2020 Emr Summary

2020 EMR SUMMARY

EMR Well Being

Body substance isolation Immunizations Proper lifting techniques Proper precautions at haz-mat scenes EMR response to death or serious injury may lead to critical incident stress. Defusing- an early intervention that occurs at the scene or shortly after the scene of an incident, designed to stop the negative stress process that may occur in the hours immediately following a disaster response. Critical incident stress debriefing (CISD)-A psychological, emotional and educational group process to diminish the impact of critical incident stress

Medical/Legal & Ethical Issues

Golden Rule “Do unto others as you would have others do unto you” Public Health Law Article 30, Part 800 This contains the rules & regulations in reference to EMS & immunities. An EMR cannot be held liable unless gross negligence can be proven.

GOOD SAMARITAN ACT (does not cover EMR in NYS) It is designed to protect private non - certified persons who assist in emergency treatment from legal action, with the exception of gross negligence.

Staying within the scope of practice & standard of care for his/her level of training, combined with proper documentation will go a long way in preventing the EMR from being involved in litigation.

NEGLIGENCE Deviation from the standard of care as recognized by law Criteria:  Duty to act – An obligation to provide care to a patient  Breech of duty  Injury occurred  Proximate cause – Injury resulted from improper action or failure to act.

ASSAULT & BATTERY- In certain circumstances the EMR can be charged with assault & battery for treating an adult without consent. Assault verbal Battery Physical

Nassau County Fire Police EMS Academy NCPD EMR Summary Rev. 3/2020 2020 EMR SUMMARY

CONSENT Agreement by the patient to accept medical intervention.

INFORMED (ACTUAL) CONSENT A patient is told, in a manner they can understand, the nature and extent of the procedure to be performed and the possible risks. The patient fully understands the procedures, the risks involved, and accepts them.

IMPLIED CONSENT The unconscious, mentally impaired, or child patient in a true emergency, in which there is a significant risk of death, disability or deterioration of the condition, the LAW assumes that the patient or guardian would give their consent.

ABANDONMENT The termination of the EMR-patient relationship without the consent from the patient. Transferring a patient to another health care professional who is not of equal or higher training than you.

DELEGATED PRACTICE The System Medical Physician delegates the rescuer to carry out actions on their behalf. Example is on line medical direction (medical control) or off-line medical direction (standing orders and/or protocols).

Quality Improvement A system of internal & external audits, that monitor every aspect of prehospital care to achieve optimal excellence in patient services rendered. When quality issues are discovered, suggestions are made to prevent re-occurrence.

DOCUMENTATION NYS PCR FORMS Includes:  Legal Document  Permanent part of the patient’s medical record’  Minimum Data Set  All times from 9-1-1 to in service  Chief Complaint  Vital signs  Demographics  Information from the patient, bystanders, and a physical examination  Subjective-Information based on opinions expressed by patients and others.  Objective-findings are Physical findings (facts)  Treatment rendered and changes in patient condition  No personal comments from the EMR

Nassau County Fire Police EMS Academy NCPD EMR Summary Rev. 3/2020 2020 EMR SUMMARY

Refusal of Medical Care by EMT or higher only EMR must not make an independent decision regarding a patient's refusal of medical care or transport.

Prouncement of death by EMT or higher only

Signs of Obvious Death  Rigor mortis  Dependent lividity  De-composition  Injury not compatible with life  Patient submerged > 1 hour in any temperature water

Advance Directives – must be present and valid (copies are acceptable with signatures)  MOLST / eMOLST – appropriate directives should be honored  NYS approved document, bracelets or necklaces  NYS nursing home or Non-hospital DNR  Healthcare Proxy and Living Will – contact Medical Control for direction.

THE HUMAN BODY

COMMON MEDICAL TERMINOLOGY

COMMON PREFIX A or An - without Brady - slow Contra/Anti - against Dys - disorder/difficult Tachy - fast Vaso - Blood vessel

COMMON WORDS Cardio - heart Cerebro - brain Cephalo - head Hemi - half Hypo - deficient/below Hyper - above/excess Inter - between Intra - inside

Nassau County Fire Police EMS Academy NCPD EMR Summary Rev. 3/2020 2020 EMR SUMMARY

TERMS OF LOCATION Anterior (Ventral) - Towards the front of the body or body part Posterior (Dorsal) - Towards the back of the body or body part Superior - Above, upper Inferior - Below, lower Superficial - Near the surface Deep - Remote to the surface Internal - Inside External - Outside Proximal - Near to the point of attachment Distal - Farthest from the point of attachment Medial - Towards the midline of the body Lateral - Away from the midline of the body Coronal Plane - Divides body in half front & rear Medial Plane - Division of body down the middle left &right.

TERMS OF DIRECTION Cranial (Cephalic) superior - towards the head Caudad (inferior) - towards the Feet

TERMS OF POSITION AND MOVEMENT Supine - Lying on spine, face up Prone - Lying on stomach, face down Abduction - Movement away from the midline of the body Adduction - Movement towards the midline of the body Flexion - Act of bending Extension - Act of straightening

TISSUE is a collection of specific cells, which carry out a specific function.

 Connective Tissue: Forms the supporting and connective surfaces of the body  Muscle Tissue: Composed of cells specialized to contract  Skeletal (striated)  Involuntary (smooth)  Cardiac  Nervous Tissue: Specialized cells that receive stimuli and conduct nerve impulses to various organs

Nassau County Fire Police EMS Academy NCPD EMR Summary Rev. 3/2020 2020 EMR SUMMARY RESPIRATORY SYSTEM

Anatomy

Nose warms & humidifies air, traps dust Trachea Windpipe Pharynx Throat Carina Bifurcation of the Trachea Larynx Voice Box Alveoli Air Sacks Epiglottis Protects the Larynx Bronchi Passageway to Lungs

Adequate Respiratory Rates Adult 12-20 breaths per min. Child 15-30 breaths per min. Infant 25-50 breaths per min.

