. The Emergency Medical Technician, or groups of Emergency Medical
Technicians, who advertise professional service, do so in conformity with the di
gnity of the profession. The Emergency Medical Technician has an obligation to p
rotect the public by not delegating to a person less qualified, any service whic
h requires the professional competence of an Emergency Medical Technician. The E
mergency Medical Technician will work harmoniously with and sustain confidence i
n Emergency Medical Technician associates, the nurses, the physicians, and other
members of the Emergency Medical Services health care team. The Emergency Medic
al Technician refuses to participate in unethical procedures, and assumes the re
sponsibility to expose incompetence or unethical conduct of others to the approp
riate authority in a proper and professional manner.
The EMT Code of Ethics was written by Dr. Charles Gillespie and adopted by the N
ational Association of EMTs in 1978.
Chapter 4: Ambulance Vehicles and Equipment

Chapter 4: Ambulance Equipment
Outline
Vehicles
and
Introduction North American Ambulance Designs European Ambulance Designs Paramed

ic Fast Response Vehicles Helicopter Emergency Medical Services (HEMS) Standard
Ambulance Equipment Daily Checks of Ambulance Equipment Cleanliness Phases of an
Ambulance Call Emergency Driving Ambulance Hygiene

M
standards.
Introduction
odern ambulances have evolved into sophisticated vehicles, with modern safety fe
atures such as ABS brakes and airbags. Many newer ambulances look similar to old
er vehicles, with changes related to the use of new
lightweight materials and increased safety features. Ambulances now are often eq
uipped with GPS and computer dispatch systems. Ambulances are equipped according
to their role - basic transport, Intermediate Life Support (ILS), Advanced Life
Support (ALS), or Mobile Intensive Care Unit (MICU).
North American Ambulance Designs
Ambulance vehicle designations in the USA are governed by federal laws and
In America, an ambulance is defined as a vehicle used for emergency medical care
that provides:
A drivers compartment. A patient compartment to accommodate an emergency medical
services provider (EMSP) and one patient located on the primary cot so positione
d that the primary patient can be given intensive life-support during transit.
E
quipment and supplies for emergency care at the scene as well as during transpor
t.
Safety, comfort, and avoidance of aggravation of the patients injury or illnes
s. Two-way radio communication. Audible and Visual Traffic warning devices

There are three basic ambulance specifications in North America:
TYPE I AMBULANC
E - a cab chassis furnished with a modular ambulance body. TYPE II AMBULANCE - a
long wheelbase van, with integral cab-body. TYPE III AMBULANCE - a cutaway van
with integrated modular ambulance body.
European Ambulance Designs
European ambulances are generally manufactured on an individual service requirem
ent basis. The general cab-chassis is similar to the North American Type II vehi
cle but the interior is generally built to the customers specific requirements. F
ibreglass is used extensively in the manufacture of European vehicles - this pro
motes vehicle handling characteristics as well as reducing overall weight and fu
el consumption.
Paramedic Fast Response Vehicles
These vehicles are utilized to deliver Advanced Life Support quickly and efficie
ntly at the scene of any emergency. The vehicle is either dispatched at the same
time as an ambulance unit or in advance of the ambulance unit when resources ar
e limited and demands on the service are high. Paramedic Fast Response Units are
mobilized to achieve early stabilization of the patient and rely heavily on amb
ulance follow-up for transportation of the victim/s to the receiving medical fac
ility.
Helicopter Emergency Medical Services (HEMS)
Helicopter Emergency Medical Services (HEMS) units are basically used for trauma
and high-dependency transfers. HEMS are particularly useful for the pickup of p
atients in isolated areas where access by other forms of air, sea or road transp
ort is difficult or just not possible at all. It should be said that HEMS units
are extremely costly to set up and

run. Due to the high cost factor, HEMS units are usually run on a regional or na
tional basis as opposed to local operations.
Standard Ambulance Equipment
Monitoring Equipment: BP Cuff / NIBP, Stethoscope, ECG Monitor Defibrillator, Vi
tal Signs Monitor, Pulse Oximeter, Thermometer. Airway Equipment: Oxygen Cylinde
r, Regulator, Flowmeter, Automated Transport Ventilator / Resuscitator, Bag Valv
e Mask, Suction unit, Guedal Airways, Combitubes, Laryngeal Mask Airway, Endotra
cheal Tubes. Immobilisation / Splinting Equipment: Scoop Stretcher, Vacuum Mattr
ess, Extrication Device (KED), Cervical Collars, Head Immobilizer, Extremity Spl
ints, Traction Splint, Straps and harnesses. Others: Stretcher Carry chair Enton
ox Medical Bag Medical disposables according to checklist

Daily Checks of Ambulance Equipment
It is the duty of the driver and assistant to check the vehicle and equipment ac
cording to the checklist when reporting for duty. As emergency care professional
s, we are dealing with peoples lives each time we respond to a call, and a faulty
vehicle or equipment could result in the loss of a life that could have been sa
ved. When checking equipment it is also vital to ensure that all the equipment o
n the ambulance is clinically clean. The safety of the crew also depends on any
faults with the vehicle being noted and corrected.
Duties of Driver
Check all fluid levels fuel, engine oil, radiator coolant, automatic transmissio
n fluid, battery water levels before starting the vehicle. Also check for leaks
under the vehicle. Check lights headlights, taillights, direction indicators, ro
tators, flashers, sirens, etc. Check communications equipment vehicle radio and
handheld radio Check tyres for pressure, wear and damage. Check brakes both foot
and handbrakes Check all windows and mirrors Check all door latches and handles
Check all seatbelts / passenger restraints
When checking the vehicle it is important to remember that the most engine wear
occurs during the first 30 seconds after start up, before the oil is circulated
through the engine. DO NOT rev the engine immediately on or after start up. It i
s also important to remember that diesel engines with a turbo need to idle befor
e shut down. NEVER rev a turbo engine before turning off the ignition, as it can
cause damage to the turbo bearings, loss of power and shorten the life of the e
ngine.

Duties of Attendant
Check equipment according to the checklist, making sure that all the equipment i
s complete and in good working order. Check medical disposables according to che
cklist, noting expiry dates. Check oxygen cylinders are full, and that gauges an
d flowmeters are working. Make sure batteries are charged for any battery powere
d equipment such as ECG monitors, pulse oximeters, etc. Make sure that the patie
nt compartment, equipment and supplies are clinically clean and thoroughly hygie
nic. Make sure that you know exactly how each item of equipment works, and the t
rouble-shooting procedures for that item of equipment.
Cleanliness
Cleanliness of the vehicle, both inside and out serves two purposes. The first i
s that a clean vehicle portrays a professional image. The second and more import
ant function is to ensure that both the crew and patients are protected from the
transmission of infection and communicable diseases by contaminated surfaces, l
inen, equipment, etc. It is vitally important to clean the interior surfaces wit
h approved disinfectants, as a surface which appears clean, can harbour bacteria
and viruses.
Phases of an Ambulance Call
1. Daily pre-run vehicle and equipment preparation
Ambulance maintenance benefits: decreases vehicle downtime


improves response times to the scene safer emergency and non-emergency responses
improves transport times to a medical facility safer patient transports to a me
dical facility
Daily inspection of the vehicle Ambulance equipment Personnel

2. Dispatch
Location of call. Nature of call. Name, location and callback number of the call
er. Location of the patient. The number of patients and severity of the problem.
Any other special problems or circumstances that may be pertinent.
3. En route to the scene.
4. At the scene.
5. En route to the receiving facility.
6. At the receiving facility.
7. En route to the station.

8. Post run.
Emergency Driving
Emergency Driving Privileges
Exceed the posted speed limit for the area as long
as you are not endangering lives or propery.
Drive the wrong way down a one-way
street or drive down the opposite side of the road.
Turn in any direction at an
intersection. Park anywhere as long as you do not endanger lives or property. Le
ave the ambulance standing in the middle of a street or intersection. Cautiously
proceed through a red flashing signal. Pass other vehicles in a no-passing zone
s.
Warning and Emergency Lights Warning lights must be activated at all times when
responding to an emergency call.
Lights should be used even when you are not usi
ng the siren. Ambulance emergency lights should be high enough to cast a beam ab
ove the traffic.
Ambulance Hygiene
After every call
Strip used linens from the stretcher and place them in a plastic bag or designat
ed receptacle.
In an appropriate receptacle, dispose of all disposable equipment used for patie

nt care. Disinfect all non-disposable equipment used for patient care. Clean the
stretcher with germicidal solution. If there is any spoilage or contamination i
n the ambulance, clean it up. Air out the ambulance with all doors and windows o
pen for 15 minutes.
At least once a day:
Empty the ambulance of the stretcher and equipment boxes. Disinfect the oxygen h
umidifier and refill with clean water. Scrub all the interior surfaces with soap
and water. Scrub again with germicidal solution, then air out again to let ever
ything dry.
Chapter 5: Medical Terminology in EMS

Outline
Words describing location Words describing position Medical terms by body system
s Common medical abbreviations
Words Describing Location
Midline Anterior Posterior Superior Inferior Medial Lateral Proximal Distal Inte
rnal External Imaginary vertical line down the middle of the front surface of th
e body Toward the front Toward the back Above; toward the head Below; toward the
feet Nearer the midline of the body Farther from the midline of the body Nearer
the point of attachment to the body Farther from the point of attachment to the
body (or the heart) Inside Outside

Superficial Deep
Near the surface Remote from the surface
Words Describing Position
Erect Recumbent Supine Prone Lateral Standing upright Lying down Lying face up L
ying face down Lying on the side

Medical Terms By Body Systems
HEENT Head, Ears, Eyes, Nose & Throat Occipital - back of the head Photophobia intolerant of light Phonophobia - intolerant of sounds Diplopia - double vision
Epistasis - nosebleed Rhinorrhea - runny nose or nasal discharge Otorrhea - dis
charge from the ear Tinnitus - ringing noise in the ear NCAT - normocephalic, at
raumatic PERRL - Pupils Equal Round and Reactive to Light Erythema - redness Pur
ulent - consisting of pus Injected - blood vessel congestion, such as red eye

Coronary & Pulmonary Cor - Coronary (the heart) Pulm - Pulmonary (respiratory sy
stem) CTAB no rrw - Clear to auscultation bilaterally, no rales, ronchi or wheez
es SOB - Shortness of Breath (dyspnea) Productive cough - phlegm producing Wheez
ing - high pitched sounds Hemoptysis - coughing up blood Pleuritic - worse with
deep inspiration Rales - crackles Ronchi - wheezes/whistling sounds Retractions
- visible skin retractions with inspiration Tachypnea - rapid breathing Abdomen
(Abd) or Gastrointestinal (GI) Anorexia - loss or lack of appetite Post-prandial
- after eating Emesis - vomiting NBNB - non-bloody, non-bilious Hematemesis - b
loody emesis Hematochezia - bloody stool BRBPR - Bright Red Blood per Rectum Mel
ena - tarry black stool

BS - bowel sounds (normoactive, hyperactive, hypoactive, absent) TTP - tender to
palpation, often more so in a single quadrant Guarding - hard abdomen when palp
ated Rebound - worse pain as examining hand is quickly pulled away Genitourinary
(GU) Dysuria - painful urination Hematuria - blood in the urine Musculoskeletal
& Extremities MS - Musculoskeletal Ext - Extremities Myalgias - muscle aches Ar
thralgias - joint aches Edema - swelling Skin Pruritic - itchy Macule - flat dis
coloration <10mm in diameter Bumps: Papule - bump 5mm or less Nodule - well defi
ned bump >5mm Plaque - raised area Sacs: Vesicle - fluid filled sac <5mm Bulla fluid filled sac >5mm

Pustule - sac filled with pus Erythema - redness
Common Medical Abbreviations
A AED Automated External Defibrillator a.c. Before meals ASA Aspirin AMA Against
medical advice AMI Acute myocardial infarction ASHD Arteriosclerotic heart dise
ase B b.i.d. Twice a day BP Blood pressure BS Breath sounds, bowel sounds, or bl
ood sugar BVM Bag-valve-mask C c/o Complaining of Ca Cancer/carcinoma cc Cubic c
entimeter CC Chief Complaint CHF Congestive heart failure CO Carbon monoxide

COPD Chronic obstructive pulmonary disease (emphysema, chronic bronchitis) CPR C
ardiopulmonary resuscitation CSF Cerebrospinal fluid CVA Cerebrovascular acciden
t CXR Chest X-ray D d/c Discontinue DM Diabetes mellitus DOA Dead on arrival DOB
Date of birth Dx Diagnosis E ECG, EKG Electrocardiogram e.g. For example ETA Es
timated time of arrival ETOH Alcohol (ethanol) F Fx Fracture G GI Gastrointestin
al GSW Gun shot wound gtt. Drop

GU Genitourinary GYN Gynecologic H h, hr. Hour H/A Headache HEENT Head, ears, ey
es, nose, throat Hg Mercury h/o History of hs At bedtime HTN Hypertension Hx His
tory I ICP Intracranial pressure ICU Intensive Care Unit IM Intramuscular IO Int
raosseous J JVD Jugular venous distension K KVO Keep vein open

L L Left or Liter LAC Laceration LOC Level of consciousness LR Lactated Ringers
solution M mcg Micrograms MS Morphine sulphate, multiple sclerosis N NAD No appa
rent distress NC Nasal cannula NKA No known allergies npo Nothing by mouth NRB N
on-rebreather mask NS Normal saline NSR Normal sinus rhythm NTG Nitroglycerin N/
V Nausea / vomiting O O2 Oxygen OB Obstetrics OD Overdose OR Operating room

P PCN Penicillin PEA Pulseless electrical activity PERL Pupils equal and reactiv
e to light PID Pelvic inflammatory disease PND Paroxysmal nocturnal dyspnea po B
y mouth PRN As needed PSVT Paroxysmal supraventricular tachycardia Pt Patient PT
A Prior to arrival PVC Premature ventricular contraction Q q.h. Every hour q.i.d
. Four times a day R R Right r/o Rule out Rx or Tx Treatment S SIDS Sudden Infan
t Death Syndrome SOB Shortness of breath

stat. immediately SVT Supraventricular tachycardia T TIA Transient ischemic atta
ck t.i.d. Three times a day TKO To keep open V V.S. Vital signs X x Times W w/o
or s without WNL Within normal limits Y y/o or y.o. Years old Symbols change + P
ositive - Negative
Chapter 6: Infection Control and the EMT

Outline
Overview The Chain of Infection Stages of Infection Methods of Transmission Defe

nses against Infection Diseases That Pose A Threat To EMS Workers Body Substance
s Isolation (BSI) Exposure Control Plan Reservoirs Portals of Exit Susceptible D
efenses of a Susceptible Host Hand Washing Recommended Use of Personal Protectiv
e Equipment by Situation
Overview
Infection Control Procedures to reduce infection in patients and health care per
sonnel. Infection The growth of an organism in a susceptible host with or withou
t signs and symptoms of illness.

Communicable Disease Any disease that can be spread from one person to another o
r to a person from contaminated objects.
The Chain of Infection
1. Etiologic Agent/Causative Agent 2. Reservoir 3. Portal of exit from reservoir
4. Method of transmission 5. Portal of entry to the susceptible host 6. Suscept
ible host
Stages of Infection
Incubation Period Interval between entrance of pathogen into body and appearance
of first symptoms (e.g., chickenpox, 2-3 weeks; common cold, 1-2 days; influenz
a, 1-3 days; mumps, 15-18 days). Prodromal Stage Interval from onset of nonspeci
fic signs and symptoms (malaise, low-grade fever, fatigue) to more specific symp
toms (during this time, microorganisms grow and multiply, and client may be more
capable of spreading disease to others).

