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Paramedic National EMS Education Standard

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NORTHWEST COMMUNITY EMERGENCY MEDICAL SERVICES SYSTEM CCCooonnntttiiinnnuuuiiinnnggg EEEddduuucccaaatttiiiooonnn SSSeeepppttteeemmmbbbeeerrr 222000111222 EEyyee && EEaarr DDiissoorrddeerrss && TTrraauummaa Questions/comments are welcome. Please direct to Jen Dyer, RN, EMT-P EMS Educator NWC EMSS Con-Ed Eye and Ear Disorders and Trauma September 2012 – page 1 Paramedic National EMS Education Standard Integrates assessment findings with principles of pathophysiology to formulate a field impression and implement a treatment/disposition plan for patients with eye and ear disorders/trauma. Objectives: Upon completion of the class and review of the independent study materials and post-test question bank, each participant will do the following with a degree of accuracy that meets or exceeds the standards established for their scope of practice: 1. Identify the anatomical structures of the eye and describe the corresponding physiologic function of each. (C) 2. Explain the physiology of normal vision. (C) 3. Identify the anatomic structures of the ear and describe the corresponding physiologic function of each. (C) 4. Explain the physiology of normal hearing. (C) 5. Explain the physiology of equilibrium. (C) 6. Select and discuss maneuvers for assessing eye structures and functions (C) and demonstrate a thorough EMS assessment of ocular structures, visual acuity, pupils and ocular movements. (P) 7. Distinguish abnormal assessment findings/conditions of the eye: blurred vision, diplopia, photophobia, changes in vision, flashing, pupil exam, Adie’s pupil, oculomotor nerve paralysis, Horner’s Syndrome, blindness, deviation/paralytic strabismus, orbit fracture, cataracts, conjunctivitis, color blindness, near sightedness, farsightedness, astigmatism, amblyopia, burns of the eye, corneal abrasions, foreign body, inflammation of the eyelid, glaucoma, hyphema, iritis, orbital cellulitis, macular degeneration and trauma. (C) 8. Associate pathophysiology with abnormal assessment findings for the eye. (C) 9. Distinguish abnormal assessment findings for conditions of the ear: drainage, deafness, foreign body; impacted cerumen, labarynthitis, Meniere’s disease, otitis externa and media; perforated tympanic membrane, and blast injury. 10. Associate pathophysiology with abnormal assessment findings for the ear. (C) 11. Discuss exam finings as aided by an otoscope. (C) 12. Predict eye injury/conditions as they relate to various mechanisms of injury or illness. (C) 13. Predict ear injury/conditions as they relate to various mechanisms of injury or illness. (C) 14. Interpret assessment findings to formulate EMS impression for diseases/injury to the eyes. (C) 15. Interpret assessment findings to formulate EMS impression for diseases/injury to the ears. (C) 16. Formulate a plan of care and establish care priorities for illness and/or injury to the eye. (C) 17. Formulate a plan of care and establish care priorities for illness and/or injury to the ear. (C) 18. Describe the etiology, clinical presentation and emergency management for patients with a retinal artery occlusion and acute glaucoma. (C) 19. Propose, value and defend modifications to EMS practice in response to challenges faced by elderly patients who experience changes in vision and/or hearing. (A) 20. List the necessary equipment and sequence the critical steps for the instillation of eye drops. (C) 21. State the action, dose, route, indications, contraindications, precautions, and side effects of Tetracaine (0.5% solution Pontocaine) topical eye drops. (C) 22. Identify indications for the procedure, list the needed equipment, and explain the process of irrigating an eye using traditional methods and using a Morgan lens. (C) 23. Describe the correct method to remove a contact lens based on the System procedure manual. (C) 24. Describe and demonstrate the correct method to shield an injured eye. (P) 25. Defend the need for a thorough EMS assessment of the eyes and ears to effectively identify conditions and injuries, minimize damage and loss of function, and ensure disposition to the most appropriate hospital. (A) Key: C: Cognitive objective P: Psychomotor objective A: Affective objective NWC EMSS Con-Ed Eye and Ear Disorders and Trauma September 2012 – page 2 Eye Anatomy and Physiology Eye function is dependent on an exact maintenance of anatomical relationships between the eyelids, ocular structures, extraocular muscles, and nerves. Permanent deficit in any may result in altered visual acuity and possible eye loss. Complete information on eye A & P, which is assumed knowledge, is found in the Independent Study Materials document. Goals of emergency care: 1 Protect intact portions of the visual system 2 Avoid further injury to