 Inhalation - Diaphragm contracts, moves downward causing the chest cavity to enlarge decreasing pressure. Air flows in through open airway. This is an active process (uses energy).  Exhalation - All muscles relax, chest cavity decreases in size, increasing pressure, air is expelled. This is a passive process.  Ventilation – The process of moving air in and out of the lungs.  Respiration – the exchange of Oxygen and Carbon dioxide.

Terms  Hypoxia - Inadequate O2 for cellular needs  Hypercarbia – excess of Carbon Dioxide in the system

Respiratory Patterns  Apnea - Absence of breathing  Dyspnea - Difficulty in breathing  Hyperpnea - Deep ventilation  Hyperventilation - Increased minute volume  Hypoventilation - Decreased minute volume  Orthopnea - Difficulty breathing while lying down  Tachypnea - Rapid breathing  Bradypnea - Slow breathing

Abnormal Respiratory Sounds Snoring - Upper airway partially blocked, usually by the tongue Stridor, Crowing - Harsh high-pitched sound, caused by laryngeal spasms, child’s partial airway obstruction Wheezing - Whistling sound, heard in Asthma, COPD, CHF Rhonchi - Rattling noises, heard in throat and bronchi Rales and Crackles - Fine, moist sounds heard in lower airways

Nassau County Fire Police EMS Academy NCPD EMR Summary Rev. 3/2020 2020 EMR SUMMARY

Assessment of the Respiratory System  Inspection - Look for signs  Auscultation - Listen (anterior & posterior)  Palpate - Feel

Respiratory Distress – Increased work of breathing.

Signs of Respiratory Distress Inadequate Chest Rise Accessory Muscle Use Nasal Flaring Cyanosis Tracheal Tugging Retractions

Respiratory Failure – Inadequate ventilations that will lead to apnea.

Signs of Respiratory Failure Lethargy AMS Poor effort Cyanosis

CARDIOVASCULAR SYSTEM

Anatomy and Physiology  Right atrium - receives deoxygenated blood from the body  Pulmonary Circulation - Right Ventricle pumps blood into the Lungs  Pulmonary Artery – Takes deoxygenated blood from Right Ventricle to Lungs  Pulmonary Vein – Vein that carries oxygenated blood from lungs to Left Atria  Left Atrium receives blood from the lungs  Systemic Circulation - Left Ventricle pumps oxygenated blood to heart and body  Coronary Arteries – Supply the heart tissue with oxygenated blood  Myocardium - Heart Muscle  Pericardium - Double layered sac that surrounds the Heart  Systole – Ventricular contraction pressure used to push blood through arteries  Diastole - Heart muscle relaxes, chambers refill

Nassau County Fire Police EMS Academy NCPD EMR Summary Rev. 3/2020 2020 EMR SUMMARY CENTRAL NERVOUS SYSTEM

Anatomy and Physiology

Brain Cerebrum - Mediates higher mental functions, such as reasoning, thought, memory, speech Cerebellum - Concerned with equilibrium, coordination, skilled movements Brain Stem - Maintenance of vital functions, medulla regulates respiration & heart activity

Spinal Cord & Nerves  Contains nerve tracts, controls position, sense, reflex activity

Spinal Vertebrae  7 cervical, 12 thoracic, 5 lumber, 5 sacral & 4 coccygeal

Muscloskeletal System Functions  Protects  Helps regulate temperature  Absorbs shock  Sensory

 Remember BLT with Mayo (Bones, ligaments, muscles and tendons)  Tendons - Tie Muscle to bone  Ligaments - Link bone to bone  Cartilage - Cushion, Connective tissue

Muscles  Smooth - Involuntary (Digestive Tract, Bronchi)  Skeletal - Voluntary (Striated)  Cardiac - Heart

Nassau County Fire Police EMS Academy NCPD EMR Summary Rev. 3/2020 2020 EMR SUMMARY

The Skin  Largest organ in the body  3 layers  Epidermis  Dermis  Subcutaneous

BASE LINE VITAL SIGNS & SAMPLE HISTORY

Pulse - rate & quality Respiratory - rate & quality Skin - temperature, color and condition Blood Pressure – systolic and diastolic Monitor unstable patients every 5 mins. Monitor stable patients every 15 mins.

Normal Vital Signs per age

______Age Respirations Pulse Systolic BP Newborn <28 days 30 – 60 100 – 180 >60 Infant < 1 year 30 – 60 100 – 160 >60 Toddler 1 – 3 years 24 – 40 90 – 150 >70 Preschooler 3 – 5 yrs 22 – 34 80 – 140 >75 School-aged 6 – 8 yrs 18 – 30 70 – 120 >80 Adult 18 – 100+ 12 – 20 60 – 100 >90

SAMPLE History S - Signs & symptoms A - Allergies M - Medications P - Past medical history L - Last meal E - Events leading up to the incident

OPQRST O – Onset P – Provocation Q – Quality R – Region/Radiation S – Severity/Scale T – Time I - Interventions

Nassau County Fire Police EMS Academy NCPD EMR Summary Rev. 3/2020 2020 EMR SUMMARY LIFTING & MOVING PATIENTS  Keep weight in close  Keep back locked  Know the approximate weight of the patient & equipment for personnel considerations  Use legs, back & power grip when lifting