Illness Stage Interval when client manifests signs and symptoms specific to type
of infection (e.g., common cold manifested by sore throat, sinus congestion, rh
initis; mumps manifested by earache, high fever, parotid and salivary gland swel
ling). Convalescence Interval when acute symptoms of infection disappear (length
of recovery depends on severity of infection and clients general state of health
; recovery may take several days to months).
Methods of Transmission
Direct contact Contact with contaminated materials Inhalation of infected drople
ts (TB, Meningitis) The bite of an infected animal, human or insect Puncture by
contaminated needle Transfusion of contaminated blood products
Defenses against Infection
Normal flora Body system defenses Inflammation Immune response (acquired immunit
y)
Diseases that pose a threat to Health Care Providers

HIV Hepatitis B and C Tuberculosis Syphilis Meningitis Rabies (Philippines)

Rabies Rabies is a zoonotic disease (a disease that is transmitted to humans fro
m animals) that is caused by a virus. Rabies infects domestic and wild animals,
and is spread to people through close contact with infected saliva (via bites or
scratches). The disease is present on nearly every continent of the world but m
ost human deaths occur in Asia and Africa (more than 95%). Once symptoms of the
disease develop, rabies is fatal. Rabies is widely distributed across the globe.
More than 55 000 people die of rabies each year. About 95% of human deaths occu
r in Asia and Africa. Wound cleansing and immunizations, done as soon as possibl
e after suspect contact with an animal and following WHO recommendations, can pr
event the onset of rabies in virtually 100% of exposures. Once the signs and sym
ptoms of rabies start to appear, there is no treatment and the disease is almost
always fatal. Hepatitis B Hepatitis B is the most common serious liver infectio
n in the world. It is caused by the hepatitis B virus (HBV) that attacks the liv
er. This disease is more infectious than AIDS because it is very easily transmit
ted by blood, a single virus particle can cause disease. It is transmitted throu
gh infected blood and other body fluids like seminal fluid, vaginal secretions,
breast milk, tears, saliva and open sores. Once infected with the hepatitis B vi
rus, approximately 10% of the people develop a chronic permanent infection. It i
s very common in Asia, Africa and the Middle East. The overall incidence of repo
rted Hepatitis B is 2 per 10,000 individuals, but the true incidence may be high
er, because many cases do not cause symptoms and go undiagnosed and unreported.
Tuberculosis Left untreated, each person with active TB disease will infect on a
verage between 10 and 15 people every year. But people infected with TB bacilli
will not necessarily become sick with the disease. The immune system walls off the
TB bacilli which, protected by a thick waxy coat, can lie dormant for years. Wh
en someones immune system is weakened, the chances of becoming sick are greater.
Someone in the world is newly infected with TB bacilli every second. Overall, on
e-third of the worlds population is currently infected with the TB bacillus. Glob
ally, the Philippines rate of TB infection is ninth among 22 high burden countrie
s and ranks third in the Western Pacific region (WHO, 2004).

Meningitis Meningitis is inflammation of the thin tissue that surrounds the brai
n and spinal cord, called the meninges. There are several types of meningitis. T
he most common is viral meningitis, which you get when a virus enters the body t
hrough the nose or mouth and travels to the brain. Bacterial meningitis is rare,
but can be deadly. It usually starts with bacteria that cause a cold-like infec
tion. It can block blood vessels in the brain and lead to stroke and brain damag
e. It can also harm other organs. Meningitis is more common in people whose bodi
es have trouble fighting infections. Meningitis can progress rapidly. Symptoms i
nclude: sudden fever severe headache stiff neck
Body Substances Isolation
Wear mask and protective eyewear in situations where droplets of body fluids may
spray onto mucus membranes. Wear gloves when in contact with blood or bodily fl
uids. Wear a gown in situations where it is likely that droplets of blood or bod
y fluids will be sprayed on your working clothes. Immediately and thoroughly was
h or other skin surfaces that come into contact with blood or body fluids. To pr
event needle stick injuries, dispose of all use needles in a puncture-resistant
container with a secured lid. Use mouthpieces, resuscitation bags or ventilation
equipment when providing resuscitation. Do not provide direct patient care when
you have open and oxidative skin lesions.
Exposure Control Plan
A comprehensive plan that helps employees reduce their risk of exposure or acqui
sition of communicable diseases.

Determination of Exposure - this area should define who is at risk at comining i
n contact with blood or body fluids. Education and Training - this area should e
xplain why a qualified individual has to answer questions about CD and why infec
tion control is required Hepatitis Vaccination Program - outlines the immunizati
on schedules for EMT personnel. Personal Protective Equipment - should list the
PPE and should be of good quality. Changing and Disinfection Practices - should
describe how to care for and maintain vehicle and equipment. Post-Exposure Manag
ement - should identify who to notify when you believe you have been exposed.
Body Fluids and the Risk of Hepatitis B/C or HIV
Primary Risk Blood Semen Vaginal Secretions Secondary Risk Synovial Fluid CSF Fl
uid Amniotic Fluid No Risk Sweat Tears Saliva

Feces Vomitus Nasal Secretions Sputum
Reservoirs Portals of Exit
Respiratory Tract
nose, mouth, through sneezing, coughing, breathing, talking, ET tubes and trache
ostomies.
Gastro-Intestinal Tract
Urinary Tract
urethral meatus, urine, urinary diversion,
ostomies mouth, saliva, vomitus, feces, anus, drainage tubes, ostomies
Reproductive Tract Blood
open wound, needle puncture site, any disruption of int
act skin or mucous membrane vaginal discharges, vagine, semen, urine
Susceptible Defenses of a Susceptible Host
Hygiene Good personal hygiene and maintaining the intactness of the skin and muc
us membrane retains a barrier against microorganisms entering the body.

Immunization The immunologic system is a major defense against infection. Nutrit
ion Adequate nutrition enhances the health of all body tissues, helps keep the s
kin intact and promotes the skins ability to repel microorganisms. Fluid Adequate
fluid intake flushes the bladder and urethra Rest and Sleep Adequate rest and s
leep are essential to health and preserving energy. Stress Predisposes people to
infection.
Personnel Protective Equipment
Vinyl latex gloves Heavy duty gloves for cleansing Protective eyewear Mask - inc
luding pocket mask for CPR Cover gown Ventilatory equipment
Handwashing
Purposes: 1. To reduce the number of microorganisms onto the hands. 2. To reduce
the risk of transmission of infectious organisms to ones self. 3. To reduce the
risk of transmission of microorganisms and cross-contamination to patients

Recommended Use of Personal Protective Equipment by Situation
Task or Activity Bleeding control with spurting blood Bleeding control with mini
mal blood Emergency childbirth Blood drawing Starting an IV line Endotracheal in
tubation Oral/nasal suctioning, manually clearing airway Handling and cleaning i
nstruments with microbial contamination Measuring blood pressure Measuring tempe
rature Giving an injection Disposable Gloves Yes Gown Yes Mask Yes Protective Ey
ewear Yes
Yes
No
No
No
Yes At certain times Yes Yes
Yes No No No
Yes, if splashing is likely No No No, unless splashing is likely No, unless spla
shing is likely No
Yes, if splashing is likely No No No, unless splashing is likely No, unless spla
shing is likely No
Yes
No
Yes
No, unless soiling is likely
No No No
No No No
No No No
No No No
Chapter 7: Anatomy for EMTs

Outline
Body Organization Anatomical Planes and Directions Metabolism Skeletal System Ci

rculatory System Respiratory System Nervous System Muscular System Body Cavities
The Abdomen
Body Organization

Anatomical Planes and Directions
Metabolism
Metabolism refers to the chemical and energy transformations which occur in the
body. In the human body, carbohydrates, proteins and fats are oxidised to produc
e CO2, H2O and form available energy (adenosine triphosphate - ATP) which is ess
ential for life processes. At the cellular level, the production of energy takes
place in the mitochondria when oxygen and pyruvate are combined.
Aerobic Metabolism
In aerobic metabolism, there is sufficient oxygen entering the cell to react wit
h and convert the available pyruvate into ATP.
Anaerobic Metabolism
In anaerobic metabolism, there is no oxygen or insufficient oxygen entering the
cell and little or no utilisation of pyruvate. The remaining pyruvate converts i
nto lactic acid and cellular acidosis occurs, invariably leading to cell damage
or death. As little as 10% of ATP is produced during anaerobic metabolism.
Skeletal System
Gives form to the body Protects vital organs Consists of 206 bones Acts as a fra
mework for attachment of muscles Designed to permit motion of the body The skele
tal system can be divided into two parts: the axial skeleton and the appendicula
r skeleton
The Spine
The spine supports the skull and gives attachment to the ribs. It is a column of
33 irregular bones called vertebrae. Discs of cartilage between the vertebrae:
allow limited movement prevent friction act as shock absorbers.

The Skeletal System
The Circulatory System
The circulatory system is a closed system which transports essential food, oxyge
n and water to the cells of the body and removes the waste products they produce
. The circulatory system consists of three parts:
The heart Blood vessels Blood
These three parts are sometimes referred to as:
Pump Pipes Fluid

Normal Heart Rates Adults Children Infants 60 to 100 bpm 70 to 150 bpm 100 to 16
0 bpm
Electrical Control Mechanism Heart contraction is controlled by nerve stimuli wh
ich originate in the sino-atrial node (the pacemaker), passing down the Bundle of
His and radiating throughput the heart muscle.

Physiology of the Circulatory System Pulse
Blood Pressure
s There are five types of blood vessels:
Arteries Arterioles
Perfusion
The wave of blood through the arteries formed when the left ventricle contracts.
Can be felt where an artery passes near the skin surface and over a bone.
Amount of force exerted against walls of arteries. Systole: Left ventricle contr
acts. Diastole: Left ventricle relaxes.
Circulation of blood within an organ or tissue. If inadequate, the patient goes
into shock.
Blood Vesse
Veins Venules Capillaries

Arteries carry blood away from the heart. The blood is moved along by the heartb
eat and the artery walls. Arteries have a strong outer wall and a thick muscle l
ayer to withstand high pressure. Veins carry blood to the heart by the action of
the surrounding muscles and by the suction of the heart. Veins have thinner wal
ls and are provided with valves, to stop the blood flowing in the wrong directio
n. Arterioles and venules dilate or contract to control the blood flow into and
out of the capillary bed. Capillaries allow for the interchange of gases and the
transfer of nutrients and waste products. Capillaries have very thin walls cons
isting of a single layer of cells only. They are semi-permeable to permit the pa
ssage of substances between the blood and the tissues.
Respiratory System
Extracts oxygen from the atmosphere and transfer it to the bloodstream in the lu
ngs Excretes water vapour and CO2 Maintains the normal acid-base status of the b
lood Ventilates the lungs
Normal Breathing Rates
Adults Children Infants Inspired Air The air we breathe in contains approximatel
y:
79% nitrogen 20% oxygen
12 to 20 breaths/min 15 to 30 breaths/min 25 to 50 breaths/min

Expired Air
0.04% carbon dioxide 1% inert gases water vapour - variable
The air we breathe out contains approximately:
dioxide 1% inert gases water vapour to saturation
79% nitrogen 16% oxygen 4% carbon

Exchange of Gases External respiration
takes place in the lungs. Oxygen from inh
aled air is absorbed into the blood via the capillaries of the lung. Carbon diox
ide is released from the blood into the lungs and is exhaled. Internal respirati
on takes place in the tissues.
The Diaphragm
Has characteristics of both voluntary and involuntary muscles Dome
-shaped muscle Divides thorax from abdomen Contracts during inhalation Relaxes d
uring exhalation
Mechanisms of Breathing Inhalation
Diaphragm and intercostal muscles contract, i
ncreasing the size of the thoracic cavity. Pressure in the lungs decreases. Air
travels to the lungs.
Exhalation
Diaphragm and intercostal muscles relax. As the muscles relax, all di
mensions of the thorax decrease. Pressure in the lungs increases. Air flows out
of the lungs.

Normal Breathing Characteristics
Normal rate and depth Regular rhythm Good breath sounds in both lungs Regular ri
se and fall movements in the chest Easy, not labored
Infant and Child Anatomy
Structures less rigid Airway smaller Tongue proportiona
lly larger Dependent on diaphragm for breathing
The Nervous System
The nervous system controls the bodys voluntary and involuntary actions.
Somatic
nervous system - regulates voluntary actions Autonomic nervous system - controls
involuntary body functions

The Brain The brain is the highest level of the nervous system and is continuous
with the spinal cord. It is divided into three main parts: Cerebrum
motor centr
es control all the voluntary muscles. sensory centres receive sensory signals fr
om the skin, muscles, bones and joints. control of the autonomic nervous system
is buried deep in the cerebrum, in the thalamus and hypothalamus regulates the c
entral nervous system, and is pivotal in maintaining consciousness and regulatin
g the sleep cycle. Cerebellum
responsible for the maintenance of balance, muscle
coordination and muscle tone.
Brainstem
the nerve connections of the motor and sensory systems from the main p
art of the brain to the rest of the body pass through the brain stem. regulation
of cardiac and respiratory function.

Divisions of the Nervous System Central Nervous System
the spinal cord
Consists of the brain and
Peripheral Nervous System

Links the organs of the body to the central nervous sy
stem. Sensory nerves carry information from the body to the central nervous syst
em. Motor nerves carry information from the central nervous system to the muscle
s of the body. Nerves There are four types of nerves: 1. Cranial nerves connect
the sense organs (eyes, ears, nose, mouth) to the brain. 2. Central nerves conne
ct areas within the brain and spinal cord. 3. Peripheral nerves connect the spin
al cord with the limbs. 4. Autonomic nerves connect the brain and spinal cord wi
th the organs (heart, stomach, intestines, blood vessels, etc.).
Muscular System
Gives the body shape Protects internal organs Provides for movement Consists of
more than 600 muscles
Three Types of Muscles 1. Skeletal (voluntary) muscle
3. Cardiac muscle
Involunt
ary muscle. Attached to the bones of the body. Carries out the automatic muscula
r functions of the body. 2. Smooth (involuntary) muscle
Has own blood supply and electrical system. Can tolerate interruptions of blood
supply for only very short periods.
Body Cavities
The Abdomen

Chapter 8: Health, Hygiene, Fitness and Safety of the EMT

Outline
Traits of a Good EMT Healthy Lifestyle of an EMT The Food Pyramid for Filipino A
dults Body Mechanics Guidelines for Preventing Back Injuries EMS and Back Injuri
es
Traits of a Good EMT
Neat and clean - to promote confidence in both patients and bystanders and to re
duce the possibility of contamination. Physically fit - should be in good health
and fit to carry out duties. Emotionally and mentally fit - should be able to c
ope with stress at work and able to overcome unpleasant aspects of any emergenci
es.
Healthy Lifestyle of an EMT
Nutrition - to perform efficiently, an EMT should eat nutritious food to fuel th
e body and make it run. Physical exertion and stress are part of an EMTs job and
require high energy output.
Exercise and relaxation - a regular program of exerc
ise will enhance the benefits of maintaining nutrition and adequate hydration. B
alancing work, family and health - as an EMT you will often be called to assist
the sick and the injured any time of the day or night. Shift work may be require
d to be apart from loved ones for long periods of time. Never let the job interf
ere

excessively with your own needs. Find a balance between work and family. Make su
re that you have the time that you need to relax with family and friends.
The Food Pyramid for Filipino Adults

Body Mechanics
The efficient coordinated and safe use of the body to produce motion and maintai
n balance during activity. Proper movement promotes body musculoskeletal functio
ning, reduces the energy required for a task, and maintains balance, thereby red
ucing fatigue and decreasing the risk of injury. Three Basic Elements of Body Me
chanics 1. Body Alignment (Posture) - when the body is well-aligned, balance is
achieved without undue strain on the joints, muscles, tendons or ligaments. Prop
er body alignment also enhances lung expansion and promotes efficient circulator
y, renal and gastrointestinal function. 2. Balance (Stability) - good body align
ment is essential to body balance. A person maintains balance as long as the lin
e of gravity passes through the centre of gravity and the base of support. 3. Co
ordinated Body Movement - body mechanics involves the integrated functioning of
the musculoskeletal and nervous system as well as joint mobility.
Guidelines for Preventing Back Injuries
1. Be consciously aware of your posture and body mechanics. 2. Minimize lumbar l
ordosis as much as possible:
when standing for a period of time, periodically fl
ex one hip and knee and rest your foot on an object if possible. when sitting, k
eep your knees slightly higher than your hips. unless you have a pillow or other
support beneath your abdomen, avoid sleeping in the prone position. 3. Exercise
regularly to maintain overall physical condition, including exercises that stre
ngthen the pelvic, abdominal and lumbar muscles. 4. Apply principles of body mec
hanics when moving objects:
Spread your feet apart to provide a wide base of sup
port. Place your feet appropriately in the direction in which the movement will
occur. Push, pull, roll or slide objects rather than lifting them whenever possi
ble.
Avoid twisting the spine by pushing or pulling an object, directly away from or
toward the body and squarely facing the direction of movement. When lifting obje
cts, distribute the weight between the large muscles of the arms and legs.
5. Wear clothing that allows you to use good body mechanics and wear comfortable
low-heeled shoes that provide good foot support and will not cause you to slip,
stumble and turn your ankle.
EMS and Back Injuries
One in four EMS workers will suffer a career ending back injury within the first
4 years of service. The number one physical reason for leaving EMS, (mytactical.c
om, EMS Back Injury Facts, 2007).
Back injury from improper lifting is the number
one injury suffered by pre-hospital care providers, according to New Mexicos EMT
training manual. Almost one in two workers(47%) have sustained a back injury whil
e performing EMS duties, (National Association of Emergency Medical Technicians,
2005). Average cost for a simple sprain or strain of the lumbar spine is approximat
ely US$18,365 in direct costs per occurrence, (Mitterre D., Back Injuries in EMS, E
MS Magazine, 1999). Lifting caused just over 62% of back injuries for EMTs, and l
ow back strain was the cause of 78% of the compensation days in a 3.5 year perio
d, (Hogya PT, Ellis L., University of Pittsburgh Affiliated Residency in Emergen
cy Medicine, PA, 1990).
Chapter 9: Patient Assessment