undamaged parts 3 Accurately assess the eye for illness/injury 4 Transport for immediate definitive care/repair 5 Preserve optimal function 6 Optimal cosmetic results Eye Assessment General examination of eye function begins with assessing the chief complaint and history while beginning the assessment of the ocular structures and function. The only exception to this is in the event of a chemical splash or burn to the eye where the only visual acuity required is to determine if the patient can see light before eye irrigation is immediately started. Eye injuries are substantial distracting injuries, to both pt & caregiver. If MOI suggests potential for head or spine injury, spine motion precautions should be followed! Also, many eye and ear assessment findings may be due to CNS etiologies. Beware of the potential for not-so-obvious traumatic and neurologic emergencies. Chief Complaint Perform simultaneously w/ eye exam. Nature of complaint: traumatic vs. non-traumatic Non-traumatic: Usually divided into complaints of vision, appearance or sensation. Obtain details regarding the rapidity of onset, duration, intermittence and frequency. Note associated symptoms. Traumatic: Blunt, penetrating, sharp or explosive; thermal, UV; time and course of events. Ask about any change in vision, and if so, was it immediate, sudden or gradual? If chemical burn, ask if it was toxic, acid or alkali. Determine any treatment rendered prior to arrival. Caveats ¾ Blunt MOI often leaves soft tissues intact –may be no evidence of internal trauma in prehospital environment ¾ Visual disturbances may be an early indicator of stroke, tumor, or other CNS disorder SAMPLE History Signs/symptoms: Obtain details about onset, provocation (what object or item caused the injury - magnetic?)/palliation, quality, region/recurrence, severity, and date and time of injury. Ocular pain; redness; burning; spots; change in vision; blurred; diplopia; halos; excessive tearing; crusting; discharge. If applicable, occupational history: dust, chemicals, metalwork, use of protective devices. Symptoms in one or both eyes? Eye injuries may be difficult to identify in patients w/ normal vision. The following should be approached w/ a high index of suspicion for serious ocular trauma. y Obvious trauma w/ eye injury y Vision loss or blurred vision that does not improve w/ blinking Diplopia (double vision) y Diplopia may indicate trauma to the globe with muscle entrapment or nerve deficit, peripheral or central y Monocular diplopia usually indicates a refractive error in the eye itself y Binocular diplopia, present only when both eyes are open, is the result of a deficiency in the movement of the eye Allergies NWC EMSS Con-Ed Eye and Ear Disorders and Trauma September 2012 – page 3 Medications: y Regular use of eye medications or over-the-counter remedies including drops or ointments y Use of anticoagulants y Recreational drug use - they can affect pupil size and reactivity Past ocular history: y Photophobia y Ocular disease or visual loss? Glaucoma? Cataracts? y Blurred vision that does not improve with blinking y Diplopia y Sectorial visual loss y Spots before eyes, curtain over the visual field? y Halos or rings around lights y Eye injury/surgery Baseline visual acuity; Corrective lenses or contacts? How long? If contacts are worn: hard, soft, extended wear? For reading, driving, distance? Past medical history in self or family y Heart disease, hypertension y Diabetes y Sickle cell disease y Liver disease y Vascular disorders Last oral intake Events surrounding the incident: Details regarding probable size, velocity, and chemical constituency of pellets or projectiles; determine treatment rendered prior to arrival. Contact Lens Removal – See procedure manual for all steps Lenses should only be removed if irrigation is required or if eye drops will be administered, and in the case of burns. Unnecessary removal in the prehospital environment may cause additional trauma or irritation. y Prepare equipment: BSI; Sterile NS; lens case; towel or 4X4s; suction cup (optional) y Remove external loose debris by gently touching adhesive tape against closed lids. Remove dirt, blood or makeup from lids. Do not dislodge clots. y Place 2 mL sterile saline into each specimen cup. Label containers L & R. y If eye appears dry, instill several drops of preservative free saline and wait a few minute before removing the lens, to help prevent corneal damage. y Locate the lens. It can be seen moving on cornea when pt blinks or by looking sideways across the eye y Position lens totally on sclera or cornea. It is safer for the lens to be entirely on the sclera or cornea than partially on each. If unable to remove, slide to either position. y With index finger, raise and hold upper lid against orbital rim. Gently pull lower lid down w/ thumb
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