Equipment  Split frame stretcher (scoop): used for moving patients with little movement  Reeves: for tight quarters or unconscious patients  Stair chair: used for moving patients down or up stairs  Stokes stretcher/basket: used for carrying over rough terrain or high-level rescue  Wheeled stretcher

Types of Moves

Emergency Moves Other Moves Cloths drag Extremity carry Foot drag Fireman carry Blanket drag 4-person log roll Firefighter drag One rescuer assist Rapid take down Two rescuer assist Rapid extrication

Narrow Spaces: Movement of a patient with a spinal injury along their long axis Straddle Slide

Positions  Fowlers - seated upright 90 degrees  Semi-fowlers - seated at a 45-degree angle  Lateral recumbent - on their side (left sided - called recovery position)  Shock - legs raised head lowered  Position of Comfort - patient preferred  Prone - on their stomach  Supine - on their back

Airway

Manual Airway Opening Methods  Head tilt chin lift (No trauma suspected)  Modified jaw thrust maneuver (Trauma)

Nassau County Fire Police EMS Academy NCPD EMR Summary Rev. 3/2020 2020 EMR SUMMARY

O2 Equipment, Ventilatory Devices & Adjuncts  BVM with a reservoir delivers >90% O2 @ 15 LPM, without supplemental O2 is 21%  BVM most effective with 2 providers  Pocket Face Mask - With O2 at 10-15 LPM can deliver up to 50% oxygen, without supplemental O2 delivers 16%  Nasal Cannula - 1 – 6 LPM can deliver 24 – 44% oxygen  Non-rebreather Mask - 12 – 15 LPM can deliver up to 90%, oxygen keep bag full  Set liter flow on non-rebreather mask so that bag stays full on inspiration of patient.  Flow restricted positive pressure ventilator device (Demand valve).

Airway Adjuncts

Oropharyngeal Airway  Indication: Unconscious patient without a gag reflex  Purpose: to help maintain a patent airway.  Contra Indication: Patient with an intact gag reflex.

Nasopharyngeal Airway  Indication: patient with a gag reflex or severe facial trauma.  Lubricate with water-soluble lube only!!!!  Purpose: to help maintain a patent airway.  Contra-indication: severe head trauma and infants.

Oxygen Cylinders  Full “D” Cylinder - 2000 PSI  Safe residual pressure (Empty) - 500 PSI  Mix of oil & O2 will cause explosion

Suctioning  Use cross finger (scissor) technique to open airway.  Power suction devices should generate 300 mm/hg  Yankaur tip is hard suction catheter  Soft tip catheter is called a French tip.  Use bulb syringe for suctioning infants.  NYS: Maximum Suction times  Adult – 15 seconds  Child – 10 seconds  Infant – 5 seconds  Limit suction on the way out only  Suctioning can cause laryngospasm, hypoxia, and/or arrhythmia’s

Nassau County Fire Police EMS Academy NCPD EMR Summary Rev. 3/2020 2020 EMR SUMMARY CPR

Rates 1 Person 2 Person Adult/Child 100 to 120/min 100 to 120/min Child 100 to 120/min 100 to 120/min Infant 100 to 120/min 100 to 120/min

Ratio Adult 30 comp. / 2 vents. 30 comp./ 2 vents. Child 30 comp. / 2 vent. 15 comp./ 2 vents. Infant 30 comp. / 2 vents. 15 comp./ 2 vents.

Depth Adult 2 to 2.4 inches or 5 cm Child about 2 inches or 1/3 depth of chest Infant about 1 ½ inches or 1/3 depth of chest

Unconscious patient pulse points  Adult /Child - Carotid Pulse  Infant - Brachial Pulse

Recoil – to refill the chambers of the heart Interruptions – keep to less than 10 seconds. Dentures - If not loose leave in place, unless they obstruct airway Cardiac arrest in children usually results from respiratory arrest.

If patient vomits, turn patient to side, sweep out mouth, continue CPR

Airway Obstruction Conscious Patient - Partial obstruction (GOOD AIR EXCHANGE). Ask if they are choking if they can speak encourage them to cough it out, stand by to assist.

- Complete obstructions, unable to speak, do abdominal thrusts.

Patient becomes Unconscious……Start CPR with Compressions first, checking mouth for obstructions prior to giving the breaths.

Nassau County Fire Police EMS Academy NCPD EMR Summary Rev. 3/2020 2020 EMR SUMMARY PATIENT ASSESSMENT

Scene Size up  Body substance isolation and Scene Safety  Mechanism of injury  Number of patients  Additional resources needed  Take C-spine precautions if appropriate

Primary Assessment - TREAT AS YOU GO

Goal: To identify & correct immediate life-threatening problems

General patient impression AVPU - Mental Status (LOC) Chief Complaint /Any life threats? - Any Major Bleeding, treat first

A - Airway- open or closed, adequate? Need assistance?

B - Breathing- Do they need Oxygen? Breathing- Are they breathing adequately? Look Listen and Feel.