Outline
Overview Purpose of Patient Assessment Scene Size-Up Body Substances Isolation S

cene Safety Number of Patients Additional Resources Mechanism of Injury (MOI) Na
ture of Illness (NOI) Cervical-Spine Immobilization Initial Assessment Baseline
Vital Signs Priority Patients Transport Decisions Trauma Assessment Focused Phys
ical Examination Significant Mechanism of Injury Patient Assessment Definitions
OPQRST The Full Assessment
Overview
Scene size-up Initial assessment Focused history and physical exam
Vital signs History Detailed physical exam Ongoing assessment
Purpose of Patient Assessment

Your total patient care and transport decisions will be based on your assessment
of the patients condition as follows:
To determine whether the patient has su
red trauma or has a medical complaint. To identify and manage immediately life t
hreatening injuries or conditions. To determine further assessment and care on t
he scene vs immediate transport with assessment and care continuing en route. To
provide further emergency care. To examine the patient and gather a patient med
ical history. To monitor the patients condition, assessing and adjusting care as
required. To communicate patient information to the medical facility to ensure c
ontinuity of care.
Scene Size-Up
Review dispatch information Inspection of scene Scene hazards Safety concerns

chanism of injury Nature of illness/chief complaint Number of patients Additiona
l resources needed
Body Substances Isolation
Assumes all body fluids present a possible risk for infection Protective equipme
nt:
Latex or vinyl gloves should always be worn Eye protection Mask Gown

Scene Safety
Park in a safe area. Speak with law enforcement first if present. The safety of
you and your partner comes first! Next concern is the safety of patient(s) and b
ystanders. Request additional resources if needed to make scene safe.
Potential hazards
Oncoming traffic Unstable surfaces Leaking gasoline Downe
ctrical lines Potential for violence Fire or smoke Hazardous materials Other dan
gers at crash or rescue scenes Crime scenes
Number of Patients
Determine the number of patients and their condition. Assess what additional res
ources will be needed. Triage to identify severity of each patients condition.
Additional Resources
Medical resources
Nonmedical resources
Additional units Advanced life support

Fire suppression Rescue
Law enforcement
Mechanism of Injury (MOI)
Helps determine the possible extent of injuries on trauma patients Evaluate:
unt of force applied to body Length of time force was applied Area of the body i
nvolved
Amo
Nature of Illness (NOI)

Search for clues to determine the nature of illness. Often described by the pati
ents chief complaint Gather information from the patient and people on scene. Obs
erve the scene.
The Importance of MOI/NOI
Guides preparation for care of the patient Suggests equipment that will be neede
d Prepares for further assessment Fundamentals of assessment are the same whethe
r the emergency appears to be related to trauma or a medical cause.
Cervical-Spine Immobilization
Consider early during assessment. Do not move without immobilization. Err on the
side of caution

Initial Assessment
1. Develop a general impression. 2. Assess mental status. 3. Assess airway. 4. A
ssess the adequacy of breathing. 5. Assess circulation. 6. Identify patient prio
rity. Forming a General Impression
Occurs as you approach the scene and the pati
ent Assessment of the environment Patients chief complaint Presenting signs and s
ymptoms of patient
Assessing Mental Status/Level of Consciousness A V P U Alert - awake and oriente
d Verbal - responds to verbal stimuli Painful: responds to painful stimuli Unres
ponsive: does not respond to stimuli
Assessing the ABCs A B C Airway Look for signs of airway compromise:
Two- to thr
ee-word dyspnea Use of accessory muscles Nasal flaring and use of accessory musc
les in children
Airway Breathing Circulation

Breathing Look for:
Circulation
Labored breathing
Choking Rate Depth Cyanosis Lung sounds Air movement
Assessing the pulse:
Presence Rate Rhythm Strength
Assessing and controlling external bleeding

Assess after clearing the airway and
stabilizing breathing Look for blood flow or blood on floor/clothes Controlling
bleeding Direct pressure Elevation Pressure points
Assessing perfusion:
Color Temperature Skin condition Capillary refill

Baseline Vital Signs
Check:
Breathing
Pulse
Skin
Pupils Blood Pressure
Pulse Oximetry Respirations No
rmal ranges for respiration: Adult Children Infants Breathing checklist: 12-20 b
reaths/min 15-30 breaths/min 25-50 breaths/min
Normal Equal chest rise
Shallow Shallow chest rise
Laboured Increased breathing effort. Use of accessory muscles; gasping, nasal fl
aring
Noisy Snoring, wheezing, gurgling and grunting noises
Rhythm
Regular Irregular

Effort
Depth
Shallow Normal Deep Effortless - Talks normally Difficulty breathin
g - Can only speak few words at a time
Pulse checklist: Normal ranges for pulse rates: Adult Children Toddlers Newborn
60-100 60 100 beats/min 80-120 80-120 beats/min 90-150 beats/min 120-160 beats/m
in
Tachycardia >100 beats/min Bradycardia <60 beats/min Strength
l Rapid Weak Normal Strong
Quality
Slow Norma

Rhythm
Skin Color Pale/grey/waxy Poor peripheral perfusion; Abnormally cold/froz
en Temperature Cold Cool Early shock, mild hypothermia, inadequate perfusion Nor
mal Hot Blue/grey Blood not properly saturated with oxygen Red/flushed Fever, po
isoning, sunburn, heatstroke, high blood pressure Regular Irregular
Shock, hypothermia
Hyperthermia, fever, sunburn
Moisture Dry/Normal Moist Early Shock Capillary Refill in Children CRT=2 secs CR
T>2 secs Blood Pressure
Blood pressure is a vital sign. Pressure of circulating
blood against the walls of the arteries. A drop in blood pressure may indicate:
Loss of blood Loss of vascular tone
Wet Shock
Normal Poor peripheral circulation
Cardiac pumping problem

Blood pressure should be measured in all patients older than 3 years of age.
Normal ranges for blood pressure: Adults 90 to 140 mmHg (s) 60 to 90 mmHg (d) Ch
ildren (1-8) Infants (up to 1 yr) 80 to 110 mmHg (s) 50 to 90 mmHg (s)
Systolic pressure Diastolic pressure Pulse pressure
The amount of pressure exerted against the walls of the arteries when the left v
entricle contracts. The pressure exerted against the wall of the arteries when t
he left ventricle is at rest. Systolic pressure minus diastolic pressure.
BP by Auscultation
BP by Palpation

Level of Responsiveness A V P U Pupil Response P - Pupils E - Equal A - And R Round R - Regular in size L - React to Light Alert - awake and oriented Verbal responds to verbal stimuli Painful: responds to painful stimuli Unresponsive: d
oes not respond to stimuli
Abnormal pupil reaction
Priority Patients
Stay and Play vs. Scoop and Run
Difficulty breathing Poor general imp
nsive with no gag reflex Severe chest pain Signs of poor perfusion Complicated c
hildbirth Uncontrolled bleeding Responsive but unable to follow commands Severe
pain Inability to move any part of the body
Transport Decisions
Patient condition Availability of advanced care Distance to transport Local prot
ocols
Rapid Trauma Assessment
A 60-90 second head-to-toe exam that is quickly conducted on a patient who has s
uffered or may have suffered severe injuries

During the Rapid Trauma Assessment, the EMT is looking for signs of: D C A P Def
ormities Contusions Abrasions Punctures/Penetrations
Remember: DCAP - BTLS
B T L S
Burns Tenderness Lacerations Swelling
Stages of the Rapid Trauma Assessment 1. Maintain spinal immobilization while ch
ecking patients ABCs. 2. Inspect and palpate the head and face, including the ear
s, pupils, nose and mouth. 3. Assess the neck. 4. Apply a cervical spine immobil
ization collar. 5. Expose and assess the chest. Perform a four-point auscultatio
n of the chest to listen for breath sounds. 6. Assess the abdomen. If the patien
t complains of pain or there is obvious trauma, do not palpate. 7. Assess the pe
lvis, checking for stability and crepitus. 8. Assess all four extremities, inclu
ding pulses, motor function and sensation (PMS). 9. Roll the patient with spinal
precautions.

Focused Physical Exam
Used to evaluate patients chief complaint. Performed on: Trauma patients without
significant MOI Responsive medical patients SAMPLE History S A M P L E Signs and
Symptoms Allergies Medications Pertinent past history Last oral intake Events l
eading to injury or illness
Remember: SAMPLE
Stages of the Focused Physical Exam Head, Neck, and Cervical Spine
Chest
Look for obvious injury, bruises, or bleeding. Evaluate for tenderness and any
bleeding.
Feel head and neck for deformity, tenderness, or crepitation. Check for bleeding
. Ask about pain or tenderness.
Watch chest rise and fall with breathing. Feel for grating bones as patient brea
thes. Listen to breath sounds.
Abdomen

Pelvis
Do not palpate too hard.
Look for any signs of obvious injury, bleeding, or deformity. Press gently inwar
d and downward on pelvic bones.
Extremities
Look for obvious injuries. Feel for deformities. Assess PMS:
otor function Sensory function
Pulse M
Posterior Body
Feel for tenderness, deformity, and open wounds. Carefully palpat
e from neck to pelvis. Look for obvious injuries.
Significant Mechanism of Injury

Ejection from vehicle Death in passenger compartment Fall greater than 15le rollover High-speed collision Vehicle-pedestrian collision Motorcycle crash U
nresponsiveness or altered mental status Penetrating trauma to the head, chest,
or abdomen

Assessment Summary
Assessment Steps for Significant MOI Rapid trauma assessment Baseline vital sign
s SAMPLE history Re-evaluate transport decision Assessment Steps for Trauma Pati
ents Without Significant MOI Focused assessment Baseline vital signs SAMPLE hist
ory Re-evaluate transport decision
Responsive Medical Patients History of illness SAMPLE history Focused assessment
Vital signs Re-evaluate transport decision
Unresponsive Medical Patients Rapid medical assessment Baseline vital signs SAMP
LE history Re-evaluate transport decision
Ongoing Assessment Is treatment improving the patients condition? Has an already
identified problem gotten better? Worse? What is the nature of any newly identif
ied problems?
Steps of the Ongoing Assessment Repeat the initial assessment. Reassess and reco
rd vital signs. Repeat focused assessment. Check interventions.

Patient Assessment Definitions
Scene Size-Up
Steps taken by EMS providers when approaching the scene of an emergency call; de
termining scene safety, taking BSI precautions, noting the mechanism of injury o
r patients nature of illness, determining the number of patients, and deciding wh
at, if any additional resources are needed including Advanced Life Support. The
process used to identify and treat lifethreatening problems, concentrating on Le
vel of Consciousness, Cervical Spinal Stabilization, Airway, Breathing, and Circ
ulation. You will also be forming a General Impression of the patient to determi
ne the priority of care based on your immediate assessment and determining if th
e patient is a medical or trauma patient. The components of the initial assessme
nt may be altered based on the patient presentation. In this step you will recon
sider the mechanism of injury, determine if a Rapid Trauma Assessment or a Focus
ed Assessment is needed, assess the patients chief complaint, assess medical pati
ents complaints and signs and symptoms using OPQRST, obtain a baseline set of vi
tal signs, and perform a SAMPLE history. The components of this step may be alte
red based on the patients presentation. This is performed on patients with signif
icant mechanism of injury to determine potential life threatening injuries. In t
he conscious patient, symptoms should be sought before and during the Rapid Trau
ma assessment. You will estimate the severity of the injuries, re-consider your
transport decision, reconsider Advanced Life Support, consider the platinum 10 m
inutes and the Golden Hour, rapidly assess the patient from head to toe using DC
AP-BTLS, obtain a baseline set of vital signs, and perform a SAMPLE history.
Initial Assessment
Focused History and Physical Exam
Rapid Trauma Assessment

This is performed on medical patients who are unconscious, confused, or unable t
o adequately relate their chief complaint. This assessment is used Rapid Medical
History to quickly identify existing or potentially lifethreatening conditions.
You will perform a head to toe rapid assessment using DACP-BTLS, obtain a basel
ine set of vital signs, and perform a SAMPLE history This is used for patients,
with no significant mechanism of injury, that have been determined to have no li
fe-threatening injuries. This assessment Focused History and Physical Exam - Tra
uma would be used in place of your Rapid Trauma Assessment. You should focus on
the patients chief complaint. An example of a patient requiring this assessment w
ould be a patient who has sustained a fractured arm with no other injuries and n
o lifethreatening conditions. This is used for patients with a medical complaint
who are conscious, able to adequately relate their Focused History and Physical
Exam - Medical chief complaint to you, and have no life-threatening conditions.
This assessment would be used in place of your Rapid Medical Assessment. You sh
ould focus on the patients chief complaint using OPQRST, obtain a baseline set of
vital signs, and perform a SAMPLE history.

This is a more in-depth assessment that builds on the Focused Physical Exam. Man
y of your patients may not require a Detailed Physical Exam because it is either
irrelevant or there is not enough time to complete it. This assessment will onl
y be performed while en route to the hospital or if there is time on Detailed Ph
ysical Exam scene while waiting for an ambulance to arrive. Patients who will ha
ve this assessment completed are patients with significant mechanism of injury,
unconscious, confused, or unable to adequately relate their chief complaint. In
the Detailed Physical Exam you will perform a head to toe assessment using DCAPBTLS to find isolated and non-life-threatening problems that were not found in t
he Rapid Assessment and also to further explore what you learned during the Rapi
d Assessment. This assessment is performed during transport on all patients. The
Ongoing Assessment will be repeated every 15 minutes for the stable patient and
every 5 minutes for the unstable patient. This assessment is used to answer the
following questions: Ongoing Assessment 1. Is the treatment improving the patie
nts condition? 2. Are any known problems getting better or worse? 3. What is the
nature of any newly identified problems? You will continue to reassess mental st
atus, ABCs, reestablish patient priorities, reassess vital signs, repeat the foc
used assessment, and continually recheck your interventions.

OPQRST
Used to assess a patients chief complaint during a medical exam. O P Q R S T OPQR
ST Explained Onset The word onset should trigger questions regarding what the pati
ent was doing just prior to and during the onset of the specific symptom(s) or c
hief complaint. What were you doing when the symptoms started? Was the onset sud
den or gradual? It may be helpful to know if the patient was at rest when the sy
mptoms began or if they were involved in some form of activity. This is especial
ly true with patients presenting with suspected cardiac signs & symptoms. Provoc
ation The word provocation should trigger questions regarding what makes the sympt
oms better or worse. Does anything you do make the symptoms better or relieve th
em in any way? Does anything you do make the symptoms worse in any way? This is
sometimes helpful in ruling in or out a possible musculoskeletal cause. A patien
t with a broken rib or pulled muscle will most likely have pain that is easily p
rovoked by palpation and/or movement. This is often in contrast to the patient h
aving chest pain of Onset Provocation Quality Radiation/Region Severity Time

a cardiac origin whose pain is not made any better or worse with movement or pal
pation. Quality The word quality should trigger questions regarding the character
of the symptoms and how they feel to the patient. Can you describe the symptom (
pain/discomfort) that you are having right now? What does it feel like? Is it sh
arp or dull? Is it steady or does it come and go? Has it changed since it began?
This if often the most difficult question for the patient to understand and to
articulate. The key here is to allow the patient to use their own words and not
try to feed the patient with suggestions that they may choose simply because you
have made it easy. It is sometime helpful to offer the patient choices and allo
w them to decide which is most appropriate for their situation. For instance, is
your pain sharp or is it dull or is your pain steady or does it come and go? Region
/Radiation The words region and radiation should trigger questions regarding the e
xact location of the symptoms. Can you point with one finger where it hurts the
most? Does the pain radiate or move anywhere else? Although it is not always eas
y for a patient to identify the exact point of pain, especially with pediatric p
atients, it is important to ask. Asking if they can point with one finger to whe
re it hurts the most is a good start. From there you will want to know if the pa
in moves or radiates anywhere from the point of origin. The patient may need you to
offer some suggestions such as, does the pain radiate anywhere else such as your
back, neck, jaw or shoulders? Always give them two or three choices and allow the
m to select from the options that you give.

Severity The word severity should trigger questions relating to the severity of th
e symptoms. On a scale of 1 to 10, how would you rate your level of discomfort r
ight now? Using the same scale, how would you rate your discomfort when it first
began? Its not always just about how bad the pain or discomfort is when you arri
ve - this is a common mistake made by many new EMTs. Once you have established t
he level of discomfort that the patient is experiencing at that moment, you must
follow this up with how severe the discomfort was at onset. This will help you
establish whether the discomfort is getting better, worse or staying the same ov
er time. You will want to follow these two checkpoints up with an additional che
ck once the patient has received some of your care and reassurance. Often times
with a little oxygen and reassurance the symptoms may subside. Ask the patient a
few minutes later how the discomfort is and if it has changed at all since your
arrival. Time The word time should trigger questions relating to the when the sym
ptoms began. When did the symptoms first begin? Have you ever experienced these
symptoms before? If so, when? Establishing an accurate duration of the symptoms
will be very helpful to the hospital staff that will be caring for the patient.
This question has special importance when caring for patients presenting with su
spected cardiac signs and symptoms.
The Full Assessment
SCENE SIZE-UP Steps taken when approaching the scene.
Ensure BSI (Body Substance
Isolation) procedures and & personal protective gear is being used. Observe sce
ne for safety of crew, patient, bystanders. Identify the mechanism of injury or
nature of illness. Identify the number of patients involved. Determine the need
for additional resources including Advanced Life Support.
Consider C-Spine stabilization

INITIAL ASSESSMENT Assessment & treatment (life-threats) General Impression
Mech
anism of injury or nature of illness Age, sex, race Find and treat life threaten
ing conditions (any obvious problems that may kill the patient within seconds).
Problems with Airway, Breathing, or Circulation Verbalize general impression of
patient
Mental Status
Airway
Is the pt. talking or crying? Do you hear any nois
he airway stay open on its own? Does anything endanger it? Open the airway - hea
d-tilt-chin-lift or jaw thrust as needed Clear the airway as needed Suction - as
needed Insert an OPA/NPA - as needed If the pt. appears to be unconscious, chec
k for responsiveness, (Hey! Are you OK?) Evaluate mental status using AVPU. Obtain
a chief complaint, if possible.
Breathing
Do you see any signs of inadequate respirations? Is the rate and quali
ty of breathing adequate to sustain life? Is the patient complaining of difficul
ty breathing? Quickly inspect the chest for impaled objects, open chest wounds,
and bruising (trauma).
Quickly palpate the chest for unstable segments, crepitation (trauma), and equal
expansion of the chest. Check pulse oximetry - if below 94% administer oxygen.
If the pt. is unresponsive and breathing is inadequate, use a BVM to maintain pu
lse oximetry at 94% or above.
Circulation
If the pt. is unresponsive, assess for presence and quality o
arotid pulse. If the pt. is responsive, assess the rate and quality of the radia
l pulse. If radial pulse is weak or absent, compare it to the carotid pulse. For
patients 1 year old or less, assess the brachial pulse. Is there life threateni
ng hemorrhage? Control life threatening hemorrhage Assess the patients perfusion
by evaluating skin for color, temperature and condition (CTC); can also check th
e conjunctiva and lips Assess capillary refill in infant or child < 6 yrs. old C
over with blanket and elevate the legs as needed for shock (hypoperfusion)
Identify Priority Patients
ble? Stable?
Is the patient:
Critical? Unstable? Potentially Unst
Consider the need for Advanced Life Support If the patient is CRITICAL, UNSTABLE
or POTENTIALLY UNSTABLE , begin packaging the patient during the rapid assessme
nt while treating life threats and transport as soon as possible.
In addition, perform the rapid trauma assessment for the trauma patient if he/sh
e has significant mechanism of injury and apply spinal immobilization as needed.
For the unresponsive medical patient perform the rapid medical assessment. If t
he patient is or STABLE, perform the appropriate focused physical exam (for the
medical pt. perform the focused physical exam; for trauma patient perform the fo
cused trauma assessment.)

FOCUSED HISTORY AND PHYSICAL EXAM - TRAUMA Re-consider the mechanism of injury.
If there is significant mechanism of injury, perform a Rapid Trauma Assessment o
n-scene while preparing for transport and then a Detailed Assessment during tran
sport. If there is no significant mechanism of injury, perform the Focused Traum
a Assessment. Direct the focused trauma assessment to the patients chief complain
t and the mechanism of injury (perform it instead of the rapid trauma assessment
). Rapid Trauma Assessment Performed on patients with significant MOI.
Continue
spinal stabilization Re-consider ALS back-up
Inspect and palpate the body for injuries to the following: HEAD
NECK
CHEST
-BTLS Paradoxical movement Crepitation Breath sounds - bilateral assessment of t
he apices, mid-clavicular line; midaxillary at the nipple line; and at the bases
ABDOMEN
DCAP-BTLS Pain Firm
DCAP-BTLS Blood & fluids from the head, including cerebrospinal fluid
DCAP-BTLS JVD (Jugular Vein Distention) Crepitation Apply CSIC (Cervical Spinal
Immobilization Collar) - if not already done

PELVIS
Soft Distended
DCAP-BTLS If no pain is noted, gently compress the pelvis to determine tendernes
s or unstable movement.
EXTREMITIES
DCAP-BTLS Crepitation Distal pulses Sensory function Motor function
POSTERIOR
Logroll the patient. Maintain c-spine stabilization. Inspect and palpa
te for injuries or signs of injury. DCAP-BTLS
FOCUSED TRAUMA ASSESSMENT Performed on patients with no significant MOI. Assess
the patients chief complaint
The specific injury they are complaining about why t
hey called EMS Assess and treat injuries not found during your Initial Assessmen
t Reconsider your transport decision Consider ALS intercept
Focused Assessment
Follow order of the Rapid Assessment Focus assessment on the
specific area of injury or complaint

Baseline Vital Signs
Obtain a full set of vital signs including:
TE:
Watch the chest/abdomen and count for no less than 30 seconds. If abnormal r
espirations are present count for a full 60 seconds. Respirations Pulse Blood Pr
essure Level of Consciousness Skin Pupils
Assess SAMPLE History Signs & Symptoms Pertinent Past Medical History Allergies
Last oral intake Medications Events leading up to the injury/illness
QUALITY:
Pulse RATE: Check the radial pulse. If pulse is regular, count for 30 s
econds and multiply x 2. If it is irregular, count for a full 60 seconds. Normal
Shallow Any unusual pattern? Labored? Deep Noisy breathing?

QUALITY:
Regular Strong Irregular Weak
Skin (CTC) COLOUR:

TEMPERATURE:
CONDITION:
Normal (unremarkable) Cyanotic Pale Flushed Jaundice

Warm Hot Cool Cold
Wet Dry
Blood Pressure
3. Auscultate the
e systolic reading
f the pupils; also
ted
Blood pressure should be measured in all patients over the age of

blood pressure. In a high noise environment, palpate (only th
can be obtained). Pupils
Use a penlight to check reactivity o
assess for size equal or unequal normal, dilated, or constric
reactive - change when exposed to light non-reactive - do not change when expose
d to light equally or unequally reactive when exposed to light
FOCUSED HISTORY AND PHYSICAL EXAM - MEDICAL During this phase of the patient ass
essment, the mnemonic OPQRST and SAMPLE will be used to gather information about
the chief complaint and history of the present illness. Baseline vital signs an
d a focused physical exam or a rapid medical assessment will be performed. The o
rder in which you perform the steps of this focused history and physical exam va
ries depending on whether the patient is responsive or unresponsive. RAPID MEDIC
AL ASSESSMENT Performed on patients who are unconscious, confused, or unable to
adequately relate their chief complaint. Perform a rapid assessment using DCAP-B
TLS following the order of the Rapid Trauma Assessment:
Assess the head A
he neck Assess the chest Assess the abdomen Assess the pelvis Assess the extremi
ties Assess the posterior Obtain baseline set of vital signs Position patient to
protect the airway Obtain the SAMPLE history from bystander, family, or friends
.
FOCUSED MEDICAL ASSESSMENT Performed on the conscious, alert patient who can ade
quately relate their chief complaint.
Obtain the history of the present illness
Onset - What were you doing when the symptoms started? Provocation - Is there anyth
ing that makes the symptoms better or worse? Quality - What does the pain/discomfo
rt feel like?
Radiation - Where do you feel the pain/discomfort? Does the pain/discomfort travel
anywhere else? Severity - How bad is the pain? How would you rate the pain on a scal
e of 1-10, with 10 being the worst pain youve felt in your life? Time - How long ha
s the problem been going on? Assess SAMPLE
Examples of questions to ask a conscious medical patient and assessment elements
according to the patients chief complaint
Altered Mental Status o Description of episode o Duration o Onset o Associated s
ymptoms o Evidence of trauma o Interventions o Seizures o Fever Poisoning & OD o
Substance o When exposed/ingested o Amount o Time period o Interventions o Esti
mated weight o Source
Allergic Reaction o History of allergies o Exposed to what? o How exposed o Effe
cts o Progression o Interventions o Onset
Cardiac/Respiratory
o Provocation o Quality o Radiation o Severity o Time o Interventions
Environmental
Behavioral o How do you feel? o Determine if suicidal: Were you trying to hurt yo
urself? Have you been feeling that life is not worth living? Have you been feeling l
ike killing yourself? o Threat to self or others o Medical problem o Intervention
s
o Environment o Duration o Loss of consciousness o Effects-general or local

Obstetrics o Are you pregnant? o How long have you been pregnant? o Pain or cont
raction o Bleeding or discharge o Has your water broke? o Do you want to push? o
Last menstrual period?
Acute Abdomen o Location of pain o Any vomiting? If so, color/substance o Taking
birth control o Vaginal bleeding or discharge o Abnormal vital signs
Loss of Consciousness o Length of time unconscious o Position o History o Blood
in vomit or stool o Trauma o Incontinence o Abnormal vital signs
Baseline Vital Signs Obtain a full set of vital signs including: - Respirations
- Pulse - Blood Pressure - Level of Consciousness - Skin - Pupils Provide Treatm
ent Provide emergency medical care based on signs and symptoms. DETAILED PHYSICA
L EXAM The Detailed Physical Exam is used to gather additional information regar
ding the patients condition only after you have provided interventions for life t
hreats and serious conditions. Not all patients will require a Detailed Physical
Exam. It is performed in a systematic head-to-toe order. You will examine the s
ame body areas that you examined during your rapid assessment. During the detail
ed physical exam, you will look more closely at each area to search for findings

of lesser priority than life threats and/or signs of injury that have worsened.
Do not delay transport to perform a detailed physical exam; it is only performed
while en route to the hospital or while waiting for transport to arrive. Detail
ed Physical Exam Trauma or Medical The Detailed Physical Exam is used to gather
additional information regarding the patients condition only after you have provi
ded interventions for life threats and serious conditions. Not all patients will
require a Detailed Physical Exam. It is performed in a systematic head-totoe or
der. You will examine the same body areas that you examined during your rapid as
sessment. During the detailed physical exam, you will look more closely at each
area to search for findings of lesser priority than life threats and/or signs of
injury that have worsened. Do not delay transport to perform a detailed physica
l exam; it is only performed while en route to the hospital or while waiting for
transport to arrive. HEAD - inspect and palpate for signs of injury. DCAP-BTLS
Blood & fluids from the head FACE - inspect and palpate for signs of injury. DCA
P-BTLS EARS - inspect and palpate for signs of injury. DCAP-BTLS Drainage (blood
or any other fluid) EYES - inspect for signs of injury. DCAP-BTLS Discoloration
Unequal Pupils Foreign Bodies Blood in Anterior Chamber

NOSE - inspect and palpate for signs of injury. DCAP-BTLS Drainage Bleeding MOUT
H - inspect for signs of injury. DCAP-BTLS Damaged/Missing Teeth Obstructions Sw
ollen or Lacerated Tongue Discoloration Unusual Odors NECK - inspect and palpate
for signs of injury. DCAP-BTLS JVD Tracheal deviation Crepitation CHEST - inspe
ct and palpate for signs of injury. DCAP-BTLS Paradoxical movement Crepitation B
reath sounds - bilateral assessment of the apices, midclavicular line; mid-axill
ary at the nipple line; and at the bases Present Absent Equal

ABDOMEN - inspect and palpate for signs of injury. DCAP-BTLS Pain/Tenderness Fir
m Soft Distended PELVIS - inspect and palpate for signs of injury. DCAP-BTLS If
no pain is noted, gently compress the pelvis to determine tenderness or unstable
movement. EXTREMITIES - inspect and palpate the lower and upper extremities for
signs of injury. DCAP-BTLS Crepitation Distal pulses Sensory function Motor fun
ction POSTERIOR Log roll the patient. Maintain c-spine stabilization. Inspect an
d palpate for injuries or signs of injury. DCAP-BTLS

ON-GOING ASSESSMENT The On-Going Assessment will be performed on all patients wh
ile the patient is being transported to the hospital. It is designed to reassess
the patient for changes that may require new intervention. You will also evalua
te the effectiveness of earlier interventions, and reassess earlier significant
findings. You should be prepared to modify treatment as appropriate and begin ne
w treatment on the basis of your findings during the On-Going Assessment. Repeat
Initial Assessment Reassess mental status. Maintain an open airway. Monitor bre
athing for rate and quality. Reassess pulse for rate and quality. Monitor skin c
olor and temperature (CTC). Re-establish patient priorities. Reassess and Record
Vital Signs Repeat Focused Assessment Check Interventions Assure adequacy of ox
ygen delivery/artificial ventilation. Assure management of bleeding. Assure adeq
uacy of other interventions
UNSTABLE PATIENTS repeat On-Going Assessment at least every 5 minutes. STABLE PA
TIENTS repeat On-Going Assessment at least every 15 minutes.
Chapter 10: Communication and Documentation

Outline
Overview Types of Communication in EMS Emergency Medical Dispatch Response Times

Dispatch Life Support EMT Communication Triage Verbal Communication Communicati
ng with Patients Documentation The Pre-hospital Care Report/Patient Care Report
Documenting Refusal Special Reporting Situations
Overview
Essential components of pre-hospital care: Verbal communications are vital. Adeq
uate reporting and accurate records ensure continuity of patient care. Reporting
and record keeping are essential aspects of patient care.

Types of Communication in EMS
Base Station Radios Transmitter and receiver located in a fixed place Power of 1
00 watts or more A dedicated line (hot line) is always open. Immediately on when y
ou lift up the receiver Mobile and Portable Radios Mobile radios installed in ve
hicle - Range of 10 to 15 miles Portable radios hand-held - Operate at 1 to 5 wa
tts of power Repeater-Based Systems Receives radio messages and retransmits A re
peater is a base station able to receive low-power signals. Digital Systems Some
EMS systems use telemetry to send an ECG from the unit to the hospital. Telemet
ry is the process of converting electronic signals into coded, audible signals.
Signals can be decoded by the hospital. Cellular Telephones Low-powered portable
radios that communicate through interconnected repeater stations Cellular telep
hones can be easily scanned.

Others Simplex - Push-to-talk communication Duplex - Simultaneous talk-listen ME
D channels - Reserved for EMS
Emergency Medical Dispatch
Responsibilities Screen and assign priorities Select and alert appropriate units
to respond Dispatch and direct units to the location Coordinate response with o
ther agencies Provide pre-arrival instructions to the caller Information Receive
d From Dispatch Nature and severity of injury, illness, or incident Location of
incident Number of patients Responses by other agencies Special information Time
dispatched

Advanced Medical Priority Dispatch System (AMPDS) The Advanced Medical Priority
Dispatch System (AMPDS), is a medically-approved, unified system used to dispatc
h appropriate aid to medical emergencies including systematized caller interroga
tion and pre-arrival instructions. AMPDS is developed and marketed by Priority D
ispatch Corporation which also has similar products for police and fire. The out
put gives a main response category - A (Immediately Life Threatening), B (Urgent
Call), C (Routine Call). This may well be linked to a performance targeting sys
tem such as ORCON where calls must be responded to within a given time period. F
or example, in the United Kingdom, calls rated as A on AMPDS are targeted with get
ting a responder on scene within 8 minutes. Positive Benefits of AMPDS
Decreased EMV accidents Decreased burn-out of field personnel Decreased lights-a

nd-siren runs Improved medical control at dispatch Improved medical dispatcher p
rofessionalism Improved standardization of care, interrogation and decision maki
ng Increased appropriateness of medical care through correct response Increased
resource availability, especially ALS Increased safety of response personnel in
the field Increased knowledge at arrival of response personnel Increased coopera
tion with associated public safety systems, law enforcement and fire departments
Response Times
Most countries have adopted a response time of 8 to 10 minutes for the most crit
ical cases, and a longer response time for non-acute calls. Toronto, Canada With
in 9 minutes in 90% of critical, life-threatening and serious cases; and within
21 minutes in 90% of non-acute cases.