C - Check voids for any serious bleeding. Circulation- Check radial pulse (if no radial pulse check carotid) Circulation- Check skin (CTC- color, temperature and condition)

DD- Decide patient priority and dispatch your findings to incoming EMS

SECONDARY ASSESSMENT

Trauma Patient Medical Patient SAMPLE history SAMPLE history Exam- Head to Toe looking for DOTS OPQRST - I questions Vital Signs - Baseline Vital Signs – Baseline Treatments Exam – Body System focused Reassessments General impression Transfer of Care Treatment interventions Reassessments Transfer of Care

Deformity Obvious Injury Tenderness Swelling 12

Nassau County Fire Police EMS Academy NCPD EMR Summary Rev. 3/2020 2020 EMR SUMMARY

MEDICATIONS

Oxygen

 Class - inhaled gas  Indications: low Oxygen state i.e.; Dyspnea, shock – hypoperfusion, etc.  Dosage /Route... 0.5-25 LPM inhaled  Contraindications: None (in pre-hospital setting.)

Aspirin  Class – platelet inhibitor and anti-inflammatory  Indications – Myocardial chest pain  Dose/route – 324mg PO (chewed)  Contraindications – Active GI Bleeds, allergy and asthma

ASSISTED MEDICATION EMR

Inhalers for patients with asthma and COPD Epinephrine intramuscular autoinjectors for anaphylaxis Diastat rectal diazepam for seizures Nitroglycerin sublingual for chest pain Narcan intranasal for opioid overdose with hypoventilation

Respiratory Emergencies

Respiratory Illness  Emphysema - Caused by progressive loss of elastic recoil of the Alveoli.  Chronic Bronchitis - Caused by constriction of the bronchi, and mucus build up  Asthma - Caused by spasms and constriction of the bronchi in otherwise normal air passages.  Status Asthmaticus - Prolonged asthmatic attack, breath sounds and wheezes are usually inaudible can cause Atelectasis Collapse of the alveoli  Pulmonary Embolism - Sudden, sharp, pleuritic chest pain, usually associated with history of thrombophlebitis, use of oral contraceptives, long bone fracture or long convalescence  Hyperventilation Syndrome – anxiety provoked rapid breathing, causing too much Carbon Dioxide to be exhaled.

Nassau County Fire Police EMS Academy NCPD EMR Summary Rev. 3/2020 2020 EMR SUMMARY

Respiratory - Chest Injury  Pneumothorax - Air in the pleural cavity. Diminished breath sounds and trachea deviation toward the injured side. (collapsed lung)  Tension Pneumothorax - Trachea deviates away from the injured side (collapsed lung). Diminished breath sounds on the effected side, low B/P, rapid HR, JVD with weak pulses.  Hemo-thorax- Blood in the pleural cavity  Hemo-pneumothorax - blood & air entering the pleural cavity  Flail Chest - Paradoxical respiratory movement, chest pain, dyspnea, deformity, 2 or more ribs broken in 2 or more places.  Sucking chest wound – opening in the thoracic cavity that can cause lung collapse

Signs & Symptoms  AMS / LOC  Short of Breath and/or increased work of breathing  Decreased or increased respiratory rate  Abnormal breathing patterns  Accessory muscle use  Retractions

Treatment  ABC’s  High flow O2 and assist with positive pressure ventilations  Seal any holes (air occlusive dressing), manage serious chest trauma  Treat for shock  Rapid transport  Consider ALS intercept

Cardiovascular Illness and Injury

Cardiac Compromise- term used to describe any type of cardiac related problem

Coronary Artery Disease:  Arteriosclerosis - Disease causing hardening and narrowing of the arteries  Atherosclerosis - Disease process that causes an accumulation of plaque (fatty deposit) within arteries

Angina Pectoris:

Short lived Chest Pain (usually under 10 minutes), caused by partial blockage of coronary arteries or a spasm of the coronary arteries. Can be relieved by rest, oxygen, and/or Nitro.

Nassau County Fire Police EMS Academy NCPD EMR Summary Rev. 3/2020 2020 EMR SUMMARY

Acute Myocardial Infarction (Heart Attack, AMI)

 Pain or discomfort, can radiate to arm, back & jaw.  Atypical presentations can be abdominal complaints or weakness or flu-like symptoms  Most frequent cause of MI death Ventricular Tachycardia/Fibrillation  Administer 324mg chewable aspirin  OPQRST-I questioning

Congestive Heart Failure

A damaged heart that fails to keep up with the demands of the body.

Signs: JVD – Jugular venous distention Pulmonary edema Pedal edema

Treatment: Oxygen, assist in ventilations if needed, seated upright, request Advanced Life Support

AED Shock-Able Rhythms

Pulseless Ventricular Tachycardia Ventricular Fibrillation

Use of defibrillator  Turn on EAD  Follow Prompts  Do not place over Medicine Patch or Pacemaker  Do not let pads touch  Do not use on submerged person o Wipe water or sweat off if covered  Make sure all rescuers are clear while analyzing and shocking  Use as soon as possible  IF available, use pediatric pads and/or attenuator for infants and children  Do not use pediatric pads or attenuator or an adult

Nassau County Fire Police EMS Academy NCPD EMR Summary Rev. 3/2020 2020 EMR SUMMARY

Medical Emergencies

Diabetes: Body Failure to produce sufficient insulin

Hyperglycemia Diabetic Coma- not enough insulin, sugar level too high.  Dry warm skin  Kussmal’s respiration (rapid deep sighing respiration’s)  Dehydration  Acetone breath odor  Gradual onset (SLOW)

Hypoglycemia Insulin Shock - Low Blood Sugar, insulin level too high.  Cool, clammy skin  AMS  Rapid onset (FAST)  Management  ABC’s, O2, give oral glucose or fruit juice if patient is able to follow commands and swallow.

Anaphylactic Reaction

 A severe allergic reaction  Signs & Symptoms- Swelling of the face and tongue, urticaria (hives), itching, dyspnea with wheezing  Management- ABC’s, treat for shock, Assist with Epi if available. Consider ALS intercept.