London, UK Within 8 minutes in 75% of immediately life-threatening cases; no tar
get set for cases that are not serious or life-threatening. Queensland, Australi
a Within 10 minutes in 68% of Emergency Transport cases; no target set for nonur
gent cases.
Dispatch Life Support
An Emergency Medical Dispatcher (EMD) is trained to dispatch EMTs based on the i
nformation given during the initial emergency call. They are trained to mobilise
resources based on these essential guidelines:
A seizure or convulsion may be a
sympton of the onset of cardiac arrest. Any person 35 years or older who presen
ts with a seizure as a chief complaint should be assumed to be in cardiac arrest
until proven otherwise.
Cardiac arrest in a previously healthy child should be
considered to be caused by a foreign body obstructing the airway until proven ot
herwise. Dispatchers should be trained to identify obvious death situations (as
defined by medical control), mobilize response accordingly and give limited prearrival instructions.
If the caller is a third-party who cannot identify if the
victim is unconscious and not breathing, the victim should be assumed to be in c
ardiac arrest until proven otherwise.
EMDs should assume that bystanders have in
appropriately placed a pillow under the head of an unconscious victim, until pro
ven otherwise, and ensure it is removed. BLS protocol for a choking victim shoul
d be modified to reflect EMDs recommend a specific number of thrusts, rather tha
n stating a range of thrusts.
The Heimlich manoeuvre should be the primary treat
ment of infants, children and adults who are choking.

Remember that Emergency Medical Dispatchers are not usually EMT-trained. They ar
e trained to ask specific questions and give basic life support advice over the
telephone. Because people calling emergency services rarely have medical trainin
g, EMDs are trained to err on the side of caution and cater for the worst case s
cenario.
EMT Communication
EMT Communication with Dispatch
Report any problems during run. Advise of arriva
l. Communicate scene size-up. Keep communications brief.
EMT Communication with Medical Control
Radio communications facilitate contact b
etween providers and medical control. Consult with medical control to: - Notify
hospital of incoming patient. - Request advice or orders. - Advise hospital of s
pecial circumstances.
Organize your thoughts before transmitting.
Calling Medical Control

The physician bases his or her instructions on the repo
t received from the EMT-B. Never use codes while communicating. Repeat all order
s received. Do not blindly follow an order that does not make sense to you - ask
the physician to clarify his or her orders. Notify as early as possible. Estima
te the potential number of patients. Identify special needs of patient.

Reporting Requirements
Acknowledge dispatch information. Notify arrival at scene
. Notify departure from scene. Notify arrival at hospital or facility. Notify yo
u are clear of the incident. Notify arrival back in quarters.
Patient Report
Identification and level of services Receiving hospital and ET
atients age and gender Chief complaint History of current problem Other medical h
istory Physical findings Summary of care given and patient response
Triage
Triage Priorities Triage is the sorting of patients according to the urgency of
their need for care. It occurs both in the field and at the hospital. Priority O
ne (Highest)
Airway or breathing difficulties Uncontrolled or severe bleeding Decreased or al

tered mental status Severe medical problems Signs and symptoms of shock Severe b
urns with airway compromise

Priority Two
Burns without airway compromise Multiple or major bone or joint injuries Back in
juries with or without spinal cord damage
Priority 3 (Lowest)
Minor bone or joint injuries Minor soft-tissue injuries Prolonged cardiac arrest
Cardiopulmonary arrest Death
Verbal Communication
Essential part of quality patient care. You must be able to find out what the pa
tient needs and then tell others. You are a vital link between the patient and t
he health care team.
Components of an Oral Report
Patients name, chief complaint, nature of illness,
echanism of injury Summary of information from radio report Any important histor
y not given earlier Patients response to treatment The vital signs assessed Any o
ther helpful information
Communicating with Patients
Make and keep eye contact. Use the patients proper name. Tell the patient the tru
th. Use language the patient can understand. Be careful of what you say about th
e patient to others. Be aware of your body language. Always speak slowly, clearl
y, and distinctly.
If the patient is hearing impaired, speak clearly and face him or her. Allow tim
e for the patient to answer questions. Act and speak in a calm, confident manner
.
Communicating With Geriatric Patients
Determine the persons functional age. Do no
t assume that an older patient is senile or confused. Allow patient ample time t
o respond. Watch for confusion, anxiety, or impaired hearing or vision. Explain
what is being done and why.
Communicating With Hearing-Impaired Patients
Always assume that the patient has
normal intelligence. Make sure you have a paper and pen. Face the patient and sp
eak slowly, clearly and distinctly. Never shout! Learn simple phrases used in si
gn language.
Communicating With Children
Children are aware of what is going on. Allow people
or objects that provide comfort to remain close. Explain procedures to children
truthfully. Position yourself on their level.
Communicating With Vision-Impaired Patients
Ask the patient if he or she can see
at all. Explain all procedures as they are being performed. If a guide dog is p
resent, transport it also, if possible.

Communicating With Non-English-Speaking Patients
Use short, simple questions and
answers. Point to specific parts of the body as you ask questions. Learn common
words and phrases in the non-English languages used in your area.
Documentation
Minimum Data Set for Written Documentation Patient information:
Mental status Systolic BP (patients older than 3 years) Capillary refill (patien
ts younger than 6 years) Skin color and temperature Pulse Respirations and effor
t
Time incident was reported Time that EMS unit was notified Time EMS unit arrived
on scene Time EMS unit left scene Time EMS unit arrived at facility Time that p
atient care was transferred
The Pre-hospital Care Report (PCR)
The Pre-hospital Care Report (or Patient Care Report) serves six functions:
inuity of care Legal documentation Education Administrative Research Evaluation
and quality improvement
Cont

Types of PCR Forms
Written forms Computerized versions Narrative sections of the
form:
Use only standard abbreviations. Spell correctly. Record time with assess
ment findings.
Report is considered confidential.
Reporting Errors
Do not write false statements on report. If error made on repor
t then:
Remember:
A PCR is a legal document. If you didnt do something - dont w
e it down. If you dont write it down - it didnt happen. Draw a single horizontal l
ine through error. Initial and date error. Write the correct information.
Documenting Right of Refusal
Document assessment findings and care given. Have the patient sign the form. Hav
e a witness sign the form. Include a statement that you explained the possible c
onsequences of refusing care to the patient
Special Reporting Situations
Be familiar with required reporting in your jurisdiction, including:
nds Animal bites
Gunshot wou
Certain infectious diseases Suspected physical, sexual, or substance abuse Multi

ple-casualty incidents (MCI)

Chapter 11: Airway Management

Outline
Anatomy Review Normal Breathing Rates Recognizing Adequate Breathing The Patent
Airway Recognizing Inadequate Breathing Hypoxia Different Types of Abnormal Resp
irations Abnormal Lung Sounds Conditions Resulting in Hypoxia Opening the Airway
Assessing the Airway Suctioning Basic Airway Adjuncts Ventilation Devices Oxyge
n Therapy Article: 10 Things Every Paramedic Should Know About Capnography Readi
ng a Capnograph Wave Oxygen Delivery Equipment Pressure Regulation Devices Artic
le: The Oxygen Myth

Anatomy Review
Normal Breathing Rates
Adult Child Infant 12-20 breaths per minute 15-30 breaths per minute 25-50 breat
hs per minute

Recognizing Adequate Breathing
Normal rate and depth Regular pattern Regular and equal chest rise and fall Adeq
uate depth
The Patent Airway
0-1 minute without oxygen 0-4 minutes without oxygen 4-6 minutes without oxygen
6-10 minutes without oxygen More than 10 minutes without oxygen Cardiac irritabi
lity Brain damage not likely Brain damage possible Brain damage very likely Irre
versible brain damage
Recognizing Inadequate Breathing
Fast or slow rate Irregular rhythm Abnormal lung sounds Reduced tidal volumes Us
e of accessory muscles Cool, damp, pale or cyanotic skin
Hypoxia
Not enough oxygen for metabolic needs Develops when patient is: - Breathing inad
equately - Not breathing

Signs of Hypoxia Nervousness, irritability, and fear Tachycardia Mental status c
hanges Use of accessory muscles for breathing Difficulty breathing, possible che
st pain
Different Types of Abnormal Respirations
BRADYPNEA - rate of breathing is abnormally slow < 10 bpm. TACHYPNEA - rate of
reathing is abnormally rapid > 24 bpm. HYPERNEA - respirations are increased in
depth and rate (occurs normally with exercise). APNEA - respirations cease for s
everal seconds. HYPERVENTILATION - rate of ventilation exceeds normal metabolic
requirements for exchange of respiratory gases. Rate and depth of respiration is
increased. HYPOVENTILATION - rate of ventilation is insufficient for metabolic
requirements. Respiratory rate is below normal and depth of ventilations is depr
essed. CHEYNE-STOKES RESPIRATION - respiratory rhythm is irregular, characterise
d by alternating periods of apnoea and hyperventilation. The respiratory cycle b
egins with slow and shallow respiration and gradually increases to abnormal dept
h and rapidity. KUSSMAUL RESPIRATION - respirations are abnormally deep but regu
lar. Similar to hyper ventilation. ORTHOPNEA - respiratory condition in which th
e person must sit or stand to breathe deeply and comfortably. BIOTS RESPIRATION condition of the central nervous system which causes shallow breathing interrup
ted by irregular periods of apnoea.
Abnormal Lung Sounds
Crackles Crackles (or rales) are caused by fluid in the small airways or atelect
asis. Crackles are referred to as discontinuous sounds; they are intermittent, n
onmusical and brief. Crackles may be heard on inspiration or expiration. The pop
ping sounds

produced are created when air is forced through respiratory passages that are na
rrowed by fluid, mucus, or pus. Crackles are often associated with inflammation
or infection of the small bronchi, bronchioles, and alveoli. Crackles that dont c
lear after a cough may indicate pulmonary edema or fluid in the alveoli due to h
eart failure or adult respiratory distress syndrome (ARDS). Crackles are often d
escribed as fine, medium, and coarse. Fine crackles are soft, high-pitched, and
very brief. You can simulate this sound by rolling a strand of hair between your
fingers near your ear, or by moistening your thumb and index finger and separat
ing them near your ear. Coarse crackles are somewhat louder, lower in pitch, and
last longer than fine crackles. They have been described as sounding like openi
ng a Velcro fastener. Wheezes Wheezes are sounds that are heard continuously dur
ing inspiration or expiration, or during both inspiration and expiration. They a
re caused by air moving through airways narrowed by constriction or swelling of
airway or partial airway obstruction. Wheezes that are relatively high pitched a
nd have a shrill or squeaking quality may be referred to as sibilant rhonchi. Th
ey are often heard continuously through both inspiration and expiration and have
a musical quality. These wheezes occur when airways are narrowed, such as may o
ccur during an acute asthmatic attack. Wheezes that are lower-pitched sounds wit
h a snoring or moaning quality may be referred to as sonorous rhonchi. Secretion
s in large airways, such as occurs with bronchitis, may produce these sounds; th
ey may clear somewhat with coughing. Stridor Stridor refers to a high-pitched ha
rsh sound heard during inspiration. Stridor is caused by obstruction of the uppe
r airway, is a sign of respiratory distress and thus requires immediate attentio
n. If abnormal lungs sounds are heard, it is important to assess: their loudness
.

timing in the respiratory cycle. location on the chest wall. persistence of the
pattern from breath to breath, and. whether or not the sounds clear after a coug
h or a few deep breaths: - secretions from bronchitis may cause wheezes, (or rho
nchi), that clear with coughing. - crackles may be heard when atelectatic alveol
i pop open after a few deep breaths.
Conditions Resulting In Hypoxia

Myocardial infarction Pulmonary edema Acute narcotic overdose Smoke inhal
troke Chest injury Shock Lung disease Asthma Premature birth
Opening the Airway
Head Tilt-Chin Lift Method Used when cervical spine injury is not suspected. 1.
Kneel beside patients head. 2. Place one hand on forehead. 3. Apply backward pres
sure. 4. Place tips of finger under lower jaw. 5. Lift chin.

Jaw Thrust Maneuver Used when cervical spine injury is suspected. 1. Kneel above
patients head. 2. Place fingers behind angle of jaw. 3. Use thumbs to keep mouth
open
Assessment of the Airway
1. Look 2. Listen 3. Feel

Suctioning
Suctioning of a patients airway may be necessary when: Blood, other liquids and f
ood particles block the airway. A gurgling sound is heard when performing artifi
cial ventilation.
Suctioning Technique Check the unit and turn it on. Select and measure proper ca
theter to be used. Open the patients mouth and insert tip. Suction as you withdra
w the catheter. Never suction adults for more than 15 seconds.
Basic Airway Adjuncts
Oropharyngeal airways Keep the tongue from blocking the upper airway Allow for e
asier suctioning of the airway Used in conjunction with BVM device Used on uncon
scious patients without a gag reflex Inserting an oropharyngeal airway 1. Select
the proper size airway. 2. Open the patients mouth. 3. Hold the airway upside do
wn and insert it in the patients mouth. 4. Rotate the airway 180 until the flange
rests on the patients lips.

Nasopharyngeal Airways Used on conscious patients who cannot maintain airway Can
be used with intact gag reflex Should not be used with head injuries or noseble
eds Inserting a nasopharyngeal airway 1. Select the proper size airway. 2. Lubri
cate the airway. 3. Gently push the nostril open. 4. With the bevel turned towar
d the septum, insert the airway.
Airway Kits
A typical EMS airway kit
Basic airways
Advanced airways

Ventilation Devices
The EMT is equipped with a range of devices to assist ventilation. Some of these
devices are not authorized for use by EMT-Bs, but the EMT-B may be called upon
to assist with the use of these devices. Pocket Mask A pocket mask may be used t
o provide artificial ventilations when no other equipment is available. Pocket m
asks may be disposable or reusable. Some pocket masks have a nozzle for the atta
chment of oxygen tubing. A pocket mask should be equipped with a one-way valve t
o prevent body fluids from transferring from the patient to the EMT. Bag-Valve M
ask The bag-valve mask should be the EMTs primary method of delivering ventilati
ons. Supplemental oxygen may be attached to the bag-valve if needed. Bag-valve m
asks can also be used in conjunction with airway adjuncts and advanced airways s
uch as the endotracheal tube. Three different sizes are available - adult, child
and infant. The child and infant BVM have a pressure valve to prevent overinfla
tion of the lungs.
Ventilation Techniques
Mouth to Mask Technique 1. Kneel at patients head and open airway. 2. Place the m
ask on the patients face. 3. Take a deep breath and breathe into the patient for
1 1/2 to 2 seconds. 4. Remove your mouth and watch for patients chest to fall.

1 Person BVM Technique 1. Insert an oral airway. 2. Establish and maintain an ad
equate seal with one hand while using the other hand to delivers ventilations. 3
. Place mask on patients face. 4. Squeeze bag to deliver ventilations.
2 Person BVM Technique 1. Insert an oral airway. 2. One caregiver maintains seal
while the other delivers ventilations. 3. Place mask on patients face. 4. Squeez
e bag to deliver ventilations.

Oxygen Therapy
Medical Oxygen Oxygen is a colourless, odourless gas normally present in the atm
osphere at concentrations of approximately 21%. The chemical symbol for the elem
ent oxygen is O. As a medicinal gas, oxygen contains not less than 99.0% by volu
me of O2. Whereas previously oxygen tended to be given to a majority of patients
, research has led to the prescription of oxygen when and as needed, using pulse
oximetry and end-tidal CO2 capnography to guide the EMT. Pulse Oximeters Used t
o measure the oxygen saturation of hemoglobin. May give false readings with CO a
bsorption because it cannot distinguish between O2 and CO. Takes several minutes
to give an accurate reading.
A pulse oximetry of 94% O2 saturation or above means the patient is receiving ad
equate oxygen for metabolism.

Capnography Capnography is increasingly being used by paramedics to aid in their
assessment and treatment of patients in the prehospital environment. These uses
include verifying and monitoring the position of an endotracheal tube. A proper
ly positioned tube in the trachea guards the patients airway and enables the para
medic to breathe for the patient. A misplaced tube in the esophagus can lead to
death. A study in the March 2005 Annals of Emergency Medicine, comparing field i
ntubations that used continuous capnography to confirm intubations versus nonuse
showed zero unrecognized misplaced intubations in the monitoring group versus 2
3% misplaced tubes in the unmonitored group. The American Heart Association (AHA
) affirmed the importance of using capnography to verify tube placement in their
2005 CPR and ECG Guidelines. The AHA also notes in their new guidelines that ca
pnography, which indirectly measures cardiac output, can also be used to monitor
the effectiveness of CPR and as an early indication of return of spontaneous ci
rculation (ROSC). Studies have shown that when a person doing CPR tires, the pat
ients end-tidal CO2 (ETCO2, the level of carbon dioxide released at the end of ex
piration) falls, and then rises when a fresh rescuer takes over. Other studies h
ave shown when a patient experiences return of spontaneous circulation, the firs
t indication is often a sudden rise in the ETCO2 as the rush of circulation wash
es untransported CO2 from the tissues. Likewise, a sudden drop in ETCO2 may indi
cate the patient has lost pulses and CPR may need to be initiated. Paramedics ar
e also now beginning to monitor the ETCO2 status of nonintubated patients by usi
ng a special nasal cannula that collects the carbon dioxide. A high ETCO2 readin
g in a patient with altered mental status or severe difficulty breathing may ind
icate hypoventilation and a possible need for the patient to be intubated. Capno
graphy, because it provides a breath by breath measurement of a patients ventilat
ion, can quickly reveal a worsening trend in a patients condition by providing pa
ramedics with an early warning system into a patients respiratory status. As more
clinical studies are conducted into the uses of capnography in asthma, congesti
ve heart failure, diabetes, circulatory shock, pulmonary embolus, acidosis, and
other conditions, the prehospital use of capnography will greatly expand.

Article: 10 Things Every Paramedic Should Know About Capnography
Adapted from an Article from JEMS (Journey of Emergency Medical Services), by Pe
ter Canning, EMT-P, December 29, 2007 10 Things Every Paramedic Should Know Abou
t Capnography Capnography is the vital sign of ventilation. By tracking the carb
on dioxide in a patients exhaled breath, capnography enables paramedics to object
ively evaluate a patients ventilatory status (and indirectly circulatory and meta
bolic status), as the medics utilize their clinical judgement to assess and trea
t their patients. Part One: The Science Definitions: Capnography the measurement
of carbon dioxide (CO2) in exhaled breath. Capnometer the numeric measurement o
f CO2. Capnogram the wave form. End Tidal CO2 (ETCO2 or PetCO2) the level of (pa
rtial pressure of) carbon dioxide released at end of expiration. Oxygenation Ver
sus Ventilation Oxygenation is how we get oxygen to the tissue. Oxygen is inhale
d into the lungs where gas exchange occurs at the capillary-alveolar membrane. O
xygen is transported to the tissues through the blood stream. Pulse oximetry mea
sures oxygenation. At the cellular level, oxygen and glucose combine to produce
energy. Carbon dioxide, a waste product of this process (The Krebs cycle), diffu
ses into the blood. Ventilation (the movement of air) is how we get rid of carbo
n dioxide. Carbon dioxide is carried back through the blood and exhaled by the l
ungs through the alveoli. Capnography measures ventilation. Capnography versus P
ulse Oximetry Capnography provides an immediate picture of patient condition. Pu
lse oximetry is delayed. Hold your breath. Capnography will show immediate apnea
, while pulse oximetry will show a high saturation for several minutes.

Circulation and Metabolism While capnography is a direct measurement of ventilat
ion in the lungs, it also indirectly measures metabolism and circulation. For ex
ample, an increased metabolism will increase the production of carbon dioxide in
creasing the ETCO2. A decrease in cardiac output will lower the delivery of carb
on dioxide to the lungs decreasing the ETCO2. Normal Capnography Values ETCO2 35
-45 mm Hg is the normal value for capnography. However, some experts say 30 mm H
G 43 mm Hg can be considered normal. Cautions: Imperfect positioning of nasal ca
nnula capnofilters may cause distorted readings. Unique nasal anatomy, obstructe
d nares and mouth breathers may skew results and/or require repositioning of can
nula. Also, oxygen by mask may lower the reading by 10% or more. Capnography Wav
e Form The normal wave form appears as straight boxes on the monitor screen but
the wave form appears more drawn out on the print out because the monitor screen
is compressed time while the print out is in real time. The capnogram wave form
begins before exhalation and ends with inspiration. Breathing out comes before
breathing in. Abnormal Values and Wave Forms ETCO2 Less Than 35 mmHg = Hyperventi
lation/Hypocapnia ETC02 Greater Than 45 mmHg = Hypoventilation/Hypercapnia Part Two
: Clinical Uses of Capnography 1. Monitoring Ventilation Capnography monitors pa
tient ventilation, providing a breath by breath trend of respirations and an ear
ly warning system of impending respiratory crisis. Hyperventilation When a perso
n hyperventilates, their CO2 goes down. Hyperventilation can be caused by many f
actors from anxiety to bronchospasm to pulmonary embolus. Other reasons C02 may
be low: cardiac arrest, decreased cardiac output, hypotension, cold, severe pulm
onary edema.

Note: Ventilation equals tidal volume X respiratory rate. A patient taking in a
large tidal volume can still hyperventilate with a normal respiratory rate just
as a person with a small tidal volume can hypoventilate with a normal respirator
y rate. Hypoventilation When a person hypoventilates, their CO2 goes up. Hypoven
tilation can be caused by altered mental status such as overdose, sedation, into
xication, postictal states, head trauma, or stroke, or by a tiring CHF patient.
Other reasons CO2 may be high: Increased cardiac output with increased breathing
, fever, sepsis, pain, severe difficulty breathing, depressed respirations, chro
nic hypercapnia. Some diseases may cause the CO2 to go down, then up, then down.
(See asthma below). Pay more attention to the ETCO2 trend than the actual numbe
r. A steadily rising ETCO2 (as the patient begins to hypoventilate) can help a p
aramedic anticipate when a patient may soon require assisted ventilations or int
ubation. Heroin Overdoses Some EMS systems permit medics to administer narcan on
ly to unresponsive patients with suspected opiate overdoses with respiratory rat
es less than 10. Monitoring ETCO2 provides a better gauge of ventilatory status
than respiratory rate. ETCO2 will show a heroin overdose with a respiratory rate
of 24 (with many shallow ineffective breaths) and an ETCO2 of 60 is more in nee
d of arousal than a patient with a respiratory rate of 8, but an ETCO2 of 35. 2.
Confirming, Maintaining , and Assisting Intubation Continuous end-tidal CO2 mon
itoring can confirm a tracheal intubation. A good wave form indicating the prese
nce of CO2 ensures the ET tube is in the trachea. A 2005 study comparing field i
ntubations that used continuous capnography to confirm intubations versus non-us
e showed zero unrecognized misplaced intubations in the monitoring group versus
23% misplaced tubes in the unmonitored group. -Silverstir, Annals of Emergency M
edicine, May 2005 Paramedics can attach the capnography filter to the ET tube pr
ior to intubation and, in cases where it is difficult to visualize the chords, u
se the monitor to assist placement. This includes cases of nasal tracheal intuba
tion.

Continuous Wave Form Capnography Versus Colorimetric Capnography In colorimetric
capnography a filter attached to an ET tube changes color from purple to yellow
when it detects carbon dioxide. This device has several drawbacks when compared
to waveform capnography. It is not continuous, has no waveform, no number, no a
larms, is easily contaminated, is hard to read in dark, and can give false readi
ngs. Paramedics should encourage their services to equip them with continuous wa
ve form capnography. 3. Measuring Cardiac Output During CPR Monitoring ETC02 mea
sures cardiac output, thus monitoring ETCO2 is a good way to measure the effecti
veness of CPR. In 1978, Kalenda reported a decrease in ETC02 as the person perfor
ming CPR fatigued, followed by an increase in ETCO2 as a new rescuer took over,
presumably providing better chest compressions. Gravenstein, Capnography: Clinical
Aspects, Cambridge Press, 2004 With the new American Heart Association Guidelin
es calling for quality compressions (push hard, push fast, push deep), rescuers sh
ould switch places every two minutes. Set the monitor up so the compressors can
view the ETCO2 readings as well as the ECG wave form generated by their compress
ions. Encourage them to keep the ETCO2 number up as high as possible. Reductions
in ETCO2 during CPR are associated with comparable reductions in cardiac output.T
he extent to which resuscitation maneuvers, especially precordial compression, m
aintain cardiac output may be more readily assessed by measurements of ETCO2 tha
n palpation of arterial pulses. -Max Weil, M.D., Cardiac Output and EndTidal carb
on dioxide, Critical Care Medicine, November 1985 Note: Patients with extended d
own times may have ETCO2 readings so low that quality of compressions will show
little difference in the number. Return of Spontaneous Circulation (ROSC) ETCO2
can be the first sign of return of spontaneous circulation (ROSC). During a card
iac arrest, if you see the CO2 number shoot up, stop CPR and check for pulses. E
nd-tidal CO2 will often overshoot baseline values when circulation is restored d
ue to carbon dioxide washout from the tissues.

A recent study found the ETCO2 shot up on average 13.5 mmHg with sudden ROSC bef
ore settling into a normal range .-Grmec S, Krizmaric M, Mally S, Kozelj A, Spin
dler M, Lesnik B.,Resuscitation. 2006 Dec 8 Loss of Spontaneous Circulation In a
resuscitated patient, if you see the stabilized ETCO2 number significantly drop
in a person with ROSC, immediately check pulses. You may have to restart CPR. 4
. End Tidal CO2 As Predictor of Resuscitation Outcome End tidal CO2 monitoring c
an confirm the futility of resuscitation as well as forecast the likelihood of r
esuscitation. An end-tidal carbon dioxide level of 10 mmHg or less measured 20 mi
nutes after the initiation of advanced cardiac life support accurately predicts
death in patients with cardiac arrest associated with electrical activity but no
pulse. Cardiopulmonary resuscitation may reasonably be terminated in such patie
nts. -Levine R, End-tidal Carbon Dioxide and Outcome of Out-of-Hospital Cardiac A
rrest, New England Journal of Medicine, July 1997 Likewise, case studies have sh
own that patients with a high initial end tidal CO2 reading were more likely to
be resuscitated than those who didnt. The greater the initial value, the likelier
the chance of a successful resuscitation. No patient who had an end-tidal carbon
dioxide of level of less than 10 mm Hg survived. Conversely, in all 35 patients
in whom spontaneous circulation was restored, end-tidal carbon dioxide rose to
at least 18 mm Hg before the clinically detectable return of vital signs.The diff
erence between survivors and nonsurvivors in 20 minute end-tidal carbon dioxide
levels is dramatic and obvious. ibid. An ETCO2 value of 16 torr or less successful
ly discriminated between the survivors and the nonsurvivors in our study because
no patient survived with an ETCO2 less than 16 torr. Our logistic regression mo
del further showed that for every increase of 1 torr in ETCO2, the odds of survi
ving increased by 16%. Salen, Can Cardiac Sonography and Capnography Be Used Indep
endently and in Combination to Predict Resuscitation Outcomes?, Academic Emergen
cy Medicine, June 2001 Caution: While a low initial ETCO2 makes resuscitation le
ss likely than a higher initial ETCO2, patients have been successfully resuscita
ted with an initial ETCO2 >10 mmHg.

Asphyxic Cardiac Arrest versus Primary Cardiac Arrest Capnography can also be ut
ilized to differentiate the nature of the cardiac arrest. A 2003 study found tha
t patients suffering from asphyxic arrest as opposed to primary cardiac arrest h
ad significantly increased initial ETCO2 reading that came down within a minute.
These high initial readings, caused by the buildup of carbon dioxide in the lun
gs while the nonbreathing/nonventilating patients heart continued pump carbon dio
xide to the lungs before the heart bradyed down to asystole, should come down wi
thin a minute. The ETCO2 values of asphyxic arrest patients then become prognost
ic of ROSC .-Grmec S, Lah K, Tusek-Bunc K,Crit Care. 2003 Dec 5. Monitoring Seda
ted Patients Capnography should be used to monitor any patients receiving pain m
anagement or sedation (enough to alter their mental status) for evidence of hypo
ventilation and/or apnea. In a 2006 published study of 60 patients undergoing se
dation, in 14 of 17 patients who suffered acute respiratory events, ETCO2 monito
ring flagged a problem before changes in SPO2 or observed changes in respiratory
rate. End-tidal carbon dioxide monitoring of patients undergoing PSA detected ma
ny clinically significant acute respiratory events before standard ED monitoring
practice did so. The majority of acute respiratory events noted in this trial o
ccurred before changes in SP02 or observed hypoventilation and apnea. -Burton, Do
es End-Tidal Carbon Dioxide Monitoring Detect Respiratory Events Prior to Curren
t Sedation Monitoring Practices, Academic Emergency Medicine, May 2006 Sedated,
Intubated Patients Capnography is also essential in sedated, intubated patients.
A small notch in the wave form indicates the patient is beginning to arouse fro
m sedation, starting to breathe on their own, and will need additional medicatio
n to prevent them from bucking the tube. 6. ETCO2 in Asthma, COPD, and CHF End-tid
al CO2 monitoring on non-intubated patients is an excellent way to assess the se
verity of Asthma/COPD, and the effectiveness of treatment. Bronchospasm will pro
duce a characteristic shark fin wave form, as the patient has to struggle to exhal
e, creating a sloping B-C upstroke. The shape is caused by uneven alveolar emptyin
g.

Hypoxic Drive Capnography will show the hypoxic drive in COPD retainers. ETCO2 rea
dings will steadily rise, alerting you to cut back on the oxygen before the pati
ent becomes obtunded. Since it has been estimated that only 5% of COPDers have a
hypoxic drive, monitoring capnography will also allow you to maintain sufficien
t oxygen levels in the majority of tachypneic COPDers without worry that they wi
ll hypoventilate. CHF: Cardiac Asthma It has been suggested that in wheezing pat
ients with CHF (because the alveoli are still, for the most part, emptying equal
ly), the wave form should be upright. This can help assist your clinical judgeme
nt when attempting to differentiate between obstructive airway wheezing such as
COPD and the cardiac asthma of CHF. 7. Ventilating Head Injured Patients Capnograp
hy can help paramedics avoid hyperventilation in intubated head injured patients
. Recent evidence suggests hyperventilation leads to ischemia almost immediatelycu
rrent models of both ischemic and TBI suggest an immediate period during which t
he brain is especially vulnerable to secondary insults. This underscores the imp
ortance of avoiding hyperventilation in the prehospital environment. Capnography a
s a Guide to Ventilation in the Field, D.P. Davis, Gravenstein, Capnography: Cli
nical Perspectives, Cambridge Press, 2004 Hyperventilation decreases intracrania
l pressure by decreasing intracranial blood flow. The decreased cerebral blood f
low may result in cerebral ischemia. In a study of 291 intubated head injured pa
tients, 144 had ETCO2 monitoring. Patients with ETCO2 monitoring had lower incid
ence of inadvertant severe hyperventilation (5.6%) than those without ETCO2 moni
toring (13.4%). Patients in both groups with severe hyperventilation had signifi
cantly higher mortality (56%) than those without (30%). Davis, The Use of Quantit
ative End-Tidal Capnometry to Avoid Inadvertant Severe Hyperventilation in Patie
nts with Head Injury After Paramedic Rapid Sequence Intubation, Journal of Traum
a, April 2004 8. Perfusion Warning Sign A target value of 35 mmHg is recommendedTh
e propensity of prehospital personnel to use excessively high respiratory rates
suggests that the number of breaths per minute should be decreased. On the other
hand, the mounting evidence against tidal volumes in excessive of 10cc/kg espec
ially in the absence of peep, would suggest the hypocapnia be addressed by lower
volume ventilation. Capnography as a Guide to Ventilation in the Field, D.P. Davi
s, Gravenstein, Capnography: Clinical Perspectives, Cambridge Press, 2004