Stroke/CVA

Obstruction or rupture of vessel disrupting blood flow to the brain. Cincinnati Stroke Scale- Facial droop, arm drift, weakness on one side Last known well Blood Glucose ABC’s and oxygen

Drowning/Near Drowning

 Do not go in the water unless trained to do so  Fresh water drowning can result in V-Fib  Salt water drowning can result in acute pulmonary edema  All near drowning patients must seek medical attention

Nassau County Fire Police EMS Academy NCPD EMR Summary Rev. 3/2020 2020 EMR SUMMARY

 Cold Emergencies General Hypothermia  Remove from environment  ABC’s, Vitals with Pulse check for 30 to 45 seconds, severe bradycardia is possible  Handle patient carefully to prevent cardiac dysrhythmias  Gently remove wet clothing and dry the patient  If oxygen is required, provide warm, humidified oxygen, if available  Place heat packs, if available, in the patient’s groin area, lateral chest, and neck  Wrap the patient in dry blankets and maintain a warm environment and Cover head with cap or towel.

Local Hypothermia Frost bite  Remove from environment  ABC’s and vitals  Protect areas from pressure, trauma, and friction  Do not break blisters  Do not rub the injured area  Remove clothing and jewelry

Heat Emergencies Hyperthermia Heat Cramps  Caused by - Profuse sweating, loss of salts  Presents - Muscle cramps

Heat Exhaustion  Caused by - Loss of water and salts  Presents - Syncope, nausea, cramping, dizziness, pale, clammy skin, headache

For patients presenting with moist, pale, and normal to cool skin temperature:  ABC’s  Vital Signs  Remove from environment  If the patient is not nauseated and able to drink water without assistance, have the patient drink water

Heat Stroke  Caused by - Body lost the ability to sweat  Presents - Unconsciousness, Dry, flushed skin, hypotension  True Emergency

For patients presenting with hot, flushed, and dry skin:  Apply cold packs to patient’s neck, groin, and armpits  Keep the patient’s skin wet by applying wet sponges or towels 17

Nassau County Fire Police EMS Academy NCPD EMR Summary Rev. 3/2020 2020 EMR SUMMARY

Radiation Exposure Emergencies  Alpha Particles - Can be stopped by paper  Beta Particles - Can be stopped by heavy clothing  Gamma Particles - Penetrating  Clean Accident - No spilling, No danger to the rescuer

Alcoholism  Problem Drinker - A person who uses alcohol to relieve tensions or other emotional difficulties  Addiction - Abstinence from alcohol causes major withdrawal symptoms

Alcoholic Prone Illnesses  Subdural Hematoma - Due to frequent falls  Cirrhosis - Liver Damage  Hypoglycemia - Due to liver damage, lack of Thiamine  Pancreatitis - Also can lead to hypoglycemia  Upper Gastrointestinal Bleeding - Ulcers

Alcohol Withdrawal Can present with Delirium Tremens (DT’s)  Confusion  Irregular heart rate  Sweating  Seizures

Overdose

Narcotic Overdose - Opium based drugs, (Morphine, Darvon, Heroin) Pin point pupils, Respiratory depression

Management - Airway, Oxygen ALS intercept. For hypoventilation - Administer naloxone (Narcan®) intranasally

Barbiturate Overdose - Sedatives / Depressants Serious when mixed with alcohol shallow respiration’s, coma, fixed dilated pupils and Hypotension

Amphetamine - Amphetamines, Dexedrine, “Speed Freak” Wild eyed appearance, excitement, Anorexia, Tachycardia, sweating, hypertension, dilated pupils, and tremors

Hallucinogens - PCP (Phencyclidines) violent, combative, paranoid, generally out of control pain perception decreased may cause mutilating self injury 18

Nassau County Fire Police EMS Academy NCPD EMR Summary Rev. 3/2020 2020 EMR SUMMARY Poisoning  Ingested  Inhaled  Injected  Absorbed

Questions to ask  What was taken?  How much was taken?  When was it taken?  Was vomiting induced?  Was anything given?

Management - Airway, 02, Contact Medical Control for treatment orders

Don’t Induce Vomiting for: 1. Comatose patient 5. Corrosives 2. Seizures 6. Petroleum products (kerosene, gasoline) 3. Pregnancy 7. Iodine, Silver Nitrate, Strychnine 4. AMI

Specific Poisonings

Carbon Monoxide- Colorless, odorless, tasteless gas Signs & symptoms- Causes pressure sensation in the head, roaring in ears, vomiting, incontinence, convulsions, coma, bounding pulse, dilated pupils, pulmonary edema, cherry red skin (late)

CO Management- Remove from environment, 100% Oxygen

Absorbed poisons- Flush site with water

Injected Poisons Bee Stings – Sharp sudden pain with redness to the site.

Management – Scrape stinger out, ABC’s, Oxygen, Epi pen as necessary, and rapid transport.

Snakebites- Instant pain with progressive local edema and ecchymosis. Nausea, vomiting, dizziness, pulse changes, hypotension, delirium may also be present.