End tidal CO2 monitoring can provide an early warning sign of shock. A patient w
ith a sudden drop in cardiac output will show a drop in ETCO2 numbers that may b
e regardless of any change in breathing. This has implications for trauma patien
ts, cardiac patients any patient at risk for shock. 9. Other Issues DKA Patients
with DKA hyperventilate to lessen their acidosis. The hyperventilation causes t
heir PAC02 to go down. End-tidal C02 is linearly related to HC03 and is significa
ntly lower in children with DKA. If confirmed by larger trials, cut-points of 29
torr and 36 torr, in conjunction with clinical assessment, may help discriminat
e between patients with and without DKA, respectively. Fearon, End-tidal carbon di
oxide predicts the presence and severity of acidosis in children with diabetes,
Academic Emergency Medicine, December 2002 Pulmonary Embolus Pulmonary embolus w
ill cause an increase in the dead space in the lungs decreasing the alveoli avai
lable to offload carbon dioxide. The ETCO2 will go down. Hyperthermia Metabolism
is on overdrive in fever, which may cause ETCO2 to rise. Observing this phenome
na can be live-saving in patients with malignant hyperthermia, a rare side effec
t of RSI (Rapid Sequence Induction). Trauma A 2004 study of blunt trauma patient
s requiring RSI showed that only 5 percent of patients with ETCO2 below 26.25 mm
Hg after 20 minutes survived to discharge. The median ETCO2 for survivors was 3
0.75. - Deakin CD, Sado DM, Coats TJ, Davies G. Prehospital end-tidal carbon diox
ide concentration and outcome in major trauma. Journal of Trauma. 2004;57:65-68.
Field Disaster Triage It has been suggested that capnography is an excellent tri
age tool to assess respiratory status in patients in mass casualty chemical inci
dents, such as those that might be caused by terrorism. Capnographycan serve as an
effective, rapid assessment and triage tool for critically injured patients and
victims of chemical exposure. It provides the ABCs in less than 15 seconds and
identifies the common complications of chemical terrorism. EMS systems should co
nsider adding capnography to their triage and patient assessment toolbox and emp
hasize its use during educational programs and MCI drills.- Krauss, Heightman, 15
Second Triage Tool, JEMS, September 2006 Anxiety- ETCO2 is being used on an amb
ulatory basis to teach patients with anxiety disorders as well as asthmatics how
to better control their breathing. Try (it may not always be possible) to get y
our anxious patient to focus on the monitor, telling them that

as they slow their breathing, their ETCO2 number will rise, their respiratory ra
te number will fall and they will feel better. Anaphylaxis- Some patients who su
ffer anaphylactic reactions to food they have ingested (nuts, seafood, etc.) may
experience a second attack after initial treatment because the allergens remain
in their stomach. Monitoring ETCO2 may provide early warning to a reoccurrence.
The wave form may start to slope before wheezing is noticed. Accurate Respirato
ry Rate Studies have shown that many medical professionals do a poor job of reco
rding a patients respiratory rate. Capnography not only provides an accurate resp
iratory rate, it provides an accurate trend or respirations. 10. The Future Capn
ography should be the prehospital standard of care for confirmation and continuo
us monitoring of intubation, as well as for monitoring ventilation in sedated pa
tients. Additionally, it should see increasing use in the monitoring of unstable
patients of many etiologies. As more research is done, the role of capnography
in prehospital medicine will continue to grow and evolve.
The normal range for exhaled CO2 is 35-45mmHg
Reading a Capnograph Wave
Segment I (A to B) of the wave represents post inspiration / dead space expirati
on.

Segment II (B to C) of the wave represents exhalation upstroke where dead space
gas mixes with alveolar gas.
Segment III (C to D) of the wave represents a continuance of exhalation and is a
lso called the plateau.
Segment IV (D to E) of the wave represents inspiration washout.

The height of the wave should be compared to the scale on the page/screen to det
ermine ETCO2 levels.

The number of wave forms per minute can be counted to get an accurate respirator
y rate. The waves should be analyzed to see if there is any difference from the
expected squaredoff wave form. Changes in the height of the waves during monitor
ing should also be evaluated.
Oxygen Delivery Devices
Nasal Cannula An oxygen tube that provides only a very limited oxygen concentrat
ion. Adult or Pediatric Simple Face Mask No reservoir and can only deliver up to
60% oxygen. Adult Nonrebreather Mask Has an oxygen reservoir bag attached to th
e mask with a one-way valve between them that prevents the patients exhaled air f
rom mixing with the oxygen in the reservoir bag. Oxygen requirement = 15 LPM.

Pediatric Nonrebreather Mask Has an oxygen reservoir bag attached to the mask wi
th a one-way valve between them that prevents the patients exhaled air from mixin
g with the oxygen in the reservoir bag. Oxygen requirement = 8 LPM. Partial Rebr
eather Mask Similar to a nonrebreather mask but is equipped with a two-way valve
that allows the patient to rebreathe about 1/3 of their exhaled air. Can provid
e an oxygen concentration of about 35% to 60%. Venturi Mask A low flow oxygen sy
stem that provides precise concentrations of oxygen through an entertainment val
ve connected to the face mask. Ventilatory Devices and Oxygen Concentration Devi
ce Nasal Cannulae Mouth-to-Mask Simple face mask BVM without reservoir Partial r
ebreather mask Simple mask with reservoir BVM with reservoir Nonrebreathing mask
with reservoir Liter Flow (LPM) 1-6 10 8-10 8-10 6 6 15 15 Oxygen Delivered 2426% 50% 40-60% 40-60% 60% 60% 100% 90-100%

Oxygen Cylinders In emergency medical care, the following sizes of oxygen cylind
ers are commonly used: D cylinder 350 liters E Cylinder 625 liters M Cylinder 30
00 liters G cylinder 5300 liters H cylinder 6900 liters Safety Precautions Oxyge
n is a gas that acts as an accelerant for combustion, and oxygen cylinders are u
nder high pressure. Never allow combustible materials, such as oil and grease, t
ouch the cylinder, regulator fittings, valves or hoses. Never smoke or allow oth
ers to smoke in any area where oxygen cylinders are in use or on standby.
Calculation of Oxygen Cylinder Contents in Liters D cylinder - Lbs per in2 x 0.1
6 = contents in liters E cylinder - Lbs per in2 x 0.28 = contents in liters G cy
linder - Lbs per in2 x 2.41 = contents in liters

H cylinder - Lbs per in2 x 3.14 = contents in liters M cylinder - Lbs per in2 x
1.56= contents in liters Calculation of Oxygen Required for Transport
Breaths per minute x tidal volume x travel time = + /2 = total requirement of oxy
gen for transport
(Note: 50% of the estimated need is added in order to cater for emergencies or u
nforeseen circumstances) Minimum Volume Requirements for Pediatrics Age in Years
1 2 3-4 5-6 7-10 11-12 13-14 15 Safety with Oxygen Cylinders Store cylinders be
low 50 degrees Celsius. Never use an oxygen cylinder without a safe, properly fi
tting regulator valve. Keep all valves closed when the cylinder is not in use, e
ven if the tank is empty. Keep oxygen cylinders secured to prevent them from top
pling over. Minimum Volume Required 120ml 156ml 170ml 200ml 270ml 380ml 420ml as
adult
When you are working with oxygen cylinders, never put any body parts over the cy
linder valve.
Pressure Regulators Pressure regulators are devices that control gas flow and re
duce the high pressure in the cylinder to a safe range (from 2000psi to around 5
0psi), and controls the flow of oxygen from 1-15 liters per minute. There are tw
o types of regulators: High-pressure regulator This type of regulator has one ga
uge that registers the content of the cylinder and that, through a step-down reg
ulator, can provide 50psi to power a flow restricted oxygen powered automatic tr
ansport ventilator (ATV). Therapy regulator This type of regulator has two gauge
s, one indicating the pressure in the tank and a flowmeter indicating the measur
ed flow of oxygen being delivered to the patient (0-15 LPM).

Article: The Oxygen Myth?
The Oxygen Myth? An article by Bryan E. Bledsoe, DO, FACEP, Mar 5 2009, JEMS (ht
tp://www.jems.com/news_and_articles/columns/Bledsoe/the_oxygen_myth.html) In EMS
, weve always emphasized two things: airway and oxygenation. In reality, we shoul
d be emphasizing ventilation. Without an airway, your patient cannot ventilate.
Without ventilation, you cannot assess the airway. Theyre inseparably linked. Lik
ewise, without ventilation, oxygenation is impossible. But ventilation involves
much more than oxygenation. It involves the elimination of carbon dioxide and to
xins and plays a role in other important biological processes. Weve always taught
that a little oxygen is good and a lot of oxygen is better. We adopted pulse ox
imeters and really only use them to document oxygen saturations -- especially lo
w thresholds. The closer to 100%, the better -- or so we thought. But is doing t
his in the best interest of the patients? Several years ago we saw a change in p
ractice in the neonatology community to limit supplemental oxygenation given to
newborns and neonates. We had always known that high-concentration oxygen was as
sociated with the development of retinopathy of prematurity (ROP), formerly call
ed retrolental fibroplasia, in premature infants. Later, clinicians found that n
eonates resuscitated with high-concentration oxygen had worse outcomes than thos
e resuscitated with room air. For example, infants resuscitated with 100% oxygen
have a greater delay to first cry and a greater delay to first respiration.(1)
In one study of depressed infants, mortality was 13% for those resuscitated with
100% oxygen and only 8% for those resuscitated with room air.(2) Further, neona
tes resuscitated with room air had a lower mortality at one week compared to tho
se resuscitated with 100% oxygen.(3) The American Heart Association now recommen
ds starting with room air and increasing oxygen concentration as needed to maint
ain an adequate oxygen saturation.(4) Next, the phenomenon of reperfusion injury
was noted. Reperfusion injury occurs when oxygen is reintroduced to ischemic ti
ssues. Stated another way, the injury does not occur during periods of hypoxia.
It occurs after oxygen is restored to the affected tissues. The primary mechanis
m is thought to be the development of toxic chemicals called reactive oxygen spec
ies or free radicals. These chemicals have an unpaired electron in their outer shel
l and are very unstable. They occur normally, to a limited degree, but the body
has enzyme systems that process the free radicals into less toxic substances, th
us avoiding significant cellular damage. But following a period of hypoxia, a la
rge number of free radicals

are produced that overwhelm the protective enzyme systems (antioxidants) and cel
lular damage occurs. This damage is called oxidative stress . The effects of agin
g are often due to oxidative stress. Also, some diseases such as atherosclerosis
, Alzheimers disease, Parkinsons disease, and others have been linked to oxidative
stress and free radical induction. Thus, the evolving thought is that, in some
conditions, high concentrations of oxygen can be harmful. So, what does this mea
n to the future evolution of EMS practice? Well, there are several disease proce
sses we must consider. Stroke: The brain is very vulnerable to the effects of ox
idative stress. The brain has fewer antioxidants than other tissues. Thus, shoul
d we give oxygen to non-hypoxic stroke patients? Studies have shown that patient
s with mild-moderate strokes have improved mortality when they receive room air
instead of high-concentration oxygen. The data on patients with severe strokes i
s less clear.(5) Current research indicates that supplemental oxygen should not
be routinely given to patients with stroke and can, in some cases, be detrimenta
l.(6) Acute Coronary Syndrome: The myocardium is highly oxygen dependent and vul
nerable to the effects of oxidative stress. Thus far, theres no evidence that giv
ing supplemental oxygen to acute coronary syndrome patients is helpful, but ther
es no evidence its harmful.(7) Post-Cardiac Arrest: Here, too, the evidence is too
scant to tell. We do know that virtually all current therapies for cardiac arre
st (drugs, airway) are of little, if any, benefit. The primary therapies remain
CPR (often with limited ventilation initially) and defibrillation followed by in
duced hypothermia. The whole purpose of induced hypothermia is to prevent the de
trimental effects of oxidative stress and the other harmful effects of reperfusi
on injury. Trauma: What role should oxygen play in non-hypoxic trauma patients?
Little research exists, but an interesting study out of New Orleans demonstrated
that there was no survival benefit to the use of supplemental oxygen in the pre
hospital setting in traumatized patients who do not require mechanical ventilati
on or airway protection.(8) Carbon Monoxide (CO) Poisoning: We have learned a lo
t about carbon monoxide poisoning in the past few years. We know that the mechan
ism of CO poisoning is a lot more complex than once thought. We also know that t
heres no reliable evidence that hyperbaric oxygen (HBO) therapy improves outcome
(although its still widely used).(9) But when you think about it, the goal of tre
atment in CO poisoning is to eliminate CO through ventilation -- not hyperoxygen
ation. Although oxygen can displace some CO from hemoglobin, the induction of fr
ee-radicals may be worse than the effects of CO. Again, the science here is in a
state of flux.

Neonates: The science is clear in regard to supplemental oxygen in neonates. It
should be used only when room air ventilation fails. Again, this is a discussion
of the changing science. Always continue to follow the direction of your medica
l director and local protocols. That said, its clear that we need to use every to
ol possible to support, but not replace, our physical exam skills. We should use
pulse oximetry and waveform capnography. Although, individually, each technolog
y has its limitations, together they provide important information about the pat
ient. The goal of therapy is to avoid hypoxia and hyperoxia. If the patients oxyg
en saturation and ventilation are adequate, supplemental oxygen is probably not
required. If the patient is hypoxic or hypercapnic, then you must determine whet
her the problem can be remedied through increased ventilation, increased oxygena
tion, or both. Thus, you have to assess the problem, recognize and understand th
e pathophysiological processes involved, plan an appropriate therapy (within the
scope of your protocols), and provide the needed therapy. That is what prehospi
tal care is all about. References 1. Martin RJ, Bookatz GB, Gelfand SL, et al: Co
nsequences of neonatal resuscitation with supplemental oxygen. Semin Perinatol. 3
2:355-366, 2008. 2. Davis PG, Tan A, ODonnell CP, et al: Resuscitation of newborn
infants with 100% oxygen or air: A systematic review and meta-analysis. Lancet. 3
64:1329-1333, 2004. 3. Rabi Y, Rabi D, Yee W: Room air resuscitation of the depre
ssed newborn: A systematic review and meta-analysis. Resuscitation. 72:353-363, 2
007. 4. American Heart Association: 2005 American Heart Association guidelines fo
r cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) of
pediatric and neonatal patients: Pediatric basic life support. Circulation.13:IV
1-203, 2005. 5. Ronning OM, Guldvog B: Should stroke victims routinely receive su
pplemental oxygen? A quasi-randomized controlled trial. Stroke. 30:2033-2037, 199
9. 6. Pancioli AM, Bullard MJ, Grulee ME, et al: Supplemental oxygen use in ische
mic stroke patients: Does utilization correspond to need for oxygen therapy. Arch
ives of Internal Medicine. 162:49-52, 2002. 7. Mackway-Jones K: Oxygen in uncompl
icated myocardial infarction. Emergency Medicine Journal. 21:75-81, 2004. 8. Stoc
kinger ZT, McSwain NE: Prehospital supplemental oxygen in trauma patients: Its ef
ficacy and implications for military medical care. Military Medicine. 169:609-612
, 2004.

9. Gilmer B, Kilkenny J, Tomaszewski C, et al: Hyperbaric oxygen does not improve
neurologic sequelae after carbon monoxide poisoning. Academic Emergency Medicine
. 9:18, 2002.
Chapter 12: The Basic ECG

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

hout the heart. The flow of electrical current causes contractions that produce
pumping of blood.

The hearts electrical system is made up of three main parts:
The sinoatrial (SA)
node, located in the right atrium of the heart. The atrioventricular (AV) node,
located on the interatrial septum close to the tricuspid valve. The His-Purkinje
system, located along the walls of the hearts ventricles.
A heartbeat is a complex series of events that take place in the heart. A heartb
eat is a single cycle in which the hearts chambers relax and contract to pump blo
od. This cycle includes the opening and closing of the inlet and outlet valves o
f the right and left ventricles of the heart. Each heartbeat has two basic parts
: diastole and atrial and ventricular systole. During diastole, the atria and ve
ntricles of the heart relax and begin to fill with blood. At the end of diastole
, the hearts atria contract (atrial systole) and pump blood into the ventricles.
The atria then begin to relax. The hearts ventricles then contract (ventricular s
ystole) pumping blood out of the heart. Each beat of the heart is set in motion
by an electrical signal from within the heart muscle. In a normal, healthy heart
, each beat begins with a signal from the SA node. This is why the SA node is so
metimes called the hearts natural pacemaker. The pulse, or heart rate, is the num
ber of signals the SA node produces per minute. The signal is generated as the t
wo vena cavae fill the hearts right atrium with blood from other parts of the bod
y. The signal spreads across the cells of the hearts right and left atria. This s
ignal causes the atria to contract. This action pushes blood through the open va
lves from the atria into both ventricles. The signal arrives at the AV node near
the ventricles. It slows for an instant to allow the hearts right and left ventr
icles to fill with blood. The signal is released and moves along a pathway calle
d the bundle of His, which is located in the walls of the hearts ventricles. From
the bundle of His, the signal fibers divide into left and right bundle branches
through the Purkinje fibers that connect directly to the cells in the walls of
the hearts left and right ventricles. The signal spreads across the cells of the
ventricle walls, and both ventricles contract. However, this doesnt happen at exa
ctly the same moment. The left ventricle contracts an instant before the right v
entricle. This pushes blood through the pulmonary valve (for the right ventricle
) to the lungs, and through the aortic valve (for the left ventricle) to the res
t of the body.