Management - Remove all jewelry, loosen restrictive clothing, Wrap the limb with ace bandage, ABC’s with Oxygen, Treat for Shock

Nassau County Fire Police EMS Academy NCPD EMR Summary Rev. 3/2020 2020 EMR SUMMARY

Acute Abdomen

Solid Organs- Liver, Spleen, Pancreas, Kidneys and Ovaries

Hollow Organs- Stomach, Small Intestine, Appendix, Gallbladder, Bladder, Large Intestines

Abnormal findings- Nausea, Vomiting, Diarrhea, Blood in urine, stool or vomit, Pain, Fever, loss of appetite

Genitourinary Problems Kidney Stone- Excruciating flank pain, radiating to the groin Renal Failure- can cause increased vitals due to fluid overload and toxicity

Blunt Trauma - Can result in a rupture to:  Liver (Contains 25% of your blood supply)  Spleen (Left sided abdominal & left shoulder pain, Shock)  Eviscerated Abdominal Organ (open abdominal injury)  Place a large sterile dressing moistened with sterile saline over exposed organ.  Cover dressing with plastic sheet and secure in place.

Nassau County Fire Police EMS Academy NCPD EMR Summary Rev. 3/2020 2020 EMR SUMMARY

Geriatric Patients  Age related changes o Altered Reactions to illness o Pain mechanism depressed. o Temperature regulation mechanism depressed. o Thirst mechanism not as active  Loss of Senses and mobility  Mental deterioration, depression  Assessment challenges

Behavioral Emergencies

 Realistic Fears - Fear of pain, disability, death  Diffused Anxiety - Feeling of helplessness  Depression - Natural, psychotic response to loss  Regression - Return to an earlier or more primitive mode of behavior  Denial - Ignore the problem  Anger - Become resentful to the situation  Confusion - Common among the elderly  Blind Panic - Individual’s judgment seems to disappear  Overreaction - Person who talks compulsively, jokes inappropriately, become overactive

Specific Psychiatric Emergencies:  Depression - Sad expression, bouts of crying, listless behavior, feelings of worthlessness  Suicide - Willful act designed to bring an end to one’s own life  Paranoia - Patient is suspicious, reclusive, distrustful - Do not play along with their delusions

Nassau County Fire Police EMS Academy NCPD EMR Summary Rev. 3/2020 2020 EMR SUMMARY OB / GYN Anatomy and Physiology  Ovaries - Produce female sex hormones, make eggs  Uterus - Muscular organ where fetus develops  Cervix - Neck of Uterus  Perineum - Area of skin between the Genitals and Anus

 Fetus - Developing Baby  Placenta – organ that delivers nutrients to baby  Umbilical Cord – from placenta to baby  Amniotic Sac - Bag of Waters  Amniotic Fluid – Cushions fetus in amniotic sac  Crowning - Head of baby starts to emerge from the vagina.  To stop bleeding, utilize uterine massage encourage mother to breast feed.

Nassau County Fire Police EMS Academy NCPD EMR Summary Rev. 3/2020 2020 EMR SUMMARY

Management of a normal delivery  Support the baby’s head over the perineum with gentle pressure  If the membranes cover the head after it emerges, tear the sac with your fingers or forceps to permit escape of the amniotic fluid  Gently guide the head downward until the shoulder appears  The other shoulder is delivered by gentle upward traction  The infant’s face should be upward at this point  Maintain firm grasp on infant  Warm, dry and stimulate  Clamp umbilical cord 8-10 inches from baby and the second 3 inches from that  Wrap infant in dry warm blanket or towel and cover infants head with hat or bunting  Keep infant warm and free from drafts.  Monitor respirations

Neonatal Resuscitation

Dry, Warm, Tactile Stimulation Call for ALS back-up if needed Suction mouth and nose if airway obstruction with bulb syringe

If RR < 30/min or if HR <100 /min

Ventilate with BVM @ 40-60/min with room air If no response after 30-60 seconds add O2 If signs of poor perfusion after adding oxygen follow neonatal CPR (below)

HR<60 after 30 sec. BVM

CPR @ 100 to 120/min – 3:1 (compressions:breaths)

1/3 to 1/2 chest depth 2 fingers or thumbs encircling chest

Nassau County Fire Police EMS Academy NCPD EMR Summary Rev. 3/2020 2020 EMR SUMMARY

OB Emergencies

 Breech Birth - Buttocks First.  Limb presentation - One extremity is the first presenting part. (True Emergency) do not push limb back in  Vaginal Bleeding (No Trauma) - Treat for shock, oxygen & monitor vitals.  Spontaneous Abortion - Occurring naturally (miscarriage)  Pre-eclampsia - Toxemia of pregnancy precursor to Eclampsia, hypertension, edema  Eclampsia - Development of seizures, no lights or sirens (promote seizures)  Prolapsed Umbilical Cord - Cord is first presenting part  Supine Hypotensive Syndrome - Fetus is pressing on the mother’s inferior vena cave. Place mother left laterally recumbent  Premature Infant - Under 5.5 lbs. or before the 38th week of gestation.

Childbirth is a natural phenomenon and the type of delivery cannot be regulated by your level of certification – if a CFR is faced with anything but a normal delivery, please feel comfortable calling medical control for assistance.

Bleeding & Shock (Hypoperfusion)

Artery Bleed-bright red spurting blood Venous Bleed – dark maroon flowing blood Capillary Bleed – Bright red oozing blood

Bleeding Control 1. Direct Pressure 2. Pressure bandage 3. Tourniquet

NYS Protocol Apply tourniquet at least 3 inches above the wound, not over a joint. In an unstable scene, or if the extent of the wound cannot be fully assessed in the field, tourniquet should be placed high and tight.

Dressing – Sterile material that is used to cover the wound.

Bandage - Material used to hold dressing in place

Blood Volume - 6 Liters in average adult (or 6 quarts, 12 pints, 12 units) 24

Nassau County Fire Police EMS Academy NCPD EMR Summary Rev. 3/2020 2020 EMR SUMMARY

Composition of Blood  Red Blood Cells/erythrocytes/ (Transport) hemoglobin carries 02  White Blood Cells – Leukocytes – fight infections  Plasma - Transport Medium  Platelets – Facilitate clotting

SHOCK/Hypo-perfusion - Inadequate Tissue perfusion/hypo perfusion

HOMEOSTASIS: Body’s attempt to maintain stability of the internal environment

Signs and Symptoms

Compensating Shock (early stage)  Restlessness/AMS  Rapid, weak pulse  Rapid shallow respiration’s  Cool, clammy skin

Decompensating Shock (late stage)  Hypotension – Low blood pressure

TYPES OF SHOCK Hypovolemic/Hemorrhagic  Blood loss either External or internal  Loss of plasma from burns and crush injuries  Loss of electrolytes from diarrhea and vomiting

Respiratory/ Metabolic - Prevention of adequate O2 and CO2 exchange Examples: Pulmonary edema, lung injury or CO poisoning

Cardiogenic – pump failure, ineffective pump

Obstructive  Tension pneumothorax  Cardiac tamponade  Pulmonary embolism

Distributive  Neurogenic - Loss of sympathetic tone, overdilation of blood vessels, usually a spinal injury  Psychogenic - Simple fainting; a sudden, but usually temporary dilation of blood vessels  Anaphylactic - Severe allergic reaction  Septic - Severe infection 25

Nassau County Fire Police EMS Academy NCPD EMR Summary Rev. 3/2020 2020 EMR SUMMARY

Treatment of Shock  Control bleeding  High concentration of O2  Place position supine  Keep patient warm  Rapid transport

SOFT TISSUE INJURIES

SKIN: largest organ of the body

Layers - Epidermis (Outer layer) Dermis (Inner layer) contains sweat glands, nerve endings Subcutaneous Layer (Connective)

Function - Protection, temperature regulation, prevents water loss, sensory organ

Exam: Color, Temperature and Conditions

Soft Tissue Wounds  Abrasion - Caused by rubbing or scraping  Evisceration - Abdominal wound with intestine protruding  Laceration - Jagged cut or slice  Incision - Smooth, clean cut  Puncture - Hole, made from a pointed object  Penetrating – Entrance, unknown path and depth  Avulsion - Tearing loose of a flap of skin  Amputation - Tearing loose of a body part. Management: wrap in moist sterile dressing gauze, seal in plastic bag and keep cool. Do not put unprotected part on ice.  Impaled Object – stabilize and control bleeding  Remove if prevents airway maintenance or CPR Burns

First step in the treatment of burns is to stop the burning process

 Superficial or 1st Degree - Reddening of the skin  Partial Thickness or 2nd Degree – Blisters (open or broken)  Full Thickness or 3rd Degree – Charred or white waxy skin

Nassau County Fire Police EMS Academy NCPD EMR Summary Rev. 3/2020 2020 EMR SUMMARY

Electrical/Lighting Injuries Burns

* First step is to assure your own safety.

Burn Management

Thermal Burns  Stop the burning process  Apply dry sterile dressings or burn sheets to the burned area(s). Chemical Burns - Flush with copious amounts of water Dry Lime Burns - Brush off first, then flush with water Electrical Burns – De-energize source, assess for burns fractures, dysrhythmias, and entrance and exit wounds.

Facial Injuries Sclera……………………… Whitish portion of the eye, mild cases of jaundice may be seen here

Eye Injuries - Cover both eyes with loose to prevent consensual movement

- when flushing, flush away from the good eye

Light Injuries - Cover with dark eye patch

Avulsion of the eye - Treat as an impaled object

Facial Injuries - Can cause cervical injuries, Airway may be obstructed

Nosebleed/Epistaxsis...... Pinch the nostrils, have patient lean forward

Trauma to the neck - Airway & Spinal injuries are major concern

Open neck injury - Can result in pulmonary embolism

Blunt Injury to neck - Can result in fracture to the trachea

Nassau County Fire Police EMS Academy NCPD EMR Summary Rev. 3/2020 2020 EMR SUMMARY Musculoskeletal System

Five Major functions 1. Support 2. Movement 3. Protection 4. Cell Reproduction 5. Body shape

Sprain - Ligament or tendon damage Strain – Muscle damage, pain, possible swelling. Dislocation – temporary or permanent separation of a joint

Closed injury – no break in the skin Open Injury – skin has broken around the fracture site

Management of Fractures 1. Manual stabilization 2. Check distal pulse 3. Immobilize joint above and below the fracture 4. Re-assess pulse motor & sensory.

Management of Joint Injury 1. Manual stabilization 2. Check distal pulse 3. Immobilize bones above and below the joint injury 4. Re-assess pulse motor & sensory.

Special Notes Hand Injuries - Splint in the position of function Fractured Humorous - Distal end can damage vessels and nerves (i.e. ulnar nerve) Suspected Hip Injury:  Medial rotation of the foot generally indicates presence of a dislocated hip.  Lateral rotation generally indicates presence of a hip fracture.

Nassau County Fire Police EMS Academy NCPD EMR Summary Rev. 3/2020 2020 EMR SUMMARY

HEAD and SPINE

Closed Head Injury  Concussion - jarring of the brain, cannot be seen on X-ray or CT-scan  Contusion - Bruising of brain tissue can cause permanent damage.