As the signal passes, the walls of the ventricles relax and await the next signa
l. This process continues over and over as the atria refill with blood and other
electrical signals come from the SA node.
The Electrocardiogram
Records potential (voltage) differences between a neutral ground and recordin
ctrodes. 3 lead ECG used for monitoring purposes. 12 lead ECG used for diagnosti
c purposes. Lead II shows life-threatening rhythms. Most ECG recordings are obta
ined with paper speeds of 25mm/sec and signal calibration of 1.0mV/1cm. The P-QR
S-T complex of the normal ECG represents electrical activity over one cardiac cy
cle. The dominant pacemaker of the heart is the sinus node in the right atrium.
It normally fires between 60 and 100 times a minute. Should the sinus node fail,
the AV node is a potential pacemaker but it only fires at 40-60 beats per minut
e.
The ECG Complex
One complex represents one beat in the heart. Complex consists of P, QRS, and T
waves.

Parts of the ECG Complex
P Wave - Atrial depolarization - 0.04-0.12 seconds - 12 small squares PR Interval - SA Node-AV Node conduction time - 0.12-0.20 second
s - 3-5 small squares QRS Complex - Ventricular depolarization - 0.04-0.10 secon
ds - 1-2 small squares ST Segment - Plateau phase ventricular depolarization - i
soelectric (baseline) T Wave - Ventricular repolarization - 0.5mV/5mm QT Interva
l - Total duration of ventricular depolarization - 0.33-0.42 seconds 8-10 small
squares
An In-depth Look at the ECG and Its Generation



ECG Rhythm Interpretation
Normal Sinus Rhythm Sinus Bradycardia Consistent P waves Consistent P-R interval
Less than 60 beats/min Consistent P waves Consistent P-R interval 60100 beats/mi
n
Sinus Tachycardia Consistent P waves Consistent P-R interval More than 100 beats
/min

Remember - A sinus rhythm is a rhythm that has a P Wave present.
Ventricular Tachycardia Three or more ventricular complexes in a row More than 1
00 beats/min
Ventricular Fibrillation Rapid, completely disorganized rhythm Deadly arrhythmia
that requires immediate treatment

Asystole Complete absence of electrical cardiac activity Patient is clinically d
ead. Decision to terminate resuscitation efforts depends on local protocol.
Chapter 13: The Automated External Defibrillator

Outline
The Chain of Survival The Purpose of Defibrillation The Importance of Early Defi
brillation Types of Defibrillators Shockable Rhythms Non-Shockable Rhythms Advan
tages of the AED Medical Direction Energy Levels for AEDs Monophasic vs. Biphasi
c Indications for AED Use Contraindications for AED Use Preparing to Operate an
AED Using an AED - 3 Simple Steps AED Treatment Algorithm Using an AED Detailed
Steps After AED shocks Transport Cardiac Arrest During Transport

The Chain of Survival
The Chain of Survival was developed by the American Heart Association in 1990 in
recognition of the fact that the vast majority of sudden cardiac arrests (SCA)
occur outside of hospitals, and that failure to defibrillate early results in a
high rate of failure to resuscitate patients. In response to the development of
the chain of survival, public awareness of the importance of its components has
increased, particularly in western countries, where AEDs are often located readi
ly in public places. To provide the best opportunity for survival, each of these
four links must be put into motion within the first few minutes of SCA onset:
arly Access to Emergency Care must be provided by calling 911 (US) or a universa
l access number. Early CPR should be started and maintained until emergency medi
cal services (EMS) arrive. Early Defibrillation is the only one that can re-star
t the heart function of a person with ventricular fibrillation (VF). If an autom
ated external defibrillator (AED) is available, a trained operator should admini
ster defibrillation as quickly as possible until EMS personnel arrive. Early Adv
anced Care, the final link, can then be administered as needed by EMS personnel.
Time After the Onset of Attack With every minute Within 4-6 minutes Survival Ch
ances Chances are reduced by 7-10% Brain damage and permanent death start to occ
ur After 10 minutes Few attempts at resuscitation succeed

Type of Care for SCA Victims after Collapse
layed defibrillation (after 10 minutes) CPR
bystander or family member) begun within 2
CPR and defibrillation within 8 minutes CPR
paramedic help within 8 minutes
No care after collapse No CPR and de

from a non-medical person (such as a
minutes, but delayed defibrillation
and defibrillation within 4 minutes;
Chance of Survival 0% 0-2%

2-8%
20% 43%
In certain environments, where the Chain is strong and when defibrillation occur
s within the first few minutes of cardiac arrest, survival rates can approach 80
% to 100%.
ILCOR AED Symbol

The Purpose of Defibrillation
Defibrillation does not jump start the heart. The purpose of the shock is to produ
ce temporary aystole. The shock attempts to completely depolarize the myocardium
and provide an opportunity for the natural pacemaker centers of the heart to re
sume normal activity.
The Importance of Early Defibrillation
Defibrillation is the single most important factor in determining the survival f
rom cardiac arrest. Rationale for Early Defibrillation
The most common initial r
hythm in witnessed sudden cardiac arrest is ventricular fibrillation. The most e
ffective treatment for ventricular fibrillation is electrical defibrillation. Th
e probability of successful defibrillation diminishes rapidly over time. VF tend
s to convert to asystole within a few minutes.
Types of Defibrillators
Manual defibrillators Automated internal defibrillators Automated external defib
rillators
fully automated semi-automated
Shockable Rhythms
Ventricular fibrillation (VF)

Ventricular Tachycardia (V-Tach) - (if the patient is pulseless and unconscious)
Non-Shockable Rhythms
Asystole
Pulseless Electrical Activity (PEA) - (any heart rhythm observed on the ECG that
should be producing a pulse, but is not)
Advantages of the AED
ALS providers do not need to be on scene. Remote, adhesive defibrillator pads ar
e used. Efficient transmission of electricity

Medical Direction
Should approve protocols. Should review AED usage. Should review speed of defibr
illation. Should provide review of skills every 3 to 6 months.
Energy Levels of the AED
Electrical current is measured in joules (J) Manual defibrillators - 5 or 10 to
360J Fully or semi-automated defibrillators - preset values of 200 and 360J prog
rammed.
Monophasic vs. Biphasic
The earliest defibrillators were monophasic, which means that they passed an ele
ctrical current in just one direction to try to reset the heart. Biphasic defibr
illators use an electrical current that flows in two directions to shock the hea
rt. The advantage of using biphasic defibrillators is that less electrical curre
nt is needed to successfully shock the heart, which makes these devices more eff
ective to restore the hearts regular rhythm more quickly.
Indications for AED Use
The patient is unresponsive, and; The patient demonstrates no effective breathin
g, and; The patient has no signs of circulation.

Contraindications for AED Use
The patient is under 1 year old; The patient suffered cardiac arrest as a result
of trauma (except electrocution); The patient has a detectable pulse or respira
tions; The patient demonstrates response to external stimulus.
Preparing to Operate an AED
Make sure the electricity injures no one. Do not defibrillate a patient lying in
pooled water. Dry a soaking wet patients chest first. Do not defibrillate a pati
ent who is touching metal. Remove nitroglycerin patches. Shave a hairy patients c
hest if needed.
AED pads for adults (left) and children (right)

Using an AED 3 Simple Steps

AED Treatment Algorithm



Using an AED - Detailed Steps
Step 1
Assess responsiveness. Stop CPR if in progress. Check breathing and pulse
. If patient is unresponsive and not breathing adequately, give two slow ventila
tions. Step 2
Step 3
Step 4
Step 5
After the shock is delivered,
ume CPR. Perform 5 cycles of CPR. Reanalyze the rhythm. If the machine advises a
shock, deliver a shock then perform 5 cycles of CPR. Push the analyze button, i
f there is one. Wait for the computer. If shock is not needed, start CPR. If sho
ck is advised, make sure that no one is touching the patient. Push the shock but
ton Remove clothing from the patients chest area. Apply pads to the chest. Stop C
PR. State aloud, Clear the patient. If there is a delay in obtaining an AED, have
your partner start or resume CPR. If an AED is close at hand, prepare the AED pa
ds. Turn on the machine.
Step 6
Check for pulse. If the patient has a pulse, check breathing. If the pati
ent is breathing adequately, provide oxygen via non-rebreathing mask if needed a
nd transport. Step 7
Step 8
If the patient has no pulse, perform 1 minute o
. Gather additional information on the arrest event. After 1 minute of CPR, make
sure no one is touching the patient. Push the analyze button again (as applicab
le). Transport and check with medical control. Continue to support the patient a
s needed. If the patient is not breathing adequately, use necessary airway adjun
cts and proper positioning to open airway. Provide artificial ventilations with
high concentration oxygen. Transport.
After AED Shocks
Check pulse. No pulse, no shock advised No pulse, shock advised If a patient is
breathing independently:
Administer oxygen if needed. Check pulse.
If a patient has a pulse, but breathing is inadequate, assist ventilations.
Transport
When patient regains pulse; or After delivering six to nine shocks; or
After receiving three consecutive no shock advised messages. Keep AED attached. Ch
eck pulse frequently. Stop ambulance to use an AED.
Cardiac Arrest During Transport
Check unconscious patients pulse every 30 seconds. If pulse is not present:
the vehicle. Perform CPR until AED is available. Analyze rhythm. Deliver shock(s
). Continue resuscitation according to local protocol Check pulse. Stop the vehi
cle. Perform CPR until AED is available. Analyze rhythm. Deliver up to three sho
cks. Continue resuscitation according to local protocol.
If patient becomes unconscious during transport:
Appendix 1
Appendix 1: Updated 2010 European Resuscitation Council Guidelines
Basic life support
Changes in basic life support (BLS) since the 2005 guidelines include:
Dispatche
rs should be trained to interrogate callers with strict protocols to elicit info
rmation. This information should focus on the recognition of unresponsiveness an
d the quality of breathing. In combination with unresponsiveness, absence of bre
athing or any abnormality of breathing should start a dispatch protocol for susp
ected cardiac arrest. The importance of gasping as sign of cardiac arrest is emp
hasised. All rescuers, trained or not, should provide chest compressions to vict
ims of cardiac arrest. A strong emphasis on delivering high quality chest compre
ssions remains essential. The aim should be to push to a depth of at least 5 cm
at a rate of at least 100 compressions min-1, to allow full chest recoil, and to
minimise interruptions in chest compressions. Trained rescuers should also prov
ide ventilations with a compressionventilation (CV) ratio of 30:2. Telephone-guid
ed chest compression-only CPR is encouraged for untrained rescuers.
The use of p
rompt/feedback devices during CPR will enable immediate feedback to rescuers and
is encouraged. The data stored in rescue equipment can be used to monitor and i
mprove the quality of CPR performance and provide feedback to professional rescu
ers during debriefing sessions.
Page a Emergency Medical Technician Basic
Appendix 1
Electrical therapies
The most important changes in the 2010 ERC Guidelines for electrical therapies i
nclude:
The importance of early, uninterrupted chest compressions is emphasized
throughout these guidelines. Much greater emphasis on minimizing the duration of
the pre-shock and postshock pauses; the continuation of compressions during cha
rging of the defibrillator is recommended. Immediate resumption of chest compres
sions following defibrillation is also emphasised; in combination with continuat
ion of compressions during defibrillator charging, the delivery of defibrillatio
n should be achievable with an interruption in chest compressions of no more tha
n 5 seconds. Safety of the rescuer remains paramount, but there is recognition i
n these guidelines that the risk of harm to a rescuer from a defibrillator is ve
ry small, particularly if the rescuer is wearing gloves. The focus is now on a r
apid safety check to minimise the preshock pause.
When treating out-of-hospital
cardiac arrest, emergency medical services (EMS) personnel should provide good-q
uality CPR while a defibrillator is retrieved, applied and charged, but routine
delivery of a pre-specified period of CPR (e.g., two or three minutes) before rh
ythm analysis and a shock is delivered is no longer recommended. For some EMS th
at have already fully implemented a pre-specified period of chest compressions b
efore defibrillation, given the lack of convincing data either supporting or ref
uting this strategy, it is reasonable for them to continue this practice.
The us
e of up to three-stacked shocks may be considered if VF/VT occurs during cardiac
catheterization or in the early post-operative period following cardiac surgery
. This three shock strategy may also be considered for an initial, witnessed VF/
VT cardiac arrest when the patient is already connected to a manual defibrillato
r. Further development of AED programmes is encouraged there is a need for furth
er deployment of AEDs in both public and residential areas.
Page b Emergency Medical Technician Basic
Appendix 1
Page c Emergency Medical Technician Basic
Appendix 1
Page d Emergency Medical Technician Basic
Appendix 1
Page e Emergency Medical Technician Basic
Appendix 1
Page f Emergency Medical Technician Basic

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Contents Chapter Page

Chapter 1: EMS In The Philippines

Life Support Training International Philippine Society of Emergency Medical Tech

Chapter 1: EMS In The Philippines

Chapter 1: EMS In The Philippines

Chapter 1: EMS In The Philippines

Chapter 1: EMS In The Philippines

PSEMT Membership Grades

Chapter 1: EMS In The Philippines

Chapter 1: EMS In The Philippines

Chapter 1: EMS In The Philippines

Chapter 1: EMS In The Philippines

Chapter 2: Roles and Responsibilities of the EMT

Chapter 2: Roles and Responsibilities of the EMT

Chapter 2: Roles and Responsibilities of the EMT

Chapter 2: Roles and Responsibilities of the EMT

Personal Safety An EMT is no good if he or she becomes another victim.

Transport A serious responsibility in ambulance operations, even more so with a

Patient Advocacy Moral responsibility to speak on behalf of the patients need of

Chapter 2: Roles and Responsibilities of the EMT

Chapter 2: Roles and Responsibilities of the EMT

Chapter 2: Roles and Responsibilities of the EMT

Chapter 2: Roles and Responsibilities of the EMT

Chapter 2: Roles and Responsibilities of the EMT

Chapter 2: Roles and Responsibilities of the EMT

Chapter 3: Medico-Legal and Ethical Issues in EMS

Definitions Patient Bill of Rights Ethical Implications Right of Refusal Legal A

Chapter 3: Medico-Legal and Ethical Issues in EMS

Different standards may be held in different legal jurisdictions.

Chapter 3: Medico-Legal and Ethical Issues in EMS

Expressed consent Implied consent Consent to treat a minor or mentally incompete

Chapter 3: Medico-Legal and Ethical Issues in EMS

Try to persuade the patient to accept treatment or transport to a hospital. Make

Chapter 3: Medico-Legal and Ethical Issues in EMS

Chapter 3: Medico-Legal and Ethical Issues in EMS

Chapter 3: Medico-Legal and Ethical Issues in EMS

Chapter 3: Medico-Legal and Ethical Issues in EMS

Chapter 4: Ambulance Vehicles and Equipment

Introduction North American Ambulance Designs European Ambulance Designs Paramed

Chapter 4: Ambulance Vehicles and Equipment

Chapter 4: Ambulance Vehicles and Equipment

Chapter 4: Ambulance Vehicles and Equipment

Chapter 4: Ambulance Vehicles and Equipment

Chapter 4: Ambulance Vehicles and Equipment

Ambulance maintenance benefits: decreases vehicle downtime

Chapter 4: Ambulance Vehicles and Equipment

Daily inspection of the vehicle Ambulance equipment Personnel

Chapter 4: Ambulance Vehicles and Equipment

Chapter 4: Ambulance Vehicles and Equipment

In an appropriate receptacle, dispose of all disposable equipment used for patie

Chapter 5: Medical Terminology in EMS

Chapter 5: Medical Terminology in EMS

Chapter 5: Medical Terminology in EMS

Chapter 5: Medical Terminology in EMS

Chapter 5: Medical Terminology in EMS

Chapter 5: Medical Terminology in EMS

Chapter 5: Medical Terminology in EMS

Chapter 5: Medical Terminology in EMS

Chapter 5: Medical Terminology in EMS