Sign and Symptoms  Changes in LOC - MOST IMPORTANT SIGN  Unequal Pupils  Vomiting - common in children, SERIOUS IN ADULTS Increasing Intercranial Pressure Developing  RISING BP  SLOW PULSE AND RESPIRATIONS  Projectile vomiting  Rising Pulse Pressure (difference between systolic & diastolic blood pressure)

Skull Fracture (open head injury) Signs and Symptoms  Cerebrospinal fluid leaking from ears or nose (cover with loose dressing)  Battle’s Sign (Basilar Skull Fracture) ecchymosis behind the ears  Raccoon’s Eyes, discoloration of and around eyes  Deformity (depressed area) of head.

Management  ABC’s  C-Spine  High flow oxygen  Rapid transport  Head injuries do not usually cause Hypovolemia (look for other injuries)

Spinal Injuries

Area of Injury Affected Paralysis Region Cervical Spine Arms and Legs affected Lumbar Spine Legs affected C – 1, C –5 Cessation of respiratory movements T - 4 Loss of sensation inferior to the nipple line T - 10 Loss of sensation inferior to the umbilicus

The cervical area is responsible for respiratory control. 3,4,5 keep you alive.

Spinal Injury Signs and Symptoms Spinal Injury Management Paralysis 1. Manual spinal motion restriction Tingling 2. jaw-thrust Pins & needles 3. Assess PMS in all 4 extremities 29

Nassau County Fire Police EMS Academy NCPD EMR Summary Rev. 3/2020 2020 EMR SUMMARY

CENTRAL NERVOUS SYSTEM MEDICAL PROBLEMS

Transient Ischemic Attack (T.I.A.)

Temporary neurological deficits lasting 5 – 10 minutes caused by interruption of blood supply to the brain. Mini stroke, usually self correcting.

Cerebrovascular Accident (CVA, Stroke or Brain Attack)

Interruption of blood flow to brain caused by clot or bleeding. Altered L.O.C., hemiparesis, hemiparalysis, weakness in ability to move extremities.

Management  Maintain airway, monitor vital signs, oxygen, check blood glucose.

Seizures Aura - Sensation of impending seizure Convulsions – Clonic/tonic states Tonic - Rigidity of muscles Clonic - Uncontrolled contraction and relaxation of muscles Postictal - Period after a seizure, patient is usually drowsy and in need of sleep Status Epilepticus - Two or more seizures without regaining consciousness between seizures Coma - state of unresponsiveness from which the patient cannot be aroused

Common Causes of Seizures (AEIOU/TIPS)  Alcohol intoxication  Epilepsy (seizures)  Infection (meningitis)  Unknown or underdose  Overdose (drugs)  Trauma  Insulin (diabetic problems)  Psychiatric  Stroke

Nassau County Fire Police EMS Academy NCPD EMR Summary Rev. 3/2020 2020 EMR SUMMARY

Infants & Children 9 Most Common Pediatric Emergencies  Respiratory  Seizures  AMS  Poisoning  Fever  Shock  Trauma  Near drowning

Treatment  Move objects away and loosen restrictive clothing  Place something soft under head  Place in lateral recumbent after seizure has stopped

Altered Mental Status (AMS) in children EMR must consider/suspect hypoglycemia, poisoning, postictal seizure, head injury, hypoxia & shock/hypo perfusion.

Common Pediatric Emergencies

 Asthma - Give humidified oxygen assist with inhaler if appropriate

 Croup – viral infection  stridor, whooping sound on inhalation and  seal like barking cough. Usually less than 4 years of age with  low grade fever, signs of respiratory distress.

 Epiglottis - bacterial infection swollen epiglottis  pain on swallowing  tripod with feet dangling  drooling  high grade fever

Management: administer humidified oxygen allow to remain in position of comfort. DO NOT EXAMINE THE THROAT

Nassau County Fire Police EMS Academy NCPD EMR Summary Rev. 3/2020 2020 EMR SUMMARY CHILD ABUSE Mandatory reporting in NYS

Signs & Symptoms  Multiple bruises in various stages of healing.  Injury inconsistent with MOI given.  Repeated calls to the same address.  Burns that are even or circumferential.  Parents seem inappropriately concerned.  Conflicting stories  Fear of the patient (child victim) to discuss injury.

Management:  Get child to a safe environment.  Keep your emotions under control  Do not accuse or confront parents with your suspicions  Treat injuries (keeping chain of evidence in mind).  Police intervention may be needed if parent RMA for child.

AMBULANCE OPERATIONS

 Must use due regard when responding with lights and sirens  Take intersections one lane at a time  Make eye contact with drivers and pedestrians before advancing  Can not pass a stopped school bus with flashing red lights  Allow plenty of stopping distance.  Extrication is the removal of the patient  Disentanglement is the remove of debris from around the patient

Incident Command System (ICS)

Utilized as a resource to respond to major EMS, Police or Fire events. Consists of a structured designed to control, direct & coordinate all of the resources available for the given incident.

Nassau County Fire Police EMS Academy NCPD EMR Summary Rev. 3/2020 2020 EMR SUMMARY

Triage - French word that means “to sort”.

START Triage (Simple Triage and Rapid Treatment)

Move Walking Wounded Green

No Resp after head tilt Black

Breathing but Unconscious RED Resp > 30 RED

Perfusion Control bleeding M D I I E Cap refill > 2 sec RED M N C or No Radial Pulse M O E E R A D Mental Status – Can’t follow commands Green S I RED E A D Otherwise Yellow T D Black E E RED L A R < 30 Y E P – 2 D Yellow M – Can do

Nassau County Fire Police EMS Academy NCPD EMR Summary Rev. 3/2020 2020 EMR SUMMARY

EMR Summary

Nassau County Fire Police EMS Academy NCPD EMR Summary Rev. 3/2020